Respiratory function and symptoms in young preterm children in the contemporary era

Long-term pulmonary outcomes of young adults born prematurely: a Polish prospective cohort study PREMATURITAS 20

BACKGROUND

The long-term consequences of prematurity are often not sufficiently recognized. To address this gap, a prospective cohort study, which is a continuation of the multicenter Polish study PREMATURITAS, was conducted, utilizing unique clinical data from 20 years ago.

OBJECTIVE

The main goal was to evaluate lung function, detect any structural abnormalities using lung ultrasound, and assess psychological well-being in young adults born between 24 and 34 weeks of gestational age (GA). Additionally, the study aimed to investigate potential associations between perinatal risk factors and abnormalities observed in pulmonary function tests (PFTs) during adulthood.

METHODS

The young survivors underwent a comprehensive set of PFTs, a lung ultrasound, along with the quality of life assessment. Information regarding the neonatal period and respiratory complications was obtained from the baseline data collected in the PREMATURITAS study.

RESULTS

A total of 52 young adults, with a mean age of 21.6 years, underwent PFTs. They were divided into two groups based on GA: 24-28 weeks (n = 12) and 29-34 weeks (n = 40). The subgroup born more prematurely had significantly higher lung clearance index (LCI), compared to the other subgroup (p = 0.013). LCI ≥ 6.99 was more frequently observed in the more premature group (50% vs. 12.5%, p = 0.005), those who did not receive prenatal steroids (p = 0.020), with a diagnosis of Respiratory Distress Syndrome (p = 0.034), those who received surfactant (p = 0.026), and mechanically ventilated ≥ 7 days (p = 0.005). Additionally, elevated LCI was associated with the diagnosis of asthma (p = 0.010).

CONCLUSIONS

The findings suggest pulmonary effects due to prematurity persist into adulthood and their insult on small airway function. Regular follow-up evaluations of young survivors born preterm should include assessments of PFTs. Specifically, the use of LCI can provide valuable insights into long-term pulmonary impairment.

Risk factors for poorer respiratory outcomes in adolescents and young adults born preterm

RATIONALE

The respiratory outcomes for adult survivors of preterm birth in the postsurfactant era are wide-ranging with prognostic factors, especially those encountered after the neonatal period, poorly understood.

OBJECTIVES

To obtain comprehensive 'peak' lung health data from survivors of very preterm birth and identify neonatal and life-course risk factors for poorer respiratory outcomes in adulthood.

METHODS

127 participants born ≤32 weeks gestation (64%, n=81 with bronchopulmonary dysplasia (BPD), initially recruited according to a 2 with-BPD:1 without-BPD strategy), and 41 term-born controls completed a lung health assessment at 16-23 years, including lung function, imaging and symptom review. Risk factors assessed against poor lung health included neonatal treatments, respiratory hospitalisation in childhood, atopy and tobacco smoke exposure.

MEASUREMENTS AND MAIN RESULTS

Young adults born prematurely had greater airflow obstruction, gas trapping and ventilation inhomogeneity, in addition to abnormalities in gas transfer and respiratory mechanics, compared with term. Beyond lung function, we observed greater structural abnormalities, respiratory symptoms and inhaled medication use. A previous respiratory admission was associated with airway obstruction; mean forced expiratory volume in 1 s/forced vital capacity z-score was -0.561 lower after neonatal confounders were accounted for (95% CI -0.998 to -0.125; p=0.012). Similarly, respiratory symptom burden was increased in the preterm group with a respiratory admission, as was peribronchial thickening (6% vs 23%, p=0.010) and bronchodilator responsiveness (17% vs 35%, p=0.025). Atopy, maternal asthma and tobacco smoke exposure did not influence lung function or structure at 16-23 years in our preterm cohort.

CONCLUSIONS

Even after accounting for the neonatal course, a respiratory admission during childhood remained significantly associated with reduced peak lung function in the preterm-born cohort, with the largest difference seen in those with BPD. A respiratory admission during childhood should, therefore, be considered a risk factor for long-term respiratory morbidity in those born preterm, especially for individuals with BPD.

Peripheral airway dysfunction in prematurity-associated obstructive lung disease identified by oscillometry

INTRODUCTION

Mechanisms underlying lung dysfunction after preterm birth are poorly understood. Studying phenotypes of prematurity-associated lung disease may aid understanding of underlying mechanisms. Preterm-born children with and without lung dysfunction and term controls were assessed using oscillometry before and after exercise, and after postexercise bronchodilation.

METHODS

Preterm-born children, born at gestation of 34 weeks or less, were classified into those with prematurity-associated obstructive lung disease (POLD; FEV1  < LLN, FEV1 /FVC < LLN), prematurity-associated preserved ratio of impaired spirometry (pPRISm; FEV1  < LLN, FEV1 /FVC ≥ LLN) and compared to preterm (FEV1  ≥ LLN) and term controls (%predicted FEV1  > 90%). All children underwent cardiopulmonary exercise, and oscillometry assessment at baseline, postexercise, and after postexercise bronchodilator administration.

RESULTS

From 241 participants aged 7-12 years, complete data were available from 179: 15 children with POLD and 11 with pPRISm were compared with 93 preterm and 60 term controls. POLD group, when compared to both control groups, had impaired impedance, greater resistance, more negative (greater magnitude) reactance at low frequencies, and also had decreased compliance. pPRISm group demonstrated impaired reactance and compliance compared to term controls. No differences were noted between the preterm and term controls. Exercise had little impact on oscillometry values, but children with POLD had greatest improvements after postexercise bronchodilator administration, with decreased resistance and decreased magnitude of reactance, particularly at low frequencies.

CONCLUSION

Preterm-born children with obstructive airway disease had the greatest oscillometry impairments and the largest improvements after postexercise bronchodilator compared to control groups. Oscillometry can potentially be used to identify preterm-born children with lung disease to institute treatment.

Oscillometry and spirometry are not interchangeable when assessing the bronchodilator response in children and young adults born preterm

INTRODUCTION

The European Respiratory Society Oscillometry Taskforce identified that clinical correlates of bronchodilator responses are needed to advance oscillometry in clinical practice. The understanding of bronchodilator-induced oscillometry changes in preterm lung disease is poor. Here we describe a comparison of bronchodilator assessments performed using oscillometry and spirometry in a population born very preterm and explore the relationship between bronchodilator-induced changes in respiratory function and clinical outcomes.

METHODS

Participants aged 6-23 born ≤32 (N = 288; 132 with bronchopulmonary dysplasia) and ≥37 weeks' gestation (N = 76, term-born controls) performed spirometry and oscillometry. A significant bronchodilator response (BDR) to 400 μg salbutamol was classified according to published criteria.

RESULTS

A BDR was identified in 30.9% (n = 85) of preterm-born individuals via spirometry and/or oscillometry, with poor agreement between spirometry and oscillometry definitions (k = 0.26; 95% confidence interval [CI] 0.18-0.40, p < .001). Those born preterm with a BDR by oscillometry but not spirometry had increased wheeze (33% vs. 11%, p = .010) and baseline resistance (Rrs5 z-score mean difference (MD) = 0.86, 95% CI 0.07-1.65, p = .025), but similar baseline spirometry to the group without a BDR (forced expiratory volume in 1 s [FEV1 ] z-score MD = -0.01, 95% CI -0.66 to 0.68, p > .999). Oscillometry was more feasible than spirometry (95% success rate vs. 85% (FEV1 ), 69% (forced vital capacity) success rate, p < .001), however being born preterm did not affect test feasibility.

