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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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Maiwald CA, Niemarkt HJ, Poets CF, Urschitz MS, König J, Hummler H, Bassler D, Engel C, Franz AR. Effects of closed-loop automatic control of the inspiratory fraction of oxygen (FiO 2-C) on outcome of extremely preterm infants - study protocol of a randomized controlled parallel group multicenter trial for safety and efficacy. BMC Pediatr 2019; 19:363. [PMID: 31630690 PMCID: PMC6802113 DOI: 10.1186/s12887-019-1735-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023] Open
Abstract
Background Most extremely low gestational age neonates (ELGANS, postmenstrual age at birth (PMA) < 28 completed weeks) require supplemental oxygen and experience frequent intermittent hypoxemic and hyperoxemic episodes. Hypoxemic episodes and exposure to inadequately high concentrations of oxygen are associated with an increased risk of retinopathy of prematurity (ROP), chronic lung disease of prematurity (BPD), necrotizing enterocolitis (NEC), neurodevelopmental impairment (NDI), and death beyond 36 weeks PMA. Closed-loop automated control of the inspiratory fraction of oxygen (FiO2-C) reduces time outside the hemoglobin oxygen saturation (SpO2) target range, number and duration of hypo- and hyperoxemic episodes and caregivers’ workload. Effects on clinically important outcomes in ELGANs such as ROP, BPD, NEC, NDI and mortality have not yet been studied. Methods An outcome-assessor-blinded, randomized controlled, parallel-group trial was designed and powered to study the effect of FiO2-C (in addition to routine manual control (RMC) of FiO2), compared to RMC only, on death and severe complications related to hypoxemia and/or hyperoxemia. 2340 ELGANS with a GA of 23 + 0/7 to 27 + 6/7 weeks will be recruited in approximately 75 European tertiary care neonatal centers. Study participants are randomly assigned to RMC (control-group) or FiO2-C in addition to RMC (intervention-group). Central randomization is stratified for center, gender and PMA at birth (< 26 weeks and ≥ 26 weeks). FiO2-C is provided by commercially available and CE-marked ventilators with an FiO2-C algorithm intended for use in newborn infants. The primary outcome variable (composite of death, severe ROP, BPD or NEC) is assessed at 36 weeks PMA (or, in case of ROP, until complete vascularization of the retina, respectively). The co-primary outcome variable (composite outcome of death, language/cognitive delay, motor impairment, severe visual impairment or hearing impairment) is assessed at 24 months corrected age. Discussion Short-term studies on FiO2-C showed improved time ELGANs spent within their assigned SpO2 target range, but effects of FiO2-C on clinical outcomes are yet unknown and will be addressed in the FiO2-C trial. This will ensure an appropriate assessment of safety and efficacy before FiO2-C may be implemented as standard therapy. Trial registration The study is registered at www.ClinicalTrials.gov: NCT03168516, May 30, 2017.
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Affiliation(s)
- Christian A Maiwald
- Department of Neonatology, University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany.,Center for Pediatric Clinical Studies (CPCS), University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany
| | | | - Christian F Poets
- Department of Neonatology, University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Michael S Urschitz
- Institute of Medical Biostatistics, Epidemiology and Informatics, Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | | | - Corinna Engel
- Center for Pediatric Clinical Studies (CPCS), University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany. .,Center for Pediatric Clinical Studies (CPCS), University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany.
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Aranda JV, Qu J, Valencia GB, Beharry KD. Pharmacologic interventions for the prevention and treatment of retinopathy of prematurity. Semin Perinatol 2019; 43:360-366. [PMID: 31153620 DOI: 10.1053/j.semperi.2019.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Retinopathy of Prematurity (ROP) is a preventable neovascular retinal disease with a lifetime impact on vision and ocular morbidities. Retinal vessel immaturity and oxygen therapy, influenced or modulated by several risk factors including oxidative stress, intermittent hypoxia and desaturations, inflammation, infection, malnutrition, retinal growth factor deficiencies or excesses, and others are determinant factors of pathologic retinal angiogenesis and ROP. These factors are pharmacologic targets for prevention and/or rescue therapy. These drugs, include intravitreal anti-vascular endothelial growth factor drugs, erythropoietin, ocular propranolol, caffeine, antioxidants, insulin-like growth factor-I, and omega 3 poly-unsaturated fatty acids, and are promising therapies to prevent ROP, but require further studies. Topical ocular non-steroidal anti-inflammatory drugs (NSAIDs) target inflammatory cascade but the best, safest, and most effective ocular NSAID and formulation remain to be developed. Timing of drug intervention appears critical. Moreover, the complex interactions of the various pathophysiologic mechanisms resulting in aberrant angiogenesis thence ROP strongly suggest that drug combinations and synergisms may be required for effective prevention of ROP and a lifetime of blindness.
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Affiliation(s)
- Jacob V Aranda
- Department of Pediatrics, Division of Neonsatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States; Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States; State University of New York Eye Institute, New York, NY 10075, United States.
| | - Jun Qu
- State University of New York Eye Institute, New York, NY 10075, United States; Department of Pharmaceutical Sciences, State University of New York in Buffalo, Buffalo, NY, United States
| | - Gloria B Valencia
- Department of Pediatrics, Division of Neonsatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonsatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States; Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States; State University of New York Eye Institute, New York, NY 10075, United States
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Claure N, Bancalari E. Targeting Arterial Oxygen Saturation by Closed-Loop Control of Inspired Oxygen in Preterm Infants. Clin Perinatol 2019; 46:567-577. [PMID: 31345547 DOI: 10.1016/j.clp.2019.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Exposure to hyperoxemia from excessive oxygen supplementation and episodes of intermittent hypoxemia have been associated with damage to the eye, lung, and central nervous system in premature infants. The inherent respiratory instability of the premature infant combined with limited staffing or equipment resources often affect SpO2 targeting and increase exposure to extreme SpO2 levels. Multiple systems for closed loop control of inspired oxygen have been developed to improve SpO2 targeting. This article reviews the evidence provided by clinical studies evaluating the efficacy of these systems in extreme premature infants.
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Affiliation(s)
- Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, PO Box 016960 R-131, Miami, FL 33101, USA.
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, PO Box 016960 R-131, Miami, FL 33101, USA
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Abstract
Intermittent hypoxemia (IH) events are common during early postnatal life, particularly in preterm infants. These events have been associated with multiple morbidities, including retinopathy of prematurity, sleep disordered breathing, neurodevelopmental impairment, and mortality. The relationship between IH and poor outcomes may depend on the patterns (frequency, duration, and timing) of the IH events. Current treatment modalities used in the clinical setting have been only partially successful in reducing the incidence of apnea and accompanying IH, but the risks and benefits of more aggressive interventions should include knowledge of the relationship between IH and morbidity.
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Affiliation(s)
- Juliann M. Di Fiore
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, Division of Neonatology, Suite RBC 3100, Cleveland, OH 44106-6010
| | - Peter M MacFarlane
- Case Western Reserve University, Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, USA
| | - Richard J Martin
- Case Western Reserve University, Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, USA
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Oxygen desaturations in the early neonatal period predict development of bronchopulmonary dysplasia. Pediatr Res 2019; 85:987-993. [PMID: 30374050 PMCID: PMC6488465 DOI: 10.1038/s41390-018-0223-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bradycardia and oxygen desaturation episodes are common among preterm very low birth weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU), and their association with adverse outcomes such as bronchopulmonary dysplasia (BPD) is unclear. METHODS For 502 VLBW infants we quantified bradycardias (HR < 100 for ≥ 4 s) and desaturations (SpO2 < 80% for ≥ 10 s), combined bradycardia and desaturation (BD) events, and percent time in events in the first 4 weeks after birth (32 infant-years of data). We tested logistic regression models of clinical risks (including a respiratory acuity score incorporating FiO2 and level of respiratory support) to estimate the risks of BPD or death and secondary outcomes. We then tested the additive value of the bradycardia and desaturation metrics for outcomes prediction. RESULTS BPD occurred in 187 infants (37%). The clinical risk model had ROC area for BPD of 0.874. Measures of desaturation, but not bradycardia, significantly added to the predictive model. Desaturation metrics also added to clinical risks for prediction of severe intraventricular hemorrhage, retinopathy of prematurity and prolonged length of stay in the NICU. CONCLUSIONS Oxygen desaturations in the first month of the NICU course are associated with risk of BPD and other morbidities in VLBW infants.
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Intermittent hypoxemia and oxidative stress in preterm infants. Respir Physiol Neurobiol 2019; 266:121-129. [PMID: 31100375 DOI: 10.1016/j.resp.2019.05.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/17/2019] [Accepted: 05/10/2019] [Indexed: 01/11/2023]
Abstract
Intermittent hypoxemia events (IH) are common in extremely preterm infants and are associated with many poor outcomes including retinopathy or prematurity, wheezing, bronchopulmonary dysplasia, cognitive or language delays and motor impairment. More recent data in animal and rodent models have suggested that specific patterns of IH may increase the risk for morbidity. The pathway by which these high risk patterns of IH initiate a pathological cascade is unknown but animal models suggest that oxidative stress may play a role. This review describes early postnatal patterns of IH in preterm infants, their relationship with morbidity, oxidative stress biomarkers relevant to the newborn infant and the relationship between IH and reactive oxygen species.
