narrow ranges are difficult to maintain for more than 50-60% of the time.13,[1] To date, the “perfect” SpO2 target range is still not known for all newborns at all times.20,[2]
 
In summary, in extremely low birth weight infants the ideal oxygen saturation range or intention to treat remains unknown and is a compromise among negative outcomes associated with either hyperoxemia (ROP, BPD) or hypoxemia (NEC, death). The appropriate SpO2 range for an individual infant will depend on the type of SpO2 monitor used, gestational age, postnatal age, hemoglobin A concentration, hemoglobin level, oxygen content, cardiac output, clinical diagnosis and illness severity.[3] Despite this variability, it is clear that in order to improve clinical outcomes, some clinical practices must be eradicated and replaced with guidelines of clinical care aimed at avoiding both hyperoxia and hypoxia.
 
Alarms:
●      Alarms should always be operative (do not disconnect or deactivate alarms).
●      Alarm limits are used to avoid harmful extremes of hyperoxemia or hypoxemia.
●      Busy NICU nurses respond much better to SpO2 alarms rather than to “mental SpO2 target ranges or intention to treat”.
●      Given the limitations of SpO2 and the uncertainty regarding the ideal SpO2 intention to treat for infants of extremely low birth weight, wider alarm limits are easier to target.
The lower alarm limit generally needs to extend somewhat below the lower SpO2 chosen as the intention to treat. It must take into account practical and clinical considerations, as well as the steepness of the oxygen saturation curve at lower saturations. It is suggested that the low alarm for extremely low birth weight infants be set no lower than 85% ( 86-87% may also be appropriate)
The upper alarm limit should not be higher than 95% for extremely low birth weight infants while the infant remains on supplemental oxygen.
●      ROP and other morbidities can be exacerbated by hyperoxemia. For example, at 5 years of age, motor impairment, cognitive impairment and severe hearing loss are 3 to 4 times more common in children with than without severe ROP.
 
Based on these considerations, there is a need to introduce clinical measures at all institutions caring for newborn infants to close the gap between knowledge and practice. The lack of a systematic approach to prevent hypoxia and hyperoxia significantly affects patient safety, quality, and cost of care. Closing the performance gap will require hospitals, healthcare systems and all members of the neonatal health care team (RN’s, RT’s and MD’s) to commit to action in the form of specific leadership, practice, and technology plans to improve safety for newborn infants who require oxygen supplementation.
[1] Di Fiore, J. M. (2014). The Effect of Monitor Design and Implementation on Patient Management. The Journal of Pediatrics, 165(4), 657-658.
[2] Saugstad, O. D. (2010). Why are we still using oxygen to resuscitate term infants & quest. Journal of Perinatology, 30, S46-S50.
[3] Castillo, A., Deulofeut, R., Critz, A., & Sola, A. (2011). Prevention of retinopathy of prematurity in preterm infants through changes in clinical practice and SpO2 technology. Acta Paediatrica, 100(2), 188-192.