51
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Segar JL. Rethinking furosemide use for infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2020; 55:1100-1103. [PMID: 32176837 DOI: 10.1002/ppul.24722] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/01/2020] [Indexed: 12/27/2022]
Abstract
Diuretics are commonly administered to infants with bronchopulmonary dysplasia (BPD) to improve respiratory function despite the absence of prospective data demonstrating long term benefits. While many potentially adverse effects of furosemide are known to clinicians, its direct and indirect impact on multiple pathophysiological processes need to be understood. While furosemide likely has a role in the management of infants with BPD, clinicians are encouraged to recognize these potential complications associated with furosemide administration. Specifically, a deeper understanding of the impact of diuretics on sodium metabolism neurohumoral regulation of cardiopulmonary physiology is required.
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Affiliation(s)
- Jeffrey L Segar
- Division of Neonatology, Departments of Pediatrics and Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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52
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Lakshminrusimha S, Kinsella JP, Krishnan US, Van Meurs K, Edwards EM, Bhatt DR, Chandrasekharan P, Oei JL, Manja V, Ramanathan R, Abman SH. Just Say No to iNO in Preterms-Really? J Pediatr 2020; 218:243-252. [PMID: 31810629 DOI: 10.1016/j.jpeds.2019.10.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/08/2019] [Accepted: 10/24/2019] [Indexed: 12/28/2022]
Affiliation(s)
| | - John P Kinsella
- Department of Pediatrics, University of Colorado, Aurora, CO
| | | | - Krisa Van Meurs
- Department of Pediatrics, Stanford University, Palo Alto, CA
| | | | | | | | - Ju-Lee Oei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Veena Manja
- Department of Pediatrics, University of California at Davis, Sacramento, CA
| | - Rangasamy Ramanathan
- Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado, Aurora, CO
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53
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Levy PT, Jain A, Nawaytou H, Teitel D, Keller R, Fineman J, Steinhorn R, Abman SH, McNamara PJ. Risk Assessment and Monitoring of Chronic Pulmonary Hypertension in Premature Infants. J Pediatr 2020; 217:199-209.e4. [PMID: 31735418 DOI: 10.1016/j.jpeds.2019.10.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/28/2019] [Accepted: 10/11/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Amish Jain
- Department of Pediatrics, University of Toronto and Department of Pediatrics and Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hythem Nawaytou
- Division of Cardiology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - David Teitel
- Division of Cardiology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Roberta Keller
- Cardiovascular Research Institute and the Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Jeffery Fineman
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Robin Steinhorn
- Department of Pediatrics, Children's National Health System, Washington, DC
| | - Steven H Abman
- Pediatric Heart Lung Center, Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA
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54
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Arjaans S, Wagner BD, Mourani PM, Mandell EW, Poindexter BB, Berger RMF, Abman SH. Early angiogenic proteins associated with high risk for bronchopulmonary dysplasia and pulmonary hypertension in preterm infants. Am J Physiol Lung Cell Mol Physiol 2020; 318:L644-L654. [PMID: 31967847 DOI: 10.1152/ajplung.00131.2019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Early pulmonary vascular disease in preterm infants is associated with the subsequent development of bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH); however, mechanisms that contribute to or identify infants with increased susceptibility for BPD and/or PH are incompletely understood. Therefore, we tested if changes in circulating angiogenic peptides during the first week of life are associated with the later development of BPD and/or PH. We further sought to determine alternate peptides and related signaling pathways with the risk for BPD or PH. We prospectively enrolled infants with gestational age <34 wk and collected blood samples during their first week of life. BPD and PH were assessed at 36 wk postmenstrual age. Samples were assayed for each of the 1,121 peptides included in the SOMAscan scan technology, with subsequent pathway analysis. Of 102 infants in the study, 82 had BPD, and 13 had PH. Multiple angiogenic proteins (PF-4, VEGF121, ANG-1, bone morphogenetic protein 10 [BMP10], hepatocyte growth factor (HGF), ANG-2) were associated with the subsequent diagnosis of BPD; and FGF-19, PF-4, connective tissue activating peptide (CTAP)-III, and PDGF-AA levels were associated with BPD severity. Early increases in BMP10 was strongly associated with the late risk for BPD and PH. We found that early alterations of circulating angiogenic peptides and others were associated with the subsequent development of BPD. We further identified peptides that were associated with BPD severity and BPD-associated PH, including BMP10. We speculate that proteomic biomarkers during the first week of life may identify infants at risk for BPD and/or PH to enhance care and research.
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Affiliation(s)
- Sanne Arjaans
- Department of Paediatric Cardiology, Centre for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Brandie D Wagner
- Pediatric Heart Lung Center, Pediatrics, University of Colorado Denver, Aurora, Colorado.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado
| | - Peter M Mourani
- Pediatric Heart Lung Center, Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Erica W Mandell
- Pediatric Heart Lung Center, Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Brenda B Poindexter
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rolf M F Berger
- Department of Paediatric Cardiology, Centre for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Steven H Abman
- Pediatric Heart Lung Center, Pediatrics, University of Colorado Denver, Aurora, Colorado
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55
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Mourani PM, Mandell EW, Meier M, Younoszai A, Brinton JT, Wagner BD, Arjaans S, Poindexter BB, Abman SH. Early Pulmonary Vascular Disease in Preterm Infants Is Associated with Late Respiratory Outcomes in Childhood. Am J Respir Crit Care Med 2020; 199:1020-1027. [PMID: 30303395 DOI: 10.1164/rccm.201803-0428oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Early pulmonary vascular disease (PVD) after preterm birth is associated with a high risk for developing bronchopulmonary dysplasia (BPD), but its relationship with late respiratory outcomes during early childhood remains uncertain. OBJECTIVES To determine whether PVD at 7 days after preterm birth is associated with late respiratory disease (LRD) during early childhood. METHODS This was a prospective study of preterm infants born before 34 weeks postmenstrual age (PMA). Echocardiograms were performed at 7 days and 36 weeks PMA. Prenatal and early postnatal factors and postdischarge follow-up survey data obtained at 6, 12, 18, and 24 months of age were analyzed in logistic regression models to identify early risk factors for LRD, defined as a physician diagnosis of asthma, reactive airways disease, BPD exacerbation, bronchiolitis, or pneumonia, or a respiratory-related hospitalization during follow-up. MEASUREMENTS AND MAIN RESULTS Of the 221 subjects (median, 27 wk PMA; interquartile range, 25-28 and 920 g; interquartile range, 770-1090 g) completing follow-up, 61% met LRD criteria. Gestational diabetes and both mechanical ventilator support and PVD at 7 days were associated with LRD. The combination of PVD and mechanical ventilator support at 7 days was among the strongest prognosticators of LRD (odds ratio, 8.1; confidence interval, 3.1-21.9; P < 0.001). Modeled prenatal and early postnatal factors accurately informed LRD (area under the curve, 0.764). Adding BPD status at 36 weeks PMA to the model did not change the accuracy (area under the curve, 0.771). CONCLUSIONS Early echocardiographic evidence of PVD after preterm birth in combination with other perinatal factors is a strong risk factor for LRD, suggesting that early PVD may contribute to the pathobiology of BPD.
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Affiliation(s)
- Peter M Mourani
- 1 The Pediatric Heart Lung Center, Department of Pediatrics.,2 Section of Critical Care
| | - Erica W Mandell
- 1 The Pediatric Heart Lung Center, Department of Pediatrics.,3 Section of Neonatology
| | - Maxene Meier
- 4 Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado
| | | | - John T Brinton
- 6 Section of Pulmonary Medicine, Children's Hospital Colorado and the University of Colorado Anschutz Medical Center, Aurora, Colorado.,4 Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado
| | - Brandie D Wagner
- 1 The Pediatric Heart Lung Center, Department of Pediatrics.,4 Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado
| | - Sanne Arjaans
- 7 University Medical Center Groningen and University of Groningen, Groningen, the Netherlands; and
| | - Brenda B Poindexter
- 8 Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Steven H Abman
- 1 The Pediatric Heart Lung Center, Department of Pediatrics.,6 Section of Pulmonary Medicine, Children's Hospital Colorado and the University of Colorado Anschutz Medical Center, Aurora, Colorado
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56
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Vyas-Read S, Wymore EM, Zaniletti I, Murthy K, Padula MA, Truog WE, Engle WA, Savani RC, Yallapragada S, Logan JW, Zhang H, Hysinger EB, Grover TR, Natarajan G, Nelin LD, Porta NFM, Potoka KP, DiGeronimo R, Lagatta JM. Utility of echocardiography in predicting mortality in infants with severe bronchopulmonary dysplasia. J Perinatol 2020; 40:149-156. [PMID: 31570799 PMCID: PMC7222140 DOI: 10.1038/s41372-019-0508-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the relationship between interventricular septal position (SP) and right ventricular systolic pressure (RVSP) and mortality in infants with severe BPD (sBPD). STUDY DESIGN Infants with sBPD in the Children's Hospitals Neonatal Database who had echocardiograms 34-44 weeks' postmenstrual age (PMA) were included. SP and RVSP were categorized normal, abnormal (flattened/bowed SP or RVSP > 40 mmHg) or missing. RESULTS Of 1157 infants, 115 infants (10%) died. Abnormal SP or RVSP increased mortality (SP 19% vs. 8% normal/missing, RVSP 20% vs. 9% normal/missing, both p < 0.01) in unadjusted and multivariable models, adjusted for significant covariates (SP OR 1.9, 95% CI 1.2-3.0; RVSP OR 2.2, 95% CI 1.1-4.7). Abnormal parameters had high specificity (SP 82%; RVSP 94%), and negative predictive value (SP 94%, NPV 91%) for mortality. CONCLUSIONS Abnormal SP or RVSP is independently associated with mortality in sBPD infants. Negative predictive values distinguish infants most likely to survive.
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Affiliation(s)
- Shilpa Vyas-Read
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
| | - Erica M Wymore
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Karna Murthy
- Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael A Padula
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - William E Truog
- Children's Mercy Hospital, University of Missouri, Kansas City, MO, USA
| | - William A Engle
- Riley Hospital for Children, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rashmin C Savani
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - J Wells Logan
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Huayan Zhang
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Erik B Hysinger
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Cincinnati, OH, USA
| | - Theresa R Grover
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Girija Natarajan
- Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Leif D Nelin
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Nicolas F M Porta
- Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karin P Potoka
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joanne M Lagatta
- Children's Hospital of Wisconsin, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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57
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Sheth S, Goto L, Bhandari V, Abraham B, Mowes A. Factors associated with development of early and late pulmonary hypertension in preterm infants with bronchopulmonary dysplasia. J Perinatol 2020; 40:138-148. [PMID: 31723236 PMCID: PMC7223406 DOI: 10.1038/s41372-019-0549-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/06/2019] [Accepted: 10/28/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate factors associated with development of early and late pulmonary hypertension (E/LPH) in preterm infants with bronchopulmonary dysplasia (BPD). STUDY DESIGN A retrospective case-control observational study of preterm infants with BPD admitted to a level IV referral neonatal intensive care unit over 5 years. We compared pre- and postnatal characteristics between infants with or without BPD-associated EPH and LPH. RESULTS Fifty-nine out of 220 infants (26.8%) had LPH, while 85 out of 193 neonates (44%) had EPH. On multiple logistic regression, novel factors associated with development of BPD-LPH included presence of maternal diabetes, EPH, tracheostomy, tracheitis, intraventricular hemorrhage (IVH, grade ≥3) and systemic steroid use. For EPH, these were maternal diabetes, IVH grade ≥3, high frequency ventilator use, and absence of maternal antibiotics use. CONCLUSION We identified novel factors and confirmed previously established factors with development of LPH and EPH, which can help develop a screening strategy in BPD patients.
