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Oxygen Does Not Hasten Resolution of Symptomatic Spontaneous Pneumothorax in Neonates

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Oxygen Does Not Hasten Resolution of Symptomatic Spontaneous Pneumothorax in Neonates Journal of Perinatology (2014) 34, 528–531 © 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp ORIGINAL ARTICLE Administration of 100% oxygen does not hasten resolution of symptomatic spontaneous pneumothorax in neonates SD Clark1,2, F Saker1,2, MT Schneeberger1,2, E Park2,3, DW Sutton2,4 and Y Littner1,2 OBJECTIVE: To compare the effectiveness of 100% oxygen therapy vs oxygen treatment with targeted pulse oximetry in the management of symptomatic small to moderate spontaneous pneumothorax (SP). In total, 100% oxygen treatment for SP has been a common practice in neonatology, albeit there is little evidence to validate its efficacy. STUDY DESIGN: A retrospective chart review of 83 neonatal records with the diagnosis of pneumothorax was conducted. Infants o35 weeks gestation, those with large pneumothoraces requiring chest tube drainage and/or ventilatory support were excluded. Data gathered included demographics, vital signs, treatment information and clinical indicators of resolution of symptoms. RESULT: In total, 45 neonates with SP were included in the study. Groups were similar for gestational age, birth weight, Apgar scores, gravidity, parity, gender, race, pneumothorax size and location. Patients in the 100% oxygen therapy group received a significantly longer oxygen treatment (21.3 vs 8 h, Po0.001), required longer intravenous fluid treatment (48.6 ± 29.9 vs 31.3 ± 18.8 h, P = 0.03) and were delayed in reaching full feeds (44.1 ± 25.7 vs 29.5 ± 18.8 h, P = 0.03) compared with the oxygen-targeted treatment group. Time to first oral feeding, time to resolution of tachypnea and length of stay were similar in both groups. CONCLUSION: There are no clinically significant advantages to using 100% oxygen in the treatment of symptomatic small to moderate SP. In fact, it may result in longer exposure to unnecessary oxygen treatment and toxicity. Oxygen should be reserved for those who are hypoxic and adjusted to comply with accepted saturation levels in neonates. Journal of Perinatology (2014) 34, 528–531; doi:10.1038/jp.2014.55; published online 3 April 2014 INTRODUCTION a long-lasting effect particularly on neonates who lack adequate 6–10 Spontaneous pneumothorax (SP) occurs in 0.05 to 2% of all live- antioxidant capacities. born infants.1,2 Most infants remain asymptomatic and do not In our facility, both administration of 100% oxygen and supple- require any intervention. Symptomatic SP, is less common (0.05 to mental oxygen with targeted pulse oximetry (range of 92 to 95%) 1% of live births), and will often present within the first hours of are common practices for the treatment of SP. Treatment choice is life.2–4 Common clinical signs may include tachypnea, cyanosis, based solely on the preference of the attending neonatologist. tachycardia and changes in blood pressure. SP can be idiopathic Using this unique opportunity, we aimed to compare these or may be associated with transient tachypnea of the newborn, two philosophies of treatment in the management of small to respiratory distress syndrome, meconium aspiration syndrome, moderate SP in neonates. We hypothesized that 100% oxygen birth depression, birth trauma and difficult delivery. treatment will accelerate the resolution of SP in neonates. The treatment of SP varies and is determined by symptoms, size of the air leak, whether or not it is under tension and the custo- mary practice of the neonatology group. For small to moderate METHODS pneumothorax that is neither under tension nor causing hemo- Patients dynamic changes, conservative treatment options consist of close observation with symptomatic treatment vs use of 100% inspired We retrospectively reviewed the medical records of babies born at Hillcrest ‘ ’ Hospital, Cleveland, OH between 2008 and 2011. Patients were selected oxygen for nitrogen washout . Nitrogen washout hastens the using the ICD-9 code for pneumothorax. Diagnosis of pneumothorax was resolution of pneumothorax by increasing the gradient for suspected based on physical exam, clinical symptoms and confirmed by nitrogen absorption from the extra-pulmonary space. In 1971, chest X-ray. Inclusion criteria included: neonates admitted to the neonatal Northfield5 described accelerated resolution of pneumothoraces intensive care unit with confirmed pneumothorax on chest X-ray within in 10 patients treated with oxygen. the first 12 h of life. A pediatric radiologist, blinded to the therapeutic Although there are no additional human studies that confirm approach, read all chest X-rays. Exclusion criteria included: neonates the efficacy or safety of this treatment, nitrogen washout became o35 weeks gestation, aggressive resuscitation and/or positive pressure a common practice in neonatology. On the other hand, there is a ventilation in the delivery room, any treatment of large pneumothorax growing body of literature about the potential detrimental effects with needle aspiration, chest tube and/or ventilatory support. We also excluded