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Zhang M, Zhang W, Liao H. Efficacy and safety of different inhaled corticosteroids for bronchopulmonary dysplasia prevention in preterm infants: A systematic review and meta-analysis. Respir Med Res 2024; 85:101096. [PMID: 38744231 DOI: 10.1016/j.resmer.2024.101096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 07/13/2023] [Accepted: 02/25/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to evaluate the efficacy and safety of inhaled corticosteroids (budesonide, beclomethasone, or fluticasone propionate) in preventing bronchopulmonary dysplasia (BPD) for premature infants. METHOD Electronic databases, including PubMed, EMBASE, Web of science, Scopus, and Cochrane library, were searched from databases inception to January 2022 for eligible randomized controlled trials. Clinical outcomes such as BPD, mortality, BPD or death, adverse events, and neurodevelopmental outcomes were assessed. RESULTS Overall, budesonide was significantly associated with a reduction in BPD at 36 weeks' postmenstrual age (RR 0.48; 95 % CI [0.38, 0.62]) and patent ductus arteriosus (PDA) (RR 0.75; 95 % CI [0.63, 0.89]) compared with control treatments. Early longer duration inhalation of budesonide alone was associated with a lower risk of BPD at 36 weeks' postmenstrual age and PDA compared with controls. Early shorter duration intratracheal instillation of budesonide with surfactant as vehicle was associated with a lower risk of BPD at 36 weeks' postmenstrual age and all-cause mortality compared with surfactant. There was no statistically significant difference between budesonide and control groups regarding neurodevelopmental impairment. Beclomethasone and fluticasone propionate did not show any superior or inferior effect on clinical outcomes compared to control treatments. CONCLUSION These findings suggest that budesonide, especially intratracheal instillation of budesonide using surfactant as a vehicle, is a safe and effective option in preventing BPD for preterm infants. More well-design large-scale trials with long-term follow-ups are necessary to verify the present findings.
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Affiliation(s)
- Minghai Zhang
- Department of Neonatal Intensive Care Unit, the First Affiliated Hospital of Gannan Medical University, Ganzhou City 341000, China.
| | - Wei Zhang
- Department of Internal Medicine, the Third Affiliated Hospital of Gannan Medical University, Ganzhou City 341000, China
| | - Hongqun Liao
- Department of Neonatal Intensive Care Unit, the First Affiliated Hospital of Gannan Medical University, Ganzhou City 341000, China
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Nobile S, Di Sipio Morgia C, Hall M. Long-term Effects of Intratracheal Budesonide and Surfactant for the Prevention of Bronchopulmonary Dysplasia: A Narrative Review. Am J Perinatol 2024; 41:e1858-e1865. [PMID: 37279790 DOI: 10.1055/s-0043-1769795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE This study aimed to compare the safety and efficacy of intratracheal administration of budesonide and surfactant with surfactant alone for bronchopulmonary dysplasia (BPD) prevention in premature infants with respiratory distress syndrome. STUDY DESIGN A literature search was performed in MEDLINE, Embase, Cochrane, ClinicalTrials.gov, and gray literature. Assessment of quality was conducted using CASP tool, ROBIS tool, and GRADE framework. RESULTS A systematic review and meta-analysis and three observational studies were identified. Budesonide was associated with reduced incidence and severity of BPD, reduced mortality, patent ductus arteriosus, need for additional surfactant doses, hypotension, duration of invasive ventilation, hospital stays, salbutamol prescriptions, and hospitalizations in the first 2 years of life. The safety of budesonide on neurodevelopmental outcomes at 2 to 3 years of corrected age was reported. CONCLUSION Budesonide might be associated with a reduction in BPD incidence and severity, without evidence of impaired neurodevelopment at 2 to 3 years of age. According to the GRADE framework, the level of evidence is low due to significant heterogeneity of studies and other bias. KEY POINTS · BPD prevention is urgently needed.. · Intratracheal budesonide and surfactant for neonatal RDS could reduce BPD.. · The grade of evidence for this intervention is low due to study heterogeneity and other bias..
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Affiliation(s)
- Stefano Nobile
- Department of Mother, Child and Public Health, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Chiara Di Sipio Morgia
- Department of Mother, Child and Public Health, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Michael Hall
- Department of Neonatal Medicine, School of Health Sciences, University of Southampton, Southampton, United Kingdom
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Leiting C, Kerns E, Euteneuer JC, McCulloh RJ, Peeples ES. Inhaled Corticosteroid Exposure in Hospitalized Infants with Bronchopulmonary Dysplasia. Am J Perinatol 2024; 41:e85-e93. [PMID: 35523409 PMCID: PMC9637235 DOI: 10.1055/a-1845-2669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The objective of this paper was to determine inhaled corticosteroid (IC) use in infants with bronchopulmonary dysplasia (BPD), define the interhospital variation of IC administration to infants with BPD, and compare clinical, demographic, and hospital factors associated with IC use. STUDY DESIGN Using the Pediatric Health Information System database, a retrospective multicenter cohort of 4,551 infants born at <32 weeks of gestation with developing BPD was studied. The clinical, demographic, and hospital characteristics of infants exposed and not exposed to ICs were compared. RESULTS IC use varied markedly between hospitals, ranging from 0 to 66% of infants with BPD exposed to ICs. Increased annual BPD census was not associated with IC use. In total, 25% (1,144 out of 4,551) of patients with BPD and 43% (536 out of 1,244) of those with severe BPD received ICs. Increased IC exposure was associated with lower birth weight and gestational age, days on respiratory support, need for positive pressure ventilation at 36-week postmenstrual age, need for tracheostomy, and increased use of systemic steroids, bronchodilators, and diuretics. CONCLUSION IC exposure is common in infants with BPD, with substantial interhospital variability. IC use was associated with more severe disease. Hospital experience did not account for the wide variability in IC use by the hospital. Further research into the effects of ICs use is urgently needed to help guide their use in this vulnerable population. KEY POINTS · The risks and benefits of IC use in infants with BPD are incompletely understood.. · IC use is common in infants with BPD (25%) and severe BPD (43%) varies widely by hospital (0-66% of patients with BPD received an IC).. · Hospital experience did not account for the wide interhospital variation in IC use..