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Affiliation(s)
- Sudip Sheth
- Department of Neonatal-Perinatal Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Lisa Goto
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Vineet Bhandari
- Department of Neonatal-Perinatal Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Boban Abraham
- Drexel University College of Medicine, Philadelphia, PA, USA
- Department of Pediatric Cardiology, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Anja Mowes
- Department of Neonatal-Perinatal Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA.
- Drexel University College of Medicine, Philadelphia, PA, USA.
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58
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Critser PJ, Higano NS, Tkach JA, Olson ES, Spielberg DR, Kingma PS, Fleck RJ, Lang SM, Moore RA, Taylor MD, Woods JC. Cardiac Magnetic Resonance Imaging Evaluation of Neonatal Bronchopulmonary Dysplasia-associated Pulmonary Hypertension. Am J Respir Crit Care Med 2020; 201:73-82. [PMID: 31539272 PMCID: PMC6938152 DOI: 10.1164/rccm.201904-0826oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/19/2019] [Indexed: 12/25/2022] Open
Abstract
Rationale: Patients with bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension (PH) have increased morbidity and mortality. Noninvasive assessment relies on echocardiograms (echos), which are technically challenging in this population. Improved assessment could augment decisions regarding PH therapies.Objectives: We hypothesized that neonatal cardiac magnetic resonance imaging (MRI) will correlate with BPD severity and predict short-term clinical outcomes, including need for PH therapies for infants with BPD.Methods: A total of 52 infants (31 severe BPD, 9 moderate BPD, and 12 with either mild or no BPD) were imaged between 39 and 47 weeks postmenstrual age on a neonatal-sized, neonatal ICU-sited 1.5-T magnetic resonance (MR) scanner. MR left ventricular eccentricity index (EI), main pulmonary artery-to-aorta (PA/AO) diameter ratio, and pulmonary arterial blood flow were determined. Echos obtained for clinical indications were reviewed. MRI and echo indices were compared with BPD severity and clinical outcomes, including length of stay (LOS), duration of respiratory support, respiratory support at discharge, and PH therapy.Measurements and Main Results: PA/AO ratio increased with BPD severity. Increased PA/AO ratio, MR-EI, and echo-EIs were associated with increased LOS and duration of respiratory support. No correlation was seen between pulmonary arterial blood flow and BPD outcomes. Controlling for gestational age, birth weight, and BPD severity, MR-EI was associated with LOS and duration of respiratory support. Increased PA/AO ratio and MR-EI were associated with PH therapy during hospitalization and at discharge.Conclusions: MRI can provide important image-based measures of cardiac morphology that relate to disease severity and clinical outcomes in neonates with BPD.
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Affiliation(s)
| | - Nara S. Higano
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine
| | | | - Emilia S. Olson
- Center for Pulmonary Imaging Research
- Department of Radiology, and
| | - David R. Spielberg
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Pulmonary Medicine Service, Texas Children’s Hospital, Houston, Texas; and
| | - Paul S. Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert J. Fleck
- Department of Radiology, and
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sean M. Lang
- Division of Cardiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ryan A. Moore
- Division of Cardiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael D. Taylor
- Division of Cardiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jason C. Woods
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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59
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Dai Y, Yu B, Ai D, Yuan L, Wang X, Huo R, Fu X, Chen S, Chen C. Mitochondrial Fission-Mediated Lung Development in Newborn Rats With Hyperoxia-Induced Bronchopulmonary Dysplasia With Pulmonary Hypertension. Front Pediatr 2020; 8:619853. [PMID: 33634054 PMCID: PMC7902063 DOI: 10.3389/fped.2020.619853] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/29/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Bronchopulmonary dysplasia (BPD) is the most common chronic respiratory disease in premature infants. Oxygen inhalation and mechanical ventilation are common treatments, which can cause hyperoxia-induced lung injury, but the underlying mechanism is not yet understood. Mitochondrial fission is essential for mitochondrial homeostasis. The objective of this study was to determine whether mitochondrial fission (dynamin-related protein 1, Drp1) is an important mediator of hyperoxia lung injury in rats. Methods: The animal model of BPD was induced with high oxygen (80-85% O2). Pulmonary histological changes were observed by hematoxylin-eosin (HE) staining. Pulmonary microvessels were observed by immunofluorescence staining of von Willebrand Factor (vWF). Protein expression levels of Drp1 and p-Drp1 (Ser616) were observed using Western Blot. We used echocardiography to measure pulmonary artery acceleration time (PAT), pulmonary vascular resistance index (PVRi), peak flow velocity of the pulmonary artery (PFVP), pulmonary arteriovenous diameter, and pulmonary vein peak velocity. Mitochondrial division inhibitor-1 (Mdivi-1) was used as an inhibitor of Drp1, and administered through intraperitoneal injection (25 mg/kg). Results: Pulmonary artery resistance of the hyperoxide-induced neonatal rat model of BPD increased after it entered normoxic convalescence. During the critical stage of alveolar development in neonatal rats exposed to high oxygen levels for an extended period, the expression and phosphorylation of Drp1 increased in lung tissues. When Drp1 expression was inhibited, small pulmonary vessel development improved and PH was relieved. Conclusion: Our study shows that excessive mitochondrial fission is an important mediator of hyperoxia-induced pulmonary vascular injury, and inhibition of mitochondrial fission may be a useful treatment for hyperoxia-induced related pulmonary diseases.
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Affiliation(s)
- Yuanyuan Dai
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Binyuan Yu
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Danyang Ai
- Department of Neonatology, The Children's Hospital of Fudan University, Shanghai, China
| | - Lin Yuan
- Department of Neonatology, The Children's Hospital of Fudan University, Shanghai, China
| | - Xinye Wang
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Ran Huo
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Xiaoqin Fu
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Shangqin Chen
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Chao Chen
- Department of Neonatology, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Neonatology, The Children's Hospital of Fudan University, Shanghai, China
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60
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Abman SH, Galambos C. Pediatric Pulmonary Hypertension on the World Stage: Do We Need Separate Neonatal Guidelines? ACTA ACUST UNITED AC 2019. [DOI: 10.21693/1933-088x-18.3.92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Steven H. Abman
- Pediatric Heart Lung Center and Pulmonary Hypertension Program, Section of Pediatric Pulmonary Medicine, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, CO
| | - Csaba Galambos
- Pediatric Heart Lung Center, Department of Pathology, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, CO
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61
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Respiratory Phenotypes for Preterm Infants, Children, and Adults: Bronchopulmonary Dysplasia and More. Ann Am Thorac Soc 2019; 15:530-538. [PMID: 29328889 DOI: 10.1513/annalsats.201709-756fr] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Ongoing advancements in neonatal care since the late 1980s have led to increased numbers of premature infants surviving well beyond the neonatal period. As a result of increased survival, many individuals born preterm manifest chronic respiratory symptoms throughout infancy, childhood, and adult life. The archetypical respiratory disease of prematurity, bronchopulmonary dysplasia, is the second most common chronic pediatric respiratory disease after asthma. However, there are several commonly held misconceptions. These misconceptions include that bronchopulmonary dysplasia is rare, that bronchopulmonary dysplasia resolves within the first few years of life, and that bronchopulmonary dysplasia does not impact respiratory health in adult life. This focused review describes a spectrum of respiratory conditions that individuals born prematurely may experience throughout their lifespan. Specifically, this review provides quantitative estimates of the number of individuals with alveolar, airway, and vascular phenotypes associated with bronchopulmonary dysplasia, as well as non-bronchopulmonary dysplasia respiratory phenotypes such as airway malacia, obstructive sleep apnea, and control of breathing issues. Furthermore, this review illustrates what is known about the potential for progression and/or lack of resolution of these respiratory phenotypes in childhood and adult life. Recognizing the spectrum of respiratory phenotypes associated with individuals born preterm and providing comprehensive and personalized care to these individuals may help to modulate adverse respiratory outcomes in later life.
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62
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Abstract
The goal of oxygen therapy and oxygen saturation targeting in extremely preterm infants is to improve outcomes and balance the risks associated with both hypoxemia and hyperoxemia. Although the NeOProM trials addressed whether low or high oxygen saturation targets affect the most important outcomes of extreme prematurity including death and other co-morbidities, the trials did not evaluate infants for pulmonary hypertension. There is limited evidence for the optimal oxygen saturation targets in extremely preterm infants that can be used to prevent the development of pulmonary hypertension and manage pulmonary hypertension once developed.
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63
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Wallace B, Peisl A, Seedorf G, Nowlin T, Kim C, Bosco J, Kenniston J, Keefe D, Abman SH. Anti-sFlt-1 Therapy Preserves Lung Alveolar and Vascular Growth in Antenatal Models of Bronchopulmonary Dysplasia. Am J Respir Crit Care Med 2019; 197:776-787. [PMID: 29268623 DOI: 10.1164/rccm.201707-1371oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
RATIONALE Pregnancies complicated by antenatal stress, including preeclampsia (PE) and chorioamnionitis (CA), increase the risk for bronchopulmonary dysplasia (BPD) in preterm infants, but biologic mechanisms linking prenatal factors with BPD are uncertain. Levels of sFlt-1 (soluble fms-like tyrosine kinase 1), an endogenous antagonist to VEGF (vascular endothelial growth factor), are increased in amniotic fluid and maternal blood in PE and associated with CA. OBJECTIVES Because impaired VEGF signaling has been implicated in the pathogenesis of BPD, we hypothesized that fetal exposure to sFlt-1 decreases lung growth and causes abnormal lung structure and pulmonary hypertension during infancy. METHODS To test this hypothesis, we studied the effects of anti-sFlt-1 monoclonal antibody (mAb) treatment on lung growth in two established antenatal models of BPD that mimic PE and CA induced by intraamniotic (i.a.) injections of sFlt-1 or endotoxin, respectively. In experimental PE, mAb was administered by three different approaches, including antenatal treatment by either i.a. instillation or maternal uterine artery infusion, or by postnatal intraperitoneal injections. RESULTS With each strategy, mAb therapy improved infant lung structure as assessed by radial alveolar count, vessel density, right ventricular hypertrophy, and lung function. As found in the PE model, the adverse lung effects of i.a. endotoxin were also reduced by antenatal or postnatal mAb therapy. CONCLUSIONS We conclude that treatment with anti-sFlt-1 mAb preserves lung structure and function and prevents right ventricular hypertrophy in two rat models of BPD of antenatal stress and speculate that early mAb therapy may provide a novel strategy for the prevention of BPD.
