1
|
Williams EE, Gunawardana S, Donaldson NK, Dassios T, Greenough A. Postnatal diuretics, weight gain and home oxygen requirement in extremely preterm infants. J Perinat Med 2022; 50:100-107. [PMID: 34265878 DOI: 10.1515/jpm-2021-0256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/25/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diuretics are often given to infants with evolving/established bronchopulmonary dysplasia (BPD) with the hope of improving their pulmonary outcomes. We aimed to determine if diuretic use in preterm infants was associated with improved pulmonary outcomes, but poorer weight gain. METHODS An observational study over a 5 year period was undertaken of all infants born at less than 29 weeks of gestation and alive at discharge in all neonatal units in England who received consecutive diuretic use for at least 7 days. Postnatal weight gain and home supplementary oxygen requirement were the outcomes. A literature review of randomised controlled trials (RCTs) and crossover studies was undertaken to determine if diuretic usage was associated with changes in lung mechanics and oxygenation, duration of supplementary oxygen and requirement for home supplementary oxygen. RESULTS In the observational study, 9,457 infants survived to discharge, 44.6% received diuretics for at least 7 days. Diuretic use was associated with an increased probability of supplementary home oxygen of 0.14 and an increase in weight gain of 2.5 g/week. In the review, seven of the 10 studies reported improvements only in short term lung mechanics. There was conflicting evidence regarding whether diuretics resulted in short term improvements in oxygenation. CONCLUSIONS Diuretic use was not associated with a reduction in requirement for supplemental oxygen on discharge. The literature review highlighted a lack of RCTs assessing meaningful long-term clinical outcomes. Randomised trials are needed to determine the long-term risk benefit ratio of chronic diuretic use.
Collapse
Affiliation(s)
- Emma E Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shannon Gunawardana
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR), Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| |
Collapse
|
2
|
Iyengar A, Davis JM. Drug therapy for the prevention and treatment of bronchopulmonary dysplasia. Front Pharmacol 2015; 6:12. [PMID: 25762933 PMCID: PMC4329808 DOI: 10.3389/fphar.2015.00012] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/13/2015] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION As more infants are surviving at younger gestational ages, bronchopulmonary dysplasia (BPD) remains as a frequent neonatal complication occurring after preterm birth. The multifactorial nature of the disease process makes BPD a challenging condition to treat. While multiple pharmacologic therapies have been investigated over the past two decades, there have been limited advances in the field. Often multiple therapies are used concurrently without clear evidence of efficacy, with potential for significant side effects from drug-drug interactions. METHODS Systematic literature review. CONCLUSION Although there is physiologic rationale for the use of many of these therapies, none of them has single-handedly altered the incidence, severity, or progression of BPD. Future research should focus on developing clinically significant end-points (short and long term respiratory assessments), investigating biomarkers that accurately predict risk and progression of disease, and creating appropriate stratification models of BPD severity. Applying a multi-modal approach to the study of new and existing drugs should be the most effective way of establishing the optimal prevention and treatment regimens for BPD.
Collapse
Affiliation(s)
- Anjali Iyengar
- Department of Pediatrics, Floating Hospital for Children at Tufts Medical CenterBoston, MA, USA
| | | |
Collapse
|
3
|
Abstract
Bronchopulmonary dysplasia (BPD) is the most prevalent long-term morbidity in surviving extremely preterm infants and is linked to increased risk of reactive airways disease, pulmonary hypertension, post-neonatal mortality, and adverse neurodevelopmental outcomes. BPD affects approximately 20% of premature newborns, and up to 60% of premature infants born before completing 26 weeks of gestation. It is characterized by the need for assisted ventilation and/or supplemental oxygen at 36 weeks postmenstrual age. Approaches to prevention and treatment of BPD have evolved with improved understanding of its pathogenesis. This review will focus on recent advancements and detail current research in pharmacotherapy for BPD. The evidence for both current and potential future experimental therapies will be reviewed in detail. As our understanding of the complex and multifactorial pathophysiology of BPD changes, research into these current and future approaches must continue to evolve.
Collapse
Affiliation(s)
- Sailaja Ghanta
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA 02115, , Tel: (774) 249 8137, Fax: (617) 730-0260
| | - Kristen Tropea Leeman
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA 02115, , Tel: (919) 475 9260, Fax: (617) 730 0222
| | - Helen Christou
- Division of Newborn Medicine, Brigham and Women’s Hospital, Boston Children’s Hospital, Harvard Medical School, 75 Francis Street, Thorn 1005, Boston, MA 02115, , Tel: (617) 515 8129, Fax: (617) 582 6026
| |
Collapse
|
4
|
Abstract
Protracted mechanical ventilation is associated with increased morbidity and mortality in preterm infants and thus the earliest possible weaning from mechanical ventilation is desirable. Weaning protocols may be helpful in achieving more rapid reduction in support. There is no clear consensus regarding the level of support at which an infant is ready for extubation. An improved ability to predict when a preterm infant has a high likelihood of successful extubation is highly desirable. In this article, available evidence is reviewed and reasonable evidence-based recommendations for expeditious weaning and extubation are provided.
