Effects of Closed-loop Automatic Control of FiO2 in Extremely Preterm Infants

Infant,Premature Clinical Trial

— FiO2-C  

Official title:

Effects of Closed-loop Automatic Control of the Inspiratory Fraction of Oxygen (FiO2-C) on Outcome of Extremely Preterm Infants - a Randomized Controlled Parallel Group Multicenter Trial for Safety and Efficacy

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT03168516
• Other study ID #: FiO2-C
• Secondary ID: 2018-000453-41BM
• Status: Active, not recruiting
• Phase: Phase 3
• Start date: July 27, 2018
• Est. completion date: December 2026

Study information

• Verified date: July 2023
• Source: University Hospital Tuebingen
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Extremely low gestational age neonates (ELGANs), i.e. those born at <28 weeks, frequently experience intermittent hypoxemic/hyperoxemic episodes. Observational data indicate that severe and prolonged hypoxemic episodes are associated with retinopathy of prematurity (ROP), impaired long-term development and death. Closed-loop automated control of the inspiratory fraction of oxygen (FiO2-C) reduces time outside the oxygen target range, decreases number and duration of hypo- and hyperoxemic episodes, and reduces caregivers' workload. The proposed observer-blinded randomized controlled trial was designed and will be powered to compare the effect of FiO2-C in addition to manual adjustments, in comparison with manual adjustments of FiO2 only, on death and severe complications of prematurity thought to be related to hypoxia/hyperoxia and neurodevelopmental impairment in ELGANs. The results of this trial may help to improve the quality of life of ELGANs and reduce the burden of significant morbidity as well as costs for health care and society

Description:

Approximately 0.5% of all neonates (i.e., about 25,000 infants per year in Europe) are extremely low gestational age neonates (ELGANs), i.e. have a gestational age (GA) of <28 completed weeks at birth. ELGANs have higher incidences of mortality, retinopathy of prematurity (ROP), chronic lung disease and other risks of prematurity as well as severe neurodevelopmental impairment.

The vast majority of ELGANs require supplemental oxygen in addition to mechanical respiratory support (including CPAP). Irrespective of the SpO2 target, the vast majority of ELGANs suffers from recurrent intermittent hypoxemic and (as a consequence of inappropriate adjustments of FiO2) hyperoxemic episodes. Recurrent intermittent hypoxic episodes - i.e. wide fluctuations in oxygen levels - are associated with an increased risk of ROP and there are data that suggest that late deaths and neurodevelopmental impairment are also linked to them.

Continuous positive airway pressure (CPAP) has been shown to reduce extubation failure in preterm infants, which may in part be due to a reduced frequency and severity of apnea of prematurity and stabilized functional residual capacity during apnea. Keeping oxygen levels (i.e., SpO2) stable despite irregular breathing patterns in ELGANs, requires frequent adjustments of the FiO2 which is both challenging, time consuming, and often impossible due to limited personnel resources.

FiO2-Controllers have been developed by several manufacturers of infant ventilators. They reduce the burden of hyper-/hypoxemia in infants while being safe and accurate in very short-term studies. The effects of FiO2-C on clinically relevant outcome measures and the safety of long-term continuous application, however, have yet to be elucidated. Hence there is now a window of opportunity to assess this new technology for benefits and harms, before it is implemented into neonatal care without appropriate evaluation of its safety and efficacy.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 1065
• Est. completion date: December 2026
• Est. primary completion date: December 2026
• Accepts healthy volunteers: No
• Gender: All
• Age group: N/A to 48 Hours

Eligibility

Inclusion Criteria:

• Preterm infants with a gestational age (GA) at birth of 23+0/7 - 27+6/7 weeks

Exclusion Criteria:

• Decision for palliative care

• congenital anomalies

• postnatal age > 48h

• missing parental consent

• lack of device enabling closed-loop automatic control of FiO2

Related Conditions & MeSH terms

• Infant,Premature
• Premature Birth

Intervention

Device:
• closed-loop automatic control of the inspiratory fraction of oxygen (FiO2-C)
Application of FiO2-C (provided by standard infant ventilators) in addition to manual adjustments of the inspired oxygen fraction (FiO2) during mechanical ventilation and continuous positive airway pressure (CPAP) in ELGANs at least up to 32weeks PMA according to a standardized protocol

