The children's oxygen administration strategies trial

Document Type



Paediatrics and Child Health (East Africa)


Background: The life-saving role of oxygen therapy in children with clinically-defined severe pneumonia is not yet established. We hypothesised liberal oxygenation strategies and/or respiratory support may improve the high in-hospital mortality.

Methods: The open-label fractional-factorial COAST trial in Ugandan and Kenyan children aged >28 days with feature of severe pneumonia. In stratum A (severe hypoxaemia: SpO2 <80%) children were randomised to high flow nasal therapy (HFNT: OptiFlow™) or low flow oxygen (LFO: standard care). In stratum B (hypoxaemia: SpO2 80-91%) children were randomised to HFNT or LFO (liberal strategies) or control (no immediate oxygen) (ratio 1:1:2). Children with cyanotic heart disease, chronic lung disease or >3hours receipt of oxygen were excluded. The primary endpoint was 48-hour mortality; secondary endpoints included mortality or neurocognitive sequelae at 28 days.

Findings: The Trial Steering Committee recommended halting recruitment for feasibility after 1842/4200 (44%) children enrolled. Of 1852 recruited, 388 in stratum A (median 7 months; median age SpO2 75%) were randomised to HFNT (n=194) or LFO (n=194) and 1454 in stratum B (median 9 months; median SpO2 88%) were randomised to HFNT (n=363) vs LFO (n=364) vs control (n=727). Per-protocol 109/726(15%) of controls received oxygen (when SpO2 <80%). In stratum A, 48-hour mortality was 9.3% (18/388) for HFNT vs. 13.4% (26/194) for LFO groups. In stratum B 48-mortality was 1.1% (4/363) for HFNT vs. 2.5% (9/364) LFO and 1.4% (10/727) for controls. In stratum B, adjusted (a)odds ratio (aOR) for 48-hour mortality in liberal vs permissive comparison was 1.16 (0.49-2.74;p=0.73); HFNT vs LFO comparison was 0.60 (0.33-1.06;p=0.08). Respective strata-specific 28-day mortality rates were: 18.6%(HFNT) versus 23.4%(LFO) and 3.3%(HFNT) versus 4.1%(LFO) versus 3.9%(control). Neurocognitive sequelae, assessed using Kilifi Neurodevelopmental Index, were rare in all groups.

Interpretation: Conservative oxygen strategies appear safe and respiratory support with HFNT showing potential benefit should prompt further trials.


This work was published before the author joined Aga Khan University.

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