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Affiliation(s)
| | | | - Gregory Seedorf
- 1 Pediatric Heart Lung Center.,3 Department of Pediatrics, University of Colorado Denver Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado; and
| | - Taylor Nowlin
- 1 Pediatric Heart Lung Center.,3 Department of Pediatrics, University of Colorado Denver Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado; and
| | - Christina Kim
- 1 Pediatric Heart Lung Center.,2 Department of Surgery, and
| | | | | | - Dennis Keefe
- 4 Shire Pharmaceuticals, Lexington, Massachusetts
| | - Steven H Abman
- 1 Pediatric Heart Lung Center.,3 Department of Pediatrics, University of Colorado Denver Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado; and
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64
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Siffel C, Kistler KD, Lewis JFM, Sarda SP. Global incidence of bronchopulmonary dysplasia among extremely preterm infants: a systematic literature review. J Matern Fetal Neonatal Med 2019; 34:1721-1731. [PMID: 31397199 DOI: 10.1080/14767058.2019.1646240] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Infants born extremely preterm (<28 weeks gestational age (GA)) face a high risk of neonatal mortality. Bronchopulmonary dysplasia (BPD) is the most common morbidity of prematurity. OBJECTIVE To evaluate the global incidence of BPD among infants born extremely preterm. DESIGN A systematic review of the literature was conducted in Embase and MEDLINE (via PubMed) using a prespecified search strategy for BPD and prematurity. Observational studies published in English between 16 May 2006 and 16 October 2017 reporting on the occurrence of BPD in infants born <28 weeks GA were included. RESULTS Literature searches yielded 103 eligible studies encompassing 37 publications from Europe, 38 publications from North America, two publications from Europe and North America, 19 publications from Asia, one publication from Asia and North America, six publications from Oceania, and zero publications from Africa or South America. The reported global incidence range of BPD was 10-89% (10-73% in Europe, 18-89% in North America, 18-82% in Asia, and 30-62% in Oceania). When only population-based observational studies that defined BPD as requiring supplemental oxygen at 36 weeks postmenstrual age were included, the global incidence range of BPD was 17-75%. The wide range of incidences reflected interstudy differences in GA (which was inversely related to BPD incidence), birthweight, and survival rates across populations and institutions. CONCLUSIONS BPD is a common health morbidity occurring with extremely preterm birth. Further study of factors that impact incidence, aside from low GA, may help to elucidate modifiable risks.
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Affiliation(s)
- Csaba Siffel
- Takeda, Lexington, MA, USA.,College of Allied Health Sciences, Augusta University, Augusta, GA, USA
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65
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Dani C, Mosca F, Cresi F, Lago P, Lista G, Laforgia N, Del Vecchio A, Corvaglia L, Paolillo P, Trevisanuto D, Capasso L, Fanos V, Maffei G, Boni L. Patent ductus arteriosus in preterm infants born at 23-24 weeks' gestation: Should we pay more attention? Early Hum Dev 2019; 135:16-22. [PMID: 31212222 DOI: 10.1016/j.earlhumdev.2019.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Infants born at 23-24 weeks' gestation have the highest risk of developing a hemodynamically significant patent ductus arteriosus (hsPDA), that is refractory to pharmacological closure requiring surgical ligation. Thus, these patients might have the greatest benefits from hsPDA closure, although previous studies on PDA closure were not focused on this population. AIM To compare the occurrence of hsPDA, failure rate of the first course of ibuprofen in closing hsPDA, and need of surgical closure in infants born at 23+0-24+6 weeks' gestation to those in infants born at 25+0-28+6 weeks' gestation. STUDY DESIGN This is a retrospective multicenter study including infants born at 23+0-28+6 weeks of gestation admitted to the neonatal care units from January 2013 to December 2017. All infants underwent echocardiographical assessment for hsPDA diagnosis and eventually pharmacological treatment, and surgical closure. RESULTS We studied a total of 842 infants of which 562 (67%) developed a PDA. Among those with PDA, 511 (91%) received a pharmacological treatment for a hsPDA. We found that a hsPDA occurred in 70% (106/151) of infants born at 23-24 weeks and in 59% (405/691) of infants born at 25-28 weeks of gestation (P < 0.001). Failure of closure with the first-treatment cycle (69 vs. 40%; P < 0.001) and need of surgical closure (19 vs 10%) were more frequent (P < 0.011) in infants born at 23-24 than 25-28 gestational weeks. Paracetamol vs. ibuprofen treatment and gestational age of 23-24 versus 25-28 weeks increased closure failure, while less severe RDS and maternal clinical chorioamnionitis decreased it. CONCLUSIONS Among extremely preterm infants, infants born at 23-24 weeks of gestation have the highest risk of developing a hsPDA refractory to pharmacological treatment requiring surgical closure. Our findings support the need of individualized more careful strategies for hsPDA management in this special population.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital of Florence, Italy.
| | - Fabio Mosca
- NICU Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesco Cresi
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Paola Lago
- NICU, Ca' Foncello Hospital, Treviso, Italy
| | - Gianluca Lista
- Division of Neonatology, "V. Buzzi" Children's Hospital - ASST FBF/Sacco, Milan, Italy
| | - Nicola Laforgia
- Neonatal Intensive Care Unit, University Aldo Moro of Bari, Bari, Italy
| | - Antonello Del Vecchio
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, "Di Venere" Hospital of Bari, Bari, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Piermichele Paolillo
- Department of Maternal and Child Health, Division of Neonatology and Neonatal Intensive Care, Casilino General Hospital, ASL RM B, Roma, Italy
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, Azienda Ospedaliera di Padova, University of Padua, Padua, Italy
| | - Letizia Capasso
- Division of Neonatology, Section of Pediatrics, Department of Translational Medical Sciences, Università Federico II of Naples, Naples, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, Institute of Puericulture and Neonatal Section, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Gianfranco Maffei
- Neonatal Intensive Care Unit, University Hospital of Foggia, Foggia, Italy
| | - Luca Boni
- Clinical Trials Coordinating Center, Careggi University Hospital of Florence, Florence, Italy
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Steurer MA, Nawaytou H, Guslits E, Colglazier E, Teitel D, Fineman JR, Keller RL. Mortality in infants with bronchopulmonary dysplasia: Data from cardiac catheterization. Pediatr Pulmonol 2019; 54:804-813. [PMID: 30938937 DOI: 10.1002/ppul.24297] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/20/2019] [Accepted: 02/12/2019] [Indexed: 01/02/2023]
Abstract
RATIONALE Pulmonary hypertension (PH) is relatively common in infants with severe bronchopulmonary dysplasia (BPD), however, hemodynamic data and factors associated with mortality in this patient group are sparsely described in the literature. OBJECTIVES To characterize the hemodynamics of former preterm infants with BPD and PH, as measured at cardiac catheterization, and to identify respiratory and cardiovascular predictors of mortality. METHODS Single-center, retrospective cohort study, including, 30 patients born at less than 32-week gestational age (GA), who had an oxygen requirement at 36 weeks postmenstrual age and underwent cardiac catheterization between July 2014 and December 2017. RESULTS Median GA at birth was 25 5/7 weeks (interquartile range [IQR], 24 4/7-26 6/7 weeks). Median birth weight was 620 g (IQR, 530-700 g). With a median of 23 months of follow up (IQR, 11-39 months), mortality as of July 2018 was 27% (8 of 30). The alveolar-arterial oxygen gradient as a measure of lung disease did not correlate with mortality (log-rank test P = 0.28). However, indexed pulmonary vascular resistance (PVR) of greater than 3 Woods units × m 2 showed a trend toward increased mortality (log-rank test P = 0.12). Pulmonary vein stenosis was the only predictor significantly associated with mortality (log-rank test P = 0.005). CONCLUSIONS In this cohort, the severity of lung disease as assessed by impaired oxygenation at cardiac catheterization did not correlate with mortality. The only factor significantly associated with mortality was the presence of pulmonary vein stenosis on cardiac catheterization, although PVR may also be an important factor.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics, University of California, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Hythem Nawaytou
- Department of Pediatrics, University of California, San Francisco, California
| | - Elyssa Guslits
- Department of Pediatrics, University of California, San Francisco, California
| | | | - David Teitel
- Department of Pediatrics, University of California, San Francisco, California
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California, San Francisco, California
| | - Roberta L Keller
- Department of Pediatrics, University of California, San Francisco, California
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Pulmonary hypertension during respiratory syncytial virus bronchiolitis: a risk factor for severity of illness. Cardiol Young 2019; 29:615-619. [PMID: 31104634 DOI: 10.1017/s1047951119000313] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Respiratory syncytial virus infection is the most frequent cause of acute lower respiratory tract disease in infants. A few reports have suggested that pulmonary hypertension is associated with increased severity of respiratory syncytial virus infection. We sought to determine the association between the pulmonary hypertension detected by echocardiography during respiratory syncytial virus bronchiolitis and clinical outcomes. METHODS We retrospectively reviewed 154 children admitted with respiratory syncytial virus bronchiolitis who had an echocardiography performed during the admission. The association between pulmonary hypertension and clinical outcomes including mortality, intensive care unit (ICU) admission, prolonged ICU stay (>10 days), tracheal intubation, and need of high frequency oscillator ventilation was evaluated. RESULTS Echocardiography detected pulmonary hypertension in 29 patients (18.7%). Pulmonary hypertension was observed more frequently in patients with congenital heart disease (CHD) (n = 11/33, 33%), chronic lung disease of infancy (n = 12/25, 48%), prematurity (<37 weeks gestational age, n = 17/59, 29%), and Down syndrome (n = 4/10, 40%). The presence of pulmonary hypertension was associated with morbidity (p < 0.001) and mortality (p = 0.02). However, in patients without these risk factors (n = 68), pulmonary hypertension was detected in five patients who presented with shock or poor perfusion. Chronic lung disease was associated with pulmonary hypertension (OR = 5.9, 95% CI 2.2-16.3, p = 0.0005). Multivariate logistic analysis demonstrated that pulmonary hypertension is associated with ICU admission (OR = 6.4, 95% CI 2.2-18.8, p = 0.0007), intubation (OR = 4.7, 95% CI 1.8-12.3, p = 0.002), high frequency oscillator ventilation (OR = 8.4, 95% CI 2.95-23.98, p < 0.0001), and prolonged ICU stay (OR = 4.9, 95% CI 2.0-11.7, p = 0.0004). CONCLUSIONS Pulmonary hypertension detected by echocardiography during respiratory syncytial virus infection was associated with increased morbidity and mortality. Chronic lung disease was associated with pulmonary hypertension detected during respiratory syncytial virus bronchiolitis. Routine echocardiography is not warranted for previously healthy, haemodynamically stable patients with respiratory syncytial virus bronchiolitis.
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68
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Vayalthrikkovil S, Vorhies E, Stritzke A, Bashir RA, Mohammad K, Kamaluddeen M, Thomas S, Al Awad E, Murthy P, Soraisham A. Prospective study of pulmonary hypertension in preterm infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2019; 54:171-178. [PMID: 30549454 DOI: 10.1002/ppul.24211] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/03/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the prevalence, risk factors, and optimal timing of echocardiogram for pulmonary hypertension (PH) in infants with bronchopulmonary dysplasia (BPD). DESIGN In this prospective study, infants with gestational age (GA) <30 weeks admitted to a tertiary NICU between July 2015 and June 2017 who required positive pressure ventilation or oxygen therapy at ≥28 days of life were evaluated with serial echocardiograms at study enrollment (4-6 weeks of age), 32 weeks (only for ≤25 weeks), 36, and 40 weeks post-menstrual age (PMA) for PH. RESULTS Of 126 infants (mean birth weight 858 ± 221 g; mean GA 26.1 ± 1.6 wks), 48 (38%) developed PH at any time during their hospital stay. The first study echocardiogram was performed at a median age of 31 weeks PMA. The prevalence of PH was 36/126 (28.5%) at enrollment, at 6/30 (20%) at 32 weeks, 24/111 (21.6%) at 36 weeks, and 10/59 (17%) at 40 weeks. No new cases of PH were identified at 40 weeks. At 36 weeks, none of the infants with mild BPD had PH, whereas 20% of moderate and 32% of severe BPD infants had PH. After controlling for confounding variables severe BPD (OR 3.31, 95%CI 1.12, 9.74), and ventilator associated pneumonia (VAP) (OR 17.9, 95%CI 3.9, 82.11) remained independent risk factors for BPD-associated PH. CONCLUSION Echocardiographic screening for PH can be safely restricted to infants with moderate or severe BPD at 36 weeks PMA. We identified VAP as an independent risk factor for PH.
