Oxygen therapy can save the lives of children with pneumonia, but careful monitoring is needed to reduce the damage, prevent over-reliance, and protect the supply.
Led by researchers at Imperial College London, the Children’s Oxygen Administration Strategies Trial (COAST) set out to examine the evidence base for oxygen therapy. The team assessed whether the liberal use of oxygen therapy had a measurable impact on infant deaths, as well as comparing the impact of different forms of oxygen delivery on mortality.
The researchers say their findings show that a global approach to providing immediate oxygen therapy may not be appropriate for all groups of patients and that excessive oxygen dependence may drain unnecessarily limited supplies in low-resource hospitals.
“There’s a big gap between what’s recommended and what happens in practice,” explained Professor Kathryn Maitland, professor of Tropical Pediatric Infectious Diseases at Imperial and head of COAST.
“There are still a lot of issues related to who needs oxygen, how to give and when to start and stop. Ultimately, oxygen is expensive, it can be difficult to administer to patients and control it properly, and even all in high concentrations be toxic to cells, so it is important that there is an evidence base for their use.
“We hope this research will stimulate debate and exploration of how we can better care for children with severe pneumonia, particularly in low-resource settings.”
Main cause of mortality
Reduced oxygen supply to the body, called hypoxaemia, is a life-threatening complication of pneumonia and oxygen therapy is recommended in hospitalized children with low NO levels.2 in the blood (usually below 92%). While simple monitors like a dust oximeter can provide reliable NO measurements2 levels are often not available in rural areas, leading to the use of visible clinical signs as an unreliable proxy.2. In hospital settings, this can cause children to receive oxygen when it can provide a limited therapeutic benefit.
“Oxygen is recommended for children with pneumonia, and ideally if you measure NO2 saturation and low, you should give oxygen to these children, ”Professor Maitland explained.
“But many hospitals do not have adequate monitors, so they allocate oxygen according to clinical signs, which is a poor indicator. Therefore, you could administer oxygen to a very large number of hospitalized children and perhaps gain very little, or even no benefit from that. “
The COAST study
As part of the study, an international team of researchers and clinicians, led by Professor Maitland, recruited more than 1,800 children hospitalized with severe pneumonia in Kenya and Uganda, about half of whom had severe hypoxemia.
All children with severe hypoxemia (n = 388), with NO2 levels below 80%, were randomized to receive standard “low flow” oxygen therapy (LFO) through a mask connected to an oxygen vessel or to receive high flow nasal therapy (HFNT), through a breathing tube in the nose delivered by a respiratory specialist.
For those with moderate hypoxemia, approximately half of the children (n = 727) did not receive oxygen immediately, but were carefully monitored, the “permissive hypoxemia” group. If at some point its NO2 levels fell below the 80% threshold and were immediately started with oxygen therapy. The remaining children were randomized to receive LFO or HFNT, for comparison.
After 48 hours, the team found that most children, in all groups with moderate hypoxemia, no longer needed oxygen and only 15% of the permissive hypoxemia group needed oxygen. Despite this, there were few differences in mortality rates, regardless of whether they initially received NO2 therapy immediately or not: 1.1% for HFNT; 2.5% for LFO; and 1.4% for permissive hypoxemia.
In addition, they found that among children receiving oxygen therapy, those receiving HFNT had a 40% lower mortality rate after 48 hours compared to standard LFO, in all groups. The researchers say these findings were inconclusive, but should stimulate further exploration of noninvasive respiratory support for children with severe pneumonia in hospitals where there is no access to ventilators (invasive mechanical respiratory support).
Following the recommendation of the Independent Process Steering Committee that it was not feasible for the trial to continue until its conclusion (due to multiple interruptions that led to the stoppage and resumption of the study), the trial ended on February 2020 *.
The researchers point out that although the trial was soon completed, it is shown that an “watch and wait” approach to active surveillance may be most appropriate for patients for whom oxygen may provide a limited benefit, preserving limited supplies for those patients who can benefit the most. They emphasize that more research is needed to clarify patient care pathways in hospital settings with limited resources.
“In those with a moderate reduction in oxygen levels, we found that there was no detrimental effect in not receiving oxygen immediately,” Professor Maitland explained.
“Although the trial ended soon, we can say that concerns were raised about the delay oxygen therapy for children at lower risk at trial were not performed. This study challenges the current thinking that oxygen is considered absolutely critical to keeping people alive.
“What we have shown in this trial is that, under certain circumstances, it is not provided oxygen mortality probably did not increase immediately, and more research should be conducted on how best to manage care in resource-limited environments.
“We have also shown that it is possible to provide HFNL-assisted respiratory support in pediatric wards in Africa with a strong possibility that this could reduce deaths from severe pneumonia.”
The Child Oxygen Management Strategy Test (COAST) began in February 2017. It was designed to help children with pneumonia receive the best possible treatment and have the best chances of survival. Pneumonia is one of the leading causes of death in young children in Africa.
Following the recommendation of the independent trial steering committee that it was not feasible for the trial to continue until its conclusion, the trial ended in February 2020.
The process had been halted and restarted several times in Uganda as a result of a campaign that called into question the security of the trial, and this disruption made it difficult for the process team to continue its work.
An independent test was periodically reviewed by an independent data control and security board, which conducted four detailed reviews, which found that there were no security issues and recommended that the test be continued.
The mortality rate of children enrolled in the trial, as analyzed by the Data Control and Safety Board, was significantly lower than expected in children receiving hospital treatment for pneumonia in Africa.
The trial had also been conducted through a rigorous scientific and ethical review, which obtained the necessary ethical approvals from three major ethics committees in the UK, Uganda and Kenya.
Randomized controlled trial of oxygen therapy and high-flow nasal therapy in African children with pneumonia, Intensive Care Medicine (2021). DOI: 10.1007 / s00134-021-06385-3
Mark J. Peters et al, A COASTal Vision: Where Previous Beliefs and Uncertainty Clash, Intensive Care Medicine (2021). DOI: 10.1007 / s00134-021-06406-1
Imperial College London
Citation: The study highlights the need to control oxygen therapy in children with pneumonia (2021, June 10) recovered on June 10, 2021 at https://medicalxpress.com/news/2021-06-highlights-oxygen -therapy-children-pneumonia.html
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