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58
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Dennery PA, Di Fiore JM, Ambalavanan N, Bancalari E, Carroll JL, Claure N, Hamvas A, Hibbs AM, Indic P, Kemp J, Krahn KN, Lake D, Laposky A, Martin RJ, Natarajan A, Rand C, Schau M, Weese-Mayer DE, Zimmet AM, Moorman JR. Pre-Vent: the prematurity-related ventilatory control study. Pediatr Res 2019; 85:769-776. [PMID: 30733614 PMCID: PMC6503843 DOI: 10.1038/s41390-019-0317-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The increasing incidence of bronchopulmonary dysplasia in premature babies may be due in part to immature ventilatory control, contributing to hypoxemia. The latter responds to ventilation and/or oxygen therapy, treatments associated with adverse sequelae. This is an overview of the Prematurity-Related Ventilatory Control Study which aims to analyze the under-utilized cardiorespiratory continuous waveform monitoring data to delineate mechanisms of immature ventilatory control in preterm infants and identify predictive markers. METHODS Continuous ECG, heart rate, respiratory, and oxygen saturation data will be collected throughout the NICU stay in 500 infants < 29 wks gestation across 5 centers. Mild permissive hypercapnia, and hyperoxia and/or hypoxia assessments will be conducted in a subcohort of infants along with inpatient questionnaires, urine, serum, and DNA samples. RESULTS Primary outcomes will be respiratory status at 40 wks and quantitative measures of immature breathing plotted on a standard curve for infants matched at 36-37 wks. Physiologic and/or biologic determinants will be collected to enhance the predictive model linking ventilatory control to outcomes. CONCLUSIONS By incorporating bedside monitoring variables along with biomarkers that predict respiratory outcomes we aim to elucidate individualized cardiopulmonary phenotypes and mechanisms of ventilatory control contributing to adverse respiratory outcomes in premature infants.
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Affiliation(s)
- Phyllis A. Dennery
- Brown University, Warren Alpert School of Medicine, Hasbro Children’s Hospital, Providence, RI,Address for Correspondence Phyllis A. Dennery, MD, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Office of the Chair, Hasbro Children’s Hospital, 593 Eddy Street, Suite 125 / Providence, RI 02903, (401) 444-5648,
| | - Juliann M. Di Fiore
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Namasivayam Ambalavanan
- University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics Molecular and Cellular Pathology, and Cell, Developmental, and Integrative Biology, Birmingham, AL
| | - Eduardo Bancalari
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - John L. Carroll
- University of Arkansas for Medical Science, Department of Pediatrics, Little Rock, AR
| | - Nelson Claure
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - Aaron Hamvas
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Anna Maria Hibbs
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Premananda Indic
- University of Texas Tyler, Department of Electrical Engineering, University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics, Tyler, TX
| | - James Kemp
- Washington University School of Medicine in St. Louis, Department of Pediatrics, St. Louis, MO
| | - Katy N. Krahn
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Douglas Lake
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Aaron Laposky
- National Institute of Health, National Center of Sleep Disorders Research, Bethesda, MD
| | - Richard J. Martin
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Aruna Natarajan
- Division of Lung Diseases, National Heart Lung and Blood Institute, National Institute of Health, Bethesda, MD
| | - Casey Rand
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Molly Schau
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Debra E. Weese-Mayer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Amanda M. Zimmet
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - J. Randall Moorman
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
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Hartnett ME, Toth CA. Experimental Evidence Behind Clinical Trial Outcomes in Retinopathy of Prematurity. Ophthalmic Surg Lasers Imaging Retina 2019; 50:228-234. [PMID: 30998244 DOI: 10.3928/23258160-20190401-05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/05/2018] [Indexed: 12/14/2022]
Abstract
Treatment of severe retinopathy of prematurity (ROP) has evolved over the last decade. This article reviews recent clinical trials and experimental evidence that supports clinical outcomes and observations, including the efficacy of anti-vascular endothelial growth factor (VEGF) agents in reducing the vascular activity of severe ROP, and the mechanisms behind recurrent stage 3 ROP and plus disease in some infants treated with anti-VEGF agents. Also discussed will be current imaging modalities that link experimental models of ROP with longitudinal human studies and which provide exciting future opportunities to enhance the understanding of pathophysiology of ROP and improve treatments. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:228-234.].
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Raffay TM, Dylag AM, Sattar A, Abu Jawdeh EG, Cao S, Pax BM, Loparo KA, Martin RJ, Di Fiore JM. Neonatal intermittent hypoxemia events are associated with diagnosis of bronchopulmonary dysplasia at 36 weeks postmenstrual age. Pediatr Res 2019; 85:318-323. [PMID: 30538265 PMCID: PMC6377834 DOI: 10.1038/s41390-018-0253-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is a chronic lung disease and major pulmonary complication after premature birth. We have previously shown that increased intermittent hypoxemia (IH) events have been correlated to adverse outcomes and mortality in extremely premature infants. We hypothesize that early IH patterns are associated with the development of BPD. METHODS IH frequency, duration, and nadirs were assessed using oxygen saturation (SpO2) waveforms in a retrospective cohort of 137 extremely premature newborns (<28 weeks gestation). Daily levels of inspired oxygen and mean airway pressure exposures were also recorded. RESULTS Diagnosis of BPD at 36 weeks postmenstrual age was associated with increased daily IH, longer IH duration, and a higher IH nadir. Significant differences were detected through day 7 to day 26 of life. Infants who developed BPD had lower mean SpO2 despite their exposure to increased inspired oxygen and increased mean airway pressure. CONCLUSIONS BPD was associated with more frequent, longer, and less severe IH events in addition to increased oxygen and pressure exposure within the first 26 days of life. Early IH patterns may contribute to the development of BPD or aid in identification of neonates at high risk.
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Affiliation(s)
- Thomas M Raffay
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Andrew M Dylag
- Division of Neonatology, Golisano Children’s Hospital, Department of Pediatrics, University of Rochester, Rochester, NY
| | - Abdus Sattar
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Elie G Abu Jawdeh
- Division of Neonatology, Kentucky Children’s Hospital, Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Shufen Cao
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH
| | - Benjamin M Pax
- Department of Electrical Engineering and Computer Science & Institute for Smart, Secure and Connected Systems, Case Western Reserve University, Cleveland, OH
| | - Kenneth A Loparo
- Department of Electrical Engineering and Computer Science & Institute for Smart, Secure and Connected Systems, Case Western Reserve University, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies & Children's Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA.
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Di Fiore JM, Dylag AM, Honomichl RD, Hibbs AM, Martin RJ, Tatsuoka C, Raffay TM. Early inspired oxygen and intermittent hypoxemic events in extremely premature infants are associated with asthma medication use at 2 years of age. J Perinatol 2019; 39:203-211. [PMID: 30367103 PMCID: PMC6351157 DOI: 10.1038/s41372-018-0264-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/07/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Extremely premature infants are at risk for childhood wheezing. Early respiratory support and intermittent hypoxemia (IH) events may be associated with adverse breathing outcomes. STUDY DESIGN A single-center retrospective cohort study of 137 premature infants <28 weeks gestational age characterized the associations of cumulative oxygen, cumulative mean airway pressure, IH, and oxygen saturation (SpO2) on the primary outcome of prescription asthma medication use at 2-year follow-up. Relative risk was calculated by generalized estimating equations. RESULTS Reported asthma medication use was 46%. At 1-3 days of age, elevated cumulative oxygen exposure, increased daily IH, and lower mean SpO2 (adjusted for gestational age and sex) and increased cumulative mean airway pressure exposure (unadjusted) were associated with asthma medication use. CONCLUSION Increased oxygen and frequent IH events during just the first 3 days of age may help identify extremely premature newborns at risk for symptomatic childhood wheezing requiring prescription asthma medications.
