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Schouten TMR, Abu-Hanna A, van Kaam AH, van den Heuvel MEN, Bachman TE, van Leuteren RW, Hutten GJ, Onland W. Prolonged use of closed-loop inspired oxygen support in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:221-226. [PMID: 37827816 DOI: 10.1136/archdischild-2023-325831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This randomised study in preterm infants on non-invasive respiratory support investigated the effectiveness of automated oxygen control (A-FiO2) in keeping the oxygen saturation (SpO2) within a target range (TR) during a 28-day period compared with manual titration (M-FiO2). DESIGN A single-centre randomised control trial. SETTING A level III neonatal intensive care unit. PATIENTS Preterm infants (<28 weeks' gestation) on non-invasive respiratory support. INTERVENTIONS A-FiO2 versus M-FiO2 control. METHODS Main outcomes were the proportion of time spent and median area of episodes in the TR, hyperoxaemia, hypoxaemia and the trend over 28 days using a linear random intercept model. RESULTS 23 preterm infants (median gestation 25.7 weeks; birth weight 820 g) were randomised. Compared with M-FiO2, the time spent within TR was higher in the A-FiO2 group (68.7% vs 48.0%, p<0.001). Infants in the A-FiO2 group spent less time in hyperoxaemia (13.8% vs 37.7%, p<0.001), but no difference was found in hypoxaemia. The time-based analyses showed that the A-FiO2 efficacy may differ over time, especially for hypoxaemia. Compared with the M-FiO2 group, the A-FiO2 group had a larger intercept but with an inversed slope for the daily median area below the TR (intercept 70.1 vs 36.3; estimate/day -0.70 vs 0.69, p<0.001). CONCLUSION A-FiO2 control was superior to manual control in keeping preterm infants on non-invasive respiratory support in a prespecified TR over a period of 28 days. This improvement may come at the expense of increased time below the TR in the first days after initiating A-FiO2 control. TRIAL REGISTRATION NUMBER NTR6731.
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Affiliation(s)
- Tim M R Schouten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Medical Informatics, University of Amsterdam, Amsterdam, the Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | | | | | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
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Scholten AWJ, van Leuteren RW, de Waal CG, Kraaijenga JV, de Jongh FH, van Kaam AH, Hutten GJ. Diaphragmatic electromyography in infants: an overview of possible clinical applications. Pediatr Res 2024; 95:52-58. [PMID: 37660179 DOI: 10.1038/s41390-023-02800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/04/2023]
Abstract
Preterm infants often experience breathing instability and a hampered lung function. Therefore, these infants receive cardiorespiratory monitoring and respiratory support. However, the current respiratory monitoring technique may be unreliable for especially obstructive apnea detection and classification and it does not provide insight in breathing effort. The latter makes the selection of the adequate mode and level of respiratory support difficult. Electromyography of the diaphragm (dEMG) has the potential of monitoring heart rate (HR) and respiratory rate (RR), and it provides additional information on breathing effort. This review summarizes the available evidence on the clinical potential of dEMG to provide cardiorespiratory monitoring, to synchronize patient-ventilator interaction, and to optimize the mode and level of respiratory support in the individual newborn infant. We also try to identify gaps in knowledge and future developments needed to ensure widespread implementation in clinical practice. IMPACT: Preterm infants require cardiorespiratory monitoring and respiratory support due to breathing instability and a hampered lung function. The current respiratory monitoring technique may provide unreliable measurements and does not provide insight in breathing effort, which makes the selection of the optimal respiratory support settings difficult. Measuring diaphragm activity could improve cardiorespiratory monitoring by providing insight in breathing effort and could potentially have an important role in individualizing respiratory support in newborn infants.
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Affiliation(s)
- Anouk W J Scholten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Juliette V Kraaijenga
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Faculty of Science and Technology, University of Twente, Drienerlolaan 5, Enschede, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands.