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Affiliation(s)
| | - Ellen Kerns
- Children’s Hospital & Medical Center, Omaha, NE
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Joshua C. Euteneuer
- Children’s Hospital & Medical Center, Omaha, NE
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Russell J. McCulloh
- Children’s Hospital & Medical Center, Omaha, NE
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Eric S. Peeples
- Children’s Hospital & Medical Center, Omaha, NE
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE
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Marzban A, Mokhtari S, Tavakkolian P, Mansouri R, Jafari N, Maleki A. The impact of combined administration of surfactant and intratracheal budesonide compared to surfactant alone on bronchopulmonary dysplasia (BPD) and mortality rate in preterm infants with respiratory distress syndrome: a single-blind randomized clinical trial. BMC Pediatr 2024; 24:262. [PMID: 38643076 PMCID: PMC11031862 DOI: 10.1186/s12887-024-04736-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is one of the most important and common disorders among premature infants. OBJECTIVE This study aimed to compare the effect of the combination of surfactant and budesonide with surfactant alone on Bronchopulmonary dysplasia (BPD) and mortality rate among premature infants with RDS. METHOD An outcome assessor-blind randomized clinical trial was conducted on 134 premature infants with RDS who were born in Ayatollah Mousavi Hospital, Zanjan, Iran in 2021. The covariate adaptive randomization method was utilized to allocate participants into two groups (surfactant alone and a combination of surfactant and budesonide). The primary outcomes were BPD and Mortality rate from admission to hospital discharge. The data in this study were analyzed using SPSS software version 18. RESULTS Overall the comparison of mortality rate and BPD between the two groups did not show a significant difference(p > 0.05). The subgroup results showed that administering surfactant with budesonide to infants under 30 weeks of age significantly reduced the number of deaths compared to using surfactant alone (5 vs. 17). Similar positive effects were observed for the occurrence of Pulmonary Hemorrhage, the need for a second dose of surfactant, oxygen index, mean blood pressure and mean arterial pressure (MAP) in infants under 34 weeks of age compared to more than 34 weeks (p < 0.05). CONCLUSION These findings suggest that the combination therapy of surfactant and budesonide may be beneficial, particularly in preterm infants with less than 34 weeks gestational age and 1500 birth weight. However, further studies with larger sample sizes and longer follow-up periods are needed to confirm these results and assess long-term outcomes. TRIAL REGISTRATION The study was registered at the Iranian Registry of Clinical Trials website under the code IRCT20201222049802N1. https://en.irct.ir/user/trial/48117/view . REGISTRATION DATE 28/02/2021. PUBLIC REPOSITORY DATA SET: This research data set link is displayed on the Zanjan-Iran Medical Sciences website: https://repository.zums.ac.ir/cgi/users/login? target=https%3 A%2 F/repository.zums.ac.ir/id/eprint .
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Affiliation(s)
- Asghar Marzban
- Dept. of neonatology, School of Medicine, Musavi hospital, Zanjan university of medical sciences, Zanjan, Iran
| | - Samira Mokhtari
- Dept. of neonatology, School of Medicine, Musavi hospital, Zanjan university of medical sciences, Zanjan, Iran
| | - Pouria Tavakkolian
- Student Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Reza Mansouri
- Department of Hematology & Medical Oncology, Vali-e-Asr Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Nahid Jafari
- Dept. of neonatology, School of Medicine, Musavi hospital, Zanjan university of medical sciences, Zanjan, Iran
| | - Azam Maleki
- Social Determinants of Health Research Center, Health and Metabolic Diseases Research Institute, Zanjan University of Medical Sciences, Azadi Square, Jomhori Eslami St, Zanjan, 4515613191, Iran.