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Affiliation(s)
- Juliann M. Di Fiore
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Andrew M. Dylag
- Division of Neonatology, Golisano Children’s Hospital, University of Rochester, Rochester, NY
| | - Ryan D. Honomichl
- Division of Neurology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH
| | - Anna Maria Hibbs
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Richard J. Martin
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Curtis Tatsuoka
- Division of Neurology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH
| | - Thomas M. Raffay
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
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Feng Y, Cheng R, Zhao L, Chen X, Mao XN, Qiu J. [Clinical effect of early or late administration of caffeine citrate in prevention and treatment of apnea in very low birth weight infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:979-984. [PMID: 30572984 PMCID: PMC7389489 DOI: 10.7499/j.issn.1008-8830.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/13/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To study the clinical effect of early or late administration of caffeine citrate in the prevention and treatment of apnea in very low birth weight (VLBW) infants. METHODS A total of 82 VLBW infants who were hospitalized and treated in the neonatal intensive care unit between June 2015 and May 2017 were enrolled. According to the age in days when caffeine citrate treatment was started, they were divided into early treatment group (<3 days) with 22 infants and late treatment group (3 - <10 days) with 60 infants. A retrospective analysis was performed for their clinical data. The two groups were compared in terms of general information during the perinatal period, treatment process, and clinical outcome. RESULTS Compared with the late treatment group, the early treatment group had a significantly lower birth weight (P=0.004), significantly shorter durations of mechanical ventilation and oxygen inhalation (P<0.05), and a significantly lower incidence rate of bronchopulmonary dysplasia (P=0.032). There were no significant differences in other general information, treatment process, and clinical outcome between the two groups (P>0.05). CONCLUSIONS Early administration of caffeine citrate can improve the prognosis of VLBW infants.
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Affiliation(s)
- Yun Feng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China.
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Beharry KD, Cai CL, Siddiqui F, Chowdhury S, D'Agrosa C, Valencia GB, Aranda JV. Comparative Effects of Coenzyme Q10 or n-3 Polyunsaturated Fatty Acid Supplementation on Retinal Angiogenesis in a Rat Model of Oxygen-Induced Retinopathy. Antioxidants (Basel) 2018; 7:E160. [PMID: 30423931 PMCID: PMC6262377 DOI: 10.3390/antiox7110160] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/19/2018] [Accepted: 11/05/2018] [Indexed: 12/27/2022] Open
Abstract
Neonatal intermittent hypoxia (IH) or apnea afflicts 70% to 90% of all preterm infants <28 weeks gestation, and is associated with severe retinopathy of prematurity (ROP). We tested the hypotheses that coenzyme Q10 (CoQ10) or omega-3 polyunsaturated fatty acids (n-3 PUFAs) supplementation during neonatal IH reduces the severity of oxygen-induced retinopathy (OIR). Newborn rats were exposed to two IH paradigms: (1) 50% O₂ with brief hypoxia (12% O₂); or (2) 21% O₂ with brief hypoxia, until postnatal day 14 (P14), during which they received daily oral CoQ10 in olive oil, n-3 PUFAs in fish oil, or olive oil only and compared to room air (RA) treated groups. Pups were examined at P14, or placed in RA until P21. Retinal angiogenesis, histopathology, and morphometry were determined. Both IH paradigms produced severe OIR, but these were worsened with 50/12% O₂ IH. CoQ10 and n-3 PUFAs reduced the severity of OIR, as well as ocular growth factors in both IH paradigms, but CoQ10 was more effective in 50/12% O₂ IH. Supplementation with either CoQ10 or n-3 PUFAs targeting IH-induced retinal injury is individually effective for ameliorating specific characteristics consistent with ROP. Given the complexity of ROP, further studies are needed to determine whether combined CoQ10 and n-3 PUFAs supplementation would optimize their efficacy and result in a better outcome.
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Affiliation(s)
- Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
- Department of Ophthalmology; State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
- State University of New York Department of Ophthalmology Eye Institute, New York, NY 10062, USA.
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| | - Faisal Siddiqui
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| | - Sara Chowdhury
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| | - Christina D'Agrosa
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| | - Gloria B Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
- Department of Ophthalmology; State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
- State University of New York Department of Ophthalmology Eye Institute, New York, NY 10062, USA.
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Oxygen-Induced Retinopathy from Recurrent Intermittent Hypoxia Is Not Dependent on Resolution with Room Air or Oxygen, in Neonatal Rats. Int J Mol Sci 2018; 19:ijms19051337. [PMID: 29724000 PMCID: PMC5983662 DOI: 10.3390/ijms19051337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 12/24/2022] Open
Abstract
Preterm infants often experience intermittent hypoxia (IH) with resolution in room air (RA) or hyperoxia (Hx) between events. Hypoxia is a major inducer of vascular endothelial growth factor, which plays a key role in normal and aberrant retinal angiogenesis. This study tested the hypothesis that neonatal IH which resolved with RA is less injurious to the immature retina than IH resolved by Hx between events. Newborn rats were exposed to: (1) Hx (50% O2) with brief hypoxia (12% O2); (2) RA with 12% O2; (3) Hx with RA; (4) Hx only; or (5) RA only, from P0 to P14. Pups were examined at P14 or placed in RA until P21. Retinal vascular and astrocyte integrity; retinal layer thickness; ocular and systemic biomarkers of angiogenesis; and somatic growth were determined at P14 and P21. All IH paradigms resulted in significant retinal vascular defects, disturbances in retinal astrocyte template, retinal thickening, and photoreceptor damage concurrent with elevations in angiogenesis biomarkers. These data suggest that the susceptibility of the immature retina to changes in oxygen render no differences in the outcomes between RA or O2 resolution. Interventions and initiatives to curtail O2 variations should remain a high priority to prevent severe retinopathy.
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Beharry KD, Cai CL, Ahmad T, Guzel S, Valencia GB, Aranda JV. Impact of Chronic Neonatal Intermittent Hypoxia on Severity of Retinal Damage in a Rat Model of Oxygen-Induced Retinopathy. JOURNAL OF NATURE AND SCIENCE 2018; 4:e488. [PMID: 29552637 PMCID: PMC5851484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Neonatal intermittent hypoxia (IH) followed by re-oxygenation in normoxia or supplemental oxygen (IHR) increases the risk for severe retinopathy of prematurity (ROP). The exact timing for the onset of retinal damage which may guide strategic interventions during retinal development, is unknown. We tested the hypothesis that chronic exposure of the immature retina to neonatal IH induces early manifestations of retinal damage that can be utilized as key time points for strategic pharmacologic intervention. Newborn rats were exposed to IH within 2 hours of birth (P0) until P14, or allowed to recover in room air (RA) from P14 to P21 (IHR). Retinal integrity and angiogenesis biomarkers were progressively assessed before (P0), during IH, and post IH (recovery in RA), or IHR, and compared to normoxic age-matched controls. Retinal damage occurred as early as day 3 of neonatal IH, consistent with vascular abnormalities and disturbances in the astrocytic template. These abnormalities worsened during IHR. Pharmacologic and non-pharmacologic interventions to identify, prevent, or minimize neonatal IH should be implemented shortly after birth in high risk preterm newborns. This strategy may lead to a reduction in the outcome of severe ROP requiring later invasive treatments.
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Affiliation(s)
- Kay D. Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
- Department of Ophthalmology; State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
- State University of New York Eye Institute, New York, NY10062, USA
| | - Charles L. Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
| | - Taimur Ahmad
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
| | - Sibel Guzel
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
| | - Gloria B. Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
| | - Jacob V. Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
- Department of Ophthalmology; State University of New York, Downstate Medical Center, Brooklyn, NY11203, USA
- State University of New York Eye Institute, New York, NY10062, USA
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66
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Beharry KD, Cai CL, Valencia GB, Lazzaro D, Valencia AM, Salomone F, Aranda JV. Human retinal endothelial cells and astrocytes cultured on 3-D scaffolds for ocular drug discovery and development. Prostaglandins Other Lipid Mediat 2018; 134:93-107. [PMID: 28923362 PMCID: PMC5803320 DOI: 10.1016/j.prostaglandins.2017.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/11/2017] [Accepted: 09/14/2017] [Indexed: 12/20/2022]
Abstract
Topical ocular ketorolac improves the outcomes of severe retinopathy of prematurity and when administered with systemic caffeine, decreases the severity of oxygen-induced retinopathy. We tested the hypothesis that co-cultures of human retinal endothelial cells (HRECs) and human retinal astrocytes (HRAs) on 3-dimensional (3-D) hydrogel scaffolds is a more representative biomimetic paradigm of the blood-retinal-barrier (BRB) than 2-D cultures, and should be utilized for preclinical drug discovery and development. Mono- and co-cultures of HRECs and HRAs were treated with standard doses of ketorolac, ibuprofen, and/or caffeine, and exposed to hyperoxia, intermittent hypoxia (IH), or normoxia on 2-D surfaces or 3-D biodegradable hydrogel scaffolds (AlgiMatrix or Geltrex). Media and cells were collected at 72h post treatment for arachidonic acid metabolites. Cells cultured on 3-D scaffolds exhibited less oxidative stress and variability in drug responses. HRAs enhanced the responses of HRECs to drugs and changes in oxygen environment. PGE2 and PGI2 were the predominant prostanoids produced in response to IH, reflecting COX-2 immunoreactivity. We conclude that HRECs and HRAs co-cultured on 3-D scaffolds may recapitulate drug responses of the dynamic BRB and therefore should be implemented for preclinical ocular drug discovery and development.
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Affiliation(s)
- Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; SUNY Eye Institute, NY, NY, USA.