Locations

Country	Name	City	State
China	Northwest Women's and Children's Hospital	Xi'an
Germany	Klinikum St. Marien - Klinik für Kinder und Jugendliche	Amberg
Germany	Josefinum - Klinik für Kinder und Jugendliche	Augsburg
Germany	Diakonie Krankenhaus der Kreuznacher Diakonie	Bad Kreuznach
Germany	Klinikum Links der Weser	Bremen
Germany	Universitätsklinikum Dresden	Dresden
Germany	Universitätsklinikum Düsseldorf	Düsseldorf
Germany	HELIOS Klinikum Erfurt	Erfurt
Germany	Klinikum Esslingen GmbH - Klinik für Kinder und Jugendliche	Esslingen
Germany	Zentrum für Kinder- und Jugendmedizin	Freiburg
Germany	Medizinische Hochschule Hannover	Hannover
Germany	Universitätsklinikum Heidelberg	Heidelberg
Germany	Städtisches Klinikum Karlsruhe	Karlsruhe
Germany	University Hospital Leipzig	Leipzig
Germany	München Klinik Harlaching	München
Germany	Städtisches Klinikum - Klinik für Neonatologie	München
Germany	Universitätsklinikum München	München - Großhadern
Germany	Klinik für Kinder- und Jugendmedizin	Münster
Germany	Klinik Hallerwiese - Cnopf'sche Kinderklinik	Nürnberg
Germany	Krankenhaus Barmherzige Brüder	Regensburg
Germany	Klinikum am Steinenberg	Reutlingen
Germany	Leopoldina Krankenhaus der Stadt Schweinfurt GmbH	Schweinfurt
Germany	Diakonissen-Stiftungs-Krankenhaus Speyer	Speyer
Germany	Klinikum Stuttgart, Olgahospital	Stuttgart
Germany	University Hospital Tübingen	Tübingen
Germany	Universitätsklinikum Ulm	Ulm
Germany	Schwarzwald-Baar-Klinik	Villingen-Schwenningen
Germany	Rems-Murr-Kliniken gGmbH	Winnenden
Netherlands	Kindergeneeskunde Maastricht Universitair Medisch Centrum	Maastricht
Netherlands	Máxima Medical Center	Veldhoven
Netherlands	Isala Kliniek Zwolle - Location Sophia	Zwolle
United Kingdom	The James Cook University Hospital	Middlesbrough

Sponsors (1)

Lead Sponsor	Collaborator
University Hospital Tuebingen

Countries where clinical trial is conducted

China,  Germany,  Netherlands,  United Kingdom, 

References & Publications (1)

