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All term newborns (gestational age ≥37weeks) admitted to the NICU from birth to 72hours of life with signs of respiratory distress and a diagnosis of spontaneous pneumothorax confirmed by chest X-ray (CXR), were included in the study. Newborns with congenital/chromosomal anomalies, history of meconium stained liquor/meconium aspiration, respiratory distress syndrome, transient tachypnea of newborn, pneumonia, tension pneumothorax requiring thoracocentesis or chest tube drainage, those who received positive pressure ventilation (PPV) or mechanical ventilation (MV) before the diagnosis of spontaneous pneumothorax were excluded.

Based on initial fraction of inspired oxygen concentration used at admission for the treatment of SP, neonates were divided into three groups: high fraction of inspired oxygen (FiO)/nitrogen washout (HO: FiO ≥ 60%), moderate oxygen (MO: FiO < 60%) or room air (RA: FiO = 21%). The decision to treat a patient with room air, high or moderate oxygen concentration was based on individual attending neonatologist preference.

The initial concentration of oxygen used for treatment of spontaneous pneumothorax was the primary exposure variable. Duration of oxygen therapy was calculated from the initiation of oxygen therapy until clinical resolution of pneumothorax or till treatment failure (development of tension pneumothorax within 72hours of diagnosis and treatment of SP). Data on maximum O concentration inspired during the treatment period was based on the highest recorded dose documented in the chart. The method of oxygen delivery at the time of admission was either via oxyhood, or nasal cannula. The concentration of inspired oxygen via oxyhood was analyzed through an oxygen analyzer. The concentration of inspired oxygen through nasal prongs was calculated according to the “STOP- ROP effective FiO conversion table” [ 20 ], a modified equation described by Benaron and Benitz [ 21 ]. The severity of respiratory distress was classified according to the validated “Acute care of at-risk newborn (ACoRN)” respiratory score [ 22 , Adidas Mens Oyster Holdings Samoa Vntg Vintage Suede St Panu Brown PQjbA
,
24 ]. The estimation of pneumothorax size was abstracted from the radiologist report; radiologists were blinded to the treatment group. There was no validated method available to measure the size of pneumothorax on CXR in neonates so an estimation was made according to adult guidelines as mentioned in the British Thoracic Society (BTS) guidelines [ 10 ], and from the neonatal literature [ 8 , Nike Mens Roshe Waffle Racer NM Black/ Chartreuse V9AJR
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,
27 ].

Clinical resolution of pneumothorax was defined as cessation of respiratory distress and discontinuation of oxygen treatment with maintenance of SpO ≥ 95%. Nitrogen washout was defined in our NICU as the use of 60 to 100% of inspired O continuously for at least 6hours.

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