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Verma S, Lumba R, Kazmi SH, Vaz MJ, Prakash SS, Bailey SM, Mally PV, Randis TM. Effects of Inhaled Iloprost for the Management of Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2022; 39:1441-1448. [PMID: 33477175 DOI: 10.1055/s-0040-1722653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The study aimed to evaluate the effects of inhaled iloprost on oxygenation indices in neonates with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN We conducted a retrospective chart review of 30 patients with PPHN from January 2014 to November 2018, who did not respond to inhaled nitric oxide (iNO) alone and received inhaled iloprost. Twenty-two patients met the inclusion criteria and eight patients were excluded from the study (complex cardiac disease and extreme prematurity). Patients were categorized as responders or nonresponders (patients who required extracorporeal membrane oxygenation or died). Oxygenation index, mean airway pressure (MAP), and arterial partial pressure of oxygen (PaO2) were recorded. RESULTS Among a total of 22 patients who were included in the study, 10 were classified as nonresponders as they required either extracorporeal membrane oxygenation or died. Gestational age and gender did not differ between responders and nonresponders. The median PaO2 was lower (37 vs. 42 mm Hg; p < 0.05) and median MAP was higher (20 vs. 17 cm H2O; p < 0.02) in nonresponders compared with responders just prior to initiating iloprost. Iloprost responders had a significant increase in median PaO2 and decrease in median oxygenation index in the 24 hours after initiating treatment (p < 0.05), with no significant change in required mean airway pressure over that same period. There was no change in vasopressor use or clinically significant worsening of platelets count, liver, and kidney functions after initiating iloprost. CONCLUSION Inhaled iloprost is well tolerated and seems to have beneficial effects in improving oxygenation indices in neonates with PPHN who do not respond to iNO. There is a need of well-designed prospective trials to further ascertain the benefits of using inhaled iloprost as an adjunct treatment in neonates with PPHN who do not respond to iNO alone. KEY POINTS · Inhaled iloprost seems to have beneficial effects in improving oxygenation indices in PPHN.. · Inhaled iloprost is generally well tolerated in newborns with PPHN.. · There is a need for prospective randomized controlled trials to further ascertain the benefits of using inhaled iloprost..
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Affiliation(s)
- Sourabh Verma
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Rishi Lumba
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Sadaf H Kazmi
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Michelle J Vaz
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | | | - Sean M Bailey
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Tara M Randis
- Division of Neonatology, Departments of Pediatrics and Molecular Medicine, University of South Florida, Tampa, Florida
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Pfluger M, Humpl T. Pulmonary veno-occlusive disease in childhood-a rare disease not to be missed. Cardiovasc Diagn Ther 2021; 11:1070-1079. [PMID: 34527533 DOI: 10.21037/cdt-20-320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/27/2020] [Indexed: 11/06/2022]
Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare disease leading to pulmonary hypertension and potentially death related to right heart failure and/or respiratory insufficiency. Clinical symptoms are heterogenous and nonspecific: fatigue, decreased exercise tolerance, shortness of breath on exertion, cough, dizziness, chest pain with exercise, palpitations, syncope, as well as nonspecific symptoms such as headache, poor appetite, pallor or perioral cyanosis. Mutations in the EIF2AK4 (eukaryotic translation initiation factor 2-alpha kinase 4) have been recently described, other risk factors include exposure to organic solvent and trichloroethylene, tobacco exposure and chemotherapy. Echocardiography helps to estimate right ventricular systemic pressure, but further diagnostic workup includes cardiac catheterization to confirm pulmonary hypertension and increased pulmonary vascular resistance. High-resolution computed tomography reveals typical findings: centrilobular ground-glass nodules or opacities, septal lines, thickened interlobular septa, mosaic perfusion, and lymphadenopathy. Histology remains the gold standard, but carries risks for the patient. Proper workup is essential in order to avoid incorrect diagnosis. Pulmonary hypertension targeted treatment has been used in patients with PVOD, however, experience is limited, vasodilatory effects on pulmonary vasculature may lead to deterioration of the patients and should be used with great caution. Lung transplantation is currently the only valid treatment option for patients with PVOD. With prolonged waiting time and progression of the disease mechanical support could be considered.
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Affiliation(s)
- Marc Pfluger
- Department of Pediatrics, Children's Hospital, Inselspital, University of Berne, Berne, Switzerland
| | - Tilman Humpl
- Department of Pediatrics, Children's Hospital, Inselspital, University of Berne, Berne, Switzerland
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Chen T, Chen J, Chen C, Zheng H, Chen Y, Liu M, Zheng B. Systematic review and cost-effectiveness of bosentan and sildenafil as therapeutic drugs for pediatric pulmonary arterial hypertension. Pediatr Pulmonol 2021; 56:2250-2258. [PMID: 33856119 DOI: 10.1002/ppul.25427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a rare disease in children, with significant mortality. Because of the limited research on pediatric PAH, first, systematic review of related drugs is conducted, and then economic evaluation of PAH drug treatment programs is conducted, which to provide a reference for the choice of more cost-effective treatment options. METHODS The search includes electronic databases such as Pubmed, ScienceDirect, and Embase. Through inclusion and exclusion criteria, screen high-quality randomized controlled trials. We used TreeAge Pro 2011 software to construct the markov model, that to simulate the total medical cost and quality-adjusted life years (QALYs), and to calculate the incremental cost-effectiveness ratio. Sensitivity analysis of transfer probability, utility, and cost was carried out. RESULTS Incorporate two studies that meet the criteria, one compared the therapeutic effects of bosentan and placebo on pediatric PAH, the other compared therapeutic effects of sildenafil and placebo on pediatric PAH, both articles were of good quality. Compared with the sildenafil group (3.38QALYs and $161,120.14), the QALY of the bosentan treatment group (3.33QALYs and $257,411.29) was reduced by 0.05, and the cost increased by $96,291.15. The estimated improvement to quality of life and reduced costs result in an estimate of economic dominance for sildenafil over bosentan. This dominant result persisted probabilistic analyses. CONCLUSIONS Based on this model, a more cost-effective treatment drug for PAH in children is sildenafil.
