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Objectives: To investigate the impact of a pre-emptive apnoea triggered oxygen response on oxygen saturation (SpO 2 ) targeting following central apnoea in preterm infants., Design: Interventional crossover study of a 12-hour period of automated oxygen control with an apnoea response (AR) module, nested within a crossover study of a 24-hour period of automated oxygen control compared with aggregated data from two flanking 12-hour periods of manual control., Setting: Neonatal intensive care unit PATIENTS: Preterm infants receiving non-invasive respiratory support and supplemental oxygen; median (IQR) birth gestation 27 (26-28) weeks, postnatal age 17 (12-23) days., Intervention: Automated oxygen titration with an automated control algorithm modified to include an AR module. Alterations to inspired oxygen concentration (FiO 2 ) were actuated by a motorised blender. Desired SpO 2 range was 90-94%. Apnoea detection was by capsule pneumography., Main Outcome Measures: Duration, magnitude and area under the curve (AUC) of SpO 2 deviations following apnoea; frequency and duration of apnoeic events. Comparisons between periods of manual, automated and automated control with AR module., Results: In 60 studies in 35 infants, inclusion of the AR module significantly reduced AUC for SpO 2 deviations below baseline compared with both automated and manual control (manual: 87.1%±107.6% s, automated: 84.6%±102.8% s, AR module: 79.4%±102.7% s). However, there was a coincident increase in SpO 2 overshoot (AUC (SpO 2 >SpO 2(onset) ); manual: 44.3±99.9% s, automated: 54.7%±103.4% s, AR module: 65.7%±126.2% s)., Conclusion: Automated control with a pre-emptive apnoea-triggered FiO 2 boost resulted in a modest reduction in post-apnoea hypoxaemia, but was followed by a greater SpO 2 overshoot., Trial Registration Number: ACTRN12616000300471., Competing Interests: Competing interests: The University of Tasmania and Royal Hobart Hospital have jointly lodged a patent application concerning automated control of inspired oxygen concentration in the newborn infant. TJG and PAD are named inventors. The authors have no other conflicts of interest relevant to this article to disclose., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the performance of a rapidly responsive adaptive algorithm (VDL1.1) for automated oxygen control in preterm infants with respiratory insufficiency., Design: Interventional cross-over study of a 24-hour period of automated oxygen control compared with aggregated data from two flanking periods of manual control (12 hours each)., Setting: Neonatal intensive care unit., Participants: Preterm infants receiving non-invasive respiratory support and supplemental oxygen; median birth gestation 27 weeks (IQR 26-28) and postnatal age 17 (12-23) days., Intervention: Automated oxygen titration with the VDL1.1 algorithm, with the incoming SpO 2 signal derived from a standard oximetry probe, and the computed inspired oxygen concentration (FiO 2 ) adjustments actuated by a motorised blender. The desired SpO 2 range was 90%-94%, with bedside clinicians able to make corrective manual FiO 2 adjustments at all times., Main Outcome Measures: Target range (TR) time (SpO 2 90%-94% or 90%-100% if in air), periods of SpO 2 deviation, number of manual FiO 2 adjustments and oxygen requirement were compared between automated and manual control periods., Results: In 60 cross-over studies in 35 infants, automated oxygen titration resulted in greater TR time (manual 58 (51-64)% vs automated 81 (72-85)%, p<0.001), less time at both extremes of oxygenation and considerably fewer prolonged hypoxaemic and hyperoxaemic episodes. The algorithm functioned effectively in every infant. Manual FiO 2 adjustments were infrequent during automated control (0.11 adjustments/hour), and oxygen requirements were similar (manual 28 (25-32)% and automated 26 (24-32)%, p=0.13)., Conclusion: The VDL1.1 algorithm was safe and effective in SpO 2 targeting in preterm infants on non-invasive respiratory support., Trial Registration Number: ACTRN12616000300471., Competing Interests: Competing interests: The University of Tasmania and Tasmanian Health Service have jointly lodged a patent application concerning automated control of inspired oxygen concentration in the newborn infant, and have entered into a licensing agreement with SLE Limited allowing use of the VDL1.1 algorithm (as OxyGenie) in SLE respiratory support devices., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)