CONCLUSION

In the preterm population, oscillometry is a feasible and clinically useful supportive test to assess the airway response to inhaled salbutamol. Changes measured by oscillometry reflect related but distinct physiological changes to those measured by spirometry, and thus these tests should not be used interchangeably.

Are Babies Born Preterm High-Risk Asthma Candidates?

Among preterm infants, the risk of developing asthma is a matter of debate. This review discusses the state of the art of poorly understood prematurity-associated asthma. Impaired pulmonary function is common in children born prematurely. Preterm infants are prone to developing viral respiratory tract infections, bronchiolitis in the first year of life, and recurrent viral wheezing in preschool age. All of these conditions may precede asthma development. We also discuss the role of both atopic sensitization and intestinal microbiome and, consequently, immune maturation. Diet and pollution have been considered to better understand how prematurity could be associated with asthma. Understanding the effect of factors involved in asthma onset may pave the way to improve the prediction of this asthma phenotype.

Preterm Birth, Developmental Smoke/Nicotine Exposure, and Life-Long Pulmonary Sequelae

This review delineates the main pulmonary issues related to preterm birth, perinatal tobacco/nicotine exposure, and its effects on offspring, focusing on respiratory health and its possible transmission to subsequent generations. We review the extent of the problem of preterm birth, prematurity-related pulmonary effects, and the associated increased risk of asthma later in life. We then review the impact of developmental tobacco/nicotine exposure on offspring asthma and the significance of transgenerational pulmonary effects following perinatal tobacco/nicotine exposure, possibly via its effects on germline epigenetics.

Respiratory morbidity in preschool and school-age children born very preterm and its association with parents' health-related quality of life and family functioning

The purpose of this study is to describe the prevalence and severity of respiratory symptoms in children born very preterm and to assess their association with parents' health-related quality of life (HRQoL) and family functioning. We conducted a cross-sectional study and recruited children born less than 32 weeks' gestation between January 2006 and December 2019, in the greater Zurich area, Switzerland. Between May and December 2021, parents were invited to complete an online survey for their preterm child and for a control term born (≥ 37 weeks' gestation) sibling aged 1 to 18 years. We used a validated questionnaire to assess respiratory symptoms and the Pediatrics Quality of Life Family Impact Module (PedsQL FIM) to assess parents' HRQoL and family functioning. The survey was completed for 616 very preterm children (99 with bronchopulmonary dysplasia (BPD)) and 180 controls. Girls made up 45% (46% in controls) of the sample, and 63% (60% in controls) of participants were aged 6 to 18 years (school-age). Very preterm children reported a higher risk of respiratory symptoms than controls, especially preschoolers and those with moderate-to-severe BPD. Parents of children with "mild" and "moderate-severe" respiratory symptoms had on average -3.9 (95%CI: -6.6 to -1.1) and -8.2 (-11.2 to -5.2) lower PedsQL FIM total score, respectively, than parents of children with no symptoms. The same pattern was observed after stratifying by age categories.  Conclusions: Our study suggests that respiratory morbidity in very preterm children has a negative impact on parents' HRQoL and family functioning, even beyond the first years of life. What is Known: • The burden of respiratory morbidity associated with very premature birth is high and last far beyond the neonatal period. • Respiratory morbidity contributes to lower health-related quality of life (HRQoL) in parents of very preterm children in early infancy. What is New: • Respiratory morbidity in very preterm children has a negative impact on parents' HRQoL and family functioning beyond the first years of life. • Parents of very preterm children with moderate and severe respiratory symptoms are the ones who report lower scores, both for preschool and school-age children.

Environmental and Behavioral Factors in Association with Lung Function Impairment in Children Living in Wuhan, China

Children’s lung function is a significant predictor of health status throughout their lifetime. This study aims to identify the prevalence of impaired lung function in children and the potential influencing factors in elementary school children of Wuhan, China. Children of 6−12 years old were enrolled from elementary schools in Wuhan, China, in 2018, on the basis of a cross-sectional study design. Information on personal behavior patterns and household characteristics, as well as parental factors, was collected based on a questionnaire survey. Spirometry was used to measure fifteen lung function indicators. Logistic regression models were used to estimate odds ratios of prevalence of impaired lung function with regard to socioeconomic, personal behavior patterns, household, and parental factors, respectively. Four lung function indicators such as FET and EVC in urban children had higher values than in the suburban children after adjusting for confounders (p < 0.05). A higher prevalence of impaired lung function (FEV6, FEV3, EVC, and VC) was found in the children from the rural area than in those from the urban area. A sex difference in FET impairment was observed, however, no significant difference in impairment in other lung function indicators were found between girls and boys. The elevated height and weight of the children was significantly associated with an increased and decreased prevalence of impaired lung function, respectively, particularly both for FEV6, FEV3, FIVC, and FIV1. Opening windows for a longer time in summer was significantly associated with a lower prevalence of impaired FEF25 and MVV, and an extended time of opening windows in winter was significantly associated with a lower prevalence of impaired FEV6. While, opening windows for a longer time in autumn was significantly associated with higher prevalence of impaired FEV6 and FEV1/VC. Home renovations, doing physical exercise for more than 30 min per day, air pollution exposure during commuting, sleeping in own rooms, height stunting, and preterm birth were significantly associated with an increased risk of impaired lung function. Breastfeeding, having a father with a white-collar profession and with a higher education level were positively associated with the lower prevalence of impaired lung function. Impaired lung function is commonly found in school children in Wuhan, nowadays. Breastfeeding, opening windows long-term in summer and winter, higher socioeconomics, and an urban living environment were protective factors for impaired lung function. However, opening windows long-term and using air conditioning short-term in autumn, as well as home renovations, doing physical exercise for more than 30 min per day, preterm birth, height stunting, and air pollution exposure during commuting were regarded as significant risk factors for impaired lung function. Promoting breastfeeding, lengthening window opening times in winter and summer, and controlling household renovation and air pollution exposure during commuting are recommended to reduce the risk of impaired lung function in children in Wuhan.

Lung structure and function on MRI in preterm born school children with and without BPD: A feasibility study

BACKGROUND AND OBJECTIVE

The most common respiratory complication of prematurity is bronchopulmonary dysplasia (BPD), leading to structural lung changes and impaired respiratory outcomes. However, also preterm children without BPD may show similar adverse respiratory outcomes. There is a need for a safe imaging modality for preterm children with and without BPD for disease severity assessment and risk stratification. Our objective was to develop a magnetic resonance imaging (MRI) protocol in preterm children with and without BPD at school age.

METHODS

Nine healthy volunteers (median age 11.6 [range: 8.8-12.8] years), 11 preterm children with BPD (11.0 [7.2-15.6] years), and 9 without BPD (11.1 [10.7-12.6] years) underwent MRI. Images were scored on hypo- and hyperintense abnormalities, bronchopathy, and architectural distortion. MRI data were correlated to spirometry. Ventilation and perfusion defects were analyzed using Fourier Decomposition (FD) MRI.