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van de Loo M, van Kaam A, Offringa M, Doyle LW, Cooper C, Onland W. Corticosteroids for the prevention and treatment of bronchopulmonary dysplasia: an overview of systematic reviews. Cochrane Database Syst Rev 2024; 4:CD013271. [PMID: 38597338 PMCID: PMC11005325 DOI: 10.1002/14651858.cd013271.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) remains an important complication of prematurity. Pulmonary inflammation plays a central role in the pathogenesis of BPD, explaining the rationale for investigating postnatal corticosteroids. Multiple systematic reviews (SRs) have summarised the evidence from numerous randomised controlled trials (RCTs) investigating different aspects of administrating postnatal corticosteroids. Besides beneficial effects on the outcome of death or BPD, potential short- and long-term harms have been reported. OBJECTIVES The primary objective of this overview was to summarise and appraise the evidence from SRs regarding the efficacy and safety of postnatal corticosteroids in preterm infants at risk of developing BPD. METHODS We searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, and Epistemonikos for SRs in April 2023. We included all SRs assessing any form of postnatal corticosteroid administration in preterm populations with the objective of ameliorating pulmonary disease. All regimens and comparisons were included. Two review authors independently checked the eligibility of the SRs comparing corticosteroids with placebo, and corticosteroids with different routes of administration and regimens. The included outcomes, considered key drivers in the decision to administer postnatal corticosteroids, were the composite outcome of death or BPD at 36 weeks' postmenstrual age (PMA), its individual components, long-term neurodevelopmental sequelae, sepsis, and gastrointestinal tract perforation. We independently assessed the methodological quality of the included SRs by using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) and ROBIS (Risk Of Bias In Systematic reviews) tools. We assessed the certainty of the evidence using GRADE. We provided a narrative description of the characteristics, methodological quality, and results of the included SRs. MAIN RESULTS We included nine SRs (seven Cochrane, two non-Cochrane) containing 87 RCTs, 1 follow-up study, and 9419 preterm infants, investigating the effects of postnatal corticosteroids to prevent or treat BPD. The quality of the included SRs according to AMSTAR 2 varied from high to critically low. Risk of bias according to ROBIS was low. The certainty of the evidence according to GRADE ranged from very low to moderate. Early initiated systemic dexamethasone (< seven days after birth) likely has a beneficial effect on death or BPD at 36 weeks' PMA (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.81 to 0.95; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 10 to 41; I2 = 39%; 17 studies; 2791 infants; moderate-certainty evidence) and on BPD at 36 weeks' PMA (RR 0.72, 95% CI 0.63 to 0.82; NNTB 13, 95% CI 9 to 21; I2 = 39%; 17 studies; 2791 infants; moderate-certainty evidence). Early initiated systemic hydrocortisone may also have a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.90, 95% CI 0.82 to 0.99; NNTB 18, 95% CI 9 to 594; I2 = 43%; 9 studies; 1376 infants; low-certainty evidence). However, these benefits are likely accompanied by harmful effects like cerebral palsy or neurosensory disability (dexamethasone) or gastrointestinal perforation (both dexamethasone and hydrocortisone). Late initiated systemic dexamethasone (≥ seven days after birth) may have a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.75, 95% CI 0.67 to 0.84; NNTB 5, 95% CI 4 to 9; I2 = 61%; 12 studies; 553 infants; low-certainty evidence), mostly contributed to by a beneficial effect on BPD at 36 weeks' PMA (RR 0.76, 95% CI 0.66 to 0.87; NNTB 6, 95% CI 4 to 13; I2 = 14%; 12 studies; 553 infants; low-certainty evidence). No harmful side effects were shown in the outcomes chosen as key drivers to the decision to start or withhold late systemic dexamethasone. No effects, either beneficial or harmful, were found in the subgroup meta-analyses of late hydrocortisone studies. Early initiated inhaled corticosteroids probably have a beneficial effect on death and BPD at 36 weeks' PMA (RR 0.86, 95% CI 0.75 to 0.99; NNTB 19, 95% CI not applicable; I2 = 0%; 6 studies; 1285 infants; moderate-certainty evidence), with no apparent adverse effects shown in the SRs. In contrast, late initiated inhaled corticosteroids do not appear to have any benefits or harms. Endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier likely has a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.60, 95% CI 0.49 to 0.74; NNTB 4, 95% CI 3 to 6; I2 = 0%; 2 studies; 381 infants; moderate-certainty evidence) and on BPD at 36 weeks' PMA. No evidence of harmful effects was found. There was little evidence for effects of different starting doses or timing of systemic corticosteroids on death or BPD at 36 weeks' PMA, but potential adverse effects were observed for some comparisons. Lowering the dose might result in a more unfavourable balance of benefits and harms. Moderately early initiated systemic corticosteroids, compared with early systemic corticosteroids, may result in a higher incidence of BPD at 36 weeks' PMA. Pulse dosing instead of continuous dosing may have a negative effect on death and BPD at 36 weeks' PMA. We found no differences for the comparisons of inhaled versus systemic corticosteroids. AUTHORS' CONCLUSIONS This overview summarises the evidence of nine SRs investigating the effect of postnatal corticosteroids in preterm infants at risk for BPD. Late initiated (≥ seven days after birth) systemic administration of dexamethasone is considered an effective intervention to reduce the risk of BPD in infants with a high risk profile for BPD, based on a favourable balance between benefits and harms. Endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier is a promising intervention, based on the beneficial effect on desirable outcomes without (so far) negative side effects. Pending results of ongoing large, multicentre RCTs investigating both short- and long-term effects, endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier is not appropriate for clinical practice at present. Early initiated (< seven days after birth) systemic dexamethasone and hydrocortisone and late initiated (≥ seven days after birth) hydrocortisone are considered ineffective interventions, because of an unfavourable balance between benefits and harms. No conclusions are possible regarding early and late inhaled corticosteroids, as more research is needed.
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Affiliation(s)
- Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Anton van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
| | - Lex W Doyle
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkville, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, Australia
| | - Chris Cooper
- Cochrane Neonatal Group, Vermont Oxford Network, Burlington, USA
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
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Sun Z, Lu H, Yang B, Li M, Ren Y, Shi H, Gao X, Chen X. Montelukast Sodium to Prevent and Treat Bronchopulmonary Dysplasia in Very Preterm Infants: A Quasi-Randomized Controlled Trial. J Clin Med 2023; 12:7745. [PMID: 38137814 PMCID: PMC10744034 DOI: 10.3390/jcm12247745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in preterm infants and lacks effective methods for prevention and treatment. The aim of this study is to explore the efficacy and safety of montelukast in preventing or treating BPD in preterm infants. The preterm infants with BPD risk factors were divided randomly into a montelukast group and a control group. In the montelukast group, preterm infants were given 1 mg/kg of montelukast sodium daily. There was no placebo in the control group. There was no significant difference in the incidence of moderate or severe BPD between the two groups (31.8% vs. 35%). The duration of respiratory support in the montelukast group was shorter than that in the control group (36.4 ± 12.8 d vs. 43.1 ± 15.9 d, p = 0.037). The pulmonary severity score (PSS) at 21 days of life in the montelukast group was significantly lower than that in the control group (0.56 ± 0.13 vs. 0.62 ± 0.14, p = 0.048). There were no significant differences in the duration of mechanical ventilation, length of stay, hospitalization expenses, or incidence of adverse events. Although montelukast cannot alleviate the severity of BPD, it may shorten the duration of respiratory support and decrease the PSS in very preterm infants. There were no significant adverse drug events associated with montelukast treatment.