Collapse
Affiliation(s)
- G M Sant'Anna
- McGill University Health Center, 2300 Tupper Street, Montreal, Québec, Canada, H3Z1L2
| | | |
Collapse
|
5
|
Tropea K, Christou H. Current pharmacologic approaches for prevention and treatment of bronchopulmonary dysplasia. Int J Pediatr 2012; 2012:598606. [PMID: 22262977 PMCID: PMC3259479 DOI: 10.1155/2012/598606] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Accepted: 11/04/2011] [Indexed: 11/23/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a major complication of preterm birth and has serious adverse long-term health consequences. The etiology of BPD is complex, multifactorial, and incompletely understood. Contributing factors include ventilator-induced lung injury, exposure to toxic oxygen levels, and infection. Several preventive and therapeutic strategies have been developed with variable success. These include lung protective ventilator strategies and pharmacological and nutritional interventions. These strategies target different components and stages of the disease process and they are commonly used in combination. The purpose of this review is to discuss the evidence for current pharmacological interventions and identify future therapeutic modalities that appear promising in the prevention and management of BPD. Continued improved understanding of BPD pathogenesis leads to opportunities for newer preventive approaches. These will need to be evaluated in the setting of current clinical practice in order to assess their efficacy.
Collapse
Affiliation(s)
- Kristen Tropea
- Division of Newborn Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Division of Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Helen Christou
- Division of Newborn Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Division of Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
6
|
Stewart AL, Brion LP. Routine use of diuretics in very-low birth-weight infants in the absence of supporting evidence. J Perinatol 2011; 31:633-4. [PMID: 21956150 DOI: 10.1038/jp.2011.44] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
7
|
Stewart A, Brion LP, Ambrosio‐Perez I. Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease. Cochrane Database Syst Rev 2011; 2011:CD001817. [PMID: 21901679 PMCID: PMC7068169 DOI: 10.1002/14651858.cd001817.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES To assess the risks and benefits of diuretics acting on distal segments of the renal tubule (distal diuretics) in preterm infants with or developing chronic lung disease (CLD). SEARCH STRATEGY The standard method of the Cochrane Neonatal Review Group were used. Initially, MEDLINE (1966 to November 2001), EMBASE (1974 to November 2001) and the Cochrane Controlled Trials Register (CENTRAL,The Cochrane Library, Issue 4, 2001) were searched. In addition, several abstract books of national and international American and European Societies were hand searched. Updated searches in April 2003, April 2007, and December 2010 did not yield any additional trials. SELECTION CRITERIA Included in this analysis are trials in which preterm infants with or developing CLD and at least five days of age were randomly allocated to receive a diuretic acting on the distal renal tubule. Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. DATA COLLECTION AND ANALYSIS The standard method for the Cochrane Collaboration described in the Cochrane Collaboration Handbook were used. Two investigators extracted, assessed and coded separately all data for each study. Any disagreement was resolved by discussion. Parallel and cross-over trials were combined. Whenever possible, baseline and final outcome data measured on a continuous scale was transformed into change scores using Follmann's formula. MAIN RESULTS Of the six studies fulfilling entry criteria, most focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy.In preterm infants > 3 weeks of age with CLD, a four week treatment with thiazide and spironolactone improved lung compliance and reduced the need for furosemide. A single study showed thiazide and spironolactone decreased the risk of death and tended to decrease the risk for remaining intubated after eight weeks in infants who did not have access to corticosteroids, bronchodilators or aminophylline. AUTHORS' CONCLUSIONS In preterm infants > 3 weeks of age with CLD, acute and chronic administration of distal diuretics improve pulmonary mechanics. However, positive effects should be interpreted with caution as the numbers of patients studied are small in surprisingly few randomized controlled trials.