RESULTS

On MRI, children with BPD had higher %diseased lung (9.1 (interquartile range [IQR] 5.9-11.6)%) compared to preterm children without BPD (3.4 (IQR 2.5-5.4)%, p < 0.001) and healthy volunteers (0.4 (IQR 0.1-0.8)%, p < 0.001). %Diseased lung correlated negatively with %predicted FEV₁ (r = -0.40, p = 0.04), FEV₁ /FVC (r = -0.49, p = 0.009) and FEF₇₅ (r = -0.63, p < 0.001). Ventilation and perfusion defects on FD sequence corresponded to hypointense regions on expiratory MRI.

CONCLUSION

Chest MRI can identify structural and functional lung damage at school age in preterm children with and without BPD, showing a good correlation with spirometry. We propose MRI as a sensitive and safe imaging method (without ionizing radiation, contrast agents, or the use of anesthesia) for the long-term follow-up of preterm children.

Pseudorandom Noise Forced Oscillation Technique to Assess Lung Function in Prematurely Born Children

The forced oscillation technique (FOT) is a non-volitional assessment that is used during tidal breathing. A variant of FOT uses a pseudorandom noise (PRN) signal which we postulated might have utility in assessing lung function in prematurely born children. We, therefore, undertook a systematic review to evaluate the evidence regarding PRN FOT. A comprehensive search of the literature was conducted by using the following databases: Medline, Embase, Web of Science and CINAHL. Observational studies, case series/reports and randomized-controlled trials were eligible for inclusion. Article abstracts and full texts were screened independently by two reviewers, with disagreements resolved by discussion or a third reviewer if necessary. Five studies were included (n = 587 preterm children). Three compared PRN FOT with spirometry, and two compare it to the interrupter technique. Most studies failed to report comprehensive methodology of the frequency spectra used to generate the PRN signal. There was evidence that poorer lung function, as assessed by PRN FOT, was associated with a greater burden of respiratory symptoms, but there was insufficient evidence to determine whether PRN FOT performed better than other lung-function tests. Detailed methodological documentation, in accordance with ERS guidance, is needed to assess the benefits of PRN FOT prior to routine clinical incorporation to assess prematurely born children.

Lifelong Lung Sequelae of Prematurity

The clinical, functional, and structural pattern of chronic lung disease of prematurity has changed enormously in last years, mirroring a better perinatal management and an increasing lung immaturity with the survival of increasingly premature infants. Respiratory symptoms and lung function impairment related to prematurity seem to improve over time, but premature birth increases the likelihood of lung function impairment in late childhood, predisposing to chronic obstructive pulmonary disease (COPD). It is mandatory to identify those individuals born premature who are at risk for developing long-term lung disease through a better awareness of physicians, the use of standardized CT imaging scores, and a more comprehensive periodic lung function evaluation. The aim of this narrative review was to provide a systematic approach to lifelong respiratory symptoms, lung function impairment, and lung structural anomalies in order to better understand the specific role of prematurity on lung health.

Clinical significance and applications of oscillometry

Recently, “Technical standards for respiratory oscillometry” was published, which reviewed the physiological basis of oscillometric measures and detailed the technical factors related to equipment and test performance, quality assurance and reporting of results. Here we present a review of the clinical significance and applications of oscillometry. We briefly review the physiological principles of oscillometry and the basics of oscillometry interpretation, and then describe what is currently known about oscillometry in its role as a sensitive measure of airway resistance, bronchodilator responsiveness and bronchial challenge testing, and response to medical therapy, particularly in asthma and COPD. The technique may have unique advantages in situations where spirometry and other lung function tests are not suitable, such as in infants, neuromuscular disease, sleep apnoea and critical care. Other potential applications include detection of bronchiolitis obliterans, vocal cord dysfunction and the effects of environmental exposures. However, despite great promise as a useful clinical tool, we identify a number of areas in which more evidence of clinical utility is needed before oscillometry becomes routinely used for diagnosing or monitoring respiratory disease.

This paper provides a current review of the interpretation, clinical significance and application of oscillometry in respiratory medicine, with special emphasis on limitations of evidence and suggestions for future research.https://bit.ly/3GQPViA

Development of Lung Function in Preterm Infants During the First Two Years of Life

INTRODUCTION

It remains unclear if prematurity itself can influence post delivery lung development and particularly, the bronchial size.

AIM

To assess lung function during the first two years of life in healthy preterm infants and compare the measurements to those obtained in healthy term infants during the same time period.

METHODS

This observational longitudinal study assessed lung function in 74 preterm (30+0 to 35+6 weeks' gestational age) and 76 healthy term control infants who were recruited between 2011 and 2013. Measurements of tidal breathing, passive respiratory mechanics, tidal and raised volume forced expirations (V'maxFRC and FEF_25-75, respectively) were undertaken following administration of oral chloral hydrate sedation according to ATS/ERS recommendations at 6- and 18-months corrected age.

RESULTS

Lung function measurements were obtained from the preterm infants and full term controls initially at 6 months of age. Preterm infants had lower absolute and adjusted values (for gestational age, postnatal age, sex, body size, and confounding factors) for respiratory compliance and V'maxFRC. At 18 months corrected postnatal age, similar measurements were repeated in 57 preterm infants and 61 term controls. A catch-up in tidal volume, respiratory mechanics parameters, FEV_0.5 and forced expiratory flows was seen in preterm infants.

CONCLUSION

When compared with term controls, the lower forced expiratory flows observed in the healthy preterm group at 6 months was no longer evident at 18 months corrected age, suggesting a catch-up growth of airway function.

Pulmonary Magnetic Resonance Imaging of Ex-preterm Children with/without Bronchopulmonary Dysplasia

RATIONALE

Children born prematurely, particularly those with bronchopulmonary dysplasia, have persisting lung abnormalities requiring longitudinal monitoring. Pulmonary ultra-short echo time magnetic resonance imaging (MRI) measurements may provide sensitive markers of persisting lung abnormalities, and have not been evaluated in school-aged children born prematurely.

OBJECTIVE

To compare pulmonary MRI and pulmonary function test measurements in preterm-born school-aged children with and without bronchopulmonary dysplasia.

METHODS

Children aged 7-9 years, born extremely preterm, with and without bronchopulmonary dysplasia, were recruited from three centers. Participants underwent pulmonary ultra-short echo time MRI and pulmonary function tests. Primary outcomes included total proton density and proton density at full expiration, measured using MRI. Multiple linear regression analysis was performed, adjusting for gestational age and bronchopulmonary dysplasia. Associations between MRI and pulmonary function were tested.

RESULTS

Thirty-five children were included in the primary analysis (24 with bronchopulmonary dysplasia, 11 without); 29 completed pulmonary function tests, of whom 11 (38%) had airflow limitation. Children with bronchopulmonary dysplasia had 44% (CI: 10%, 66%) lower mean total proton density (mean ± SD: 3.6 ± 2.6) compared to those without (6.1 ± 4.0). Those with bronchopulmonary dysplasia had 25% (CI: 3%, 42%) lower proton density at full expiration than those without. Lower total proton density and proton density at full expiration were moderately correlated with greater residual volume, residual volume/total lung capacity, and lung clearance index (Spearman correlations for total proton density: -0.42, -0.57, and -0.53, respectively. Spearman correlations for proton density at full expiration: -0.28, -0.57, and -0.45, respectively).