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Affiliation(s)
- Zhongyi Sun
- Department of Neonatology, Xuzhou Central Hospital, Xuzhou Clinical School, Xuzhou Medical University, Xuzhou 221009, China; (Z.S.)
- Department of Pediatrics, The First Affiliation Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Hongyan Lu
- Department of Pediatrics, Affiliation Hospital of Jiangsu University, Zhenjiang 212001, China
| | - Bo Yang
- Department of Neonatology, Xuzhou Central Hospital, Xuzhou Clinical School, Xuzhou Medical University, Xuzhou 221009, China; (Z.S.)
| | - Min Li
- Department of Neonatology, Xuzhou Central Hospital, Xuzhou Clinical School, Xuzhou Medical University, Xuzhou 221009, China; (Z.S.)
| | - Yi Ren
- Department of Neonatology, Xuzhou Central Hospital, Xuzhou Clinical School, Xuzhou Medical University, Xuzhou 221009, China; (Z.S.)
| | - Hongshan Shi
- Department of Neonatology, Xuzhou Central Hospital, Xuzhou Clinical School, Xuzhou Medical University, Xuzhou 221009, China; (Z.S.)
| | - Xiangyu Gao
- Department of Neonatology, Xuzhou Central Hospital, Xuzhou Clinical School, Xuzhou Medical University, Xuzhou 221009, China; (Z.S.)
| | - Xiaoqing Chen
- Department of Pediatrics, The First Affiliation Hospital of Nanjing Medical University, Nanjing 210029, China
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Jensen EA, Watterberg KL. Postnatal Corticosteroids To Prevent Bronchopulmonary Dysplasia. Neoreviews 2023; 24:e691-e703. [PMID: 37907402 DOI: 10.1542/neo.24-11-e691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a common, severe chronic respiratory disease that affects very preterm infants. In utero and postnatal exposure to proinflammatory stimuli contribute to the pathophysiology of BPD. Corticosteroids, because of their potent anti-inflammatory properties, may decrease respiratory morbidity and reduce the risk of BPD in very preterm infants. However, these medications can have adverse effects on the developing brain and other organ systems. This review examines current evidence on the risks and benefits of postnatal corticosteroids used to prevent BPD in preterm infants.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
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Khudadah K, Ramadan A, Othman A, Refaey N, Elrosasy A, Rezkallah A, Heseba T, Moawad M, Mektebi A, Elejla S, Abouzid M, Abdelazeem B. Surfactant replacement therapy as promising treatment for COVID-19: an updated narrative review. Biosci Rep 2023; 43:BSR20230504. [PMID: 37497603 PMCID: PMC10412525 DOI: 10.1042/bsr20230504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 07/28/2023] Open
Abstract
Patients with COVID-19 exhibit similar symptoms to neonatal respiratory distress syndrome. SARS-CoV-2 spike protein has been shown to target alveolar type 2 lung cells which synthesize and secrete endogenous surfactants leading to acute respiratory distress syndrome in some patients. This was proven by post-mortem histopathological findings revealing desquamated alveolar type 2 cells. Surfactant use in patients with COVID-19 respiratory distress syndrome results in marked improvement in respiratory parameters but not mortality which needs further clinical trials comparing surfactant formulas and modes of administration to decrease the mortality. In addition, surfactants could be a promising vehicle for specific drug delivery as a liposomal carrier, which requires more and more challenging efforts. In this review, we highlight the current reviews and two clinical trials on exogenous surfactant therapy in COVID-19-associated respiratory distress in adults, and how surfactant could be a promising drug to help fight the COVID-19 infection.
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Affiliation(s)
| | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ahmed Othman
- Kuwait Oil Company Ahmadi Hospital, Al Ahmadi, Kuwait
| | - Neveen Refaey
- Women’s Health department, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Amr Elrosasy
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ayoub Rezkallah
- Faculty of Medicine, University of Algeirs, Algeirs, Algeria
- Department of Hematology Laboratory and Blood Transfusion, Hospital Center University Lamine Debaghine, Algeirs, Algeria
| | - Toka Heseba
- Faculty of Medicine, Assuit University, Assuit, Egypt
| | - Mostafa Hossam El Din Moawad
- Faculty of Pharmacy, Clinical Department, Alexandria University, Egypt
- Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ammar Mektebi
- Faculty of Medicine, Kutahya Health Sciences University, Kutahya, Turkey
| | - Sewar A Elejla
- Faculty of Medicine, Alquds University, Jerusalem, Palestine
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St., 60-806 Poznan, Poland
- Doctoral School, Poznan University of Medical Sciences, 60-812 Poznan, Poland
| | - Basel Abdelazeem
- McLaren Health Care, Flint, Michigan, U.S.A
- Michigan State University, East Lansing, Michigan, U.S.A
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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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10
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Beyond the Interface: Improved Pulmonary Surfactant-Assisted Drug Delivery through Surface-Associated Structures. Pharmaceutics 2023; 15:pharmaceutics15010256. [PMID: 36678885 PMCID: PMC9866215 DOI: 10.3390/pharmaceutics15010256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/01/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Pulmonary surfactant (PS) has been proposed as an efficient drug delivery vehicle for inhaled therapies. Its ability to adsorb and spread interfacially and transport different drugs associated with it has been studied mainly by different surface balance designs, typically interconnecting various compartments by interfacial paper bridges, mimicking in vitro the respiratory air-liquid interface. It has been demonstrated that only a monomolecular surface layer of PS/drug is able to cross this bridge. However, surfactant films are typically organized as multi-layered structures associated with the interface. The aim of this work was to explore the contribution of surface-associated structures to the spreading of PS and the transport of drugs. We have designed a novel vehiculization balance in which donor and recipient compartments are connected by a whole three-dimensional layer of liquid and not only by an interfacial bridge. By combining different surfactant formulations and liposomes with a fluorescent lipid dye and a model hydrophobic drug, budesonide (BUD), we observed that the use of the bridge significantly reduced the transfer of lipids and drug through the air-liquid interface in comparison to what can be spread through a fully open interfacial liquid layer. We conclude that three-dimensional structures connected to the surfactant interfacial film can provide an important additional contribution to interfacial delivery, as they are able to transport significant amounts of lipids and drugs during surfactant spreading.