Collapse
Affiliation(s)
- Audra Stewart
- University of Texas Southwestern Medical Center at DallasNeonatal‐Perinatal Medicine5323 Harry Hines BoulevardDallasTexasUSA75390‐9063
| | - Luc P Brion
- University of Texas Southwestern at DallasDivision of Neonatal‐Perinatal Medicine5323 Harry Hines BoulevardDallasTexasUSA75390‐9063
| | - Iris Ambrosio‐Perez
- Children's Hospital of Los AngelesDivision of Pediatric Pulmonology4650 Sunset Blvd, MS # 83Los AngelesCAUSA90027
| | | |
Collapse
|
8
|
Stewart A, Brion LP. Intravenous or enteral loop diuretics for preterm infants with (or developing) chronic lung disease. Cochrane Database Syst Rev 2011; 2011:CD001453. [PMID: 21901676 PMCID: PMC7055198 DOI: 10.1002/14651858.cd001453.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES To assess the risks and benefits of administration of a diuretic acting on the loop of Henle (loop diuretic) in preterm infants with or developing chronic lung disease (CLD). SEARCH STRATEGY Standard search method of the Cochrane Neonatal Review Group was used. Initial search included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1974 to 1998). In addition, several abstract books of national and international American and European Societies were hand searched. The MEDLINE and the Cochrane Central searches were updated in March 2007 and December 2010. The EMBASE search was completed in April 2007 and December 2010. Additional searches in CINAHL, clinicaltrials.gov and controlled-trials.com was completed in December 2010. SELECTION CRITERIA Trials in which preterm infants with or developing chronic lung disease and at least five days of age were all randomly allocated to receive a loop diuretic either enterally or intravenously were included in this analysis. DATA COLLECTION AND ANALYSIS The standard method for the Cochrane Collaboration described in the Cochrane Collaboration Handbook were used. Two investigators extracted, assessed and coded separately all data for each study. Parallel and cross-over trials were combined and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS The only loop diuretic used in the six studies that met the selection criteria was furosemide. Most studies focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy. In preterm infants < 3 weeks of age developing CLD, furosemide administration has either inconsistent effects or no detectable effect. In infants > 3 weeks of age with CLD, a single intravenous dose of 1 mg/kg of furosemide improves lung compliance and airway resistance for one hour. Chronic administration of furosemide improves both oxygenation and lung compliance. AUTHORS' CONCLUSIONS In view of the lack of data from randomized trials concerning effects on important clinical outcomes, routine or sustained use of systemic loop diuretics in infants with (or developing) CLD cannot be recommended based on current evidence. Randomized trials are needed to assess the effects of furosemide administration on survival, duration of ventilatory support and oxygen administration, length of hospital stay, potential complications and long-term outcome.
Collapse
Affiliation(s)
- Audra Stewart
- University of Texas Southwestern Medical Center at DallasNeonatal‐Perinatal Medicine5323 Harry Hines BoulevardDallasTexasUSA75390‐9063
| | - Luc P Brion
- University of Texas Southwestern at DallasDivision of Neonatal‐Perinatal Medicine5323 Harry Hines BoulevardDallasTexasUSA75390‐9063
| | | |
Collapse
|
9
|
Han S, Yu Z, Guo X, Dong X, Chen X, Soll R. Intratracheal instillation of corticosteroids using surfactant as a vehicle for the prevention of chronic lung disease in preterm infants with respiratory distress syndrome. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Shuping Han
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Zhangbin Yu
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Xirong Guo
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Xiaoyue Dong
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Xiaohui Chen
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Roger Soll
- University of Vermont; Division of Neonatal-Perinatal Medicine; Fletcher Allen Health Care, Smith 552A 111 Colchester Avenue Burlington Vermont USA 05401
| |
Collapse
|
10
|
Sahni J, Phelps SJ. Nebulized furosemide in the treatment of bronchopulmonary dysplasia in preterm infants. J Pediatr Pharmacol Ther 2011; 16:14-22. [PMID: 22477820 PMCID: PMC3136229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic pulmonary disease commonly seen in preterm infants who require supplemental oxygen and/or assisted mechanical ventilation. BPD, a major cause of morbidity and mortality among premature infants, occurs in 5,000 to 10,000 premature infants in the United States each year. Despite numerous medical advances, no single intervention will prevent or treat BPD; hence, premature infants have an increased risk for developing significant sequelae that affect both cognitive and motor function. This article provides a brief overview of BPD and reviews the available literature regarding the safe and effective use of nebulized furosemide in the treatment of this disorder.