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Scholten AWJ, Zhan Z, Niemarkt HJ, Vervoorn M, van Leuteren RW, de Jongh FH, van Kaam AH, Heuvel ERVD, Hutten GJ. Cardiorespiratory monitoring with a wireless and nonadhesive belt measuring diaphragm activity in preterm and term infants: A multicenter non-inferiority study. Pediatr Pulmonol 2023; 58:3574-3581. [PMID: 37795597 DOI: 10.1002/ppul.26695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION We determined if the heart rate (HR) monitoring performance of a wireless and nonadhesive belt is non-inferior compared to standard electrocardiography (ECG). Secondary objective was to explore the belt's respiratory rate (RR) monitoring performance compared to chest impedance (CI). METHOD In this multicenter non-inferiority trial, preterm and term infants were simultaneously monitored with the belt and conventional ECG/CI for 24 h. HR monitoring performance was estimated with the HR difference and ability to detect cardiac events compared to the ECG, and the incidence of HR-data loss per second. These estimations were statistically compared to prespecified margins to confirm equivalence/non-inferiority. Exploratory RR analyses estimated the RR trend difference and ability to detect apnea/tachypnea compared to CI, and the incidence of RR-data loss per second. RESULTS Thirty-nine infants were included. HR monitoring with the belt was non-inferior to the ECG with a mean HR difference of 0.03 beats per minute (bpm) (standard error [SE] = 0.02) (95% limits of agreement [LoA]: [-5 to 5] bpm) (p < 0.001). Second, sensitivity and positive predictive value (PPV) for cardiac event detection were 94.0% (SE = 0.5%) and 92.6% (SE = 0.6%), respectively (p ≤ 0.001). Third, the incidence of HR-data loss was 2.1% (SE = 0.4%) per second (p < 0.05). The exploratory analyses of RR showed moderate trend agreement with a mean RR-difference of 3.7 breaths/min (SE = 0.8) (LoA: [-12 to 19] breaths/min), but low sensitivities and PPV's for apnea/tachypnea detection. The incidence of RR-data loss was 2.2% (SE = 0.4%) per second. CONCLUSION The nonadhesive, wireless belt showed non-inferior HR monitoring and a moderate agreement in RR trend compared to ECG/CI. Future research on apnea/tachypnea detection is required.
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Affiliation(s)
- Anouk W J Scholten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Zhuozhao Zhan
- Department of Mathemaatics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Hendrik J Niemarkt
- Department of Neonatology, Màxima Medical Center, Veldhoven, The Netherlands
| | - Marieke Vervoorn
- Department of Neonatology, Màxima Medical Center, Veldhoven, The Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Edwin R van den Heuvel
- Department of Mathemaatics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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van Leuteren RW, Bem RA. Measuring Expiratory Diaphragm Activity: An Electrifying Tool to Guide Positive End-Expiratory Pressure Strategy in Critically Ill Children? Pediatr Crit Care Med 2023; 24:515-517. [PMID: 37260335 DOI: 10.1097/pcc.0000000000003228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Reinout A Bem
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Pigmans RRWP, van Leuteren RW, Scholten AWJ, Veneroni C, van Kaam AH, Hutten J, Dellacà RL, de Jongh FHC. Influence of neonatal endotracheal tube dimensions on oscillometry-acquired reactance: a bench study. Physiol Meas 2023; 44. [PMID: 36599175 DOI: 10.1088/1361-6579/acb03a] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/04/2023] [Indexed: 01/06/2023]
Abstract
Objective.To examine the influence of the endotracheal tube (ETT) on respiratory reactance (Xrs) measured with the forced oscillation technique (FOT) and develop a correction method for it.Approach.In a bench study, the reactance of ETTs (Xtube) with different dimensions was measured on a breathing test lung in various respiratory settings.Main results.Xtubecan be accurately predicted by a fitted formula, with an R2of 0.97, with negligible effects due to changes in respiratory pattern and lung volume.Significance.The developed formula offers the ability to measure ETT-independent Xrsvalues of patients, improving the potential of FOT for lung function testing in mechanically ventilated newborns.