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Gloria B Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Douglas Lazzaro
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; SUNY Eye Institute, NY, NY, USA
| | | | | | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; SUNY Eye Institute, NY, NY, USA
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67
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Ocular Adverse Effects of Intravitreal Bevacizumab Are Potentiated by Intermittent Hypoxia in a Rat Model of Oxygen-Induced Retinopathy. J Ophthalmol 2017; 2017:4353129. [PMID: 28770109 PMCID: PMC5523466 DOI: 10.1155/2017/4353129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/09/2017] [Accepted: 05/30/2017] [Indexed: 12/02/2022] Open
Abstract
Intravitreal bevacizumab (Avastin) use in preterm infants with retinopathy of prematurity is associated with severe neurological disabilities, suggesting vascular leakage. We examined the hypothesis that intermittent hypoxia (IH) potentiates intravitreal Avastin leakage. Neonatal rats at birth were exposed to IH from birth (P0)–P14. At P14, the time of eye opening in rats, a single dose of Avastin (0.125 mg) was injected intravitreally into the left eye. Animals were placed in room air (RA) until P23 or P45 for recovery (IHR). Hyperoxia-exposed and RA littermates served as oxygen controls, and equivalent volume saline served as the placebo controls. At P23 and P45 ocular angiogenesis, retinal pathology and ocular and systemic biomarkers of angiogenesis were examined. Retinal flatmounts showed poor peripheral vascularization in Avastin-treated and fellow eyes at P23, with numerous punctate hemorrhages and dilated, tortuous vessels with anastomoses at P45 in the rats exposed to IH. These adverse effects were associated with robust increases in systemic VEGF and in both treated and untreated fellow eyes. Histological analysis showed severe damage in the inner plexiform and inner nuclear layers. Exposure of IH/IHR-induced injured retinal microvasculature to anti-VEGF substances can result in vascular leakage and adverse effects in the developing neonate.
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Patterns of Oxygenation, Mortality, and Growth Status in the Surfactant Positive Pressure and Oxygen Trial Cohort. J Pediatr 2017; 186:49-56.e1. [PMID: 28279433 PMCID: PMC5484739 DOI: 10.1016/j.jpeds.2017.01.057] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/05/2016] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To characterize actual achieved patterns of oxygenation in infants born appropriate vs small for gestational age (SGA) randomized to a lower (85-89%) vs higher (91%-95%) oxygen saturation target in the Surfactant Positive Pressure and Oxygen Trial. To determine the association between achieved oxygen saturation levels and survival in infants born appropriate vs SGA enrolled in the Surfactant Positive Pressure and Oxygen Trial. STUDY DESIGN Median oxygen saturation and intermittent hypoxemia events (<80%, 20 seconds-5 minutes) were documented in 1054 infants of 240/7-276/7 weeks of gestation while receiving supplemental oxygen during the first 3 days of life. RESULTS Lower target infants who were small for gestational age had the lowest oxygen saturation and highest incidence of intermittent hypoxemia during the first 3 days of life. The lowest quartile of oxygen saturation (≤92%) during the first 3 days of life was associated with lower 90-day survival for both infants born appropriate and SGA. An increased incidence of intermittent hypoxemia events during the first 3 days of life was associated with lower 90-day survival only in infants born SGA. CONCLUSION Lower achieved oxygen saturation during the first 3 days of life was associated with lower 90-day survival in extremely preterm infants. Infants born SGA had enhanced vulnerability to lower oxygen saturation targets as evidenced by lower achieved oxygen saturation and an association between increased intermittent hypoxemia events and lower survival. TRIAL REGISTRATION ClinicalTrials.gov: NCT00233324.
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69
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Valencia AM, Cai CL, Tan J, Duggan TJ, Valencia GB, Aranda JV, Beharry KD. Intravitreal bevacizumab alters type IV collagenases and exacerbates arrested alveologenesis in the neonatal rat lungs. Exp Lung Res 2017; 43:120-133. [PMID: 28409646 DOI: 10.1080/01902148.2017.1306897] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Purpose/Aim: Intravitreal bevacizumab (Avastin) is an irreversible vascular endothelial growth factor (VEGF) inhibitor used off-label to treat severe retinopathy of prematurity in extremely low gestational age neonates. VEGF and matrix metalloproteinases (MMPs) and the tissue inhibitors of metalloproteinases (TIMPs) participate in lung maturation. We tested the hypothesis that intravitreal bevacizumab enters the systemic circulation and has long-lasting effects on lung MMPs. MATERIALS AND METHODS Neonatal rats were exposed to: (1) hyperoxia (50% O2); (2) intermittent hypoxia (IH) (50% O2 with brief episodes of 12% O2); or (3) room air (RA) from birth (P0) to P14. At P14, the time of eye opening in rats, a single dose of Avastin (0.125 mg) was injected into the vitreous cavity of the left eye. A control group received equivalent volume saline. At P23 and P45, lung MMP-2 and MMP-9, and TIMP-1, and TIMP-2 were assessed in the lungs. RESULTS At P23, Avastin increased MMP-2, MMP-9, and TIMP-1 levels in the hyperoxia group but decreased TIMP-1 levels in the IH group. The ratios of MMP-2/TIMP-1 and MMP-9/TIMP-1 were significantly elevated at P23 in the IH group treated with Avastin. At P45, the levels of MMP-2 and MMP-9 remained elevated in the hyperoxia and IH groups treated with Avastin, while a rebound increase in TIMP-1 levels was noted in the IH group. CONCLUSIONS Avastin treatment in IH has lasting alterations in the balance between MMPs and their tissue inhibitors. These changes may lead to impaired alveologenesis and tissue damage consistent with bronchopulmonary dysplasia/chronic lung disease.
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Affiliation(s)
- Arwin M Valencia
- a Department of Pediatrics, Division of Neonatal-Perinatal Medicine , State University of New York, Downstate Medical Center , Brooklyn , New York , USA.,b Department of Pediatrics, Division of Neonatal-Perinatal Medicine , Sumerlin Hospital Medical Center, Valley Healthcare System , Las Vegas , Nevada , USA
| | - Charles L Cai
- a Department of Pediatrics, Division of Neonatal-Perinatal Medicine , State University of New York, Downstate Medical Center , Brooklyn , New York , USA
| | - Jeffrey Tan
- c Department of Ophthalmology , State University of New York, Downstate Medical Center , Brooklyn, New York , USA.,d SUNY Eye Institute , New York , New York , USA
| | - Thomas J Duggan
- a Department of Pediatrics, Division of Neonatal-Perinatal Medicine , State University of New York, Downstate Medical Center , Brooklyn , New York , USA
| | - Gloria B Valencia
- a Department of Pediatrics, Division of Neonatal-Perinatal Medicine , State University of New York, Downstate Medical Center , Brooklyn , New York , USA
| | - Jacob V Aranda
- a Department of Pediatrics, Division of Neonatal-Perinatal Medicine , State University of New York, Downstate Medical Center , Brooklyn , New York , USA.,c Department of Ophthalmology , State University of New York, Downstate Medical Center , Brooklyn, New York , USA.,d SUNY Eye Institute , New York , New York , USA
| | - Kay D Beharry
- a Department of Pediatrics, Division of Neonatal-Perinatal Medicine , State University of New York, Downstate Medical Center , Brooklyn , New York , USA.,c Department of Ophthalmology , State University of New York, Downstate Medical Center , Brooklyn, New York , USA.,d SUNY Eye Institute , New York , New York , USA
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Plottier GK, Wheeler KI, Ali SKM, Fathabadi OS, Jayakar R, Gale TJ, Dargaville PA. Clinical evaluation of a novel adaptive algorithm for automated control of oxygen therapy in preterm infants on non-invasive respiratory support. Arch Dis Child Fetal Neonatal Ed 2017; 102:F37-F43. [PMID: 27573518 DOI: 10.1136/archdischild-2016-310647] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the performance of a novel rapidly responsive proportional-integral-derivative (PID) algorithm for automated oxygen control in preterm infants with respiratory insufficiency. DESIGN Interventional study of a 4-hour period of automated oxygen control compared with combined data from two flanking periods of manual control (4 hours each). SETTING Neonatal intensive care unit. PARTICIPANTS Preterm infants (n=20) on non-invasive respiratory support and supplemental oxygen, with oxygen saturation (SpO2) target range 90%-94% (manual control) and 91%-95% (automated control). Median gestation at birth 27.5 weeks (IQR 26-30 weeks), postnatal age 8.0 (1.8-34) days. INTERVENTION Automated oxygen control using a standalone device, receiving SpO2 input from a standard oximeter and computing alterations to oxygen concentration that were actuated with a modified blender. The PID algorithm was enhanced to avoid iatrogenic hyperoxaemia and adapt to the severity of lung dysfunction. MAIN OUTCOME MEASURE Proportion of time in the SpO2 target range, or above target range when in air. RESULTS Automated oxygen control resulted in more time in the target range or above in air (manual 56 (48-63)% vs automated 81 (76-90)%, p<0.001) and less time at both extremes of oxygenation. Prolonged episodes of hypoxaemia and hyperoxaemia were virtually eliminated. The control algorithm showed benefit in every infant. Manual changes to oxygen therapy were infrequent during automated control (0.24/hour vs 2.3/hour during manual control), and oxygen requirements were unchanged (automated control period 27%, manual 27% and 26%, p>0.05). CONCLUSIONS The novel PID algorithm was very effective for automated oxygen control in preterm infants, and deserves further investigation.