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Affiliation(s)
- Sakeer Vayalthrikkovil
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, Neonatology, Renai Medicity, Cochin, Kerala, India
| | - Erika Vorhies
- Department of Pediatrics, Section of Pediatric Cardiology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Amelie Stritzke
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada
| | - Rani A Bashir
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, Neonatology, Renai Medicity, Cochin, Kerala, India
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Majeeda Kamaluddeen
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Essa Al Awad
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Prashanth Murthy
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Amuchou Soraisham
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada
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69
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Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 350] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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70
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Laliberté C, Hanna Y, Ben Fadel N, Lemyre B, Bijelic V, Barrowman N, Hoey L, Thébaud B, Katz SL. Target oxygen saturation and development of pulmonary hypertension and increased pulmonary vascular resistance in preterm infants. Pediatr Pulmonol 2019; 54:73-81. [PMID: 30461218 DOI: 10.1002/ppul.24193] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/12/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Determine whether higher targeted oxygen levels are associated with reduced incidence of pulmonary hypertension (PH) and elevated pulmonary vascular resistance (PVR) in extremely premature infants. STUDY DESIGN Retrospective chart review of 252 extremely preterm infants (<29 weeks), who underwent echocardiogram prior to discharge. PH rates were compared during periods (June 2012-May 2015 and June 2015-April 2016) when lower (88-92%) or higher (90-95%) oxygen saturation targets were used. PH was determined on echocardiography. The ratio of pulmonary artery acceleration time to right ventricular ejection time was computed, with values <0.31 indicative of elevated PVR. Survival analysis compared the effects of oxygen saturation group on development/resolution of PH and elevated PVR. RESULTS The higher saturation group had significantly lower risk of developing PH (hazard ratio (HR) = 0.50, 95%CI 0.26-0.95; P = 0.03) or elevated PVR (HR = 0.55, 95%CI 0.38-0.81; P = 0.002), compared to the lower oxygen saturation group. Median time to PH development was significantly shorter in the lower saturation group than in the higher saturation group (5 days vs 12 days; P = 0.02), as was time to development of elevated PVR (4 days vs 6 days; P < 0.001). Duration of PH (P = 0.12) and elevated PVR (P = 0.86) did not differ significantly between groups. Cumulative incidence of PH (P = 0.04) and elevated PVR (P = 0.01) at 36 weeks post-menstrual age was significantly lower in the high saturation group compared to the lower saturation group. CONCLUSION Higher targeted oxygen saturation was associated with reduced risk of PH or elevated PVR in extremely preterm infants compared to lower oxygen saturation target.
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Affiliation(s)
| | - Youstina Hanna
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nadya Ben Fadel
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Ontario, Canada
| | - Brigitte Lemyre
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Ontario, Canada
| | - Vid Bijelic
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Lynda Hoey
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Bernard Thébaud
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Ontario, Canada
| | - Sherri L Katz
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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71
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Blanca AJ, Duijts L, van Mastrigt E, Pijnenburg MW, Ten Harkel DJD, Helbing WA, Bartelds B, Reis I, Koopman LP. Right ventricular function in infants with bronchopulmonary dysplasia and pulmonary hypertension: a pilot study. Pulm Circ 2018; 9:2045894018816063. [PMID: 30419798 PMCID: PMC6295707 DOI: 10.1177/2045894018816063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Premature birth and bronchopulmonary dysplasia (BPD) are risk factors for the development of echocardiographic signs of pulmonary hypertension (PH) and are associated with changes in cardiac structure and function. It is unclear whether this association persists beyond early infancy. The aims of this study are to prospectively investigate the prevalence of PH in children with severe BPD and to investigate the effect of BPD and PH on myocardial structure and function at six months corrected age. Preterm infants (gestational age ≤ 32 weeks) with severe BPD were included. Echocardiography was used to define PH and to measure speckle tracking derived longitudinal and circumferential strain of the left ventricle (LV) and right ventricle (RV). Sixty-nine infants with a median (interquartile range [IQR]) gestational age of 25.6 (24.9–26.4) weeks and a median birthweight of 770 (645–945) gram were included. Eight (12%) infants had signs of PH at six months corrected age. RV fractional area change was lower in infants with severe BPD and PH at six months compared to infants without PH (35% ± 9% vs. 43% ± 9%, P = 0.03). RV mean longitudinal systolic strain was lower in infants with severe BPD and PH compared to infants without PH (17.6% [−19.5%/−16.1%] vs. −20.9% [−25.9%/−17.9%], P = 0.04). RV size and LV longitudinal and circumferential strain in children with BPD with or without PH were similar. Signs of PH were found in 12% of infants with severe BPD at six months corrected age and the presence of PH is associated with reduced RV systolic function.
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Affiliation(s)
- Arabella J Blanca
- 1 Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Liesbeth Duijts
- 2 Division of Pediatric Pulmonology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands.,3 Division of Neonatology, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Esther van Mastrigt
- 2 Division of Pediatric Pulmonology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marielle W Pijnenburg
- 2 Division of Pediatric Pulmonology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Derk-Jan D Ten Harkel
- 4 Department of Pediatric Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Willem A Helbing
- 1 Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Beatrijs Bartelds
- 1 Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin Reis
- 3 Division of Neonatology, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Laurens P Koopman
- 1 Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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72
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Kumar KR, Clark DA, Kim EM, Perry JD, Wright K, Thomas SA, Thompson EJ, Greenberg RG, Smith PB, Benjamin DK, Laughon MM, Clark RH, Hornik CP. Association of Atrial Septal Defects and Bronchopulmonary Dysplasia in Premature Infants. J Pediatr 2018; 202:56-62.e2. [PMID: 30172431 PMCID: PMC6317846 DOI: 10.1016/j.jpeds.2018.07.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/04/2018] [Accepted: 07/06/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the association between the presence of an atrial septal defect (ASD) and the odds of developing bronchopulmonary dysplasia (BPD) in premature infants. STUDY DESIGN We identified a cohort of infants that underwent at least one echocardiogram assessment, birth weight 501-1249 g, and gestational age 23-30 weeks discharged from the neonatal intensive care unit from 2004 to 2016. We used a BPD risk estimator to calculate the predicted risk of developing BPD at 6 postnatal ages within the first 28 days of life. We examined the association between the presence of an ASD and the development of BPD using 2 multivariable logistic regression models for each BPD risk severity on each postnatal day. The first model adjusted for predicted BPD risk and the second added therapeutic interventions for BPD. RESULTS Of 20 496 infants from 228 NICUs who met inclusion criteria, 8892 (43%) were diagnosed with BPD and 1314 (6%) had an ASD. BPD was present in 48% of infants with an ASD and 43% of infants without an ASD. In infants with an ASD, the OR of developing BPD was higher after adjusting for predicted risk of BPD plus therapeutic interventions, regardless of postnatal age or predicted BPD risk severity. CONCLUSIONS The presence of an ASD was associated with an increased odds of BPD in this cohort. Future trials should consider ASD as a potentially modifiable risk factor in this vulnerable population.
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Affiliation(s)
- Karan R Kumar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - David A Clark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Evan M Kim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Jasmine D Perry
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Kaylyn Wright
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Sheikisha A Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Rachel G Greenberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC.
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73
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Wang CH, Shi LP, Ma XL, DU LZ. [Clinical features and prognosis of bronchopulmonary dysplasia complicated by pulmonary hypertension in preterm infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:893-896. [PMID: 30477618 PMCID: PMC7389022 DOI: 10.7499/j.issn.1008-8830.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/05/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To study the clinical features and prognosis of bronchopulmonary dysplasia (BPD) complicated by pulmonary hypertension (PH) in preterm infants. METHODS A retrospective analysis was performed on the clinical data of 191 preterm infants with BPD. RESULTS In the 191 preterm infants with BPD, 37 (19.4%), all with moderate or severe BPD, developed PH beyond 36 weeks' corrected age. The incidence rates of PH in infants with moderate and severe BPD were 5.7% (5/87) and 47.8% (32/67) respectively. Gestational age and birth weight were lower in infants with PH than in those without PH (P<0.01). Infants with PH had higher incidence rates of small for gestational age (SGA), severe BPD, surgical ligation of patent ductus arteriosus (PDA), neonatal respiratory distress syndrome, hemodynamically significant PDA, and pneumonia than those without PH (P<0.01). Durations of oxygen therapy, intubation, and positive pressure ventilation were longer in infants with PH than in those without PH (P<0.01). Infants with PH had higher incidence rates of retinopathy of prematurity and extrauterine growth retardation, a higher mortality, and a longer length of hospital stay compared with those without PH (P<0.01). In the 37 infants with PH (6 with mild PH, 14 with moderate PH, and 17 with severe PH), those with mild or moderate PH all survived; 15(88%) out of 17 infants with severe PH died. CONCLUSIONS The incidence of PH is high in preterm infants with moderate or severe BPD. Regular screening of pulmonary artery pressure is recommended for infants with BPD. Infants with low gestational age and birth weight, SGA, and severe BPD are more likely to develop PH. Infants with BPD complicated by PH have relatively high incidence rates of complications, high mortality, and poor prognosis.
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Affiliation(s)
- Chen-Hong Wang
- Department of Neonatal Intensive Care Unit, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China.
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74
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Taglauer E, Abman SH, Keller RL. Recent advances in antenatal factors predisposing to bronchopulmonary dysplasia. Semin Perinatol 2018; 42:413-424. [PMID: 30389227 PMCID: PMC6286866 DOI: 10.1053/j.semperi.2018.09.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bronchopulmonary dysplasia (BPD) remains a major cause of late morbidities and death after preterm birth. BPD is characterized by an arrest of vascular and alveolar growth and high risk for pulmonary hypertension; yet mechanisms contributing to its pathogenesis and early strategies to prevent BPD are poorly understood. Strong epidemiologic studies have shown that the "new BPD" reflects the long-lasting impact of antenatal factors on lung development, partly due to placental dysfunction, as reflected in recent data from animal models. Improved understanding of mechanisms through which antenatal stress alters placental function and contributes to BPD may lead to preventive therapies.
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Affiliation(s)
| | - Steven H. Abman
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO USA
| | - Roberta L. Keller
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA USA
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75
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Berkelhamer SK, Mestan KK, Steinhorn R. An update on the diagnosis and management of bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension. Semin Perinatol 2018; 42:432-443. [PMID: 30384985 DOI: 10.1053/j.semperi.2018.09.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The past decade of neonatal care has been highlighted by increased survival rates in smaller and more premature infants. Despite reduction in mortality associated with extreme prematurity, long term pulmonary morbidities remain a concern, with growing recognition of the clinical burden attributable to infants with bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension (PH). Recent publications shed light on the critical contributions of maternal placental pathology and compromised intrauterine growth to fetal pulmonary vascular development. A body of literature has further clarified postnatal risk factors for PH, most notably the severity of BPD but surprisingly the additional presence of non-pulmonary morbidities including necrotizing enterocolitis (NEC). Limitations of current diagnostics persist with growing consideration of novel echocardiographic approaches as well as complementary non-invasive biomarkers to better identify infants at risk. In 2015, a joint report published by the American Heart Association and American Thoracic Society provided the first guidelines for the care of children with PH with limited content to address BPD-associated PH. These guidelines were expanded upon in an expert consensus report produced by the Pediatric Pulmonary Hypertension Network (PPHNet). These recommendations encouraged the use of standardized screening protocols and emphasized the importance of evaluation and treatment of comorbidities when PH is identified. Cardiac catheterization was recommended prior to initiation of therapy for more accurate quantification of pulmonary pressures, clarification of anatomy and guidance in the use of pharmacotherapy. Despite these guidelines, significant practice variation persists and gaps remain with respect to optimal evaluation and management of BPD-associated PH.