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Affiliation(s)
- Rosemijne R W P Pigmans
- Department of neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Ruud W van Leuteren
- Department of neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Anouk W J Scholten
- Department of neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Chiara Veneroni
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Anton H van Kaam
- Department of neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Jeroen Hutten
- Department of neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Raffaele L Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Frans H C de Jongh
- Department of neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
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Scholten AWJ, van Leuteren RW, de Jongh FH, van Kaam AH, Hutten GJ. Simultaneous measurement of diaphragm activity, chest impedance, and ECG using three standard cardiorespiratory monitoring electrodes. Pediatr Pulmonol 2022; 57:2754-2762. [PMID: 35938231 PMCID: PMC9804169 DOI: 10.1002/ppul.26096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Current cardiorespiratory monitoring in neonates with electrocardiogram (ECG) and chest impedance (CI) has limitations. Adding transcutaneous electromyography of the diaphragm (dEMG) may improve respiratory monitoring, but requires additional hardware. We aimed to determine the feasibility of measuring dEMG and ECG/CI simultaneously using the standard ECG/CI hardware, with its three electrodes repositioned to dEMG electrode locations. METHODS Thirty infants (median postmenstrual age 30.4 weeks) were included. First, we assessed the feasibility of extracting dEMG from the ECG-signal. If successful, the agreement between dEMG-based respiratory rate (RR), using three different ECG-leads, and a respiratory reference signal was assessed using the Bland-Altman analysis and the intraclass correlation coefficient (ICC). Furthermore, we studied the agreement between CI-based RR and the reference signal with the electrodes placed at the standard and dEMG position. Finally, we explored the quality of the ECG-signal at the different electrode positions. RESULTS In 15 infants, feasibility of measuring dEMG with the monitoring electrodes was confirmed. In the next 15 infants, comparing dEMG-based RR to the reference signal resulted in a mean difference and limits of agreement for ECG-lead I, II and III of 4.2 [-8.2 to 16.6], 4.3 [-10.7 to 19.3] and 5.0 [-14.2 to 24.2] breaths/min, respectively. ICC analysis showed a moderate agreement for all ECG-leads. CI-based RR agreement was similar at the standard and dEMG electrode position. An exploratory analysis suggested similar quality of the ECG-signal at both electrode positions. CONCLUSION Measuring dEMG using the ECG/CI hardware with its electrodes on the diaphragm is feasible, leaving ECG/CI monitoring unaffected.
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Affiliation(s)
- Anouk W J Scholten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
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Scholten AWJ, Zhan Z, Niemarkt HJ, Vervoorn M, van Leuteren RW, de Jongh FH, van Kaam AH, van den Heuvel ER, Hutten GJ. Multicentre paired non-inferiority study of the cardiorespiratory monitoring performance of the wireless and non-adhesive Bambi® belt measuring diaphragm activity in neonates: study protocol. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001430. [PMID: 36053638 PMCID: PMC9185582 DOI: 10.1136/bmjpo-2022-001430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/26/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Cardiorespiratory monitoring is used in the neonatal intensive care unit (NICU) to assess the clinical status of newborn infants and detect critical deteriorations in cardiorespiratory function. Currently, heart rate (HR) is monitored by electrocardiography (ECG) and respiration by chest impedance (CI). Disadvantages of current monitoring techniques are usage of wired adhesive electrodes which may damage the skin and hinder care. The Bambi® belt is a wireless and non-adhesive alternative that enables cardiorespiratory monitoring by measuring electrical activity of the diaphragm via transcutaneous electromyography. A previous study showed feasibility of the Bambi® belt and this study compares the belt performance to ECG and CI. METHODS AND ANALYSIS This multicentre non-inferiority paired study will be performed in the NICU of the Máxima Medical Center (MMC) in Veldhoven and the Emma Children's Hospital, Amsterdam University Medical Centre (AmsterdamUMC) in Amsterdam, The Netherlands. 39 infants in different postmenstrual age groups (minimally 10 infants<30 weeks, between 30-32 weeks and >32 weeks) will be recruited. These infants will be monitored with the Bambi® belt in addition to standard ECG and CI for 24 hours. The primary outcome is the HR, studied with three criteria: (1) the limits of agreement of the HR measurements in terms of the second-to-second difference in the HR between the belt and standard ECG, (2) the detection of cardiac events consisting of bradycardia and tachycardia and (3) the quality of HR-monitoring. The secondary outcome is the respiratory rate (RR), studied with the criteria (1) agreement in RR-trend monitoring, (2) apnoea and tachypnoea detection and (3) reliable registrations. ETHICS AND DISSEMINATION This protocol was approved by the Medical Ethical Committee of the MMC and the Central Committee for Human Research. The MMC started patient recruitment in July and the AmsterdamUMC in August 2021. The results will be presented at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NL9480.