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Affiliation(s)
- Gemma K Plottier
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Kevin I Wheeler
- Neonatal Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Sanoj K M Ali
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Rohan Jayakar
- School of Engineering and ICT, University of Tasmania, Hobart, Tasmania, Australia
| | - Timothy J Gale
- School of Engineering and ICT, University of Tasmania, Hobart, Tasmania, Australia
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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71
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Quan M, Cai CL, Valencia GB, Aranda JV, Beharry KD. MnTBAP or Catalase Is More Protective against Oxidative Stress in Human Retinal Endothelial Cells Exposed to Intermittent Hypoxia than Their Co-Administration (EUK-134). REACTIVE OXYGEN SPECIES (APEX, N.C.) 2017; 3:47-65. [PMID: 29806034 PMCID: PMC5967656 DOI: 10.20455/ros.2017.801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Retinopathy of prematurity is a blinding disease that affects extremely low gestational age neonates. Its etiology is due to extrauterinehyperoxia in an immature antioxidant system culminating as oxidative stress on the retina. Our aim is to elucidate the role of pharmacological antioxidants in modulating the biochemical and molecular response of human retinal microvascular endothelial cells (HRECs) exposed to oxidative stress. HRECs were treated with MnTBAP [a superoxide dismutase (SOD) mimetic], catalase, EUK-134 (SOD + catalase), or saline prior to exposure to normoxia (Nx), hyperoxia (Hx), or intermittent hypoxia (IH). Media levels of SOD, catalase, glutathione peroxidase (GPx), 8-isoPGF2α, and H2O2; cellular SOD and catalase; cellular function (migration and tube formation); and antioxidant gene expression were assessed. Pharmacological antioxidants had delayed suppressive effect on 8-isoPGF2α. MnTBAP and catalase were more effective for H2O2 scavenging in the media than co-administration in the form of EUK-134. A delayed response was noted in SOD and catalase media activity in MnTBAP- and catalase-treated cells, respectively in 50% and IH. MnTBAP had progressively increased media GPx in all oxygen conditions. Antioxidants resulted in normal, but more abundant tubulogenesis in IH and Hx. The distinct temporal response to oxidative stress reflected the respective antioxidant's potency and catalytic properties. The cell permeability of the antioxidants limited the ability to scavenge intracellular free radicals. The results support that MnTBAP or catalase may be more effective for the prevention of oxidative stress in oxygen-induced retinopathy.
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Affiliation(s)
- Michelle Quan
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Gloria B Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- SUNY Eye Institute, New York, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- SUNY Eye Institute, New York, NY, USA
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72
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Beharry KD, Cai CL, Valencia GB, Valencia AM, Lazzaro DR, Bany-Mohammed F, Aranda JV. Neonatal Intermittent Hypoxia, Reactive Oxygen Species, and Oxygen-Induced Retinopathy. REACTIVE OXYGEN SPECIES (APEX, N.C.) 2017; 3:12-25. [PMID: 29951586 DOI: 10.20455/ros.2017.805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Most of the major morbidities in the preterm newborn are caused by or are associated with oxygen-induced injuries and are aptly called "oxygen radical diseases in neonatology or ORDIN". These include bronchopulmonary dysplasia, retinopathy of prematurity, periventricular leukomalacia, intraventricular hemorrhage, necrotizing enterocolitis and others. Relative hyperoxia immediately after birth, immature antioxidant systems, biomolecular events favoring oxidative stress such as iron availability and the role of hydrogen peroxide as a key molecular mediator of these events are reviewed. Potential therapeutic strategies such as caffeine, antioxidants, non-steroidal anti-inflammatory drugs, and others targeted to these critical sites may help prevent oxidative radical diseases in the newborn resulting in improved neonatal outcomes.
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Affiliation(s)
- Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.,State University of New York Eye Institute, New York, NY 10075, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Gloria B Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Arwin M Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Summerlin Hospital Medical Center, Valley Healthcare System, Las Vegas, NV 89135, USA
| | - Douglas R Lazzaro
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.,State University of New York Eye Institute, New York, NY 10075, USA
| | - Fayez Bany-Mohammed
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of California, Irvine, CA 92868, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.,State University of New York Eye Institute, New York, NY 10075, USA
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73
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Pharmacologic synergism of ocular ketorolac and systemic caffeine citrate in rat oxygen-induced retinopathy. Pediatr Res 2016; 80:554-65. [PMID: 27438224 PMCID: PMC5030702 DOI: 10.1038/pr.2016.105] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Caffeine or ketorolac decrease the risk of retinopathy of prematurity and may act synergistically to improve beneficial effect. Combination of caffeine (Caff) and ketorolac (Keto) to prevent oxygen-induced retinopathy was studied. METHODS Newborn rats exposed to room air (RA) or intermittent hypoxia (IH) consisting of 12% O2 during hyperoxia (50% O2) from birth (P0) had single daily IP injections of Caff from P0-P13 or saline; and/or ocular Keto (Acuvail, 0.45% ophthalmic solution) administered subcutaneously over the eyes from P5-P7. Pups were studied at P14 or placed in RA for recovery from IH (IHR) until P21. Eyes were examined for neovascularization, histopathology, growth factors, and VEGF-signaling genes. RESULTS Severe retinal damage noted during IHR in the untreated groups evidenced by hemorrhage, neovascularization, and oxygen-induced retinopathy (OIR) pathologies were prevented with Keto/Caff treatment. Keto and/or Caff treatment in IH also promoted retinal neural development evidenced by eye opening (92%, P < 0.001 vs. 31% in the placebo-treated IH group). No corneal pathologies were noted with Keto. CONCLUSION Caff or Keto given individually reduced retinal neovascularization, but the two drugs given together prevented severe OIR.
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Jones JG, Lockwood GG, Fung N, Lasenby J, Ross-Russell RI, Quine D, Stenson BJ. Influence of pulmonary factors on pulse oximeter saturation in preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F319-22. [PMID: 26602315 DOI: 10.1136/archdischild-2015-308675] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/08/2015] [Indexed: 11/04/2022]
Abstract
AIM To describe how the stability of oxygen saturation measured by pulse oximetry (SpO2%) varies within and between infants with bronchopulmonary dysplasia (BPD). METHODS Clinically stable infants with BPD had SpO2 measured at different inspired oxygen concentrations (FIO2 expressed as %). A computer model of gas exchange, that is, ventilation/perfusion ratio (VA/Q) and shunt, plotted the curve of SpO2 versus FIO2 best fitting these data. The slope of this curve is the change in SpO2 per % change in FIO2, hence SpO2 stability, calculated at each SpO2 from 85% to 95%. RESULTS Data from 16 infants with BPD previously described were analysed. The dominant gas exchange impairment was low VA/Q (median 0.35, IQR, 0.16-0.4, normal 0.86). Median shunt was 1% (IQR, 0-10.5; normal <2%). Slope varied markedly between infants, but above 95% SpO2 was always <1.5. In infants with least severe BPD (VA/Q ≈0.4, shunt ≤2%) median slope at 85% SpO2 was 5.1 (IQR, 3.7-5.5). With more severe BPD (VA/Q ≤0.3) slope was flatter throughout the SpO2 range. The highest FIO2 for 90% SpO2 was in infants with the lowest VA/Q values. CONCLUSIONS In infants with BPD, there was large variation in the slope of the curve relating SpO2% to inspired oxygen fraction in the SpO2 range 85%-95%. Slopes were considerably steeper at lower than higher SpO2, especially in infants with least severe BPD, meaning that higher SpO2 target values are intrinsically much more stable. Steep slopes below 90% SpO2 may explain why some infants appear dependent on remarkably low oxygen flows.