Collapse
Affiliation(s)
- Jasmine Sahni
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Stephanie J Phelps
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
| |
Collapse
|
11
|
Sahni J, Phelps SJ. Nebulized Furosemide in the Treatment of Bronchopulmonary Dysplasia in Preterm Infants. J Pediatr Pharmacol Ther 2011. [DOI: 10.5863/1551-6776-16.1.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ABSTRACT
Bronchopulmonary dysplasia (BPD) is a chronic pulmonary disease commonly seen in preterm infants who require supplemental oxygen and/or assisted mechanical ventilation. BPD, a major cause of morbidity and mortality among premature infants, occurs in 5,000 to 10,000 premature infants in the United States each year. Despite numerous medical advances, no single intervention will prevent or treat BPD; hence, premature infants have an increased risk for developing significant sequelae that affect both cognitive and motor function. This article provides a brief overview of BPD and reviews the available literature regarding the safe and effective use of nebulized furosemide in the treatment of this disorder.
Collapse
Affiliation(s)
- Jasmine Sahni
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center
- Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Stephanie J. Phelps
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center
- Department of Pediatrics, The University of Tennessee Health Science Center
- Le Bonheur Children's Hospital, Memphis, Tennessee
| |
Collapse
|
12
|
Abstract
Considerable effort has been devoted to the development of strategies to reduce the incidence of bronchopulmonary dysplasia (BPD), including use of medications, nutritional therapies, and respiratory care practices. Unfortunately, most of these strategies have not been successful. To date, the only two treatments developed specifically to prevent BPD whose efficacy is supported by evidence from randomized, controlled trials are the parenteral administration of vitamin A and corticosteroids. Two other therapies, the use of caffeine for the treatment of apnea of prematurity and aggressive phototherapy for the treatment of hyperbilirubinemia, were evaluated for the improvement of other outcomes and found to reduce BPD. Cohort studies suggest that the use of continuous positive airway pressure as a strategy for avoiding mechanical ventilation might also be beneficial. Other therapies reduce lung injury in animal models but do not appear to reduce BPD in humans. The benefits of the efficacious therapies have been modest, with an absolute risk reduction in the 7-11% range. Further preventive strategies are needed to reduce the burden of this disease. However, each will need to be tested in randomized, controlled trials, and the expectations of new therapies should be modest reductions of the incidence of the disease.
Collapse
Affiliation(s)
- Matthew M. Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, NC, CB# 7596, 4 Floor, UNC Hospitals, Chapel Hill, NC 27599-7596, Phone: (919) 966-5063, Fax: (919) 966-3034
| | - P. Brian Smith
- Duke University, Durham, NC, PO Box 17969, Durham, NC 27715, Phone: (919) 668-8951, Fax: (919) 668-7058
| | - Carl Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, CB# 7596, 4 Floor, UNC Hospitals, Chapel Hill, NC 27599-7596, Phone: (919) 966-5063, Fax: (919) 966-3034
| |
Collapse
|
13
|
Cerny L, Torday JS, Rehan VK. Prevention and Treatment of Bronchopulmonary Dysplasia: Contemporary Status and Future Outlook. Lung 2008; 186:75-89. [DOI: 10.1007/s00408-007-9069-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 12/27/2007] [Indexed: 01/06/2023]
|
14
|
Brok J, Greisen G, Jacobsen T, Gluud LL, Gluud C. Agreement between Cochrane Neonatal Group reviews and clinical guidelines for newborns at a Copenhagen University Hospital - a cross-sectional study. Acta Paediatr 2007; 96:39-43. [PMID: 17187601 DOI: 10.1111/j.1651-2227.2006.00035.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To assess the agreement between Cochrane Neonatal Group reviews and clinical guidelines of a University Neonatology Department, to evaluate the reasons for potential disagreements and to ascertain whether Cochrane reviews were considered for the guidelines development. METHODS The recommendations in the reviews and guidelines were compared and classified as being in 'agreement', 'partial agreement' or 'disagreement'. The guideline authors were interviewed for reasons about disagreement and whether Cochrane reviews were considered during the guideline development. RESULTS Agreement between reviews and guidelines was found for 133 interventions (77%), partial agreement for 31 interventions (18%) and disagreement for nine interventions (5%). Six interventions were recommended in the guidelines, but not in the reviews. Three interventions were recommended in the reviews, but not in the guidelines. Use of consensus statements, evidence on surrogate markers, observational studies, basic immunology and pathophysiological knowledge, expert opinion, economical constraints, reservations about the external validity and unawareness of reviews were reasons for disagreement. Cochrane reviews were rarely (22%) used during the guideline development. CONCLUSION We found agreement between more than three quarters of Cochrane reviews and neonatal guidelines. However, few important disagreements occurred. Reviews were only used for guideline development in about a fifth of cases.