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Affiliation(s)
- Anouk W J Scholten
- Amsterdam UMC location University of Amsterdam, Department of Neonatology, Meibergdreef 9, Amsterdam, The Netherlands .,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Zhuozhao Zhan
- Eindhoven University of Technology, Department of Mathematics and Computer Science, Eindhoven, The Netherlands
| | - Hendrik J Niemarkt
- Máxima Medical Center, Department of Neonatology, Veldhoven, The Netherlands
| | - Marieke Vervoorn
- Máxima Medical Center, Department of Neonatology, Veldhoven, The Netherlands
| | - Ruud W van Leuteren
- Amsterdam UMC location University of Amsterdam, Department of Neonatology, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Amsterdam UMC location University of Amsterdam, Department of Neonatology, Meibergdreef 9, Amsterdam, The Netherlands.,University of Twente, Faculty of Science and Technology, Enschede, The Netherlands
| | - Anton H van Kaam
- Amsterdam UMC location University of Amsterdam, Department of Neonatology, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
| | - Edwin R van den Heuvel
- Eindhoven University of Technology, Department of Mathematics and Computer Science, Eindhoven, The Netherlands
| | - G Jeroen Hutten
- Amsterdam UMC location University of Amsterdam, Department of Neonatology, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
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Scholten AWJ, van Leuteren RW, de Waal CG, de Jongh FH, van Kaam AH, Hutten GJ. Feasibility of wireless cardiorespiratory monitoring with dry electrodes incorporated in a belt in preterm infants. Physiol Meas 2022; 43. [PMID: 35453135 DOI: 10.1088/1361-6579/ac69a9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/22/2022] [Indexed: 11/11/2022]
Abstract
Objective Monitoring heart rate (HR) and respiratory rate (RR) is essential in preterm infants and is currently measured with ECG and chest impedance (CI), respectively. However, in current clinical practice these techniques use wired adhesive electrodes which can cause skin damage and hinder parent-infant interaction. Moreover, CI is not always reliable. We assessed the feasibility of a wireless dry electrode belt to measure HR and RR via transcutaneous diaphragmatic electromyography (dEMG). Approach In this prospective, observational study, infants were monitored up to 72 hours with the belt and standard CI. Feasibility of the belt was expressed by its ability to retrieve a respiratory waveform from dEMG, determining the percentage of time with stable respiration data without signal errors ('lead-off' and Bluetooth Loss Error, 'BLE'), skin-friendliness of the belt (skin score) and by exploring the ability to monitor trends in HR and RR with the belt. Main results In all 19 included infants (median gestational age 27.3 weeks) a respiratory waveform could be obtained. The amount of signal errors was low (lead-off 0.5% (IQR 0.1-1.6) and BLE 0.3% (IQR 0.1-0.9)) and 76.5% (IQR 69.3-80.0) of the respiration measurement was stable. No adverse skin effects were observed (median skin score of 3(3-4)). A similar HR and RR trend between the belt and CI was observed. Significance Dry electrodes incorporated in a non-adhesive belt can measure dEMG in preterm infants. The belt provided a HR and RR trend similar to CI. Future studies are required to investigate the non-inferiority of the belt as a cardiorespiratory monitor compared to CI.
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Affiliation(s)
- Anouk W J Scholten
- Department of neonatology, Emma Children's Hospital, AmsterdamUMC, Meibergdreef 9, Amsterdam, 1105 AZ, NETHERLANDS
| | - Ruud W van Leuteren
- Department of neonatology, Emma Children's Hospital, AmsterdamUMC, Meibergdreef 9, Amsterdam, 1105 AZ, NETHERLANDS
| | - Cornelia G de Waal
- Department of neonatology, Emma Children's Hospital, AmsterdamUMC, Meibergdreef 9, Amsterdam, 1105 AZ, NETHERLANDS
| | - Frans H de Jongh
- Department of neonatology, Emma Children's Hospital, AmsterdamUMC, Meibergdreef 9, Amsterdam, 1105 AZ, NETHERLANDS
| | - Anton H van Kaam
- Department of neonatology, Emma Children's Hospital, AmsterdamUMC, Meibergdreef 9, Amsterdam, Noord-Holland, 1105 AZ, NETHERLANDS
| | - G Jeroen Hutten
- Department of neonatology, Emma Children's Hospital, AmsterdamUMC, Meibergdreef 9, Amsterdam, 1105 AZ, NETHERLANDS