CONCLUSIONS

School-aged preterm-born children with bronchopulmonary dysplasia have parenchymal tissue abnormalities measured using ultrashort MRI proton density, compared to those without. MRI proton density correlated with pulmonary function measures indicative of gas trapping. Clinical trial registered with ClinicalTrials.gov (NCT02921308).

Early extubation to noninvasive respiratory support of former preterm lambs improves long-term respiratory outcomes

Invasive mechanical ventilation (IMV) and exposure to oxygen-rich gas during early postnatal life are contributing factors for long-term pulmonary morbidities faced by survivors of preterm birth and bronchopulmonary dysplasia. The duration of IMV that leads to long-term pulmonary morbidities is unknown. We compared two durations of IMV (3 h vs. 6 days) during the first 6-7 days of postnatal life in preterm lambs to test the hypothesis that minimizing the duration of IMV will improve long-term respiratory system mechanics and structural outcomes later in life. Moderately preterm (∼85% gestation) lambs were supported by IMV for either 3 h or 6 days before weaning from all respiratory support to become former preterm lambs. Respiratory system mechanics and airway reactivity were assessed monthly from 1 to 6 mo of chronological postnatal age by the forced oscillation technique. Quantitative morphological measurements were made for smooth muscle accumulation around terminal bronchioles and indices of alveolar formation. Minimizing IMV to 3 h led to significantly better (P < 0.05) baseline respiratory system mechanics and less reactivity to methacholine in the first 3 mo of chronological age (2 mo corrected age), significantly less (P < 0.05) accumulation of smooth muscle around peripheral resistance airways (terminal bronchioles), and significantly better (P < 0.05) alveolarization at the end of 5 mo corrected age compared with continuous IMV for 6 days. We conclude that limiting the duration of IMV following preterm birth of fetal lambs leads to better respiratory system mechanics and structural outcomes later in life.

Lung function trajectories in children with post-prematurity respiratory disease: identifying risk factors for abnormal growth

Background

Survivors of prematurity are at risk for abnormal childhood lung function. Few studies have addressed trajectories of lung function and risk factors for abnormal growth in childhood. This study aims to describe changes in lung function in a contemporary cohort of children born preterm followed longitudinally in pulmonary clinic for post-prematurity respiratory disease and to assess maternal and neonatal risk factors associated with decreased lung function trajectories.

Methods

Observational cohort of 164 children born preterm ≤ 32 weeks gestation followed in pulmonary clinic at Boston Children’s Hospital with pulmonary function testing. We collected demographics and neonatal history. We used multivariable linear regression to identify the impact of neonatal and maternal risk factors on lung function trajectories in childhood.

Results

We identified 264 studies from 82 subjects with acceptable longitudinal FEV₁ data and 138 studies from 47 subjects with acceptable longitudinal FVC and FEV₁/FVC data. FEV₁% predicted and FEV₁/FVC were reduced compared to childhood norms. Growth in FVC outpaced FEV₁, resulting in an FEV₁/FVC that declined over time. In multivariable analyses, longer duration of mechanical ventilation was associated with a lower rate of rise in FEV₁% predicted and greater decline in FEV₁/FVC, and postnatal steroid exposure in the NICU was associated with a lower rate of rise in FEV₁ and FVC % predicted. Maternal atopy and asthma were associated with a lower rate of rise in FEV₁% predicted.

Conclusions

Children with post-prematurity respiratory disease demonstrate worsening obstruction in lung function throughout childhood. Neonatal risk factors including exposure to mechanical ventilation and postnatal steroids, as well as maternal atopy and asthma, were associated with diminished rate of rise in lung function. These results may have implications for lung function trajectories into adulthood.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01720-0.

Multimodal longitudinal respiratory function assessment in very low birth weight 7-year-old children

PURPOSE

Preterm birth is associated with adverse pulmonary outcomes. We aimed to evaluate respiratory morbidities and lung function of very low birth weight (VLBW) Polish children followed up at the age of 7 years old, and to compare with electrical impedance segmentography (EIS) results recorded at 4 years of age.

MATERIALS AND METHODS

VLBW children were compared with term controls using impulse oscillometry and spirometry. Perinatal data and current respiratory morbidities were analyzed and pulmonary function test results were compared with previous EIS results.

RESULTS

We included 40 VLBW children and 30 controls in the analysis. Elevated total airway resistance and forced expiratory volume in the first second below the lower limit of normal were more prevalent in VLBW children compared with term controls (15 vs 0%; 18 vs 0%). A positive bronchodilator response was more common in VLBW children (R_{5 Hz}: 46 vs 13.3%; R_5-20 ​Hz: 65 vs 36.7%). Children with bronchopulmonary dysplasia (BPD) had higher total airway resistance (R_{5 Hz}/R_{5 Hz pred}: 1.35 vs 0.95; p ​< ​0.001), large airway resistance (R_{20 Hz}/R_{20 Hz pred}: 0.89 vs 0.66; p ​= ​0.001), small airway resistance (R_5-20 ​Hz: 0.57 vs 0.34 ​kPa ​L^-1 ​s^-1; p ​= ​0.009), than controls. Strong correlation between BDR in EIS and R_{5 Hz}/R_{5 Hz pred} was observed in children with BPD (r ​= ​0.7).

CONCLUSION

VLBW school-aged children with BPD presented with substantial respiratory morbidity and persistent reduction of lung function, affecting small and large airways and lung parenchyma. EIS may be an alternative tool for lung function assessment in children with BPD.

Long-term respiratory and developmental outcomes in children with bronchopulmonary dysplasia and history of tracheostomy

OBJECTIVE

The long-term morbidity among children with severe bronchopulmonary dysplasia who require tracheostomy (tBPD) relative to those without tracheostomy (sBPD) is not well characterized. We compared childhood lung function and neurodevelopmental outcomes in tBPD and sBPD.

STUDY DESIGN

Retrospective case-control study of N = 49 tBPD and N = 280 sBPD subjects in Boston Children's Hospital Preterm Lung Patient Registry and medical record. We compared NICU course, childhood spirometry, and neurodevelopmental testing.

RESULT

tBPD subjects were more likely than sBPD to be Black, have pulmonary hypertension, and have subglottic stenosis. tBPD subjects had lower maximal childhood FEV₁ % predicted (β = -0.14) and FEV₁/FVC (β = -0.08); spirometry curves were more likely to suggest fixed extrathoracic obstruction. tBPD subjects had greater cognitive and motor delays <24 months, and greater cognitive delays >24 months.

CONCLUSION

Compared to subjects with sBPD who did not require tracheostomy, tBPD subjects suffer from increased long-term impairment in respiratory function and neurodevelopment.

Predicting Long-Term Respiratory Outcomes in Premature Infants: Is It Time to Move beyond Bronchopulmonary Dysplasia?