Maiwald CA, Niemarkt HJ, Poets CF, Urschitz MS, Konig J, Hummler H, Bassler D, Engel C, Franz AR; FiO2-C Study Group. Effects of closed-loop automatic control of the inspiratory fraction of oxygen (FiO2-C) on outcome of extremely preterm infants - study protocol of a randomized controlled parallel group multicenter trial for safety and efficacy. BMC Pediatr. 2019 Oct 21;19(1):363. doi: 10.1186/s12887-019-1735-9. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Primary outcome I: composite outcome of death, severe retinopathy of prematurity (ROP), chronic lung disease of prematurity (BPD), necrotizing enterocolitis (NEC)	The primary outcome I is a composite of any of the following: Death; Severe retinopathy of prematurity (severe ROP, as defined in 7.3.1); Chronic lung disease of prematurity (BPD, according to the physiological definition, which is described in detail in the study protocol); Necrotizing enterocolitis (NEC, as defined in the study protocol) until discharge from hospital; The primary endpoint I will be analysed between the two intervention groups using a stratified chi2-test and Cochrane Mantel-Haenszel statistics will be presented (risk ratios and 95%-confidence intervals). The factors considered for randomization (center, sex and gestational age at birth (<26 weeks and =26 weeks) will also be used for analysis.	until/at post-menstrual age (PMA) 36 weeks (death, BPD and NEC) and at latest at PMA 44 weeks for severity of ROP
Primary	Primary outcome II: composite of death or neurodevelopmental impairment (NDI)	The primary outcome II is a composite of any of the following: • death or neurodevelopmental impairment (defined as at least one of the following components: motor disability (GMFCS 2-5), language or cognitive delay (language composite score < 85 or cognitive composite score < 85 on Bayley Scales of Infant Development, 3rd edition) or severe visual or hearing impairment (need for a hearing aid or cochlear implant)). In case of missing Bayley III test results, Bayley II results, other developmental test results or PARCA-R parent questionnaire results may substitute for the Bayley III test results in a hierarchical manner described in the study protocol.; The primary outcome II will be analysed between the two intervention groups using chi2-test and Cochrane Mantel-Haenszel statistics will be presented (risk ratios and 95%-confidence intervals). The factors considered for randomization (center, sex and gestational age at birth (<26 weeks and =26 weeks) will also be used for analysis.	at 24 months of age corrected for prematurity
Secondary	Death	Death rates will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	24 months of age corrected for prematurity
Secondary	ROP Severity Score	The most severe grade of ROP according to 25 categories currently developed by the working group of the international neonatal consortium (may have to be adapted as the consensus process proceeds), documented in either eye (for at least 2 consecutive examinations) will be analysed using Wilcoxon-Mann-Whitney test.	at latest at PMA 44 weeks
Secondary	Severe ROP	defined as: ROP stage 0, 1 or 2 (in Zone 2 or 3) = no/non-severe ROP versus 3, 4 or 5, or AP-ROP, or any ROP in Zone 1, or any treatment for ROP = severe ROP.; Rates of severe ROP will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	at latest at PMA 44 weeks
Secondary	bronchopulmonary Dysplasia (BPD)	As part of routine care, the presence of BPD will be determined at 36 weeks postmenstrual age (PMA) according to the physiological definition of Walsh et al. [Walsh, J Perinatol 2003].; BPD rates will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	until 36 weeks PMA
Secondary	Necrotizing enterocolitis (NEC)	NEC (modified Bell stage = IIA according to [Bell, Ann Surg 1978]) or intestinal perforation will be diagnosed at surgery, at autopsy, or by either the finding of pneumatosis intestinalis, hepatobiliary gas, or free intraperitoneal air on abdominal x-ray, or by demonstration of gas (bubbles) in the portal vein on abdominal ultrasound or abdominal x-ray.; NEC rates will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	until 36 weeks PMA
Secondary	Neurodevelopmental impairment (NDI)	NDI is defined as at least one of the following components: motor disability (modified GMFCS 2-5), language or cognitive delay (language composite score < 85 or cognitive composite score < 85 on Bayley Scales of Infant Development, 3rd edition) or severe visual or hearing impairment (need for a hearing aid or cochlear implant).; In case of missing Bayley III test results, Bayley II results, other developmental test results or PARCA-R parent questionnaire results may substitute for the Bayley III test results in a hierarchical manner described in the study protocol.; NDI rates will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity
Secondary	Bayley III. Language composite score - dichotomized	The results of the language composite score of the Bayley Scales of Infant Development, 3rd edition, will be dichotomized by <85 (abnormal) versus >=85 (normal) and compared between the two treatment groups by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity
Secondary	Bayley III: Language composite score - numerical	The raw numerical data of the language-composite-score will be analysed using Wilcoxon-Mann-Whitney test. The use of this test accounts for the fact that data will be cut due to lack sensitivity below 50 points.	at 24 months corrected age
Secondary	Bayley III: Cognitive composite score - dichotomized	The results of the cognitive composite score of the Bayley Scales of Infant Development, 3rd edition, will be dichotomized by <85 (abnormal) versus >=85 (normal) and compared between the two treatment groups by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity
Secondary	Bayley III: Cognitive composite score - numerical	The numerical data of the cognitive-composite-score will be analysed using Wilcoxon-Mann-Whitney test. The use of this test accounts for the fact that data will be cut due to lack sensitivity below 50 points.	at 24 months of age corrected for prematurity
Secondary	Cerebral palsy	Cerebral palsy will be diagnosed if the child has a non-progressive motor impairment characterized by abnormal muscle tone and impaired range or control of movements, according to the criteria defined by the European network 'Surveillance of CP in Europe'.; Rates of cerebral palsy will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity
Secondary	Motor disability	Motor disability is defined as a modified GMFCS 2-5 versus a modified GMFCS 0-1, which is regarded as being normal. Rates of motor disability will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity
Secondary	Score data of modified Gross Motor Function Classification Scale (GMFCS)	GMFCS-Score for quantification of the effects of cerebral palsy and other motor impairments (adapted from Palisano et al. [Palisano Med Child Neurol 1997]) using the FiO2-C-GMFCS-score sheet (separate document not part of this protocol) will be analysed. GMFCS-score consists of six categories. Analysis will be done by using Wilcoxon-Mann-Whitney test.	at 24 months of age corrected for prematurity
Secondary	Bayley III: Motor composite score - numerical	The numerical data of the motor-composite-score will be analysed using Wilcoxon-Mann-Whitney test. The use of this test accounts for the fact that data will be cut due to lack of sensitivity below 50 points.	at 24 months of age corrected for prematurity
Secondary	Severe visual impairment	Severe visual impairment is defined as an ophthalmological assesment indicating "severe visual impairment", e.g. the best corrected vision in the better eye yields a visual acuity less than 6/60 m (20/200 ft).; Rates will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity
Secondary	Severe hearing impairment	Severe hearing impairment is defined as need for a hearing aid or cochlear implant. Rates will be compared between the two treatment groups and analyzed by Cochrane-Mantel-Haenszel- X²-Test.	at 24 months of age corrected for prematurity

External Links

•   study homepage