Collapse
Affiliation(s)
- Jesper Brok
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, H:S Rigshospitalet, Denmark.
| | | | | | | | | |
Collapse
|
15
|
Brion LP, Primhak RA, Yong W. Aerosolized diuretics for preterm infants with (or developing) chronic lung disease. Cochrane Database Syst Rev 2006; 2006:CD001694. [PMID: 16855973 PMCID: PMC6769054 DOI: 10.1002/14651858.cd001694.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES The aim of this review is to assess the risks and benefits of aerosolized diuretic administration in preterm infants with or developing chronic lung disease (CLD). Primary objectives are to assess effects on short term outcome (changes in need for oxygen or ventilatory support) and effects on long-term outcome. Secondary objectives are to assess changes in pulmonary mechanics and potential complications of therapy. SEARCH STRATEGY We used the standard search method of the Cochrane Neonatal Review Group. We used the following keywords: {<bronchopulmonary dysplasia> or <chronic lung disease>} and <explode diuretics>, limited to <human> and limited to <infant, newborn> or <infant>. We searched MEDLINE (1966 - 1998), EMBASE (1974 - 1998) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2006). In addition, we hand searched several abstract books of national and international American and European Societies. The search of MEDLINE and of CENTRAL was last updated in March 2006. SELECTION CRITERIA For the purpose of this analysis, we included trials in which preterm infants with or developing chronic lung disease and at least five days of age were all randomly allocated to receive an aerosolized loop diuretic. Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. Primary outcome variables included need for ventilator support, chronic lung disease, mortality and other important clinical outcomes. Secondary outcome variables included pulmonary mechanics and potential complications of therapy. DATA COLLECTION AND ANALYSIS We used the standard method for the Cochrane Collaboration which is described in the Cochrane Collaboration Handbook. Two investigators extracted, assessed and coded separately all data for each study, using a form that was designed specifically for this review. Any disagreement was resolved by discussion. We combined parallel and cross-over trials and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS We identified eight studies that met selection criteria. Most studies focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review or the potential complications of diuretic therapy. No study assessed the amount of diuretic effectively delivered to the patient. Furosemide was the only diuretic used in the eight studies included in this review. Among preterm infants < 3 weeks of age developing CLD, not enough information is available to assess the effect of aerosolized furosemide on outcome or lung function. Among infants > 3 weeks with CLD, a single aerosolized dose of 1 mg/kg of furosemide may transiently improve pulmonary mechanics. Not enough information is available to assess the effect of chronic administration of aerosolized furosemide on oxygenation and pulmonary mechanics. AUTHORS' CONCLUSIONS In preterm infants > 3 weeks with CLD administration of a single dose of aerosolized furosemide improves pulmonary mechanics. In view of the lack of data from randomized trials concerning effects on important clinical outcomes, routine or sustained use of aerosolized loop diuretics in infants with (or developing) CLD cannot be recommended based on current evidence.More double-blinded randomized trials are needed (1) to analyze factors likely to affect the response to aerosolized furosemide, e.g., washout period and delivery of furosemide to distal airways, and (2) to assess the effects of chronic administration of aerosolized furosemide on mortality, O2 dependency, ventilator dependency, length of hospital stay and long-term outcome.
Collapse
Affiliation(s)
- L P Brion
- Albert Einstein College of Medicine, Children's Hospital at Montefiore, Pediatrics, Section of Neonatology, Weiler Hospital Room 725, 1825 Eastchester Road, Bronx, NY 10461-2373, USA.
| | | | | |
Collapse
|
16
|
McMahon CJ, Penny DJ, Nelson DP, Ades AM, Al Maskary S, Speer M, Katkin J, McKenzie ED, Fraser CD, Chang AC. Preterm infants with congenital heart disease and bronchopulmonary dysplasia: postoperative course and outcome after cardiac surgery. Pediatrics 2005; 116:423-30. [PMID: 16061598 DOI: 10.1542/peds.2004-2168] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Success in treatment of premature infants has resulted in increased numbers of neonates who have bronchopulmonary dysplasia (BPD) and require surgical palliation or repair of congenital heart disease (CHD). We sought to investigate the impact of BPD on children with CHD after heart surgery. METHODS This was a retrospective, multicenter study of patients who had BPD, defined as being oxygen dependent at 28 days of age with radiographic changes, and CHD and had cardiac surgery (excluding arterial duct ligation) between January 1991 and January 2002. Forty-three infants underwent a total of 52 cardiac operations. The median gestational age at birth was 28 weeks (range: 23-35 weeks), birth weight was 1460 g (range: 431-2500 g), and age at surgery was 2.7 months (range: 1.0-11.6 months). Diagnoses included left-to-right shunts (n = 15), conotruncal abnormalities (n = 13), arch obstruction (n = 6), univentricular hearts (n = 4), semilunar valve obstruction (n = 3), Shone syndrome (n = 1), and cor triatriatum (n = 1). RESULTS Thirty-day survival was 84% with 6 early and 6 late postoperative deaths. Survival to hospital discharge was 68%. There was 50% mortality for patients with univentricular hearts and severe BPD. The median duration of preoperative ventilation was 76 days (range: 2-244 days) and of postoperative ventilation was 15 days (range: 1-141 days). The median duration of cardiac ICU stay was 7.5 days (range: 1-30 days) and of hospital stay was 115 days (range: 35-475 days). Current pulmonary status includes on room air (n = 14), O2 at home (n = 4), and ventilated at home (n = 4) or in hospital (n = 4), and 5 patients were lost to follow-up. CONCLUSIONS BPD has significant implications for children who have CHD and undergo cardiac surgery, leading to prolonged ICU and hospital stays, although most survivors are not O2 dependent. Postoperative mortality was highest among patients with univentricular hearts and severe BPD. Optimal timing of surgery and strategies to improve outcome remains to be delineated.