Premature birth has been shown to be associated with adverse respiratory health in children and adults; children diagnosed with bronchopulmonary dysplasia (BPD) in infancy are at particularly high risk. Since its first description by Northway et al. about half a century ago, the definition of BPD has gone through several iterations reflecting the changes in the patient population, advancements in knowledge of lung development and injury, and improvements in perinatal care practices. One of the key benchmarks for optimally defining BPD has been the ability to predict long-term respiratory and health outcomes. This definition is needed by multiple stakeholders for hosts of reasons including: providing parents with some expectations for the future, to guide clinicians for developing longer term follow-up practices, to assist policy makers to allocate resources, and to support researchers involved in developing preventive or therapeutic strategies and designing studies with meaningful outcome measures. Long-term respiratory outcomes in preterm infants with BPD have shown variable results reflecting not only limitations of the current definition of BPD, but also potentially the impact of other prenatal, postnatal and childhood factors on the respiratory health. In this manuscript, we present an overview of the long-term respiratory outcomes in infants with BPD and discuss the role of other modifiable or non-modifiable factors affecting respiratory health in preterm infants. We will also discuss the limitations of using BPD as a predictor of respiratory morbidities and some of the recent advances in delineating the causes and severity of respiratory insufficiency in infants diagnosed with BPD.

Lung abnormalities do not influence aerobic capacity in school children born preterm

PURPOSE

Children born preterm have impaired lung function and altered lung structure. However, there are conflicting reports on how preterm birth impacts aerobic exercise capacity in childhood. We aimed to investigate how neonatal history and a diagnosis of bronchopulmonary dysplasia (BPD) impact the relationship between function and structure of the lung, and aerobic capacity in school-aged children born very preterm.

METHODS

Preterm children (≤ 32 w completed gestation) aged 9-12 years with (n = 38) and without (n = 35) BPD, and term-born controls (n = 31), underwent spirometry, lung volume measurements, gas transfer capacity, a high-resolution computer tomography (CT) scan of the chest, and an incremental treadmill exercise test.

RESULTS

Children born preterm with BPD had an elevated breathing frequency to tidal volume ratio compared to term controls (76% vs 63%, p = 0.002). The majority (88%) of preterm children had structural changes on CT scan. There were no differences in peak V̇O₂ (47.1 vs 47.7 mL/kg/min, p = 0.407) or oxygen uptake efficiency slope when corrected for body weight (67.6 vs 67.3, p = 0.5) between preterm children with BPD and term controls. There were no differences in any other exercise outcomes. The severity of structural lung disease was not associated with exercise outcomes in this preterm population.

CONCLUSION

Children born preterm have impaired lung function, and a high prevalence of structural lung abnormalities. However, abnormal lung function and structure do not appear to impact on the aerobic exercise capacity of preterm children at school age.

Agreement between spirometry and impulse oscillometry for lung function assessment in 6-year-old children born extremely preterm and at term

BACKGROUND

Extremely preterm birth is a risk factor for reduced lung function later in life, and clinical follow-up from early childhood is recommended. Dynamic spirometry is the most widely used method to assess airway obstruction, but impulse oscillometry (IOS) may be an alternative method that is easier to perform in young children. The feasibility and agreement between spirometry and IOS outcome variables has not been investigated in children born extremely preterm.

AIM

To determine the feasibility of and correlation between spirometry and IOS in pre-school children born extremely preterm.

METHODS

Spirometry and IOS were performed in 6-year-old children born extremely preterm (n = 88) and age-matched term controls (n = 84) in Stockholm, Sweden. Correlations between spirometry and IOS outcome variables were analyzed using Pearson's partial correlation, adjusting for height.

RESULTS

Success rate for spirometry (60%) was lower than for IOS (93%) but did not differ significantly between the preterm and term groups (56% and 64% for spirometry, P = .25; and 92% and 94% for IOS, P = .61). Correlations between spirometry and IOS outcomes were at best moderate (Spearman's r = -0.31 to -0.56). Normal IOS identified 69% to 90% of those with normal spirometry. A negative predictive value of 90% was found for R5-R20 versus FEV_0.75 /FVC, suggesting that IOS may be used to exclude obstructive airway disease as measured by spirometry.

CONCLUSION

IOS is a more feasible method than spirometry to assess lung function in young children irrespective of gestational age at birth and could be considered an alternative in children who cannot perform spirometry.

Duration of neonatal oxygen supplementation, erythropoiesis and blood pressure in young adults born preterm

BACKGROUND

Although erythropoiesis is impaired and anaemia frequent in neonates born preterm, haematopoiesis in adults born preterm has not been previously studied.

OBJECTIVE

We, thus, aimed to evaluate haemoglobin and erythropoietin levels in young adults born preterm, to identify neonatal events associated with erythropoiesis in adulthood and to examine the relationships of haemoglobin levels with respiratory function and blood pressure.

METHODS

We assessed a cohort of 101 young adults (ages 18-29) born preterm (≤29 weeks of gestation), in comparison to 105 full-term controls. We measured haemoglobin, erythropoietin levels and blood pressure. We also assessed respiratory function using spirometry.

RESULTS

Compared with controls, tobacco use and sex-adjusted haemoglobin levels were 5.3 (95% CI 2.9 to 7.7) g/L higher in preterm-born individuals, but erythropoietin levels were similar. Duration of oxygen supplementation in the neonatal period was independently associated with higher haemoglobin levels in the preterm group. In young adults born preterm with bronchopulmonary dysplasia, airflow limitation was associated with higher haemoglobin levels. Both systolic (SBP) and diastolic (DBP) blood pressure were increased in individuals born preterm (p=0.042 and p=0.0008, respectively). Higher haemoglobin levels were associated with higher SBP and DBP, independently of term or preterm status. Mediation analysis suggests that haemoglobin increase contributes to 37% and 32% of the effect of preterm birth on SBP and DBP, respectively.

CONCLUSIONS

Haemoglobin levels are higher in young adults born preterm, while erythropoietin levels are similar, especially in case of bronchopulmonary dysplasia and airflow limitation, and haemoglobin increase is associated with elevated blood pressure in this population.

Intermittent CPAP limits hyperoxia-induced lung damage in a rabbit model of bronchopulmonary dysplasia

A significant proportion of preterm infants develop bronchopulmonary dysplasia (BPD) leading to poor lifelong respiratory health. Limited treatment options exist with continuous positive airway pressure (CPAP) ventilation being one of the few associated with diminished BPD. However, little is known about the effect of the distending pressure of CPAP on the developing lung exposed to hyperoxia. We aimed to identify the functional and structural effects of CPAP in a preterm hyperoxia rabbit model of BPD. Premature rabbit pups were randomized to normoxia, hyperoxia (≥95% O₂), or hyperoxia plus 4 h daily CPAP [fraction of inspired oxygen (Fi_O2) 0.95, 5 cmH₂O]. On day 7 postdelivery we performed invasive pressure-volume- and forced oscillation-based pulmonary function tests, before lung harvest for histological evaluation. Alveolar and vascular morphology, airway smooth muscle content, respiratory epithelium height, extracellular matrix components, and inflammatory cytokine expression were quantified. Hyperoxia-reared pups had restrictive lungs: alveolar walls were thickened, with the lung parenchymal tissue, collagen content, and airway smooth muscle content increased. In addition, peripheral pulmonary artery wall thickness was increased. CPAP increased alveolar recruitment and limited the structural effect of hyperoxia on the respiratory epithelium and pulmonary arteries. Additionally, CPAP improved lung function, mitigating hyperoxia-associated changes to respiratory system resistance, tissue damping, and tissue elastance. Hyperoxia disrupted functional and structural lung development. Daily intermittent CPAP limited hyperoxia-associated decreased lung function and attenuated structural changes to pulmonary arteries and respiratory epithelium while having no structural alveolar consequences. The mechanism by which CPAP has these beneficial effects needs further investigation.