patients who expired or were transferred to a tertiary level of hyperoxia in newborns. Animal and human newborn studies center, and patients who crossed over treatment strategies. Discontinua- have demonstrated that hyperoxia-induced oxidative stress may tion of O2 therapy in the conventional oxygen therapy group was guided contribute to the pathogenesis of several disorders and may have by pulse oximetry readings, whereas in the nitrogen washout group O2 1Department of Neonatology, The Cleveland Clinic Children's, Cleveland Clinic, Cleveland, OH, USA; 2Cleveland Clinic Lerner College of Medicine of Medicine of Case Western Reserve University, Cleveland, OH, USA; 3Department of Radiology, The Cleveland Clinic Children's, Cleveland Clinic, Cleveland, OH, USA and 4Respiratory Therapy, The Cleveland Clinic Children's, Cleveland Clinic, Cleveland, OH, USA. Correspondence: Dr Y Littner, Department of Neonatology, Cleveland Clinic Children’s, The Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA. E-mail: [email protected] Received 19 November 2013; revised 17 February 2014; accepted 24 February 2014; published online 3 April 2014 Nitrogen washout treatment for SP SD Clark et al 529 therapy was stopped when pneumothorax on chest X-ray and/or Demographics and patient characteristics respiratory distress resolved. Groups were similar for gestational age, birth weight, gender, gra- vidity, parity, mode of delivery and Apgar scores. In both groups, the Data collection majority of patients were Caucasians (85% in the nitrogen washout After institutional review board approval was obtained, the history was group and 81% in the conventional therapy group). In addition, rate retrieved from the medical records of all participating patients. The of delivery complications, sepsis risk factors and SNAPPE-II scores following data were collected: demographics, maternal and perinatal were comparable between groups. Spontaneous pneumothorax history, delivery room details, neonatal vital signs (in the first 24 h of life), was more common in males than females (Table 1). clinical indicators of respiratory distress (e.g., tachypnea, grunting and retractions), respiratory support treatment (e.g., delivery method such as Vital signs oxygen hood or nasal cannula, FiO2 and the length of respiratory support), time to first introduction of oral feeding and time to achieve full feeding, Both groups remained hemodynamically stable during their length of intravenous fluid treatment, length of hospitalization, lab results hospitalization. Average heart rate, mean arterial pressure and and radiological findings. Scores for Neonatal Acute Physiology and urine output in the first 24 h of life were similar in both groups. Perinatal Extension II (SNAPPE-II) were determined on the first day of life fi 11 Average pulse pressures were signi cantly higher in the nitrogen for each patient. To evaluate the extent of oxygen exposure, an area washout group (29.3 ± 7.9 vs 25 ± 4.9 mm Hg, P = 0.03) (Table 2). under the curve analysis was performed. This method, quantifies the cumulative oxygen exposure as an integration of oxygen concentration ∑ − 12 over time ( (FiO2 0.21) × time (hours)). Respiratory status, laboratory values and treatment The groups did not differ in either pneumothorax size (small or Primary and secondary endpoints medium) or its location (right, left or bilateral) (Table 2). Pulse The primary endpoints of our study were the length of oxygen therapy and time to resolution of respiratory distress. Secondary endpoints included the time to first introduction of oral feeding, time to achieve full feeding and length of hospitalization. Table 1. Demographic, perinatal characteristics and SNAPPE-II scores in study groups Statistical analysis Conventional therapy Nitrogen washout P The Minitab statistical program (version 13.1) was utilized for statistical (n = 19) (n = 26) analyses (Minitab, State College, PA, USA). Continuous variables were compared using the Student's t-test for normally distributed variables. Gestational age (weeks) 38.9 ± 1.5 39.4 ± 1.5 NS The Mann–Whitney test was used for variables with skewed distribution. Birth weight (grams) 3295 ± 469 3359 ± 509 NS A P-value o0.05 was considered significant. Sex M:F 16:3 21:5 NS Gravidity (range) 2 (1–4) 2 (1–5) NS Parity (range) 1 (1–3) 1 (1–4) NS RESULTS Cesarean section % 32% 56% NS Apgar 1 min (range) 8 (2–9) 8 (4–9) NS We identified 83 neonates with the diagnosis of pneumothorax. A Apgar 5 min (range) 9 (8–9) 9 (7–9) NS total of 45 neonates met inclusion criteria and 38 were excluded. SNAPPE-II 0 (0–12) 0 (0–12) NS Twenty-six neonates received nitrogen washout, whereas 19 fi neonates received supplemental oxygen to maintain a pulse Abbreviations: NS, non signi cant; SNAPPE, Score for Neonatal Acute Physiology and Perinatal Extension II. oximetry range of 92 to 95% (conventional oxygen therapy) All data expressed as mean ± s.d., except Apgar scores, gravidity, parity and (Figure 1). Based on total of 11 412 deliveries during the study SNAPPE-II scores, which are expressed as median (range). period, our occurrence of SP was 0.39%. Figure 1. Flow diagram of included and excluded patients.
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