Collapse
Affiliation(s)
- Colin J McMahon
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
Bronchopulmonary dysplasia (BPD) has classically been described as including inflammation, architectural disruption, fibrosis, and disordered/delayed development of the infant lung. As infants born at progressively earlier gestations have begun to survive the neonatal period, a 'new' BPD, consisting primarily of disordered/delayed development, has emerged. BPD causes not only significant complications in the newborn period, but is associated with continuing mortality, cardiopulmonary dysfunction, re-hospitalization, growth failure, and poor neurodevelopmental outcome after hospital discharge. Four major risk factors for BPD include premature birth, respiratory failure, oxygen supplementation, and mechanical ventilation, although it is unclear whether any of these factors is absolutely necessary for development of the condition. Genetic susceptibility, infection, and patent ductus arteriosus have also been implicated in the pathogenesis of the disease. The strategies with the strongest evidence for effectiveness in preventing or lessening the severity of BPD include prevention of prematurity and closure of a clinically significant patent ductus arteriosus. Some evidence of effectiveness also exists for single-course therapy with antenatal glucocorticoids in women at risk for delivering premature infants, surfactant replacement therapy in intubated infants with respiratory distress syndrome, retinol (vitamin A) therapy, and modes of respiratory support designed to minimize 'volutrauma' and oxygen toxicity. The most effective treatments for ameliorating symptoms or preventing exacerbation in established BPD include oxygen therapy, inhaled glucocorticoid therapy, and vaccination against respiratory pathogens.Many other strategies for the prevention or treatment of BPD have been proposed, but have weaker or conflicting evidence of effectiveness. In addition, many therapies have significant side effects, including the possibility of worsening the disease despite symptom improvement. For instance, supraphysiologic systemic doses of glucocorticoids lessen the incidence of BPD in infants at risk for the disease, and promote weaning of oxygen and mechanical ventilation in infants with established BPD. However, the side effects of systemic glucocorticoid therapy, most notably the recently recognized adverse effects on neurodevelopment, preclude their routine use for the prevention or treatment of BPD. Future research in BPD will most probably focus on continued incremental improvements in outcome, which are likely to be achieved through the combined effects of many therapeutic modalities.
Collapse
Affiliation(s)
- Carl T D'Angio
- Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | | |
Collapse
|
18
|
Abstract
Chronic lung disease (CLD) or bronchopulmonary dysplasia is a recognized sequel of preterm birth. With improving survival of infants at lower gestational ages, the incidence is on the rise. Pathological features of CLD include alveolar maldevelopment, with or without areas of pulmonary fibrosis. Assisted ventilation, infection/inflammation, oxygen administration, and fluid overload are the major risk factors in the evolution of CLD.Interventions, including the treatment of maternal infection, administration of prenatal glucocorticoids, and postnatal surfactant replacement therapy, improve the survival of preterm infants; however, their effect on CLD is difficult to determine. Strategies that have been effective in reducing CLD are the administration of retinol (vitamin A), high frequency oscillatory ventilation, and administration of glucocorticoids. Previous concerns regarding neurological problems associated with high frequency ventilation have not been substantiated in recent studies. Current recommendations do not advise the routine use of glucocorticoids due to concerns regarding long-term neurodevelopment. Therapies that were found to be ineffective in reducing the incidence of CLD include prenatal thyrotropin, cromolyn sodium (sodium cromoglycate), alpha-1 antitrypsin, superoxide dismutase, tocopherol (vitamin E), ascorbic acid (vitamin C), allopurinol, ambroxol, inositol, inhaled bronchodilators, and fluid restriction. Strategies that may be effective in reducing lung injury and subsequent CLD include avoiding assisted ventilation, lung protective ventilatory maneuvers, permissive hypercapnia, prevention of infection, early aggressive nutrition, and the treatment of a patent ductus arteriosus. The use of inhaled glucocorticoids improves pulmonary dynamics but long-term effects are unknown. The management of infants with established CLD has not been studied adequately, and the role of various ventilatory strategies for infants with established CLD is not clear. Adequate oxygenation should be maintained to prevent hypoxic episodes. Diuretics are helpful during acute decompensation; however, their long-term impact has not been well studied. Provision of adequate nutrition, immunization (routine and against respiratory syncytial virus), follow-up, and monitoring are the key elements in the long-term management of infants with CLD. Future research priorities should be to identify strategies to prevent/treat inflammation and promote the healing processes in the injured lung. The long-term effects of lung-protective ventilation strategies need to be studied.