Reduced Lung Function at Preschool Age in Survivors of Very Low Birth Weight Preterm Infants

Background: Survivors of preterm birth are at risk of long-term respiratory consequences. The objective of this prospective study was to assess pulmonary function at preschool age of former very low birth weight (VLBW) preterm children. Methods: Lung function of children born preterm and term controls aged 5-6 years were assessed by spirometry. The results were converted to z-scores. A questionnaire regarding respiratory symptoms was completed. Associations to gestational age (GA), birth weight (BW), bronchopulmonary dysplasia (BPD), and perinatal factors were assessed. Results: In total, 85 VLBW preterm children and 29 term controls were studied. Of the preterm children, the mean GA was 28.6 ± 2.6 weeks and the mean BW was 1,047 ± 273 gm. Preterm children had significantly lower z-scores of forced expiratory volume in 1 s (FEV₁), FEV₁/forced vital capacity (FVC) ratio, and forced expiratory flow rate between 25-75% of FVC (FEF_25-75), compared with term controls (-0.73 vs. 0.04, p = 0.002; -0.22 vs. 0.39, p = 0.003; -0.93 vs. 0.0, p < 0.001; respectively). Further segregation of the preterm group revealed significantly impaired FEV₁, FEF_25-75 in children at earlier gestation (≤ 28 weeks, n = 45), lighter at birth (≤ 1,000 g, n = 38), or with BPD (n = 55) compared with term controls (p < 0.05). There were significant negative relationships between the severity of BPD with FEV₁, FVC, and FEF_25-75 (p < 0.05). However, no correlation between lung function measurements and respiratory symptoms was found. Conclusions: VLBW preterm infants have reduced lung function at preschool age, especially among those with younger GA, lower BW, and BPD. Additional long-term follow-up of respiratory outcomes are needed for this vulnerable population.

[Dynamic observation of pulmonary function by plethysmography in preterm infants with bronchopulmonary dysplasia]

OBJECTIVE

To study the effect of bronchopulmonary dysplasia (BPD) on lung function in preterm infants.

METHODS

According to the presence/absence or the severity of BPD, 72 preterm infants were divided into non-BPD group (n=44), mild BPD group (n=15) and moderate BPD group (n=13). Lung function was assessed by plethysmography on days 7, 14 and 28 after birth.

RESULTS

The preterm infants in the three groups had gradual increases in tidal volume per kilogram (TV/kg), functional residual capacity (FRC), ratio of time to peak tidal expiratory flow to total expiratory time (%T-PF) and ratio of volume to peak tidal expiratory flow to total expiratory volume (%V-PF) on days 7, 14 and 28 after birth, while there were gradual reductions in effective airway resistance per kilogram (Reff/kg) and respiratory rate (RR) (P<0.05). Compared with the non-BPD group on days 7, 14 and 28 after birth, the mild and moderate BPD groups had significantly lower TV/kg, FRC, %T-PF, and %V-PF and significantly higher Reff/kg and RR (P<0.05). On day 7 after birth, the moderate BPD group had significantly higher airway resistance, Reff/kg and FRC/kg than the mild BPD group (P<0.05).

CONCLUSIONS

There is a certain degree of pulmonary function impairment in preterm infants with BPD. Dynamic monitoring of lung function by plethysmography is useful for assessing lung development in the neonatal period in these infants.

Upper Airway Pathology Contributes to Respiratory Symptoms in Children Born Very Preterm

OBJECTIVE

To evaluate the role of upper airway dysfunction, indicated by altered vocal quality (dysphonia), on the respiratory symptoms of children surviving very preterm birth.

STUDY DESIGN

Children born <32 weeks of gestation participated in 2 separate assessments during midchildhood. The first visit assessed voice quality by a subjective evaluation using the Consensus Auditory-Perceptual Evaluation of Voice and a computerized analysis of the properties of the voice via the Acoustic Voice Quality Index. The second assessment recorded parentally reported respiratory symptoms and measures of lung function, including spirometry, lung volumes, oscillatory mechanics, and a cardiopulmonary exercise test.

RESULTS

Preterm children (n = 35; median gestation 24.3 weeks) underwent paired voice and lung assessments at approximately 11 years of age. Preterm children with dysphonia (n = 25) reported significantly more respiratory symptoms than those with normal voices (n = 10) including wheeze (92% vs 40%; P = .001) and asthma diagnosed by a physician (60% vs 10%; P = .007). Lung function outcomes were generally not different between the dysphonic group and the group with normal voice (P > .05), except for the oscillatory mechanics measures, which were all at least 0.5 z score lower in the dysphonic group (Xrs₈ mean difference = -0.91 z scores, P = .003; f_res = 1.06 z scores, P = .019; AX = -0.87 z scores, P = .010; Rrs₈ = 0.63 z scores, P = .068).

CONCLUSIONS

The upper airway may play a role in the respiratory symptoms experienced by some very preterm children and should be considered by clinicians, especially when symptoms are in the presence of normal lung function and are refractory to treatment.

Neonatal respiratory status predicts longitudinal respiratory health outcomes in preterm infants

OBJECTIVES

To examine the relationship between neonatal respiratory status and longitudinal respiratory health outcomes in preterm infants with very low birth weight (VLBW, birth weight <1500 g).

METHODS

A total of 109 VLBW preterm infants were prospectively assessed for respiratory status using the Toce clinical and radiographic scoring method on a postnatal day 28, and severity of bronchopulmonary dysplasia (BPD) at 36-weeks postmenstrual age (PMA), respiratory morbidity within 1 year of corrected age (CA), pulmonary function test, and six-minute walk test at 4 years of age.

RESULTS

A high Toce clinical score on day 28 was associated with the occurrence of respiratory morbidity within 1 year of CA and poor pulmonary function and functional exercise performance at 4 years of age in VLBW preterm infants (all P < 0.05). BPD at 36-weeks PMA was associated with an increased risk of respiratory morbidity within 1 year of CA and its negative impact on pulmonary function and functional exercise performance at 4 years of age was most pronounced in the severe form (all P < 0.05).

CONCLUSIONS

Early assessments of neonatal respiratory status including Toce clinical score and the severity of BPD are valid to identify VLBW preterm infants who are at risk of adverse longitudinal respiratory health outcomes.

Identifying pediatric lung disease: A comparison of forced oscillation technique outcomes

RATIONALE

Increasing evidence suggests the forced oscillation technique (FOT) has the capacity to provide non-invasive monitoring and diagnosis of respiratory disease in young children. However, which FOT outcomes provide the most pertinent clinical information is currently unknown. The aim of this study was to determine which FOT outcomes were most sensitive for differentiating between health and specific childhood respiratory disease.