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11
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Onland W, Offringa M, van Kaam A. Late (≥ 7 days) inhaled corticosteroids to reduce bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2022; 12:CD002311. [PMID: 36521169 PMCID: PMC9754672 DOI: 10.1002/14651858.cd002311.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), defined as oxygen dependence at 36 weeks' postmenstrual age (PMA), remains an important complication of prematurity. Pulmonary inflammation plays a central role in the pathogenesis of BPD. Attenuating pulmonary inflammation with postnatal systemic corticosteroids reduces the incidence of BPD in preterm infants but may be associated with an increased risk of adverse neurodevelopmental outcomes. Local administration of corticosteroids via inhalation may be an effective and safe alternative. OBJECTIVES To assess the benefits and harms of inhaled corticosteroids versus placebo, initiated between seven days of postnatal life and 36 weeks' postmenstrual age, to preterm infants at risk of developing bronchopulmonary dysplasia. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and three trials registries to August 2022. We searched conference proceedings and the reference lists of retrieved articles for additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing inhaled corticosteroids to placebo, started between seven days' postnatal age (PNA) and 36 weeks' PMA, in infants at risk of BPD. We excluded trials investigating systemic corticosteroids versus inhaled corticosteroids. DATA COLLECTION AND ANALYSIS We collected data on participant characteristics, trial methodology, and inhalation regimens. The primary outcomes were mortality, BPD, or both at 36 weeks' PMA. Secondary outcomes included short-term respiratory outcomes (mortality or BPD at 28 days' PNA, failure to extubate, total days of mechanical ventilation and oxygen use, and need for systemic corticosteroids) and adverse effects. We contacted the trial authors to verify the validity of extracted data and to request missing data. We analysed all data using Review Manager 5. Where possible, we reported the results of meta-analyses using risk ratios (RRs) and risk differences (RDs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, along with their 95% confidence intervals (CIs). We analysed ventilated and non-ventilated participants separately. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included seven trials involving 218 preterm infants in this review. We identified no new eligible studies in this update. The evidence is very uncertain regarding whether inhaled corticosteroids affects the combined outcome of mortality or BPD at 36 weeks' PMA (RR 1.10, 95% CI 0.74 to 1.63; RD 0.07, 95% CI -0.21 to 0.34; 1 study, 30 infants; very low-certainty) or its separate components: mortality (RR 3.00, 95% CI 0.35 to 25.78; RD 0.07, 95% CI -0.08 to 0.21; 3 studies, 61 infants; very low-certainty) and BPD (RR 1.00, 95% CI 0.59 to 1.70; RD 0.00, 95% CI -0.31 to 0.31; 1 study, 30 infants; very low-certainty) at 36 weeks' PMA. Inhaled corticosteroids may reduce the need for systemic corticosteroids, but the evidence is very uncertain (RR 0.51, 95% CI 0.26 to 1.00; RD -0.22, 95% CI -0.42 to -0.02; number needed to treat for an additional beneficial outcome 5, 95% CI 2 to 115; 4 studies, 74 infants; very low-certainty). There was a paucity of data on short-term and long-term adverse effects. Despite a low risk of bias in the individual studies, we considered the certainty of the evidence for all comparisons discussed above to be very low, because the studies had few participants, there was substantial clinical heterogeneity between studies, and only three studies reported the primary outcome of this review. AUTHORS' CONCLUSIONS Based on the available evidence, we do not know if inhaled corticosteroids initiated from seven days of life in preterm infants at risk of developing BPD reduces mortality or BPD at 36 weeks' PMA. There is a need for larger randomised placebo-controlled trials to establish the benefits and harms of inhaled corticosteroids.
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Affiliation(s)
- Wes Onland
- Department of Neonatology, Emma Children's Hospital Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
| | - Anton van Kaam
- Department of Neonatology, Emma Children's Hospital Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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12
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The administration of a pre-digested fat-enriched formula prevents necrotising enterocolitis-induced lung injury in mice. Br J Nutr 2022; 128:1050-1063. [PMID: 34632971 PMCID: PMC8995403 DOI: 10.1017/s0007114521004104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Necrotising enterocolitis (NEC) is a devastating gastrointestinal disease of prematurity that typically develops after the administration of infant formula, suggesting a link between nutritional components and disease development. One of the most significant complications that develops in patients with NEC is severe lung injury. We have previously shown that the administration of a nutritional formula that is enriched in pre-digested Triacylglyceride that do not require lipase action can significantly reduce the severity of NEC in a mouse model. We now hypothesise that this 'pre-digested fat (PDF) system' may reduce NEC-associated lung injury. In support of this hypothesis, we now show that rearing newborn mice on a nutritional formula based on the 'PDF system' promotes lung development, as evidenced by increased tight junctions and surfactant protein expression. Mice that were administered this 'PDF system' were significantly less vulnerable to the development of NEC-induced lung inflammation, and the administration of the 'PDF system' conferred lung protection. In seeking to define the mechanisms involved, the administration of the 'PDF system' significantly enhanced lung maturation and reduced the production of reactive oxygen species (ROS). These findings suggest that the PDF system protects the development of NEC-induced lung injury through effects on lung maturation and reduced ROS in the lung and also increases lung maturation in non-NEC mice.