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Affiliation(s)
- J G Jones
- Department of Anaesthesia, Addenbrookes Hospital, Cambridge, UK
| | - G G Lockwood
- Anaesthetic Department, Hammersmith Hospital, London, UK
| | - N Fung
- Signal Processing Group, Cambridge University Engineering Department, Cambridge, UK Biomedical Signals and Systems Group, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands
| | - J Lasenby
- Signal Processing Group, Cambridge University Engineering Department, Cambridge, UK
| | | | - D Quine
- Neonatal Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - B J Stenson
- Neonatal Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
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Characterizing Fluctuations of Arterial and Cerebral Tissue Oxygenation in Preterm Neonates by Means of Data Analysis Techniques for Nonlinear Dynamical Systems. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 876:511-519. [PMID: 26782252 PMCID: PMC6125790 DOI: 10.1007/978-1-4939-3023-4_64] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The cerebral autoregulatory state as well as fluctuations in arterial (SpO2) and cerebral tissue oxygen saturation (StO2) are potentially new relevant clinical parameters in preterm neonates. The aim of the present study was to test the investigative capabilities of data analysis techniques for nonlinear dynamical systems, looking at fluctuations and their interdependence. StO2, SpO2 and the heart rate (HR) were measured on four preterm neonates for several hours. The fractional tissue oxygenation extraction (FTOE) was calculated. To characterize the fluctuations in StO2, SpO2, FTOE and HR, two methods were employed: (1) phase-space modeling and application of the recurrence quantification analysis (RQA), and (2) maximum entropy spectral analysis (MESA). The correlation between StO2 and SpO2 as well as FTOE and HR was quantified by (1) nonparametric nonlinear regression based on the alternating conditional expectation (ACE) algorithm, and (2) the maximal information-based nonparametric exploration (MINE) technique. We found that (1) each neonate showed individual characteristics, (2) a ~60 min oscillation was observed in all of the signals, (3) the nonlinear correlation strength between StO2 and SpO2 as well as FTOE and HR was specific for each neonate and showed a high value for a neonate with a reduced health status, possibly indicating an impaired cerebral autoregulation. In conclusion, our data analysis framework enabled novel insights into the characteristics of hemodynamic and oxygenation changes in preterm infants. To the best of our knowledge, this is the first application of RQA, MESA, ACE and MINE to human StO2 data measured with near-infrared spectroscopy (NIRS).
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76
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Beharry KD, Valencia G, Lazzaro D, Aranda J. Pharmacologic interventions for the prevention and treatment of retinopathy of prematurity. Semin Perinatol 2016; 40:189-202. [PMID: 26831641 PMCID: PMC4808450 DOI: 10.1053/j.semperi.2015.12.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Retinopathy of prematurity (ROP), a significant morbidity in prematurely born infants, is the most common cause of visual impairment and blindness in children and persists till adulthood. Strict control of oxygen therapy and prevention of intermittent hypoxia are the keys in the prevention of ROP, but pharmacologic interventions have decreased risk of ROP. Various drug classes such as methylxanthines (caffeine), VEGF inhibitors, antioxidants, and others have decreased ROP occurrence. The timing of pharmacologic intervention remains unsettled, but early prevention rather than controlling disease progression may be preferred. These drugs act through different mechanisms, and synergistic approaches should be considered to maximize efficacy and safety.
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77
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Abstract
Hypoxic episodes are troublesome components of bronchopulmonary dysplasia (BPD) in preterm infants. Immature respiratory control seems to be the major contributor, superimposed on abnormal respiratory function. Relatively short respiratory pauses may precipitate desaturation and bradycardia. This population is predisposed to pulmonary hypertension; it is likely that pulmonary vasoconstriction also plays a role. The natural history has been well-characterized in the preterm population at risk for BPD; however, the consequences are less clear. Proposed associations of intermittent hypoxia include retinopathy of prematurity, sleep disordered breathing, and neurodevelopmental delay. Future study should address whether these associations are causal relationships.
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Affiliation(s)
- Richard J. Martin
- Case Western Reserve University School of Medicine, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, Ohio 44106-6010, Ph: 216-844-3387/Fax: 216-844-3380
| | - Juliann M. Di Fiore
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, Ohio 44106-6010, Ph: 216-368-1245/Fax: 216-844-3380
| | - Michele C. Walsh
- Case Western Reserve University School of Medicine, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, Ohio 44106-6010, Ph: 216-844-3759/Fax: 216-844-3380
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78
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Jivabhai Patel S, Bany-Mohammed F, McNally L, Valencia GB, Lazzaro DR, Aranda JV, Beharry KD. Exogenous Superoxide Dismutase Mimetic Without Scavenging H2O2 Causes Photoreceptor Damage in a Rat Model for Oxygen-Induced Retinopathy. Invest Ophthalmol Vis Sci 2015; 56:1665-77. [PMID: 25670494 DOI: 10.1167/iovs.14-15321] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Frequent, brief intermittent episodes of hypoxia (IH) during hyperoxia increase reactive oxygen species in the immature retina with compromised antioxidant systems, thus leading to oxygen-induced retinopathy (OIR). We examined the hypothesis that early exposure to a mimetic of superoxide dismutase (SOD), the first line of defense against oxidative stress, will decrease IH-induced reactive oxygen species (ROS) and prevent severe OIR in our rat model. METHODS To test this hypothesis, newborn rats (P0) were exposed to IH consisting of alternating cycles of 50% O₂ with brief hypoxia (12% O₂) until P14 during which they were treated with a single daily intraperitoneal (IP) dose of MnTBAP (a SOD mimetic) at 1.0, 5.0, or 10.0 mg/kg on P0, P1, and P2. A saline-treated group served as vehicle controls. Groups were analyzed following IH at P14 or allowed to recover in room air (RA) until P21. Control littermates were raised in RA with all conditions identical except for inspired O₂. Ocular assessment of OIR severity, oxidative stress, angiogenesis, antioxidant activity, and oxidative phosphorylation (OXPHOS) were conducted at P14 and P21. RESULTS Collectively, the data show increased oxidative stress and angiogenesis with MnTBAP, which was associated with photoreceptor damage, retinal characteristics consistent with severe OIR, and changes in genes regulating OXPHOS. CONCLUSIONS In the setting of IH, the use of exogenous SOD mimetics must be combined with H₂O₂ scavengers in order to prevent photoreceptor damage and severe OIR.
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Affiliation(s)
- Shamin Jivabhai Patel
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of California-Irvine, Irvine, California, United States
| | - Fayez Bany-Mohammed
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of California-Irvine, Irvine, California, United States
| | - Lois McNally
- Department of Ophthalmology, State University of New York, Downstate Medical Center, New York, New York, United States State University of New York Eye Institute, New York, New York, United States
| | - Gloria B Valencia
- Department of Pediatrics, State University of New York, Downstate Medical Center, New York, New York, United States
| | - Douglas R Lazzaro
- Department of Ophthalmology, State University of New York, Downstate Medical Center, New York, New York, United States State University of New York Eye Institute, New York, New York, United States
| | - Jacob V Aranda
- Department of Ophthalmology, State University of New York, Downstate Medical Center, New York, New York, United States
| | - Kay D Beharry
- Department of Ophthalmology, State University of New York, Downstate Medical Center, New York, New York, United States
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79
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Serebrovskaya TV, Xi L. Intermittent hypoxia in childhood: the harmful consequences versus potential benefits of therapeutic uses. Front Pediatr 2015; 3:44. [PMID: 26042211 PMCID: PMC4436817 DOI: 10.3389/fped.2015.00044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/07/2015] [Indexed: 12/04/2022] Open
Abstract
Intermittent hypoxia (IH) often occurs in early infancy in both preterm and term infants and especially at 36-44 weeks postmenstrual age. These episodes of IH could result from sleep-disordered breathing or may be temporally unrelated to apnea or bradycardia events. There are numerous reports indicating adverse effects of IH on development, behavior, academic achievement, and cognition in children with sleep apnea syndrome. It remains uncertain about the exact causative relationship between the neurocognitive and behavioral morbidities and IH and/or its associated sleep fragmentation. On the other hand, well-controlled and moderate IH conditioning/training has been used in sick children for treating their various forms of bronchial asthma, allergic dermatoses, autoimmune thyroiditis, cerebral palsy, and obesity. This review article provides an updated and impartial analysis on the currently available evidence in supporting either side of the seemingly contradictory scenarios. We wish to stimulate a comprehensive understanding of such a complex physiological phenomenon as intermittent hypoxia, which may be accompanied by other confounding factors (e.g., hypercapnia, polycythemia), in order to prevent or reduce its harmful consequences, while maximizing its potential utility as an effective therapeutic tool in pediatric patients.
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Affiliation(s)
| | - Lei Xi
- Department of Internal Medicine, Virginia Commonwealth University , Richmond, VA , USA
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80
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Siljehav V, Shvarev Y, Herlenius E. Il-1β and prostaglandin E2 attenuate the hypercapnic as well as the hypoxic respiratory response via prostaglandin E receptor type 3 in neonatal mice. J Appl Physiol (1985) 2014; 117:1027-36. [DOI: 10.1152/japplphysiol.00542.2014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Prostaglandin E2 (PGE2) serves as a critical mediator of hypoxia, infection, and apnea in term and preterm babies. We hypothesized that the prostaglandin E receptor type 3 (EP3R) is the receptor responsible for PGE2-induced apneas. Plethysmographic recordings revealed that IL-1β (ip) attenuated the hypercapnic response in C57BL/6J wild-type (WT) but not in neonatal (P9) EP3R−/− mice ( P < 0.05). The hypercapnic responses in brain stem spinal cord en bloc preparations also differed depending on EP3R expression whereby the response was attenuated in EP3R−/− preparations ( P < 0.05). After severe hypoxic exposure in vivo, IL-1β prolonged time to autoresuscitation in WT but not in EP3R−/− mice. Moreover, during severe hypoxic stress EP3R−/− mice had an increased gasping duration ( P < 0.01) as well as number of gasps ( P < 0.01), irrespective of intraperitoneal treatment, compared with WT mice. Furthermore, EP3R−/− mice exhibited longer hyperpneic breathing efforts when exposed to severe hypoxia ( P < 0.01). This was then followed by a longer period of secondary apnea before autoresuscitation occurred in EP3R−/− mice ( P < 0.05). In vitro, EP3R−/− brain stem spinal cord preparations had a prolonged respiratory burst activity during severe hypoxia accompanied by a prolonged neuronal arrest during recovery in oxygenated medium ( P < 0.05). In conclusion, PGE2 exerts its effects on respiration via EP3R activation that attenuates the respiratory response to hypercapnia as well as severe hypoxia. Modulation of the EP3R may serve as a potential therapeutic target for treatment of inflammatory and hypoxic-induced detrimental apneas and respiratory disorders in neonates.