METHODS

Respiratory impedance was measured using a commercial device (i2M, Chess Medical, Belgium) in children aged between 3 and 7 years, who had been diagnosed with either cystic fibrosis (N = 84), asthma (N = 99) or were born very preterm (N = 114). Z-scores were calculated for respiratory system resistance (Rrs) and reactance (Xrs) at 6, 8, and 10 Hz, the resonance frequency (Fres), frequency dependence (Fdep_4-24 ), and area under the reactance curve (AX). Pairwise comparisons of the area under the receiver operating characteristic (ROC) curve were used to determine the most relevant FOT variables.

RESULTS AND CONCLUSIONS

The FOT outcomes best able to discern between health and disease were Fres (P < 0.0001) in cystic fibrosis, Fres (P < 0.0001) in asthma and Xrs₈ (P < 0.0001) in children born preterm. These findings suggest the utility of specific FOT outcomes is dependent on the respiratory disease being assessed. It is hoped that a disease-specific approach to interpreting FOT data can help further refine the FOT technique to aid in the diagnosis of children with pediatric respiratory disease.

Correcting standardized expiratory flows for prematurity in ex-preterm survivors-Is it necessary?

OBJECTIVE

To determine the effect of correcting for prematurity on standardized values for expiratory flow rates for participants from 5 years through to 70 years of age.

METHODS

In a theoretical model we assumed starting values for expiratory flows that were expected to give ranges within ±2 SD. Keeping expiratory flows, ethnicity and height constant, we then determined how z scores varied between 5 and 16.9 years, and, with two different fixed values for height and expiratory flows, between 16 and 70 years of ages, for both sexes. In a clinical example, we compared expiratory flows with age both corrected and uncorrected for prematurity between 144 survivors born extremely preterm and 141 term-born controls at both 8 and 18 years of age.

RESULTS

In the theoretical models, z scores mostly declined through childhood until the late teenage years, and then began to rise through later life. The maximum difference in z-scores between corrected and uncorrected scores for a participant born 4 months' preterm would occur in the early teenage years, and for the forced vital capacity would be approximately -0.09 SD wider. In the clinical example not correcting for prematurity resulted in a maximum gap between preterm and term cohorts 0.06 SD wider for the forced vital capacity at 8 years than if age was corrected for prematurity.

CONCLUSIONS

Correction for prematurity is not necessary in clinical practice, and is probably not required for research in studies of respiratory airflow through childhood or adulthood.

Lung function in a cohort of 5-year-old children born very preterm

OBJECTIVE

We assessed lung function and respiratory health in an area-based prospective cohort of preschool children born very preterm.

DESIGN

Lung function was measured by interrupter respiratory resistance (Rint) and forced oscillation technique (FOT) (respiratory resistance (Rrs8), reactance (Xrs8), and area under the reactance curve (AX)) at a median age of 5.2 years in a cohort of 194 children born at 22-31 weeks of gestational age (GA) in Tuscany, Italy. Respiratory symptoms and hospitalizations were also assessed.

RESULTS

Mean (SD) lung function Z-scores were impaired in preterm children for Rint (0.72 (1.13)), Xrs8 (-0.28 (1.34)), and AX (0.29 (1.41)). However, only a relatively small proportion of children (14.5-17.4%) had values beyond the 95th centile or below the 5th. Children with bronchopulmonary dysplasia (BPD) (n = 24) had slightly but not significantly impaired lung function indices in comparison with those without BPD (n = 170). In a multivariable analysis, lower GA was associated with worse lung function indices. Fifty-five percent of children had a history of wheezing ever and 21% had been hospitalized in their lifetime because of lower respiratory infections; 31% had wheezing in the last 12 months and this was associated with increased Rrs8 (P = 0.04) and AX (P = 0.08), and with decreased Xrs8 (P = 0.04) Z-scores.

CONCLUSIONS

Irrespectively of BPD preschool children born very preterm had impaired lung function indices, as measured by Rint and FOT, and a slightly higher burden of respiratory problems than the general population. GA seems to be crucial for lung development.

Increased prevalence of expiratory flow limitation during exercise in children with bronchopulmonary dysplasia

Evidence regarding the prevalence of expiratory flow limitation (EFL) during exercise and the ventilatory response to exercise in children born preterm is limited. This study aimed to determine the prevalence of EFL as well as contributing factors to EFL and the ventilatory response to exercise in preterm children with and without bronchopulmonary dysplasia (BPD).

Preterm children (≤32 weeks gestational age) aged 9–12 years with (n=64) and without (n=42) BPD and term controls (n=43), performed an incremental treadmill exercise test with exercise tidal flow–volume loops.

More preterm children with BPD (53%) had EFL compared with preterm children without BPD (26%) or term controls (28%) (p<0.05). The presence of EFL was independently associated with decreased forced expiratory volume in 1 s/forced vital capacity z-score and lower gestational age (p<0.05). There was no difference in peak oxygen uptake between preterm children with BPD and term controls (48.0 versus 48.4 mL·kg⁻¹·min⁻¹; p=0.063); however, children with BPD had a lower tidal volume at peak exercise (mean difference −27 mL·kg⁻¹, 95% CI −49– −5; p<0.05). Children born preterm without BPD had ventilatory responses to exercise similar to term controls.

Expiratory flow limitation is more prevalent in children born preterm with BPD and is associated with airway obstruction and a lower gestational age.

Children born preterm have an increased prevalence of expiratory limitation during exercise associated with reduced lung function and lower gestational agehttp://ow.ly/jLsk30leOVI

Lung function tests to monitor respiratory disease in preschool children

Pulmonary function tests are routinely used in the diagnosis and follow-up of respiratory diseases. In preschool children assessment and evaluation of lung function has always been challenging but improved techniques that require only minimal collaboration allowed obtaining reliable and useful results even in this group of patients. In this review we will describe the different techniques used in clinical practice to measure lung function in preschool children.(www.actabiomedica.it)

Lung function trajectories throughout childhood in survivors of very preterm birth: a longitudinal cohort study

BACKGROUND

Data on longitudinal respiratory follow-up after preterm birth in the surfactant era are scarce and of increasing importance, with concerns that preterm survivors are destined for early onset chronic obstructive airway disease. We aimed to comprehensively assess lung function longitudinally from early childhood to mid-childhood in very preterm children (≤32 weeks gestation), and to explore factors negatively impacting on lung function trajectories.

METHODS

Preterm children (with and without bronchopulmonary dysplasia) and healthy term children as controls were studied. All preterm participants were born at 32 weeks' gestation or earlier at King Edward Memorial Hospital, Perth, WA, Australia, between 1997 and 2003. Bronchopulmonary dysplasia was defined as at least 28 days of supplemental oxygen requirement as assessed at 36 weeks' post-menstrual age. Spirometry, oscillatory mechanics, gas exchange, lung volumes, and respiratory symptoms were assessed at three visits, two in early childhood (4-8 years) and one in mid-childhood (9-12 years). CT of the chest was done in preterm children in mid-childhood. Respiratory symptoms were documented via questionnaire at each visit. Data were analysed longitudinally using linear mixed models.