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13
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Feldman K, Nitkin CR, Cuna A, Oschman A, Truog WE, Norberg M, Nyp M, Taylor JB, Lewis T. Corticosteroid response predicts bronchopulmonary dysplasia status at 36 weeks in preterm infants treated with dexamethasone: A pilot study. Pediatr Pulmonol 2022; 57:1760-1769. [PMID: 35434928 DOI: 10.1002/ppul.25928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/06/2022] [Accepted: 04/15/2022] [Indexed: 11/09/2022]
Abstract
IMPORTANCE A major barrier to therapeutic development in neonates is a lack of standardized drug response measures that can be used as clinical trial endpoints. The ability to quantify treatment response in a way that aligns with relevant downstream outcomes may be useful as a surrogate marker for new therapies, such as those for bronchopulmonary dysplasia (BPD). OBJECTIVE To construct a measure of clinical response to dexamethasone that was well aligned with the incidence of severe BPD or death at 36 weeks' postmenstrual age. DESIGN Retrospective cohort study. SETTING Level IV Neonatal Intensive Care Unit. PARTICIPANTS Infants treated with dexamethasone for developing BPD between 2010 and 2020. MAIN OUTCOME(S) AND MEASURE(S) Two models were built based on demographics, changes in ventilatory support, and partial pressure of carbon dioxide (pCO2 ) after dexamethasone administration. An ordinal logistic regression and regularized binary logistic model for the composite outcome were used to associate response level to BPD outcomes defined by both the 2017 BPD Collaborative and 2018 Neonatal Research Network definitions. RESULTS Ninety-five infants were treated with dexamethasone before 36 weeks. Compared to the baseline support and demographic data at the time of treatment, changes in ventilatory support improved ordinal model sensitivity and specificity. For the binary classification, BPD incidence was well aligned with risk levels, increasing from 16% to 59%. CONCLUSIONS AND RELEVANCE Incorporation of response variables as measured by changes in ventilatory parameters and pCO2 following dexamethasone administration were associated with downstream outcomes. Incorporating drug response phenotype into a BPD model may enable more rapid development of future therapeutics.
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Affiliation(s)
- Keith Feldman
- Department of Pediatrics, Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Christopher R Nitkin
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Alain Cuna
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Alexandra Oschman
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - William E Truog
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Michael Norberg
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Michael Nyp
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Jane B Taylor
- Department of Pediatrics, Division of Pulmonology, UPMC - Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tamorah Lewis
- Children's Mercy Kansas City, Center for Infant Pulmonary Disorders, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA.,Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
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14
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Zhang Y, Kong X, Zhang J, Wang X. Functional Analysis of Bronchopulmonary Dysplasia-Related Neuropeptides in Preterm Infants and miRNA-Based Diagnostic Model Construction. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5682599. [PMID: 35509863 PMCID: PMC9061009 DOI: 10.1155/2022/5682599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/17/2022]
Abstract
Background Bronchopulmonary dysplasia (BPD) has a high mortality rate. This study was aimed at identifying and analysing the risk factors associated with BPD using bioinformatic and mechanical analyses and establishing a predictive model to assess the risk of BPD in preterm infants. Methods We identified differentially expressed RNAs via the intersection of miRNAs between datasets. Online analysis tools were used to predict genes targeted by differentially expressed miRNAs (DEmiRNAs) and to generate and visualise competing endogenous RNA (ceRNA) coexpression networks. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were subsequently performed on the DEmiRNAs. In addition, an intersection analysis was performed on mRNA and neuropeptide-related genes in the ceRNA network. DEmiRNAs associated with BPD and those involved in ceRNA networks were used to establish a diagnostic prediction model. The GSE108604 dataset was used as a validation set to verify the model. Results A total of 26 DEmiRNAs were identified from the tracheal aspirates (TAs) of patients with BPD and healthy controls. In addition, a total of 1076 DEmRNAs were obtained from the GSE8586 dataset. Functional enrichment analysis of DEmRNAs revealed an abnormal reduction in mitochondrial-related activity and cellular responses to oxidative stress in patients with BPD. The neuropeptide-related genes OPRL1 and NPPA were found to be upregulated in BPD samples. Eventually, hsa-miR-1258, hsa-miR-298, hsa-miR-483-3p, and hsa-miR-769-5p were screened out and used to establish the prediction model. Calibration curves and detrended correspondence analysis (DCA) revealed that the model had good clinical applicability. Conclusions The prediction model provided a simple method for individualised assessment, early diagnosis, and prevention of BPD risk in preterm infants.