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Affiliation(s)
| | - Karen K Mestan
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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76
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La Frano MR, Fahrmann JF, Grapov D, Pedersen TL, Newman JW, Fiehn O, Underwood MA, Mestan K, Steinhorn RH, Wedgwood S. Umbilical cord blood metabolomics reveal distinct signatures of dyslipidemia prior to bronchopulmonary dysplasia and pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2018; 315:L870-L881. [PMID: 30113229 PMCID: PMC6295510 DOI: 10.1152/ajplung.00283.2017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/31/2018] [Accepted: 08/15/2018] [Indexed: 01/27/2023] Open
Abstract
Pulmonary hypertension (PH) is a common consequence of bronchopulmonary dysplasia (BPD) and remains a primary contributor to increased morbidity and mortality among preterm infants. Unfortunately, at the present time, there are no reliable early predictive markers for BPD-associated PH. Considering its health consequences, understanding in utero perturbations that lead to the development of BPD and BPD-associated PH and identifying early predictive markers is of utmost importance. As part of the discovery phase, we applied a multiplatform metabolomics approach consisting of untargeted and targeted methodologies to screen for metabolic perturbations in umbilical cord blood (UCB) plasma from preterm infants that did ( n = 21; cases) or did not ( n = 21; controls) develop subsequent PH. A total of 1,656 features were detected, of which 407 were annotated by metabolite structures. PH-associated metabolic perturbations were characterized by reductions in major choline-containing phospholipids, such as phosphatidylcholines and sphingomyelins, indicating altered lipid metabolism. The reduction in UCB abundances of major choline-containing phospholipids was confirmed in an independent validation cohort consisting of UCB plasmas from 10 cases and 10 controls matched for gestational age and BPD status. Subanalyses in the discovery cohort indicated that elevations in the oxylipins PGE1, PGE2, PGF2a, 9- and 13-HOTE, 9- and 13-HODE, and 9- and 13-KODE were positively associated with BPD presence and severity. This expansive evaluation of cord blood plasma identifies compounds reflecting dyslipidemia and suggests altered metabolite provision associated with metabolic immaturity that differentiate subjects, both by BPD severity and PH development.
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Affiliation(s)
- Michael R La Frano
- West Coast Metabolomics Center, University of California, Davis Genome Center, University of California , Davis, California
- Department of Nutrition, University of California , Davis, California
- Department of Food Science and Nutrition, California Polytechnic State University , San Luis Obispo, California
| | - Johannes F Fahrmann
- West Coast Metabolomics Center, University of California, Davis Genome Center, University of California , Davis, California
- Department of Clinical Cancer Prevention, University of Texas M. D. Anderson Cancer Center , Houston, Texas
| | | | - Theresa L Pedersen
- Obesity and Metabolism Research Unit, United States Department of Agriculture, Agricultural Research Service, Western Human Nutrition Research Center , Davis, California
| | - John W Newman
- West Coast Metabolomics Center, University of California, Davis Genome Center, University of California , Davis, California
- Department of Nutrition, University of California , Davis, California
- Obesity and Metabolism Research Unit, United States Department of Agriculture, Agricultural Research Service, Western Human Nutrition Research Center , Davis, California
| | - Oliver Fiehn
- West Coast Metabolomics Center, University of California, Davis Genome Center, University of California , Davis, California
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi-Arabia
| | - Mark A Underwood
- Department of Pediatrics, University of California, Davis Medical Center , Sacramento, California
| | - Karen Mestan
- Department of Pediatrics, Division of Neonatology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Robin H Steinhorn
- Department of Pediatrics, Children's National Medical Center, George Washington University , Washington, District of Columbia
| | - Stephen Wedgwood
- Department of Pediatrics, University of California, Davis Medical Center , Sacramento, California
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77
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Qasim A, Dasgupta S, Aly AM, Jain SK. Sildenafil Use in the Treatment of Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension: A Case Series. AJP Rep 2018; 8:e219-e222. [PMID: 30345157 PMCID: PMC6188884 DOI: 10.1055/s-0038-1673343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 04/18/2018] [Indexed: 11/02/2022] Open
Abstract
Objective This article studies the role of sildenafil in reducing myocardial stress (measured by serial N-terminal pro b-type natriuretic peptide [NTproBNP] levels) secondary to bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH). Study Design This is a case series of three extremely low birth weight infants with severe BPD at 36 weeks' postmenstrual age. All infants had very elevated NTproBNP (> 2,000 ng/dL) levels and echocardiographic evidence of BPD-PH. Sildenafil was started and infants were followed up every 2 weeks clinically along with NTproBNP levels and echocardiograms. Results After 4 weeks of sildenafil treatment, NTproBNP levels decreased significantly in all infants, echocardiograms showed significant improvement in one infant, and respiratory severity score improved significantly in one infant. All infants tolerated sildenafil. Conclusion Sildenafil reduced NTproBNP levels in all infants with BPD-PH but the echocardiographic findings and respiratory scores did not improve consistently. We speculate that this may be due to a delay in diagnosis and initiation of therapy after irreversible pulmonary changes have set in.
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Affiliation(s)
- Amna Qasim
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas
| | - Soham Dasgupta
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas
| | - Ashraf M Aly
- Division of Pediatric Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Sunil K Jain
- Division of Neonatology, University of Texas Medical Branch, Galveston, Texas
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78
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Kim DH, Kim HS. Clinical Characteristics, Presentation, and Outcomes of Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension. NEONATAL MEDICINE 2018. [DOI: 10.5385/nm.2018.25.3.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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79
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Aboudi D, Swaminathan N, Brumberg H, Shi Q, Friedman D, Parvez B, Krishnan U. Sildenafil and Retinopathy of Prematurity in Preterm Infants with Bronchopulmonary Dysplasia. J Pediatr 2018; 199:16-21. [PMID: 29753546 DOI: 10.1016/j.jpeds.2018.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess whether sildenafil is associated with worsening retinopathy of prematurity (ROP) in very low birth weight (VLBW) infants (≤1500 g) with bronchopulmonary dysplasia (BPD). STUDY DESIGN This retrospective case-control study included VLBW infants admitted to the neonatal intensive care unit between January 1, 2006, and December 31, 2012. Each infant treated with sildenafil was assigned 3 unexposed controls matched for gestational age, birth weight, and BPD diagnosis. Severe ROP was defined as stage ≥3 ROP. Worsening ROP was defined as increased stage of ROP within 8 weeks + 4 days after initiation of sildenafil or matched postmenstrual age. RESULTS Twenty-three exposed infants and 69 matched controls met the inclusion criteria for the study (mean birth weight, 715 ± 210 g; mean gestational age, 25 ± 1 weeks). The mean postmenstrual age at sildenafil treatment was 42 ± 8 weeks. Exposed infants had more days of respiratory support (mean, 208 ± 101 days vs 102 ± 33 days; P < .001). Exposed infants had a higher prevalence of severe ROP (26% [6 of 23] vs 7% [5 of 69]; OR, 6.4; 95% CI, 1.2-32.9; P = .026). Five exposed infants and 2 unexposed infants had severe ROP before starting sildenafil and were excluded from the analysis for worsening ROP. The rate of worsening ROP did not differ significantly between exposed infants and unexposed infants ((41% [7 of 17] vs 24% [12 of 51]; OR, 8.4; 95% CI, 0.9-78.6; P = .061). CONCLUSION Although sildenafil treatment was not statistically significantly associated with worsening of ROP, the raw difference in ROP rate is concerning. Larger studies are warranted to confirm this finding.
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Affiliation(s)
- David Aboudi
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY; Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY
| | - Nithya Swaminathan
- Department of Pediatrics, Columbia University Medical Center, New York, NY; Department of Pediatrics, Le Bonheur Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Heather Brumberg
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY
| | - Deborah Friedman
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY
| | - Boriana Parvez
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY
| | - Usha Krishnan
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY; Department of Pediatrics, Columbia University Medical Center, New York, NY.
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80
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Mirza H, Garcia JA, Crawford E, Pepe J, Zussman M, Wadhawan R, Oh W. Natural History of Postnatal Cardiopulmonary Adaptation in Infants Born Extremely Preterm and Risk for Death or Bronchopulmonary Dysplasia. J Pediatr 2018; 198:187-193.e1. [PMID: 29625730 DOI: 10.1016/j.jpeds.2018.02.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 01/04/2018] [Accepted: 02/13/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To study the natural history of postnatal cardiopulmonary adaptation in infants born extremely preterm and establish its association with death or bronchopulmonary dysplasia (BPD). STUDY DESIGN This was a prospective, observational, cohort study of infants born extremely preterm (<29 weeks). Initial echocardiogram was performed at <48 hours of life, followed by serial echocardiograms every 24-48 hours until 14 days of life. Resolution or no resolution of pulmonary hypertension (PH) at 72-96 hours was considered normal or delayed postnatal cardiopulmonary adaptation, respectively. PH between 96 hours and 14 days was defined as subsequent PH. Elevated pulmonary artery pressure throughout the 14 days of life was considered persistent PH. BPD was assessed at 36 weeks of postmenstrual age. RESULTS Sixty infants were enrolled; 2 died before a sequential echocardiogram could be done at 72-96 hours. Normal and delayed cardiopulmonary adaptation were noted in 26 (45%) and 32 (55%) infants, respectively. Five patterns of postnatal cardiopulmonary adaptation were recognized: normal without subsequent PH (n = 20), normal with subsequent PH (n = 6), delayed adaptation without subsequent PH (n = 6), delayed adaptation with subsequent PH (n = 16), and persistent PH (n = 10). Infants with delayed cardiopulmonary adaptation were of lower gestation and birth weight and required prolonged ventilation and supplemental oxygen (P < .05). On multivariate analysis, the incidence of death or BPD was significantly greater among infants with delayed adaptation (P < .001). CONCLUSION Infants born extremely preterm have normal or delayed postnatal cardiopulmonary adaptation that can be complicated by subsequent or persistent PH. Delayed cardiopulmonary adaptation is associated independently with death or BPD.
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Affiliation(s)
- Hussnain Mirza
- Center for Neonatal Care, Florida Hospital for Children/University of Central Florida College of Medicine, Orlando, FL.
| | - Jorge A Garcia
- Division of Pediatric Cardiology, Florida Hospital for Children, Orlando, FL
| | - Elizabeth Crawford
- Division of Pediatric Echocardiography, Florida Hospital Cardiovascular Institute, Orlando, FL
| | - Julie Pepe
- Office of Research Advancement and Support, Florida Hospital, Orlando, FL
| | - Matthew Zussman
- Division of Pediatric Cardiology, Florida Hospital for Children, Orlando, FL
| | - Rajan Wadhawan
- Center for Neonatal Care, Florida Hospital for Children/University of Central Florida College of Medicine, Orlando, FL
| | - William Oh
- Center for Pediatric Research, Florida Hospital for Children, Orlando, FL
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81
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Arjaans S, Zwart EAH, Ploegstra MJ, Bos AF, Kooi EMW, Hillege HL, Berger RMF. Identification of gaps in the current knowledge on pulmonary hypertension in extremely preterm infants: A systematic review and meta-analysis. Paediatr Perinat Epidemiol 2018; 32:258-267. [PMID: 29341209 DOI: 10.1111/ppe.12444] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pulmonary hypertension complicates the clinical course of extremely preterm infants and is associated with bronchopulmonary dysplasia (BPD). However, prevalence, risk factors, and outcome of pulmonary hypertension in these infants are insufficiently known. This systematic review and meta-analysis aims to provide an up-to-date overview of available data on prevalence, risk factors, and outcome of pulmonary hypertension and to identify current knowledge gaps. METHODS Medline, EMBASE, and the Cochrane Library databases were searched in July 2017. Two authors reviewed titles/abstracts and full-texts. Eligible studies reported prevalence, patient characteristics or mortality of infants with/without pulmonary hypertension. Studies were excluded if they did not include extremely preterm infants. Only similar study samples (selected infants with BPD or infants both with/without BPD) were compared in the meta-analyses. RESULTS Of 1829 unique articles identified, 25 were eligible for inclusion. Pulmonary hypertension was observed in infants with BPD (20%, 95% confidence interval [CI] 14, 25), but also in those without BPD (2%, 95% CI 0, 8). Infants with severe BPD were most at risk of pulmonary hypertension (risk ratio [RR] 2.7, 95% CI 1.7, 4.2). Infants with pulmonary hypertension were more at risk of mortality (RR 4.7, 95% CI 2.7, 8.3). CONCLUSIONS Pulmonary hypertension occurs in particularly in infants with severe BPD, and increases risk of mortality. Due to selected study populations, heterogeneous pulmonary hypertension-definitions and poorly reported timing of pulmonary hypertension assessments, however, data available in current reports are insufficient to allow accurate assessment of true prevalence, risk factors, and time-related outcome. Prospective studies, with standardised methodology and follow-up are needed to determine these factors.
