Above, photo by Jonathan Hyams, Save the Children, Bangladesh, July 2018: Laila,* holds an oxygen mask to the face of her son Sohai,* two, at Save the Children’s primary healthcare centre (PHCC) in Cox’s Bazar, Bangladesh. Sohai* was admitted to the inpatient ward at the PHCC, suffering from acute pneumonia.
by Kathryn Maitland, Professor of Tropical Paediatric Infectious Diseases at Imperial College, London and KEMRI-Wellcome Trust
Although oxygen is a basic element of hospital care, strongly recommended as a life-saving therapy for children with severe pneumonia and specifically for children with hypoxaemia (oxygen saturations, SpO2 less than 90%), the evidence underpinning these recommendations is weak. Yet, many African hospitals lack the facility to measure oxygen saturations (using pulse oximetry) and thus, therapeutic oxygen is often poorly targeted. Furthermore, despite a high demand, there is often very limited resources of oxygen therapy which is both costly (if using bottled oxygen) and erratic (if using oxygen concentrators) as electricity is unreliable. Although oxygen has been used in supportive treatment for a large part of the last century, the recognition of oxygen toxicity as a problem has been relatively recent. Toxicity is related to the concentration of oxygen and length of exposure. Worldwide, there is an increasing recognition of the harms of oxygen therapy. The evolving literature on its harms has resulted in oxygen no longer being recommended for a number of indications. Thus, there is a justifiable scientific question about whether oxygen can be safely and effectively administered, and results in better outcomes in children with severe pneumonia.
The 2012 World Health Organization recommendations for management indicated that current guidelines were based on very low quality evidence. Key ‘Research Gaps’ identified included large-scale effectiveness trials of improved oxygen systems on outcomes from pneumonia, and clinical studies comparing outcomes when oxygen is given at different thresholds. The Children’s Oxygen Administration Strategies Trial (COAST -ISRCTN15622505) has been designed to address both of these questions simultaneously.
The COAST trial is being conducted in 4,200 children aged between 28 days and 12 years presenting to 4 hospitals in Uganda and Kenya with clinical symptoms of pneumonia complicated by hypoxaemia (defined as SpO2 <92%). The trial aims to establish whether oxygen given to children with SpO2 ≥80% reduces mortality (at 48 hours, the primary endpoint, and up to 28 days, a secondary endpoint) compared with a strategy that includes permissive hypoxaemia. In addition, the trial aims to establish whether use of high flow oxygen delivery by OptiFlowTM (AirVO 2 donated to the trial by Fisher and Paykel) will decrease mortality compared to oxygen by low flow delivery methods (standard care) to all children with hypoxaemia (SpO2 <92%).
We hypothesize that giving an air/oxygen mixture delivered by AirVO 2 will reduce the work of breathing, and ultimately respiratory failure in critically sick children with limited access to mechanical ventilation which occurs in the majority of hospitals in Africa. The trial is collecting information on the costs of each of the interventions which will be of benefit to policy makers as they aim to inform future costs for widespread implementation.
The trial started in February 2017. The trial protocol is available to be downloaded on Wellcome Open (DOI: 10.12688/wellcomeopenres.12747.2).
Sponsor: Imperial College of London
Donation of AirVO 2 and consumables: Fisher & Paykel Healthcare
Funders: Medical Research Council (MRC)
UK Aid Direct
About the author: Kathryn Maitland is a professor of Paediatric Tropical Infectious Diseases at the Faculty of Medicine and Director of the ICCARE Centre at the Global Centre of Health Innovation, Imperial College, London and an Honorary Fellow at MRC Clinical Trials Unit, University College, London. Over the last 18 years, she has been based full-time in East Africa where she leads a research group who have highlighted the unique importance of emergency-care research as a highly targeted and cost-effective means of tackling childhood mortality in resource-limited sub- Saharan African hospitals.