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Affiliation(s)
- Tingting Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jiahe Chen
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
| | - Chaoxin Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Huanrui Zheng
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yanhui Chen
- Department of Pediatrics, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bin Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
| | - Girija G Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
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Farhat N, Lador F, Beghetti M. Diagnosis and treatment of pediatric pulmonary arterial hypertension. Expert Rev Cardiovasc Ther 2019; 17:161-175. [PMID: 30698043 DOI: 10.1080/14779072.2019.1576523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Pediatric pulmonary arterial hypertension (PAH) remains a rare and severe disease with a poor prognosis. PAH may be idiopathic, heritable or associated with systemic conditions in particular associated with congenital heart disease. Areas covered: A thorough and extensive diagnostic approach is required for a correct diagnosis. The outcome has improved over the last decade with a better diagnostic approach and with the initiation of new targeted therapies. However, there is still significant progress to achieve as there is still no cure for this devastating disease. Expert opinion: Adapted clinical studies to define the best therapeutic approach are needed. Even if the treatment approach is still mainly derived from adult data and expert consensus, several studies and registries are currently underway and should deliver important information in the next future. This review aims to give an overview of the current diagnosis and treatment strategies of PAH.
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Affiliation(s)
- Nesrine Farhat
- a Pediatric Cardiology Unit , University Children's Hospital of Geneva , Geneva , Switzerland
| | - Frederic Lador
- b Pulmonary Hypertension Program , University Hospital of Geneva , Geneva , Switzerland.,c Service de Pneumologie , University Hospital of Geneva , Geneva , Switzerland
| | - Maurice Beghetti
- a Pediatric Cardiology Unit , University Children's Hospital of Geneva , Geneva , Switzerland.,c Service de Pneumologie , University Hospital of Geneva , Geneva , Switzerland.,d Centre Universitaire Romand de Cardiologie et Chirurgie Cardiaque Pédiatrique , University of Geneva and Lausane Switzerland , Geneva , Switzerland
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Olave N, Lal CV, Halloran B, Bhandari V, Ambalavanan N. Iloprost attenuates hyperoxia-mediated impairment of lung development in newborn mice. Am J Physiol Lung Cell Mol Physiol 2018; 315:L535-L544. [PMID: 29952221 PMCID: PMC6230878 DOI: 10.1152/ajplung.00125.2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/21/2018] [Accepted: 06/21/2018] [Indexed: 11/22/2022] Open
Abstract
Cyclooxygenase-2 (COX-2/PTGS2) mediates hyperoxia-induced impairment of lung development in newborn animals and is increased in the lungs of human infants with bronchopulmonary dysplasia (BPD). COX-2 catalyzes the production of cytoprotective prostaglandins, such as prostacyclin (PGI2), as well as proinflammatory mediators, such as thromboxane A2. Our objective was to determine whether iloprost, a synthetic analog of PGI2, would attenuate hyperoxia effects in the newborn mouse lung. To test this hypothesis, newborn C57BL/6 mice along with their dams were exposed to normoxia (21% O2) or hyperoxia (85% O2) from 4 to 14 days of age in combination with daily intraperitoneal injections of either iloprost 200 µg·kg-1·day-1, nimesulide (selective COX-2 antagonist) 100 mg·kg-1·day-1, or vehicle. Alveolar development was estimated by radial alveolar counts and mean linear intercepts. Lung function was determined on a flexiVent, and multiple cytokines and myeloperoxidase (MPO) were quantitated in lung homogenates. Lung vascular and microvascular morphometry was performed, and right ventricle/left ventricle ratios were determined. We determined that iloprost (but not nimesulide) administration attenuated hyperoxia-induced inhibition of alveolar development and microvascular density in newborn mice. Iloprost and nimesulide both attenuated hyperoxia-induced, increased lung resistance but did not improve lung compliance that was reduced by hyperoxia. Iloprost and nimesulide reduced hyperoxia-induced increases in MPO and some cytokines (IL-1β and TNF-α) but not others (IL-6 and KC/Gro). There were no changes in pulmonary arterial wall thickness or right ventricle/left ventricle ratios. We conclude that iloprost improves lung development and reduces lung inflammation in a newborn mouse model of BPD.
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Affiliation(s)
- Nelida Olave
- Department of Pediatrics, University of Alabama at Birmingham , Birmingham, Alabama
| | | | - Brian Halloran
- Department of Pediatrics, University of Alabama at Birmingham , Birmingham, Alabama
| | - Vineet Bhandari
- Department of Pediatrics, Drexel University College of Medicine , Philadelphia, Pennsylvania
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