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Affiliation(s)
- Sanne Arjaans
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Elvira A H Zwart
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mark-Jan Ploegstra
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arend F Bos
- Department of Neonatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Elisabeth M W Kooi
- Department of Neonatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hans L Hillege
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rolf M F Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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82
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Carey WA, Weaver AL, Mara KC, Clark RH. Inhaled Nitric Oxide in Extremely Premature Neonates With Respiratory Distress Syndrome. Pediatrics 2018; 141:peds.2017-3108. [PMID: 29439205 DOI: 10.1542/peds.2017-3108] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is increasingly prescribed to extremely premature neonates with respiratory distress syndrome (RDS). Most of this off-label use occurs during the first week of life. We studied this practice, hypothesizing that it would not be associated with improved survival. METHODS We queried the Pediatrix Medical Group Clinical Data Warehouse to identify all neonates born at 22 to 29 weeks' gestation from 2004 to 2014. In our study sample, we included singletons who required mechanical ventilation for treatment of RDS and excluded those with anomalies. The primary outcome was death before discharge. Through a sequential risk set approach, each patient who received iNO during the first 7 days of life ("case patient") was matched by using propensity scores to a patient who had not received iNO at a chronological age before the case patient's iNO initiation age (defined as the index age for the matched pair). The association between iNO status and in-hospital mortality was evaluated in a Cox proportional hazards regression model by using age as the time scale with patients entering the risk set at their respective index age. RESULTS Among 37 909 neonates in our study sample, we identified 993 (2.6%) who received iNO. The 2 matched cohorts each contained 971 patients. We did not observe a significant association between iNO exposure and mortality (hazard ratio, 1.08; 95% confidence interval, 0.94-1.25; P = .29). CONCLUSIONS Off-label prescription of iNO is not associated with reduced in-hospital mortality among extremely premature neonates with RDS.
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Affiliation(s)
| | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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83
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Yum SK, Kim MS, Kwun Y, Moon CJ, Youn YA, Sung IK. Impact of histologic chorioamnionitis on pulmonary hypertension and respiratory outcomes in preterm infants. Pulm Circ 2018; 8:2045894018760166. [PMID: 29480140 PMCID: PMC5843110 DOI: 10.1177/2045894018760166] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We aimed to evaluate the association between the presence of histologic chorioamnionitis (HC) and development of pulmonary hypertension (PH) during neonatal intensive care unit (NICU) stay. Data of preterm infants born at 32 weeks of gestation or less were reviewed. The development of PH and other respiratory outcomes were compared according to the presence of HC. Potential risk factors associated with the development of PH during NICU stay were used for multivariable logistic regression analysis. A total of 188 infants were enrolled: 72 in the HC group and 116 in the no HC group. The HC group infants were born at a significantly shorter gestational age and lower birthweight, with a greater proportion presenting preterm premature rupture of membrane (pPROM) > 18 h before delivery. More infants in the HC group developed pneumothorax (P = 0.008), and moderate and severe bronchopulmonary dysplasia (BPD; P = 0.001 and P = 0.006, respectively). PH in the HC group was significantly more frequent compared to the no HC group (25.0% versus 8.6%, P = 0.002). Based on a multivariable logistic regression analysis, birthweight (P = 0.009, odds ratio [OR] = 0.997, 95% confidence interval [CI] = 0.995–0.999), the presence of HC (P = 0.047, OR = 2.799, 95% CI = 1.014–7.731), and duration of invasive mechanical ventilation (MV) > 14 days (P = 0.015, OR = 8.036, 95% CI = 1.051–43.030) were significant factors. The presence of HC and prolonged invasive MV in infants with lower birthweight possibly synergistically act against preterm pulmonary outcomes and leads to the development of PH. Verification of this result and further investigation to establish effective strategies to prevent or ameliorate these adverse outcomes are needed.
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Affiliation(s)
- Sook Kyung Yum
- Division of Neonatology, Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min-Sung Kim
- Division of Neonatology, Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoojin Kwun
- Division of Neonatology, Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Cheong-Jun Moon
- Division of Neonatology, Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Ah Youn
- Division of Neonatology, Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Kyung Sung
- Division of Neonatology, Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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84
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Perez VADJ. Long-Term Right Ventricular Adaptation to Postnatal Hyperoxia: Too Much of a Good Thing? Am J Respir Cell Mol Biol 2018; 56:559-560. [PMID: 28459383 DOI: 10.1165/rcmb.2016-0429ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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85
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Trittmann JK, Velten M, Heyob KM, Almazroue H, Jin Y, Nelin LD, Rogers LK. Arginase and α-smooth muscle actin induction after hyperoxic exposure in a mouse model of bronchopulmonary dysplasia. Clin Exp Pharmacol Physiol 2018; 45:556-562. [PMID: 29266319 DOI: 10.1111/1440-1681.12909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/30/2017] [Accepted: 12/12/2017] [Indexed: 12/26/2022]
Abstract
The L-arginine/NO pathway is an important regulator of pulmonary hypertension, the leading cause of mortality in patients with the chronic lung disease of prematurity, bronchopulmonary dysplasia. L-arginine can be metabolized by NO synthase (NOS) to form L-citrulline and NO, a potent vasodilator. Alternatively, L-arginine can be metabolized by arginase to form urea and L-ornithine, a precursor to collagen and proline formation important in vascular remodelling. In the current study, we hypothesized that C3H/HeN mice exposed to prolonged hyperoxia would have increased arginase expression and pulmonary vascular wall cell proliferation. C3H/HeN mice were exposed to 14 days of 85% O2 or room air and lung homogenates analyzed by western blot for protein levels of arginase I, arginase II, endothelial NOS (eNOS), ornithine decarboxylase (ODC), ornithine aminotransferase (OAT), and α-smooth muscle actin (α-SMA). Hyperoxia did not change arginase I or eNOS protein levels. However, arginase II protein levels were 15-fold greater after hyperoxia exposure than in lungs exposed to room air. Greater protein levels of ODC and OAT were found in lungs following hyperoxic exposure than in room air animals. α-SMA protein levels were found to be 7-fold greater in the hyperoxia exposed lungs than in room air lungs. In the hyperoxia exposed lungs there was evidence of greater pulmonary vascular wall cell proliferation by α-SMA immunohistochemistry than in room air lungs. Taken together, these data are consistent with a more proliferative vascular phenotype, and may explain the propensity of patients with bronchopulmonary dysplasia to develop pulmonary hypertension.
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Affiliation(s)
- Jennifer K Trittmann
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms University, University Medical Center, Bonn, Germany
| | - Kathryn M Heyob
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Hanadi Almazroue
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Yi Jin
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Leif D Nelin
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Lynette K Rogers
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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86
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Kanaan U, Srivatsa B, Huckaby J, Kelleman M. Association of unit-wide oxygen saturation target on incidence of pulmonary hypertension in very low birthweight premature infants. J Perinatol 2018; 38:148-153. [PMID: 29048404 DOI: 10.1038/jp.2017.166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Assess the effect of increasing pulse oximetry targets on incidence of pulmonary hypertension in very low birthweight premature infants. STUDY DESIGN Retrospective cohort study comparing pulmonary hypertension incidence among three cohorts of premature infants exposed to varying oxygen saturation targets (Cohort 1: n=459, 1 May 2009 to 30 April 2011, 85-94%; Cohort 2: n=474, 1 May 2011 to 31 May 2013, 88-94%; Cohort 3: n=387, 1 June 2013 to 31 May 2015, 90-95%). Subjects had birth weight <1500 g and gestational age 23-32 weeks. Chi-square, Kruskall-Wallis and Anderson-Darling tests were used, as well as multivariable logistic regression. RESULTS Incidence of pulmonary hypertension declined with higher oxygen saturation targets (19.0% Cohort 1, 7.9% Cohort 2, 9.6% Cohort 3, P<0.001). Other parameters were largely not different between cohorts though rates of chorioamnionitis and prenatal steroids increased and oxygen use, inhaled nitric oxide use, necrotizing enterocolitis and patent ductus arteriosus ligation decreased over time. CONCLUSION Higher oxygen saturation targets for very low-birthweight premature infants were associated with reduced rates of pulmonary hypertension in this retrospective cohort study.
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Affiliation(s)
- U Kanaan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA.,Northside Hospital, Atlanta, GA, USA
| | - B Srivatsa
- Northside Hospital, Atlanta, GA, USA.,Mednax, Sunrise, FL, USA
| | - J Huckaby
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - M Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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87
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Vyas-Read S, Guglani L, Shankar P, Travers C, Kanaan U. Atrial Septal Defects Accelerate Pulmonary Hypertension Diagnoses in Premature Infants. Front Pediatr 2018; 6:342. [PMID: 30533406 PMCID: PMC6266546 DOI: 10.3389/fped.2018.00342] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/23/2018] [Indexed: 11/13/2022] Open
Abstract
Between 4 and 16% of extremely premature infants have late pulmonary hypertension (PH) (onset >30 days of life), and infants with PH have a higher risk of tracheostomy and death. Atrial septal defects (ASD) increase pulmonary blood flow and may promote PH in at-risk infants. The objective of this study was to determine if infants with ASD develop PH sooner than those without ASD. Infants who were born at < 32 weeks' gestation, with an echocardiogram on day of life > 30, and without congenital anomalies were included. Infants with and without ASD were evaluated for the time to PH diagnosis, defined as the day of the first echocardiogram that showed PH. A multivariable model with ASD and significant variables on PH and a Cox proportional hazard model evaluating time to PH was determined. Of the 334 infants with echocardiograms, 57 had an ASD and 26% of these developed PH vs. 12% without ASD (p = 0.006). Infants with PH had lower gestational age (25.2 vs. 26.2 weeks, p = 0.005), smaller birthweight (699 vs. 816 gm, p = 0.001), and more prematurity complications than infants without PH. More PH infants had maternal African-American race (63.9 vs. 36.1%), right ventricular dysfunction (23.9 vs. 3.2%, p < 0.001), right ventricular dilation (52.1 vs. 8.6%, p < 0.001), or right ventricular hypertrophy (51.2 vs. 10.1%, p < 0.001), than infants without PH. At 150 days of life, 78.1% (95% CI 64.6-86.9%) of infants with ASD survived without PH, compared with 90.9% (95% CI 86.7-93.8%) of infants without ASD, and the unadjusted hazard for development of PH for infants with ASD was 2.37 (95% CI 1.29-4.36). When significant clinical variables were controlled, infants with ASD had a 2.44-fold (95% CI 1.27-4.68) increase in PH, compared with infants without ASD. Most PH in infants with or without ASD was diagnosed by day of life 150, but infants with ASD had an over 2-fold increased hazard for PH during their neonatal hospitalization. Premature infants with ASD should be followed closely for PH development and further studies to investigate the optimal timing of closure are needed.