Collapse
Affiliation(s)
- Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
19
|
Allen J, Zwerdling R, Ehrenkranz R, Gaultier C, Geggel R, Greenough A, Kleinman R, Klijanowicz A, Martinez F, Ozdemir A, Panitch HB, Nickerson B, Stein MT, Tomezsko J, Van Der Anker J. Statement on the care of the child with chronic lung disease of infancy and childhood. Am J Respir Crit Care Med 2003; 168:356-96. [PMID: 12888611 DOI: 10.1164/rccm.168.3.356] [Citation(s) in RCA: 195] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
20
|
Primhak RA. Discharge and aftercare in chronic lung disease of the newborn. ACTA ACUST UNITED AC 2003; 8:117-26. [PMID: 15001148 DOI: 10.1016/s1084-2756(02)00136-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2002] [Revised: 03/09/2002] [Accepted: 03/09/2002] [Indexed: 10/27/2022]
Abstract
This article deals with the discharge planning and continuing care of babies with chronic lung disease of the newborn (CLD), especially those with a continuing oxygen requirement, with some reference to longer term outcome. The pattern of CLD has changed since early descriptions, and the most useful definition for persisting morbidity in a baby with lung disease is a continuing oxygen requirement beyond 36 weeks post-menstrual age. Long-term oxygen therapy to maintain oxygen saturation at a mean of 95% or more and prevent levels below 90% is the cornerstone of management, and with adequate oxygen therapy the excess mortality previously reported in CLD can largely be avoided. Care must be given to the method of assessing oxygen saturation: overnight monitoring using appropriate recording devices is recommended. Exposure to respiratory viruses should be minimized where possible. Metabolic requirements are increased, but if efforts are made to maintain adequate energy input the long-term outlook for catch-up growth in height is good. Respiratory morbidity is increased in early life, but this improves in later childhood, along with lung function and exercise tolerance. Although respiratory symptoms should be treated as they arise, there is no evidence for long-term benefit from any pharmacological intervention in CLD.
Collapse
Affiliation(s)
- R A Primhak
- University Department of Child Health, Sheffield Children's Hospital NHS Trust, Western Bank, Sheffield S10 2TH, UK.
| |
Collapse
|
21
|
Brion LP, Primhak RA, Ambrosio-Perez I. Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease. Cochrane Database Syst Rev 2002:CD001817. [PMID: 11869608 DOI: 10.1002/14651858.cd001817] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The aim of this review is to assess the risks and benefits of diuretics acting on distal segments of the renal tubule (distal diuretics) in preterm infants with or developing chronic lung disease (CLD). Primary objectives are to assess changes in need for oxygen or ventilatory support and effects on long-term outcome, and secondary objectives are to assess changes in pulmonary mechanics and potential complications of therapy. SEARCH STRATEGY We used the standard method of the Cochrane Neonatal Review Group. We searched MEDLINE (1966-November 2001), EMBASE (1974-November 2001) and the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 4, 2001). In addition, we hand searched several abstract books of national and international American and European Societies. SELECTION CRITERIA We included in this analysis trials in which preterm infants with or developing CLD and at least five days of age were all randomly allocated to receive a distal diuretic (i.e., a diuretic acting on the distal renal tubule). Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. Primary outcome variables included changes in need for respiratory support and oxygen supplementation, mortality, bronchopulmonary dysplasia (BPD), death or BPD, chronic lung disease at 36 weeks of postconceptional age (gestational age + postnatal age), length of stay, and number of rehospitalizations during the first year of life. Secondary outcome variables included pulmonary mechanics and potential complications of therapy. DATA COLLECTION AND ANALYSIS We used the standard method for the Cochrane Collaboration which is described in the Cochrane Collaboration Handbook. Two investigators extracted, assessed and coded separately all data for each study, using a form that was designed specifically for this review. Any disagreement was resolved by discussion. We combined parallel and cross-over trials and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS Of six studies fulfilling entry criteria, most focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy. In preterm infants > 3 weeks of age with CLD, a four-week treatment with thiazide and spironolactone improved lung compliance and reduced the need for furosemide. Thiazide