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van Leuteren RW, Kho E, de Waal CG, Te Pas AB, Salverda HH, de Jongh FH, van Kaam AH, Hutten GJ. Cardiorespiratory monitoring in the delivery room using transcutaneous electromyography. Arch Dis Child Fetal Neonatal Ed 2021; 106:352-356. [PMID: 33214154 DOI: 10.1136/archdischild-2020-319535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To assess feasibility of transcutaneous electromyography of the diaphragm (dEMG) as a monitoring tool for vital signs and diaphragm activity in the delivery room (DR). DESIGN Prospective observational study. SETTING Delivery room. PATIENTS Newborn infants requiring respiratory stabilisation after birth. INTERVENTIONS In addition to pulse oximetry (PO) and ECG, dEMG was measured with skin electrodes for 30 min after birth. OUTCOME MEASURES We assessed signal quality of dEMG and ECG recording, agreement between heart rate (HR) measured by dEMG and ECG or PO, time between sensor application and first HR read-out and agreement between respiratory rate (RR) measured with dEMG and ECG, compared with airway flow. Furthermore, we analysed peak, tonic and amplitude diaphragmatic activity from the dEMG-based respiratory waveform. RESULTS Thirty-three infants (gestational age: 31.7±2.8 weeks, birth weight: 1525±661 g) were included.18%±14% and 22%±21% of dEMG and ECG data showed poor quality, respectively. Monitoring HR with dEMG was fast (median 10 (IQR 10-11) s) and accurate (intraclass correlation coefficient (ICC) 0.92 and 0.82 compared with ECG and PO, respectively). RR monitoring with dEMG showed moderate (ICC 0.49) and ECG low (ICC 0.25) agreement with airway flow. Diaphragm activity started high with a decreasing trend in the first 15 min and subsequent stabilisation. CONCLUSION Monitoring vital signs with dEMG in the DR is feasible and fast. Diaphragm activity can be detected and described with dEMG, making dEMG promising for future DR studies.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands .,Amsterdam Reproduction & Development Research Institute, Amsterdam, North-Holland, Netherlands
| | - Eline Kho
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Technical Medicine, University of Twente, Enschede, Overijssel, Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Hylke H Salverda
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, Overijssel, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
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van Leuteren RW, de Waal CG, Hutten GJ, de Jongh FH, van Kaam AH. Transcutaneous monitoring of diaphragm activity as a measure of work of breathing in preterm infants. Pediatr Pulmonol 2021; 56:1593-1600. [PMID: 33524225 PMCID: PMC8248030 DOI: 10.1002/ppul.25284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Monitoring work of breathing (WOB) is important to assess the pulmonary condition and adjust respiratory support in preterm infants. Conventional WOB measurement (esophageal pressure, tidal volume) is invasive and we hypothesized that monitoring diaphragm activity could be a noninvasive alternative to estimate WOB. The objective was to determine the correlation between conventional WOB measures and diaphragm activity, in preterm infants. METHODS WOB and diaphragm activity, measured with transcutaneous electromyography (dEMG), were simultaneously recorded at different nasal continuous positive airway pressure (nCPAP) levels. During a 30-s recording at each nCPAP level, dEMG parameters, inspiratory WOB (WOBi ), and pressure time product (PTPin ) were calculated per breath. The correlation coefficient between WOB- and dEMG-measures was calculated using single breaths and after aggregating all breaths into deciles of incremental WOBi . RESULTS Fifteen preterm infants were included (median gestational age, 28 weeks). Single-breath analysis showed a poor median correlation of 0.27 (interquartile range [IQR], 0.03 to 0.33) and 0.08 (IQR, -0.03 to 0.28), respectively, for WOBi and PTPin with peak diaphragmatic activity (dEMGpeak ). A modest median correlation coefficient of 0.65 (IQR, 0.13 to 0.79) and 0.43 (IQR, -0.33 to 0.69) was found for, respectively, WOBi and PTPin with dEMGpeak in the aggregated analysis. CONCLUSION Diaphragm activity showed a modest correlation with WOBi and PTPin in an aggregated analysis. This finding warrants further studies in infants with more significant lung disease.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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van Leuteren RW, Scholten AWJ, Dekker J, Martherus T, de Jongh FH, van Kaam AH, Te Pas AB, Hutten J. The Effect of Initial Oxygen Exposure on Diaphragm Activity in Preterm Infants at Birth. Front Pediatr 2021; 9:640491. [PMID: 33634059 PMCID: PMC7899995 DOI: 10.3389/fped.2021.640491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The initial FiO2 that should be used for the stabilization of preterm infants in the delivery room (DR) is still a matter of debate as both hypoxia and hyperoxia should be prevented. A recent randomized controlled trial showed that preterm infants [gestational age (GA) < 30 weeks] stabilized with an initial high FiO2 (1.0) had a significantly higher breathing effort than infants stabilized with a low FiO2 (0.3). As the diaphragm is the main respiratory