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Affiliation(s)
- Shilpa Vyas-Read
- Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Lokesh Guglani
- Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Prabhu Shankar
- Department of Public Health Sciences, University of California, Davis, Davis, CA, United States
| | - Curtis Travers
- Biostatistics Core, Pediatric Research Alliance, Atlanta, GA, United States
| | - Usama Kanaan
- Department of Pediatrics, Emory University, Atlanta, GA, United States.,Sibley Heart Center, Atlanta, GA, United States
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88
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Young KC, Bancalari E. Should All Extremely Premature Infants Be Screened for Pulmonary Hypertension? Neonatology 2018; 113:89-91. [PMID: 29183024 DOI: 10.1159/000481526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Karen C Young
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
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89
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Seo YH, Choi HJ. Clinical Utility of Echocardiography for Early and Late Pulmonary Hypertension in Preterm Infants: Relation with Bronchopulmonary Dysplasia. J Cardiovasc Ultrasound 2017; 25:124-130. [PMID: 29333219 PMCID: PMC5762695 DOI: 10.4250/jcu.2017.25.4.124] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 11/22/2022] Open
Abstract
Background We evaluated early and late pulmonary hypertension (PH) in preterm infants and its relation with bronchopulmonary dysplasia (BPD). Methods Sixty-seven preterm infants < 30 weeks' gestation underwent echocardiography within 14 days after birth for early PH and over 28 days after birth for late PH. We measured tricuspid regurgitation (TR) peak velocity, pulse Doppler-derived myocardial performance index (MPI) of right ventricle (RV) (RV MPI), eccentricity index (EI), and tricuspid annular plane systolic excursion (TAPSE). Results The median gestation age of patients was 27 weeks (range, 23–30 weeks) and median birth weight was 1030 g (range, 450–1780 g). TR peak velocity was measured only in 19 patients (28.4%). Patients with symptomatic early PH (n = 11) showed a significantly lower systolic EI and a significantly higher incidence of RV MPI > 0.38 and TAPSE < 0.5 cm than patients without PH. The incidence of symptomatic early PH was highest in severe BPD, although this was not statistically significant. Early echocardiographic parameters are not associated with BPD development. Patients with severe BPD showed a significantly higher RV MPI and a significantly higher incidence of RV MPI > 0.38 than patients with mild BPD, and a significantly lower systolic EI and a significantly higher incidence of systolic EI < 0.81 than patients without BPD. Conclusion Systolic EI, RV MPI, and TAPSE were well represented symptomatic early PH, while systolic EI and RV MPI could be useful parameters for identifying late PH in preterm infants with BPD, even if they did not present PH symptoms.
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Affiliation(s)
- Yo Han Seo
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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90
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Dani C, Corsini I, Cangemi J, Vangi V, Pratesi S. Nitric oxide for the treatment of preterm infants with severe RDS and pulmonary hypertension. Pediatr Pulmonol 2017; 52:1461-1468. [PMID: 29058384 DOI: 10.1002/ppul.23843] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) cannot be recommended for the routine treatment of respiratory failure in premature neonates, but it has been suggested that the effectiveness of iNO therapy should be further studied in more select preterm infants, such as those with persistent pulmonary hypertension of the newborn (PPHN). OBJECTIVE To evaluate the frequency of PPHN in very preterm infants with severe respiratory distress syndrome (RDS), to assess the effectiveness of iNO in these patients, and to individuate possible predictive factors for the response to iNO in preterm infants with RDS. STUDY DESIGN We retrospectively studied infants <30 weeks of gestational age or birth weight <1250 g, who were affected by severe RDS and treated with iNO during the first week of life. Clinical characteristics of infants with or without echocardiographic diagnosis of PPHN were compared, as well as those of responder or no responder to iNO therapy. Effectiveness of iNO was evaluated by recording changes of MAP, FiO2 , SpO2 /FiO2 ratio, and oxygenation index (OI) before, and 3 ± 1, 6 ± 1, 12 ± 3, 24 ± 6, 48 ± 6, and 72 ± 12 h after beginning therapy. RESULTS We studied 42 (4.6%) infants, of whom 28 (67%) had PPHN and 14 (33%) did not. iNO therapy was associated with improved oxygenation in both the groups but it was quicker in the PPHN than in the no PPHN group. Multivariate analysis showed that FiO2 >0.65, diagnosis of PPHN, and birth weight >750 g independently predicts effectiveness of iNO in very preterm infants with RDS. CONCLUSION We found that PPHN is a frequent complication of severe RDS in very preterm infants and iNO therapy can improve their oxygenation earlier than in infants without PPHN. iNO therapy is not recommended for the routinely treatment of RDS in premature neonates but in cases of concurrent diagnosis of PPHN it should be considered carefully.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Jessica Cangemi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Venturella Vangi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
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91
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Chou HC, Lin W, Chen CM. Human mesenchymal stem cells attenuate pulmonary hypertension induced by prenatal lipopolysaccharide treatment in rats. Clin Exp Pharmacol Physiol 2017; 43:906-14. [PMID: 27273502 DOI: 10.1111/1440-1681.12604] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 05/17/2016] [Accepted: 06/04/2016] [Indexed: 11/26/2022]
Abstract
Intra-amniotic injection of lipopolysaccharide (LPS) induces pulmonary hypertension in newborn rats. This study was designed to test whether human mesenchymal stem cells (MSCs) reduce pulmonary hypertension and alleviate cardiac hypertrophy in prenatal LPS-treated rats. Pregnant Sprague-Dawley rats were injected intraperitoneally with LPS (0.5 mg/kg per day) or untreated on gestational days 20 and 21. Human MSCs (3×10(5) cells and 1×10(6) cells) in 0.03 mL of normal saline (NS) were transplanted intratracheally on postnatal day 5. Four study groups were considered: normal, LPS+NS, LPS+MSCs (3×10(5) cells), and LPS+MSCs (1×10(6) cells). On postnatal day 14, lung and heart tissues were collected for measuring the arterial medial wall thickness (MWT) and β-myosin heavy chain (β-MHC) level as markers of pulmonary hypertension and cardiac hypertrophy, respectively. The LPS+NS group exhibited a significantly higher right ventricle (RV)/[left ventricle (LV)+ interventricular septum (IVS)] thickness ratio and MWT, a greater cardiomyocyte width, a greater number of cardiomyocyte nuclei per squared millimeter, and higher β-MHC expression than those observed in the normal group. Human MSC transplantation (3×10(5) cells and 1×10(6) cells) in LPS-treated rats reduced MWT and the RV/(LV+IVS) thickness ratio to normal levels. This improvement in right ventricular hypertrophy was accompanied by a decrease in toll-like receptor 4 (TLR4), nuclear factor-κB, and tumor necrosis factor-α expression in the heart. Intratracheal human MSCs transplantation can attenuate pulmonary hypertension and right ventricular hypertrophy in prenatal LPS-treated rats; this attenuation may be associated with suppression of TLR4 expression via paracrine pathways.
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Affiliation(s)
- Hsiu-Chu Chou
- Department of Anatomy and Cellular Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Willie Lin
- Meridigen Biotech Co., Ltd., Taipei, Taiwan
| | - Chung-Ming Chen
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan
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92
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93
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Diagnostic Approach to Pulmonary Hypertension in Premature Neonates. CHILDREN-BASEL 2017; 4:children4090075. [PMID: 28837121 PMCID: PMC5615265 DOI: 10.3390/children4090075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/01/2017] [Accepted: 08/09/2017] [Indexed: 02/01/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease in premature infants following respiratory distress at birth. With increasing survival of extremely low birth weight infants, alveolar simplification is the defining lung characteristic of infants with BPD, and along with pulmonary hypertension, increasingly contributes to both respiratory morbidity and mortality in these infants. Growth restricted infants, infants born to mothers with oligohydramnios or following prolonged preterm rupture of membranes are at particular risk for early onset pulmonary hypertension. Altered vascular and alveolar growth particularly in canalicular and early saccular stages of lung development following mechanical ventilation and oxygen therapy, results in developmental lung arrest leading to BPD with pulmonary hypertension (PH). Early recognition of PH in infants with risk factors is important for optimal management of these infants. Screening tools for early diagnosis of PH are evolving; however, echocardiography is the mainstay for non-invasive diagnosis of PH in infants. Cardiac computed tomography (CT) and magnetic resonance are being used as imaging modalities, however their role in improving outcomes in these patients is uncertain. Follow-up of infants at risk for PH will help not only in early diagnosis, but also in appropriate management of these infants. Aggressive management of lung disease, avoidance of hypoxemic episodes, and optimal nutrition determine the progression of PH, as epigenetic factors may have significant effects, particularly in growth-restricted infants. Infants with diagnosis of PH are managed with pulmonary vasodilators and those resistant to therapy need to be worked up for the presence of cardio-vascular anomalies. The management of infants and toddlers with PH, especially following premature birth is an emerging field. Nonetheless, combination therapies in a multi-disciplinary setting improves outcomes for these infants.
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94
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Seth SA, Soraisham AS, Harabor A. Risk factors and outcomes of early pulmonary hypertension in preterm infants. J Matern Fetal Neonatal Med 2017; 31:3147-3152. [PMID: 28783986 DOI: 10.1080/14767058.2017.1365129] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Data on early pulmonary arterial hypertension (PAH) in preterm infants is limited and outcomes are conflicting. Our objectives are to examine the risk factors and neonatal outcomes of early onset PAH (EOPAH) diagnosed in the first 2 weeks of age in preterm infants in a large perinatal center. METHODS We performed a case-control study to assess the risk factors and clinical outcomes of preterm infants with EOPAH. Preterm infants (<34 weeks) admitted to NICU between 2009 and 2013 with a diagnosis of PAH in the first 2 weeks of age were matched to two consecutive controls for gestational age, birth weight, and year of birth. We performed univariate and multivariate analyses. RESULTS Of 1798 eligible infants, 60 (3.3%) had EOPAH with 57/60 (95%) diagnosed in the first 7 d of age. Infants with early PAH had higher incidence of prolonged rupture of membrane (47% versus 29%), oligohydramnios (37% versus 16%) and received less antenatal steroids (78% versus 91%). Fifty-one infants received inhaled nitric oxide (iNO) and all responded well. The overall mortality rate was not significantly different between two groups (13.3% versus 8%). After adjusting for potential confounding variables, early PAH is associated with bronchopulmonary dysplasia (BPD) (aOR 3.06, 95% CI 1.43, 6.54) and BPD/death (aOR 2.65, 95% CI 1.25, 5.64) and severe intraventricular hemorrhage (aOR 3.08, 95% CI 1.28, 7.39). CONCLUSION Early onset pulmonary arterial hypertension in preterm is not uncommon and is associated with bronchopulmonary dysplasia and severe intraventricular hemorrhage. Inhaled nitric oxide was used to treat in majority of cases with good response and survival is high.