and spironolactone decreased the risk of death and tended to decrease the risk for lack of extubation after 8 weeks in intubated infants who did not have access to corticosteroids, bronchodilators or aminophylline. However, there is little or no evidence to support any benefit of diuretic administration on need for ventilatory support, length of hospital stay, or long-term outcome in patients receiving current therapy. There is no evidence to support the hypothesis that adding spironolactone to thiazide or that adding metolazone to furosemide improves the outcome of preterm infants with CLD. REVIEWER'S CONCLUSIONS In preterm infants > 3 weeks of age with CLD, acute and chronic administration of distal diuretics improve pulmonary mechanics. Studies are needed to assess (1) whether thiazide administration improves mortality, duration of oxygen dependency, ventilator dependency, length of hospital stay and long-term outcome in patients exposed to corticosteroids and bronchodilators (2) whether adding spironolactone to thiazides or adding metolazone to furosemide has any beneficial effect.
Collapse
Affiliation(s)
- L P Brion
- Pediatrics, Division of Neonatology, Albert Einstein College of Medicine and Montefiore Medical Center, Weiler Hospital Room 725, 1825 Eastchester Road, Bronx, NY 10461, USA. ,
| | | | | |
Collapse
|
22
|
Brion LP, Primhak RA. Intravenous or enteral loop diuretics for preterm infants with (or developing) chronic lung disease. Cochrane Database Syst Rev 2002:CD001453. [PMID: 11869600 DOI: 10.1002/14651858.cd001453] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES The aim of this review was to assess the risks and benefits of administration of a diuretic acting on the loop of Henle (loop diuretic) in preterm infants with or developing chronic lung disease (CLD). Primary objectives were to assess changes in need for oxygen or ventilatory support and effects on long-term outcome, and secondary objectives were to assess changes in pulmonary mechanics and potential complications of therapy. SEARCH STRATEGY We used the standard search method of the Cochrane Neonatal Review Group. We searched MEDLINE (1966-October 2001), EMBASE (1974-November 2001) and the Cochrane Controlled Trials Register (CCTR) (Cochrane Library, Issue 4, 2001). In addition, we hand searched several abstract books of national and international American and European Societies. SELECTION CRITERIA We included in this analysis trials in which preterm infants with or developing chronic lung disease and at least 5 days of age were all randomly allocated to receive a loop diuretic either enterally or intravenously. Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. Primary outcome variables included important clinical outcomes, and secondary outcome variables included toxicity and pulmonary mechanics (e.g., lung compliance and airway resistance). DATA COLLECTION AND ANALYSIS We used the standard method for the Cochrane Collaboration which is described in the Cochrane Collaboration Handbook. Two investigators extracted, assessed and coded separately all data for each study, using a form that was designed specifically for this review. Any disagreement was resolved by discussion. We combined parallel and cross-over trials and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS The only loop diuretic used in the studies which met the selection criteria was furosemide. Most studies focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy. In preterm infants < 3 weeks of age developing CLD, furosemide administration has either inconsistent effects or no detectable effect. In infants > 3 weeks of age with CLD, a single intravenous dose of 1 mg/kg of furosemide improves lung compliance and airway resistance for 1 hour. Chronic administration of furosemide improves both oxygenation and lung compliance. REVIEWER'S CONCLUSIONS In preterm infants > 3 weeks of age with CLD, acute and chronic administration of furosemide improve lung compliance. Chronic administration of intravenous or enteral furosemide improves oxygenation. In view of the lack of data from randomized trials concerning effects on important clinical outcomes, routine or sustained use of systemic loop diuretics in infants with (or developing) CLD cannot be recommended based on current evidence. Randomized trials are needed to assess the effects of furosemide administration on survival, duration of ventilatory support and oxygen administration, length of hospital stay, potential complications and long-term outcome.
Collapse
Affiliation(s)
- L P Brion
- Pediatrics, Division of Neonatology, Albert Einstein College of Medicine and Montefiore Medical Center, Weiler Hospital Room 725, 1825 Eastchester Road, Bronx, NY 10461, USA. @aecom.yu.edu
| | | |
Collapse
|
23
|
|