muscle in these infants, we aimed to describe the effects of the initial FiO2 on diaphragm activity. Methods: In a subgroup of infants from the original bi-center randomized controlled trial diaphragm activity was measured with transcutaneous electromyography of the diaphragm (dEMG), using three skin electrodes that were placed directly after birth. Diaphragm activity was compared in the first 5 min after birth. From the dEMG respiratory waveform several outcome measures were determined for comparison of the groups: average peak- and tonic inspiratory activity (dEMGpeak and dEMGton, respectively), inspiratory amplitude (dEMGamp), area under the curve (dEMGAUC) and the respiratory rate (RR). Results: Thirty-one infants were included in this subgroup, of which 29 could be analyzed [n = 15 (median GA 28.4 weeks) and n = 14 (median GA 27.9 weeks) for the 100 and 30% oxygen group, respectively]. Tonic diaphragm activity was significantly higher in the high FiO2-group (4.3 ± 2.1 μV vs. 2.9 ± 1.1 μV; p = 0.047). The other dEMG-parameters (dEMGpeak, dEMGamp, dEMGAUC) showed consistently higher values in the high FiO2 group, but did not reach statistical significance. Average RR showed similar values in both groups (34 ± 9 vs. 32 ± 10 breaths/min for the high and low oxygen group, respectively). Conclusion: Preterm infants stabilized with an initial high FiO2 showed significantly more tonic diaphragm activity and an overall trend toward a higher level of diaphragm activity than those stabilized with an initial low FiO2. These results confirm that a high initial FiO2 after birth stimulates breathing effort, which can be objectified with dEMG.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Anouk W J Scholten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Janneke Dekker
- Department of Neonatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Tessa Martherus
- Department of Neonatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands
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van Leuteren RW, Bekhuis RE, de Waal CG, de Jongh FH, van Kaam AH, Hutten GJ. Diaphragmatic electromyography in preterm infants: The influence of electrode positioning. Pediatr Pulmonol 2020; 55:354-359. [PMID: 31765520 PMCID: PMC7004062 DOI: 10.1002/ppul.24585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/11/2019] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To determine the effect of changing electrode positions on vital signs and respiratory effort parameters measured with transcutaneous electromyography of the diaphragm (dEMG) in preterm infants. METHODS In this observational study, simultaneous dEMG measurements were performed at the standard position and at one alternative electrode position (randomly assigned to lateral, superior, medial, inferior to the standard placement, or dorsal). The activity of the diaphragm was measured for 1 hour at both positions. Main outcome measures were the agreement in heart rate (HR), respiratory rate (RR), and percentage difference in dEMG parameters of respiratory effort (peak and tonic activity, amplitude, area under the curve, and frequency content) between the standard and alternative electrode positions. RESULTS Thirty clinically stable preterm infants (gestational age 30.1 ± 3.0 weeks) with either no or noninvasive respiratory support were included. Agreement in HR was excellent at all positions (ICC > 0.95) while RR agreement showed more diversity (ICC range 0.40-0.86). Mixed modeling of dEMG parameters revealed that medial and inferior placement measured the weakest signals (median 75.5% and 64.5% lower dEMG amplitude). Lateral electrode placement showed the highest similarity to standard positioning (median 23.5% lower amplitude). CONCLUSION Measuring HR showed high similarity at all positions. However, registration of RR and respiratory effort is clearly influenced by the electrode position. Electrodes in the same transversal plane as the diaphragm, and at sufficient distance from each other, provide the best agreement with the standard positioning.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robin E Bekhuis