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Affiliation(s)
- Saad Ahmed Seth
- a Department of Pediatrics, Section of Neonatology, Cumming School of Medicine , Alberta Children's Hospital Research Institute, University of Calgary , Calgary , Alberta , Canada
| | - Amuchou Singh Soraisham
- a Department of Pediatrics, Section of Neonatology, Cumming School of Medicine , Alberta Children's Hospital Research Institute, University of Calgary , Calgary , Alberta , Canada
| | - Andrei Harabor
- a Department of Pediatrics, Section of Neonatology, Cumming School of Medicine , Alberta Children's Hospital Research Institute, University of Calgary , Calgary , Alberta , Canada
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95
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Mahgoub L, Kaddoura T, Kameny AR, Lopez Ortego P, Vanderlaan RD, Kakadekar A, Dicke F, Rebeyka I, Calderone CA, Redington A, Del Cerro MJ, Fineman J, Adatia I. Pulmonary vein stenosis of ex-premature infants with pulmonary hypertension and bronchopulmonary dysplasia, epidemiology, and survival from a multicenter cohort. Pediatr Pulmonol 2017; 52:1063-1070. [PMID: 28152279 DOI: 10.1002/ppul.23679] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/16/2016] [Accepted: 01/13/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pulmonary vein stenosis is emerging as an important clinical problem in ex-premature infants. METHODS We sought to describe the epidemiology of pulmonary vein stenosis affecting ex-premature infants by a multicenter retrospective cohort study of patients from seven children's hospitals diagnosed between 2000-2014. RESULTS We identified 39 ex-premature patients (26 males, median gestational age 28 weeks range 22-36 weeks, birth weight 1.1 kg range 433-2645-g) with pulmonary vein stenosis. Median age at diagnosis was 6.5 months (1 month-6 years). Presentation with pulmonary hypertension occurred in 26/39 (67%) and 29/39 (74%) had bronchopulmonary dysplasia, 15 (39%) were born of twin pregnancies with unaffected twin siblings. A median of 5 (range 1-25) echocardiograms was performed prior to diagnosis. The diagnosis was made using echocardiography in 22/39 (56%), by multi-detector contrast computed tomography scan (CT) in 8/39 (21%), cardiac catheterization in 6/39 (15%) patients, magnetic resonance imaging in 3/39 (8%). Freedom from death or re-stenosis was 73% at 1-year, 55% at 2, 5, and 10 years. Factors associated with shorter survival or re-stenosis were stenosis of ≥3 pulmonary veins (P < 0.01), bilateral pulmonary vein stenosis (P < 0.01) small for gestational age (P = 0.05), aged <6 months at diagnosis (P < 0.01). CONCLUSION Pulmonary vein stenosis of ex-premature infants is a complex problem with poor survival, delayed diagnosis, and unsatisfactory treatment. The lack of concordance in twins suggests epigenetic or environmental factors may play a role in the development of pulmonary vein stenosis. In ex-premature infants with pulmonary hypertension and bronchopulmonary dysplasia a focused echocardiographic assessment of the pulmonary veins is required with further imaging if the echocardiogram is inconclusive.
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Affiliation(s)
- Linda Mahgoub
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Tarek Kaddoura
- Electrical and Computer Engineering, University of Alberta, Edmonton, Canada
| | - A Rebecca Kameny
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | | | | | - Frank Dicke
- Alberta Children's Hospital, Calgary, Canada
| | - Ivan Rebeyka
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | | | | | - Maria Jesus Del Cerro
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Jeff Fineman
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Ian Adatia
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
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96
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Chen CM, Lin W, Huang LT, Chou HC. Human mesenchymal stem cells ameliorate experimental pulmonary hypertension induced by maternal inflammation and neonatal hyperoxia in rats. Oncotarget 2017; 8:82366-82375. [PMID: 29137270 PMCID: PMC5669896 DOI: 10.18632/oncotarget.19388] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 06/30/2017] [Indexed: 01/05/2023] Open
Abstract
Pulmonary hypertension is a critical problem in infants with bronchopulmonary dysplasia. This study determined the therapeutic effects of human mesenchymal stem cells (MSCs) on pulmonary hypertension in an animal model. Pregnant Sprague-Dawley rats were intraperitoneally injected with lipopolysaccharide (LPS, 0.5 mg/kg/day) on gestational days 20 and 21. The pups were randomly assigned to two treatment conditions: room air (RA) or an O2-enriched atmosphere. On postnatal day 5, they were intratracheally transplanted with human MSCs (3 × 105 and 1 × 106 cells) in 0.03 mL of normal saline (NS). Five study groups were examined: normal, LPS+RA+NS, LPS+O2+NS, LPS+O2+MSCs (3 × 105 cells), and LPS+O2+MSCs (1 × 106 cells). On postnatal day 14, the pup lungs and hearts were collected for histological examinations. The LPS+RA+NS and LPS+O2+NS groups exhibited a significantly higher right ventricle (RV):left ventricle (LV) thickness ratio and medial wall thickness (MWT) and higher β-myosin heavy chain (β-MHC) and toll-like receptor (TLR) 4 expression than did the normal group. Human MSC transplantation in LPS- and O2-treated rats reduced the MWT, RV:LV thickness ratio, and β-MHC and TLR4 expression to normal levels. Thus, intratracheal human MSC transplantation ameliorates pulmonary hypertension, probably by suppressing TLR4 expression in newborn rats.
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Affiliation(s)
- Chung-Ming Chen
- Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Willie Lin
- Meridigen Biotech Co., Ltd., Taipei, Taiwan
| | - Liang-Ti Huang
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Chu Chou
- Department of Anatomy and Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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97
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Vyas-Read S, Kanaan U, Shankar P, Stremming J, Travers C, Carlton DP, Fitzpatrick A. Early characteristics of infants with pulmonary hypertension in a referral neonatal intensive care unit. BMC Pediatr 2017; 17:163. [PMID: 28697724 PMCID: PMC5506674 DOI: 10.1186/s12887-017-0910-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/29/2017] [Indexed: 12/17/2022] Open
Abstract
Background Approximately 8–23% of premature infants develop pulmonary hypertension (PH), and this diagnosis confers a higher possibility of mortality. As a result, professional societies recommend PH screening in premature infants. However, the risk factors for and the outcomes of PH may differ depending on the timing of its diagnosis, and little evidence is available to determine at-risk infants in the referral neonatal population. The objective of this study was to define clinical and echocardiographic characteristics of infants with pulmonary hypertension during the neonatal hospital course and at or near-term. Methods Infants who had the following billing codes: < 32 weeks, birth weight < 1500 g, neonatal unit, and echocardiograph had records abstracted from a data warehouse at Children’s Healthcare of Atlanta. The outcome was defined as late PH on the final echocardiogram for all patients, and, separately, for patients with multiple studies. Descriptive statistics, univariable, and multivariable models were evaluated, and odds ratios and 95% confidence intervals are expressed below as (OR, CI). Results 556 infants were included in the overall study, 59 had PH on their final echocardiogram (11%). In multivariable analyses, atrial septal defect (2.9, 1.4–6.1), and intrauterine growth restriction (2.7, 1.2–6.3) increased the odds of late PH, whereas caffeine therapy decreased PH (0.4, 0.2–0.8). When the analyses were restricted to 32 infants who had multiple echocardiograms during their hospitalization, the association between atrial septal defect (5.9, 2.0–16.5) and growth restriction (3.7, 1.3–10.7) and late PH was strengthened, but the effect of caffeine therapy was no longer significant. In this smaller subgroup, infants with late PH had their final echocardiogram at a median of 116 days of life, and 42–74% of them had right ventricular pathology. Conclusions Early clinical variables are associated with PH persistence in a referral neonatal population. Identification of early clinical factors may help guide the ascertainment of infant risk for late PH, and may aid in targeting sub-groups that are most likely to benefit from PH screening.
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Affiliation(s)
- Shilpa Vyas-Read
- Pediatrics, Emory University School of Medicine, Atlanta, GA, USA. .,Division of Neonatology, Emory University School of Medicine, 2015 Uppergate Dr. NE, 3rd floor, 30322, Atlanta, GA, USA.
| | - Usama Kanaan
- Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Sibley Heart Center, Pulmonary Hypertension Program, Atlanta, GA, USA
| | - Prabhu Shankar
- Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Jane Stremming
- Department of Pediatrics, University of Colorado, Denver, CO, USA
| | - Curtis Travers
- Biostatistics, Pediatric Research Alliance, Atlanta, GA, USA
| | - David P Carlton
- Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Anne Fitzpatrick
- Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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98
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Mandell EW, Abman SH. Fetal Vascular Origins of Bronchopulmonary Dysplasia. J Pediatr 2017; 185:7-10.e1. [PMID: 28359535 DOI: 10.1016/j.jpeds.2017.03.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/08/2017] [Indexed: 12/13/2022]
Affiliation(s)
| | - Steven H Abman
- Pediatric Heart Lung Center; Section of Pulmonary Medicine Department of Pediatrics University of Colorado Denver Anschutz Medical Center Children's Hospital Colorado Aurora, Colorado.
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Altit G, Dancea A, Renaud C, Perreault T, Lands LC, Sant'Anna G. Pathophysiology, screening and diagnosis of pulmonary hypertension in infants with bronchopulmonary dysplasia - A review of the literature. Paediatr Respir Rev 2017; 23:16-26. [PMID: 27986502 DOI: 10.1016/j.prrv.2016.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a common complication of extreme prematurity, which has increased over the last 20 years. BPD is associated with increased morbidities and mortality. It has been increasingly recognized that BPD affects overall lung development including the pulmonary vasculature. More recent studies have demonstrated an increased awareness of pulmonary arterial hypertension (PH) in BPD patients and recent international guidelines have advocated for better screening. This review will describe the current understanding of the pathophysiology of PH in infants with BPD, the in-depth assessment of the available literature linking PH and BPD, and propose an approach of screening and diagnosis of PH in infants with BPD.
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Weismann CG, Asnes JD, Bazzy-Asaad A, Tolomeo C, Ehrenkranz RA, Bizzarro MJ. Pulmonary hypertension in preterm infants: results of a prospective screening program. J Perinatol 2017; 37:572-577. [PMID: 28206997 DOI: 10.1038/jp.2016.255] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 11/02/2016] [Accepted: 12/13/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Determine prevalence and associations with pulmonary hypertension (PH) in preterm infants. STUDY DESIGN Prospective institutional echocardiographic PH screening at 36 to 38 weeks' corrected gestational age (GA) for infants born <32 weeks' GA who had bronchopulmonary dysplasia (BPD; group BPD), and infants without BPD who had a birth weight (BW) <750 g, or clinical suspicion for PH (group NoBPD). RESULTS Two hundred and four infants were screened (GA 25.9±2 weeks, BW 831±286 g). The PH prevalence in group BPD was higher than in group NoBPD (44/159 (28%) vs 5/45 (11%); P=0.028). In group BPD, BW and GA were lower in infants with PH compared with NoPH. Following correction for BW and GA, necrotizing enterocolitis (NEC), severe intraventricular hemorrhage (IVH), atrial septal defect (ASD), and mortality were independently associated with PH in infants with BPD. In group NoBPD, NEC was the only identified factor associated with PH. Altogether, screening only those infants with NEC and infants with BPD who also had a BW <840 g would have yielded a 84% sensitivity for detecting PH, and reduced the number of screening echocardiograms by 43%. CONCLUSIONS PH in prematurity is associated with NEC in infants with and without BPD. In infants with BPD, smaller GA and BW, severe IVH, ASD and mortality are also associated with PH. Infants without identified PH-associated factors may not require routine echocardiographic PH screening.
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Affiliation(s)
- C G Weismann
- Department of Pediatrics, Division of Pediatric Cardiology, Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA.,Pediatric Heart Center, Skåne Universitetssjukhus, Lasarettgatan 48, Lund, Sweden
| | - J D Asnes
- Department of Pediatrics, Division of Pediatric Cardiology, Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - A Bazzy-Asaad
- Department of Pediatrics, Section of Pediatric Respiratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - C Tolomeo
- Department of Pediatrics, Section of Pediatric Respiratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - R A Ehrenkranz
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - M J Bizzarro
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT, USA
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