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Affiliation(s)
- Yue Zhang
- Department of Neonatal Intensive Care Unit, Beijing Aiyuhua Maternal and Children Hospital, Beijing, China
| | - Xiangyong Kong
- BaYi Children's Hospital, Seventh Medical Center of Chinese PLA General Hospital, China
| | - Jie Zhang
- Department of Neonatal Intensive Care Unit, Beijing Aiyuhua Maternal and Children Hospital, Beijing, China
| | - Xu Wang
- Department of Neonatal Intensive Care Unit, Beijing Aiyuhua Maternal and Children Hospital, Beijing, China
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15
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Yi Z, Tan Y, Liu Y, Jiang L, Luo L, Wang L, Lei W, Tan J, Yan R. A systematic review and meta-analysis of pulmonary surfactant combined with budesonide in the treatment of neonatal respiratory distress syndrome. Transl Pediatr 2022; 11:526-536. [PMID: 35558978 PMCID: PMC9085948 DOI: 10.21037/tp-22-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/18/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Neonatal respiratory distress syndrome (NRDS), if caused by a lack of pulmonary surfactant (PS), leads to progressive alveolar collapse. Glucocorticoids have anti-inflammatory and anti-allergic effects and can reduce bronchial and pulmonary edema. This research hopes to systematically evaluate the efficacy and safety of animal-derived PS combined with the glucocorticoid drug budesonide in the treatment of NRDS. METHODS Electronic databases (i.e., Wanfang, Weipu, CNKI, PubMed, Embase, Cochrane Library) were searched from inception until May 30th, 2021. Studies relevant to the treatment of pulmonary surfactant combined with budesonide in the treatment of neonatal respiratory distress syndrome were identified. Consequently, all the studies that met the inclusion criteria were considered qualified for screening. For the meta-analysis, all data were analyzed using RevMan 5.3 software. Furthermore, subgroup analysis was performed to evaluate the administration method of budesonide (nebulized inhalation, intratracheal instillation) combined with intratracheal instillation of pulmonary surfactant. RESULTS A total of 10 articles were included in this study, involving 527 children. This meta-analysis suggests that the treatment of intratracheal infusion of pulmonary surfactant combined with budesonide therapy can effectively (I) reduce the time of mechanical ventilation (OR =-1.72,95% CI: -2.44 to -1.01, P<0.00001); (II) reduce the length of stay (OR =-5.17, 95% CI: -9.35 to -0.99, P=0.02); (III) reduce the incidence of bronchopulmonary dysplasia (BPD) (OR =0.52, 95% CI: 0.39-0.68, P<0.00001); and (IV) reduce the incidence of BPD (RR =0.73, 95% CI: 0.40-1.35, P=0.32). There was no significant difference in the incidence of retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), or sepsis between the experimental group and the control group. DISCUSSION The treatment of animal-derived pulmonary surfactant combined with budesonide can effectively shorten the hospital stay and reduce the time of invasive mechanical ventilation and the incidence of BPD. Meanwhile, it does not increase the risk of related complications or death. This approach can be applied clinically.
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Affiliation(s)
- Zongyan Yi
- Department of Pediatrics, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Yajuan Tan
- Department of Pediatrics, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Yang Liu
- Department of Pediatrics, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Ling Jiang
- Department of Pediatrics, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Li Luo
- Department of Pediatrics, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Liang Wang
- Department of Pediatrics, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Wei Lei
- Department of Nursing, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Jiping Tan
- Department of Nursing, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Ruofen Yan
- Department of Nursing, The Ethnic Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
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16
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Szabó H, Baraldi E, Colin AA. Corticosteroids in the prevention and treatment of infants with bronchopulmonary dysplasia: Part II. Inhaled corticosteroids alone or in combination with surfactants. Pediatr Pulmonol 2022; 57:787-795. [PMID: 34964564 DOI: 10.1002/ppul.25808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 11/09/2022]
Abstract
This paper is the second in a two-part State-of-the-Art series that reviews the latest relevant clinical trials investigating the short-term and long-term effects of corticosteroids in the prevention and treatment of bronchopulmonary dysplasia (BPD). Inhaled postnatal corticosteroids demonstrate low systemic bioavailability and rapid systemic clearance with high pulmonary deposition and were expected to reduce the incidence of BPD with reduced adverse effects, however, increased rate of mortality in the neonatal period and at the 18-24 months follow-up was observed. In a milestone study, intratracheal instillation of corticosteroids combined with surfactant decreased the incidence of BPD without increasing the mortality or the long-term neurodevelopmental adverse outcomes. However, subsequent trials using different types of surfactants, different surfactant to budesonide ratio, different time of the drug administration for infants with different severity of respiratory distress syndrome could not reproduce all the beneficial effects. Future perspectives for the identification of premature infants at high risk of BPD and the prevention or treatment of established BPD are discussed.