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Affiliation(s)
- Veronica Siljehav
- Neonatal Research Unit Q2:07, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; and
| | - Yuri Shvarev
- Neonatal Research Unit Q2:07, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; and
- Institute of Cytology and Genetics, Siberian Division of the Russian Academy of Sciences, Novosibirsk, Russia
| | - Eric Herlenius
- Neonatal Research Unit Q2:07, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; and
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81
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Hartnett ME. Pathophysiology and mechanisms of severe retinopathy of prematurity. Ophthalmology 2014; 122:200-10. [PMID: 25444347 DOI: 10.1016/j.ophtha.2014.07.050] [Citation(s) in RCA: 240] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/21/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022] Open
Abstract
Retinopathy of prematurity (ROP) affects only premature infants, but as premature births increase in many areas of the world, ROP has become a leading cause of childhood blindness. Blindness can occur from aberrant developmental angiogenesis that leads to fibrovascular retinal detachment. To treat severe ROP, it is important to study normal developmental angiogenesis and the stresses that activate pathologic signaling events and aberrant angiogenesis in ROP. Vascular endothelial growth factor (VEGF) signaling is important in both physiologic and pathologic developmental angiogenesis. Based on studies in animal models of oxygen-induced retinopathy (OIR), exogenous factors such as oxygen levels, oxidative stress, inflammation, and nutritional capacity have been linked to severe ROP through dysregulated signaling pathways involving hypoxia-inducible factors and angiogenic factors like VEGF, oxidative species, and neuroprotective growth factors to cause phases of ROP. This translational science review focuses on studies performed in animal models of OIR representative of human ROP and highlights several areas: mechanisms for aberrant growth of blood vessels into the vitreous rather than into the retina through over-activation of VEGF receptor 2 signaling, the importance of targeting different cells in the retina to inhibit aberrant angiogenesis and promote physiologic retinal vascular development, toxicity from broad and targeted inhibition of VEGF bioactivity, and the role of VEGF in neuroprotection in retinal development. Several future translational treatments are discussed, including considerations for targeted inhibition of VEGF signaling instead of broad intravitreal anti-VEGF treatment.
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82
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Dobson NR, Patel RM, Smith PB, Kuehn DR, Clark J, Vyas-Read S, Herring A, Laughon MM, Carlton D, Hunt CE. Trends in caffeine use and association between clinical outcomes and timing of therapy in very low birth weight infants. J Pediatr 2014; 164:992-998.e3. [PMID: 24461786 PMCID: PMC3992195 DOI: 10.1016/j.jpeds.2013.12.025] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 10/30/2013] [Accepted: 12/12/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To examine the effect of early initiation of caffeine therapy on neonatal outcomes and characterize the use of caffeine therapy in very low birth weight (VLBW) infants. STUDY DESIGN We analyzed a cohort of 62 056 VLBW infants discharged between 1997 and 2010 who received caffeine therapy. We compared outcomes in infants receiving early caffeine therapy (initial dose before 3 days of life) and those receiving late caffeine therapy (initial dose at or after 3 days of life) through propensity scoring using baseline and early clinical variables. The primary outcome was the association between the timing of caffeine initiation and the incidence of bronchopulmonary dysplasia (BPD) or death. RESULTS We propensity score-matched 29 070 VLBW infants at a 1:1. Of infants receiving early caffeine therapy, 3681 (27.6%) died or developed BPD, compared with 4591 infants (34.0%) receiving late caffeine therapy (OR, 0.74; 99% CI, 0.69-0.80). Infants receiving early caffeine had a lower incidence of BPD (23.1% vs 30.7%; OR, 0.68; 95% CI, 0.63-0.73) and a higher incidence of death (4.5% vs 3.7%; OR, 1.23; 95% CI, 1.05-1.43). Infants receiving early caffeine therapy had less treatment of patent ductus arteriosus (OR, 0.60; 95% CI, 0.55-0.65) and a shorter duration of mechanical ventilation (mean difference, 6 days; P < .001). CONCLUSION Early caffeine initiation is associated with a decreased incidence of BPD. Randomized trials are needed to determine the efficacy and safety of early caffeine prophylaxis in VLBW infants.
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Affiliation(s)
- Nicole R. Dobson
- Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Ravi M. Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | | | | | - Jennifer Clark
- University of North Carolina School of Public Health, Chapel Hill, NC
| | - Shilpa Vyas-Read
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Amy Herring
- University of North Carolina School of Public Health, Chapel Hill, NC
| | - Matthew M. Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David Carlton
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Carl E. Hunt
- Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, MD
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83
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Lim K, Wheeler KI, Gale TJ, Jackson HD, Kihlstrand JF, Sand C, Dawson JA, Dargaville PA. Oxygen saturation targeting in preterm infants receiving continuous positive airway pressure. J Pediatr 2014; 164:730-736.e1. [PMID: 24433828 DOI: 10.1016/j.jpeds.2013.11.072] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/30/2013] [Accepted: 11/27/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The precision of oxygen saturation (SpO2) targeting in preterm infants on continuous positive airway pressure (CPAP) is incompletely characterized. We therefore evaluated SpO2 targeting in infants solely receiving CPAP, aiming to describe their SpO2 profile, to document the frequency of prolonged hyperoxia and hypoxia episodes and of fraction of inspired oxygen (FiO2) adjustments, and to explore the relationships with neonatal intensive care unit operational factors. STUDY DESIGN Preterm infants <37 weeks' gestation in 2 neonatal intensive care units were studied if they were receiving CPAP and in supplemental oxygen at the beginning of each 24-hour recording. SpO2, heart rate, and FiO2 were recorded (sampling interval 1-2 seconds). We measured the proportion of time spent in predefined SpO2 ranges, the frequency of prolonged episodes (≥30 seconds) of SpO2 deviation, and the effect of operational factors including nurse-patient ratio. RESULTS A total of 4034 usable hours of data were recorded from 45 infants of gestation 30 (27-32) weeks (median [IQR]). When requiring supplemental oxygen, infants were in the target SpO2 range (88%-92%) for only 31% (19%-39%) of total recording time, with 48 (6.9-90) episodes per 24 hours of severe hyperoxia (SpO2 ≥98%), and 9.0 (1.6-21) episodes per 24 hours of hypoxia (SpO2 <80%). An increased frequency of prolonged hyperoxia in supplemental oxygen was noted when nurses were each caring for more patients. Adjustments to FiO2 were made 25 (16-41) times per day. CONCLUSION SpO2 targeting is challenging in preterm infants receiving CPAP support, with a high proportion of time spent outside the target range and frequent prolonged hypoxic and hyperoxic episodes.
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Affiliation(s)
- Kathleen Lim
- Department of Pediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Tasmania, Australia
| | - Kevin I Wheeler
- Department of Pediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Tasmania, Australia
| | - Timothy J Gale
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Hamish D Jackson
- Department of Pediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Tasmania, Australia
| | - Jonna F Kihlstrand
- The Faculty of Health Sciences, Linköpings University, Linköpings, Sweden; Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Cajsa Sand
- The Faculty of Health Sciences, Linköpings University, Linköpings, Sweden; Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Jennifer A Dawson
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia; The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter A Dargaville
- Department of Pediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Tasmania, Australia.
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84
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Al-Shabrawey M, Elsherbiny M, Nussbaum J, Othman A, Megyerdi S, Tawfik A. Targeting Neovascularization in Ischemic Retinopathy: Recent Advances. EXPERT REVIEW OF OPHTHALMOLOGY 2014; 8:267-286. [PMID: 25598837 DOI: 10.1586/eop.13.17] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pathological retinal neovascularization (RNV) is a common micro-vascular complication in several retinal diseases including retinopathy of prematurity, diabetic retinopathy, age-related macular degeneration and central vein occlusion. The current therapeutic modalities of RNV are invasive and although they may slow or halt the progression of the disease they are unlikely to restore normal acuity. Therefore, there is an urgent need to develop treatment modalities, which are less invasive and therefore associated with fewer procedural complications and systemic side effects. This review article summarizes our understanding of the pathophysiology and current treatment of RNV in ischemic retinopathies; lists potential therapeutic targets; and provides a framework for the development of future treatment modalities.