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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de Waal CG, van Leuteren RW, de Jongh FH, van Kaam AH, Hutten GJ. Patient-ventilator asynchrony in preterm infants on nasal intermittent positive pressure ventilation. Arch Dis Child Fetal Neonatal Ed 2019; 104:F280-F284. [PMID: 30032105 DOI: 10.1136/archdischild-2018-315102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/26/2018] [Accepted: 06/08/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To describe the incidence of patient-ventilator asynchrony and different types of asynchrony in preterm infants treated with non-synchronised nasal intermittent positive pressure ventilation (nIPPV). DESIGN An observational study was conducted including preterm infants born with a gestational age (GA) less than 32 weeks treated with non-synchronised nIPPV. During 1 hour, spontaneous breathing was measured with transcutaneous electromyography of the diaphragm simultaneous with ventilator inflations. An asynchrony index (AI), a percentage of asynchronous breaths, was calculated and the incidence of different types of inspiratory and expiratory asynchrony were reported. RESULTS Twenty-one preterm infants with a mean GA of 26.0±1.2 weeks were included in the study. The mean inspiratory AI was 68.3%±4.7% and the mean expiratory AI was 67.1%±7.3%. Out of 5044 comparisons of spontaneous inspirations and mechanical inflations, 45.3% of the mechanical inflations occurred late, 23.3% of the mechanical inflations were early and 31.4% of the mechanical inflation were synchronous. 40.3% of 5127 expiratory comparisons showed an early termination of ventilator inflations, 26.7% of the mechanical inflations terminated late and 33.0% mechanical inflations terminated in synchrony with a spontaneous expiration. In addition, 1380 spontaneous breaths were unsupported and 611 extra mechanical inflations were delivered. CONCLUSION Non-synchronised nIPPV results in high patient-ventilator asynchrony in preterm infants during both the inspiratory and expiratory phase of the breathing cycle. New synchronisation techniques are urgently needed and should address both inspiratory and expiratory asynchrony.
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Affiliation(s)
- Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.,Department of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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Dekker J, Martherus T, Lopriore E, Giera M, McGillick EV, Hutten J, van Leuteren RW, van Kaam AH, Hooper SB, Te Pas AB. The Effect of Initial High vs. Low FiO 2 on Breathing Effort in Preterm Infants at Birth: A Randomized Controlled Trial. Front Pediatr 2019; 7:504. [PMID: 31921719 PMCID: PMC6927294 DOI: 10.3389/fped.2019.00504] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Infants are currently stabilized at birth with initial low FiO2 which increases the risk of hypoxia and suppression of breathing in the first minutes after birth. We hypothesized that initiating stabilization at birth with a high O2 concentration, followed by titration, would improve breathing effort when compared to a low O2 concentration, followed by titration. Methods: In a bi-center randomized controlled trial, infants <30 weeks gestation were stabilized at birth with an initial O2 concentration of 30 or 100%, followed by oxygen titration. Primary outcome was minute volume of spontaneous breathing. We also assessed tidal volumes, mean inspiratory flow rate (MIFR) and respiratory rate with a respiratory function monitor in the first 5 min after birth, and evaluated the duration of mask ventilation in the first 10 min after birth. Pulse oximetry was used to measure heart rate and SpO2 values in the first 10 min. Hypoxemia was defined as SpO2 < 25th percentile and hyperoxemia as SpO2 >95%. 8-iso-prostaglandin F2α (8iPGF2α) was measured to assess oxidative stress in cord blood and 1 and 24 h after birth. Results: Fifty-two infants were randomized and recordings were obtained in 44 infants (100% O2-group: n = 20, 30% O2-group: n = 24). Minute volumes were significantly higher in the 100% O2-group (146.34 ± 112.68 mL/kg/min) compared to the 30% O2-group (74.43 ± 52.19 mL/kg/min), p = 0.014. Tidal volumes and MIFR were significantly higher in the 100% O2-group, while the duration of mask ventilation given was significantly shorter. Oxygenation in the first 5 min after birth was significantly higher in infants in the 100% O2-group [85 (64-93)%] compared to the 30% O2-group [58 (46-67)%], p < 0.001. The duration of hypoxemia was significantly shorter in the 100% O2-group, while the duration of hyperoxemia was not different between groups. There was no difference in oxidative stress marker 8iPGF2α between the groups. Conclusion: Initiating stabilization of preterm infants at birth with 100% O2 led to higher breathing effort, improved oxygenation, and a shorter duration of mask ventilation as compared to 30% O2, without increasing the risk for hyperoxia or oxidative stress. Clinical Trial Registration: This study was registered in www.trialregister.nl, with registration number NTR6878.
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Affiliation(s)
- Janneke Dekker
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Tessa Martherus
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Enrico Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martin Giera
- Center Proteomics Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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