FINDINGS

200 very preterm children (126 with bronchopulmonary dysplasia and 74 without bronchopulmonary dysplasia) and 67 healthy term control children attended 458 visits between age 4 and 12 years. Chest CT was done on 133 preterm children at a mean age of 10·9 (SD 0·6) years. Preterm children, with and without bronchopulmonary dysplasia, had declines in spirometry z-scores over time compared with controls: forced expiratory volume in 1 s (FEV₁), forced expiratory flow at 25-75% of the pulmonary volume, and FEV₁/forced vital capacity all declined by at least 0·1 z-score per year in children with bronchopulmonary dysplasia (all p<0·001). Respiratory mechanics and gas exchange also deteriorated over time in children with bronchopulmonary dysplasia (relative to term controls, respiratory system reactance at 8 Hz decreased by -0·05 z-score per year [95% CI -0·08 to -0·01; p=0·006] and diffusing capacity of the lungs for carbon monoxide decreased by -0·03 z-score per year [95% CI -0·06 to -0·01; p=0·048]). Preterm children with bronchial wall thickening on chest CT (suggestive of inflammation) had bigger decreases in spirometry outcomes through childhood. For example, children with bronchial wall thickening on chest CT had an FEV₁ z-score decline of -0·61 (95% CI -1·03 to-0·19; p=0·005) more than those without. Similarly, children exposed to tobacco smoke, those with earlier gestation, or those requiring more neonatal supplemental oxygen declined at a faster rate.

INTERPRETATION

Lung function trajectories are impaired in survivors of very preterm birth. Survivors with bronchopulmonary dysplasia, ongoing respiratory symptoms, or CT changes reflecting inflammation have the poorest trajectories and might be at increased risk of lung disease in later life. Close targeted pulmonary follow-up of these individuals is necessary.

FUNDING

National Health and Medical Research Council grants APP634519, APP1073301 (to SJS), APP1077691 (to JJP), and APP1025550 (to GLH), Princess Margret Hospital Foundation, and Raine Medical Foundation.

Lung function after extremely preterm birth-A population-based cohort study (EXPRESS)

BACKGROUND AND OBJECTIVES

Follow-up studies of children and young adults born very-to-moderately preterm show persistent and significant lung function deficits. The aim of the study was to determine lung function and airway mechanics in school-aged children born in 2004 to 2007 and extremely preterm (after 22-26 weeks of gestation).

METHODS

In a population-based cohort of children born extremely preterm and controls born at term (n = 350), follow-up at 6½-years-of-age was performed using spirometry and impulse oscillometry. Associations to gestational age, smallness for gestational age (SGA), and bronchopulmonary dysplasia (BPD) were assessed.

RESULTS

Children born extremely preterm had lower forced vital capacity (FVC, z-score: -0.7, 95%CI: -1.0;-0.4), forced expiratory volume (FEV₁ , z-score: -1.1, 95%CI: -1.4; -0.8), higher frequency-dependence of resistance (R_5-20 , 0.09, 95%CI: 0.05; 0.12 kPa · L^-1  · s^-1 ) and larger area under the reactance curve (AX, 0.78, 95%CI: 0.49; 1.07 kPa · L^-1 ) than controls. In children born at 22-24 weeks of gestation, 24% had FVC and 44% had FEV₁ below the lower limit of normal. SGA and severe BPD only marginally contributed to pulmonary outcomes. Asthma-like disease was reported in 40% of extremely preterm children and 15% of controls.

CONCLUSION

Many children born extremely preterm have altered airway mechanics and significant obstructive reduction in lung function. This warrants consideration for treatment and continued follow-up.

Defining 'healthy' in preschool-aged children for forced oscillation technique reference equations

BACKGROUND AND OBJECTIVE

Selecting 'healthy' preschool-aged children for reference ranges may not be straightforward. Relaxing inclusion criteria for normative data does not affect spirometry z-scores. We therefore investigated the effect of similarly relaxing inclusion criteria in preschoolers on reference ranges for respiratory impedance (Zrs) using a modified forced oscillation technique (FOT).

METHODS

The International Study of Asthma and Allergies in Childhood questionnaire classified 585 children into a healthy and five mutually exclusive groups. Zrs was measured between 4 and 26 Hz and resistance (R) and compliance (C) obtained by model fitting. Prediction models were determined using mixed effect models and z-scores compared between healthy children and the five groups.

RESULTS

Zrs data were obtained for 494 participants (4.30 ± 0.7 years) on 587 occasions. Comparison of the Zrs z-scores between the healthy children and the health groups found significant differences in children with asthma, current wheeze and respiratory symptoms, but not in children born preterm or with early-life wheeze. Adding these two groups to the healthy dataset had no significant effect on the distribution of z-scores and increased the size of the dataset by 22.3%.

CONCLUSION

Our data suggest that preschool-aged children born preterm or with early-life wheeze can be included in FOT reference equations, while those with asthma, current wheeze and respiratory symptoms within 4 weeks of testing should be excluded. This more inclusive approach results in more robust FOT reference ranges.

Pediatric pulmonology year in review 2016: Part 2

Pediatric Pulmonology continues to publish research and clinical topics related to the entire range of children's respiratory disorders. As we have done annually in recent years, we here summarize some of the past year's publications in our major topic areas, as well as selected literature in these areas from other core journals relevant to our discipline. This review (Part 2) covers selected articles on neonatology, asthma, physiology and lung function testing, and infectious diseases.

Structural and functional ventilatory impairment in infants with severe bronchopulmonary dysplasia

BACKGROUND

Bronchopulmonary dysplasia (BPD) is the most frequent serious complication in preterm infants. We aimed to describe lung structure and ventilatory function of preterm infants with severe BPD and explored the association between early postnatal growth and these outcomes.

METHODS

We included preterm infants born ≤32 weeks gestational age (GA) with severe BPD. Lung structure was assessed on chest CT with the PRAGMA-BPD scoring system and ventilatory function by polysomnography (PSG) at 6 months corrected age. Postnatal growth was assessed by weight measured at birth, and at 2 and 6 months corrected age.

RESULTS

We included 49 infants (median [IQR] GA of 25.7 [24.6-26.3] weeks and mean [SD] birth weight of 760 [210] g). A 95.5% of the chest CT scans showed architectural distortion of the lung, and an oxygen desaturation index (ODI) >5 was found in 74% of the infants. An increase in GA of 1 week was associated with higher total and normal lung volume (β coefficient [95% CI]: 1.86 [0.15, 3.57] and 2.03 [0.41, 3.65]), less hypoattenuation (-4.3 [-7.70, -0.90]%) and lower ODI (-36.7 [-64.2, -9.10]%). Higher weight at 6 months was independently associated with higher total and normal lung volume, and with less severe desaturations. Increased weight gain between 2 and 6 months of corrected age was associated with less severe desaturations during sleep (β coefficient [95% CI]: 2.09 [0.49, 3.70]).

CONCLUSION

Most preterm infants with severe BPD have structural lung abnormalities and impaired ventilatory function early in life, partly explained by birth characteristics and infant growth.