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Affiliation(s)
- Mohamed Al-Shabrawey
- Oral Biology/Anatomy, College of Dental Medicine, GeorgiaRegentsUniversity (GRU), Augusta GA, USA ; Ophthalmology and Vision Discovery Institute, Medical College of Georgia, GRU ; Anatomy, Mansoura Faculty of Medicine, Mansoura University-Egypt ; Vascular Biology Center, Medical College of Georgia, GRU
| | - Mohamed Elsherbiny
- Oral Biology/Anatomy, College of Dental Medicine, GeorgiaRegentsUniversity (GRU), Augusta GA, USA ; Ophthalmology and Vision Discovery Institute, Medical College of Georgia, GRU ; Anatomy, Mansoura Faculty of Medicine, Mansoura University-Egypt
| | - Julian Nussbaum
- Ophthalmology and Vision Discovery Institute, Medical College of Georgia, GRU
| | - Amira Othman
- Anatomy, Mansoura Faculty of Medicine, Mansoura University-Egypt
| | - Sylvia Megyerdi
- Oral Biology/Anatomy, College of Dental Medicine, GeorgiaRegentsUniversity (GRU), Augusta GA, USA
| | - Amany Tawfik
- Ophthalmology and Vision Discovery Institute, Medical College of Georgia, GRU ; Cellular Biology and Anatomy, Medical College of Georgia, GRU
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85
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Abstract
Oxygen is one of the most widely used drugs in the neonatal period. A lack of knowledge of oxygen metabolism and toxicity has prompted guidelines to fluctuate from liberal use to treat respiratory distress to restriction to avoid retinopathy of prematurity. In recent years, studies performed in the immediate postnatal period have revealed that newly born infants achieve a stable saturation only several minutes after birth. Moreover, the time needed to reach a saturation plateau is inversely proportional to a newborn's gestational age. As a consequence, guidelines have changed and recommend an individualized supplementation in the first minutes after birth with the inspiratory fraction of oxygen titrated against preductal pulse oximetry. However, randomized controlled trials have concluded that, after postnatal stabilization, keeping preterm babies within a low-saturation target range (85-89%) may lead to increased mortality while keeping them in a higher saturation range (91-95%) increases the risk of retinopathy of prematurity. The present state of the art in the management of oxygen supplementation recommends that caregivers in the delivery room allow preductal oxygen saturation to spontaneously increase in the first minutes of life; however, if supplemented, it should be titrated according to pulse oximeter readings and kept within the safe margins of the nomogram. Thereafter, if oxygen is still needed, it should be kept within stringent security margins (90-95%) to avoid deleterious consequences. Importantly, in babies with chronic lung disease, oxygen should be supplemented to allow the patient to grow and develop.
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Affiliation(s)
- Máximo Vento
- Neonatal Research Unit, Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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86
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Morken TS, Nyman AKG, Sandvig I, Torp SH, Skranes J, Goa PE, Brubakk AM, Widerøe M. Brain development after neonatal intermittent hyperoxia-hypoxia in the rat studied by longitudinal MRI and immunohistochemistry. PLoS One 2013; 8:e84109. [PMID: 24358332 PMCID: PMC3866165 DOI: 10.1371/journal.pone.0084109] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 11/12/2013] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonatal intermittent hyperoxia-hypoxia (IHH) is involved in the pathogenesis of retinopathy of prematurity. Whether similar oxygen fluctuations will create pathological changes in the grey and white matter of the brain is unknown. METHODS From birth until postnatal day 14 (P14), two litters (total n = 22) were reared in IHH: hyperoxia (50% O2) interrupted by three consecutive two-minute episodes of hypoxia (12% O2) every sixth hour. Controls (n = 8) were reared in room-air (20.9% O2). Longitudinal MRI (Diffusion Tensor Imaging and T2-mapping) was performed on P14 and P28 and retinal and brain tissue were examined for histopathological changes. Long-term neurodevelopment was assessed on P20 and P27. RESULTS Mean, radial and axial diffusivity were higher in white matter of IHH versus controls at P14 (p < 0.04), while fractional anisotropy (FA) was lower in the hippocampal fimbria and tended to be lower in corpus callosum (p = 0.08) and external capsule (p = 0.05). White matter diffusivity in IHH was similar to controls at P28. Higher cortical vessel density (p = 0.005) was observed at P14. Cortical and thalamic T2-relaxation time and mean diffusivity were higher in the IHH group at P14 (p ≤ 0.03), and albumin leakage was present at P28. Rats in the IHH group ran for a longer time on a Rotarod than the control group (p ≤ 0.005). Pups with lower bodyweight had more severe MRI alterations and albumin leakage. CONCLUSION IHH led to subtle reversible changes in brain white matter diffusivity, grey matter water content and vascular density. However, alterations in blood-brain barrier permeability may point to long-term effects. The changes seen after IHH exposure were more severe in animals with lower bodyweight and future studies should aim at exploring possible interactions between IHH and growth restriction.
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Affiliation(s)
- Tora Sund Morken
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Axel Karl Gottfrid Nyman
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ioanna Sandvig
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sverre Helge Torp
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jon Skranes
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Pediatrics, St. Olav University Hospital, Central Norway Regional Health Authority, Trondheim, Norway
| | - Pål Erik Goa
- Department of Radiology, St. Olav University Hospital, Central Norway Regional Health Authority, Trondheim, Norway
| | - Ann-Mari Brubakk
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Pediatrics, St. Olav University Hospital, Central Norway Regional Health Authority, Trondheim, Norway
| | - Marius Widerøe
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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87
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Beharry KD, Cai CL, Sharma P, Bronshtein V, Valencia GB, Lazzaro DR, Aranda JV. Hydrogen peroxide accumulation in the choroid during intermittent hypoxia increases risk of severe oxygen-induced retinopathy in neonatal rats. Invest Ophthalmol Vis Sci 2013; 54:7644-57. [PMID: 24168990 DOI: 10.1167/iovs.13-13040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Extremely low gestational age neonates (ELGANs) requiring oxygen therapy often experience frequent episodes of intermittent hypoxia (IH) and are at high risk for severe retinopathy of prematurity (ROP). Using an established model for oxygen-induced retinopathy (OIR), we examined the hypothesis that there is a critical number of daily brief IH episodes which will result in irreversible retinal oxidative damage. METHODS Newborn rats were exposed to increasing daily clustered IH episodes (12% O₂ with 50% O₂) from postnatal day (P) 0 to P7 or P0 to P14, or placed in room air (RA) until P21 following 7- or 14-day IH. RA littermates at P7, P14, and P21 served as controls. A group exposed to constant 50% O₂ (CH) served as a second control. Blood gases, eye opening at P14, retinal, and choroidal oxidative stress and lipid peroxidation (8-isoPGF(2α)), oxidants (H₂O₂) and antioxidants (catalase and SOD), retinal pathology (adenosine diphosphatase (ADPase)-stained retinal flatmounts), and mitochondria-related genes were assessed. RESULTS pO₂ levels were higher with increasing IH episodes and remained elevated during the reoxygenation period. High SO₂ levels were associated with most severe OIR. Levels of all measured biomarkers peaked with six IH episodes and decreased with 8 to 12 episodes. H₂O₂ accumulated in the choroid during the reoxygenation period with irreversible retinal damage. CONCLUSIONS Our data suggest that six is the maximum number of IH episodes that the retina can sustain. Accumulation of H₂O₂ in the choroid may result in high levels being delivered to the entire retina, ultimately resulting in irreversible retinal oxidative damage.
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Affiliation(s)
- Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
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Apnea of prematurity--perfect storm. Respir Physiol Neurobiol 2013; 189:213-22. [PMID: 23727228 DOI: 10.1016/j.resp.2013.05.026] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 05/17/2013] [Accepted: 05/21/2013] [Indexed: 12/23/2022]
Abstract
With increased survival of preterm infants as young as 23 weeks gestation, maintaining adequate respiration and corresponding oxygenation represents a clinical challenge in this unique patient cohort. Respiratory instability characterized by apnea and periodic breathing occurs in premature infants because of immature development of the respiratory network. While short respiratory pauses and apnea may be of minimal consequence if oxygenation is maintained, they can be problematic if accompanied by chronic intermittent hypoxemia. Underdevelopment of the lung and the resultant lung injury that occurs in this population concurrent with respiratory instability creates the perfect storm leading to frequent episodes of profound and recurrent hypoxemia. Chronic intermittent hypoxemia contributes to the immediate and long term co-morbidities that occur in this population. In this review we discuss the pathophysiology leading to the perfect storm, diagnostic assessment of breathing instability in this unique population and therapeutic interventions that aim to stabilize breathing without contributing to tissue injury.
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