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Affiliation(s)
- Hajnalka Szabó
- Department of Pediatrics, Faculty of Medicine & Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Padova University Hospital, Padova, Italy
| | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida, USA
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17
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Tang W, Chen S, Shi D, Ai T, Zhang L, Huang Y, Fan Y, Du Y. Effectiveness and safety of early combined utilization of budesonide and surfactant by airway for bronchopulmonary dysplasia prevention in premature infants with RDS: A meta-analysis. Pediatr Pulmonol 2022; 57:455-469. [PMID: 34783192 DOI: 10.1002/ppul.25759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To address the effectiveness and safety of early airway combined utilization of budesonide and surfactant for bronchopulmonary dysplasia (BPD) prevention in premature infants with respiratory distress syndrome (RDS). METHODS Literature retrieval was carried out in the PubMed, Web of Science, EMBASE, Cochrane Library, Wanfang, CQ VIP, and China National Knowledge Infrastructure databases, searching from the inception to September 2021. Stata 16.0 software was used for statistical analysis. RESULTS This meta-analysis suggested that early combined utilization of budesonide and surfactant by airway have a superiority on BPD incidence (risk ratio [RR] = 0.62; 95% confidence interval [CI]: 0.54-0.71, p < 0.001], mortality (RR = 0.64; 95%CI: 0.45-0.92, p = 0.016), the composite outcome of BPD or mortality (RR = 0.58; 95%CI: 0.50-0.68, p < 0.001), the additional doses of surfactant (RR = 0.53; 95%CI: 0.44-0.63, p < 0.001), the duration of assisted ventilation (standard mean difference [SMD] = -1.14; 95%CI: -1.58 to -0.70, p < 0.001), duration of invasive ventilation(SMD = -1.77; 95% CI: -2.61 to -0.93, p < 0.001), and hospital stays (SMD = -1.11; 95% CI: -1.73 to -0.49, p = 0.001) in preterm infants with RDS. And these benefits were not associated with increased adverse outcomes. Furthermore, a decreased incidence of patent ducts arterious (PDA) (RR = 0.79; 95% CI: 0.65 to 0.97, p = 0.028) was found in premature infants treated with budesonide and surfactant. Subgroup analysis based on budesonide delivery methods (inhalation or intratracheal instillation) indicated that the decrease of mortality (RR = 0.63; 95% CI: 0.43-0.93, p = 0.019), duration of assisted ventilation (SMD = -0.95; 95% CI: -1.30 to -0.61, p < 0.001), hospital stays (SMD = -1.23; 95% CI: -2.05 to -0.41, p = 0.003) and PDA incidence (RR = 0.80; 95% CI: 0.65 to 0.99, p = 0.044) were mainly in budesonide intratracheal instillation subgroup, rather than in budesonide inhalation subgroup. CONCLUSIONS This meta-analysis suggested that early combined utilization of budesonide and surfactant by airway might be an effective and safe clinical practice for BPD prevention in premature infants with RDS, especially when budesonide was delivered by intratracheal instillation. However, many of the included studies were small and were from Asian origin. More well-designed randomized controlled trials with larger sample sizes and longer follow-up from all over the world ought to be conducted in the future.
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Affiliation(s)
- Wei Tang
- Department of Respiratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Sisi Chen
- School of Clinical Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Dongmei Shi
- Department of Endocrinology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Tao Ai
- Department of Respiratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lei Zhang
- Department of Respiratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yijie Huang
- Department of Respiratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yinghong Fan
- Department of Respiratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yiting Du
- Department of Emergency, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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18
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Elfarargy MS, Al-Ashmawy GM, Abu-Risha SM, Khattab HA. Inhaled Budesonide in Neonatal Respiratory Distress Syndrome of Near-Term Neonates: A Randomized, Placebo-Controlled Trial. J Pediatr Pharmacol Ther 2022; 27:38-44. [PMID: 35002557 DOI: 10.5863/1551-6776-27.1.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study evaluates the value of inhaled budesonide (BUD) administration in neonatal respiratory distress syndrome (RDS) cases especially for near-term neonates. METHODS A randomized controlled trial involving 120 neonates with respiratory distress, which was diagnosed as RDS, was conducted from July 2016 to March 2018. The neonates studied were divided into 2 groups: group 1 (the inhaled BUD group), consisting of 60 neonates who received BUD (2 mL, 0.25-mg/mL suspension) inhalation, twice daily for 5 days; and group 2 (the placebo group), consisting of 60 neonates with RDS who received humidified distilled sterile water inhalation (2 mL). Downes score, RDS grades, and interleukin 8 (IL-8) levels were monitored and measured on the first and fifth days of incubation. RESULTS Statistically significant differences (SSDs) in RDS grades, Downes score, and IL-8 levels on the fifth day of admission were observed between groups 1 and 2 (p = 0.001) and between the first and fifth days of incubation in group 1 (p = 0.001). The SSDs in the duration of hospitalization (p = 0.001) and the number of neonates receiving mechanical ventilation (p = 0.032) were found between both groups. CONCLUSIONS Budesonide inhalation is associated with improvements in clinical and laboratory parameters in neonates with RDS.
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Affiliation(s)
- Mohamed S Elfarargy
- Department of Pediatrics (MSE), Faculty of Medicine, Tanta University, City, Country
| | - Ghada M Al-Ashmawy
- Department of Biochemistry (GMA-A), Faculty of Pharmacy, Tanta University, City, Country
| | - Sally M Abu-Risha
- Department of Pharmacology (SMA-R), Faculty of Pharmacy, Tanta University, City, Country
| | - Haidy A Khattab
- Department of Physiology (HAK), Faculty of Medicine, Tanta University, Tanta, Egypt
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19
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Josephsen JB, Hemmann BM, Anderson CD, Hemmann BM, Buchanan PM, Williams HL, Lubsch LM, Hillman NH. Presumed adrenal insufficiency in neonates treated with corticosteroids for the prevention of bronchopulmonary dysplasia. J Perinatol 2022; 42:65-71. [PMID: 34725449 DOI: 10.1038/s41372-021-01251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if extremely preterm (EPT) neonates receiving dexamethasone for the prevention of BPD have a higher incidence of presumed adrenal insufficiency (PAI). STUDY DESIGN Retrospective cohort study of neonates <28 weeks gestation examining PAI after dexamethasone use and PAI after intratracheal budesonide with surfactant administration. RESULT Of 332 neonates, 38% received dexamethasone. The incidence of PAI was higher in neonates who had received dexamethasone (20.8% vs 2.9%, p < 0.001). However, for intubated babies receiving surfactant, dexamethasone was not independently associated with increased PAI after adjusting for gestational age, birthweight, and race (aOR 2.92, 95% CI: 0.79-10.85). Dexamethasone was independently associated with increased PAI in infants previously receiving budesonide/surfactant treatment (aOR 5.38, 95% CI: 1.38-20.90). CONCLUSION The use of dexamethasone alone was not associated with increased PAI, when adjusted for prematurity-related factors. The combination of budesonide with dexamethasone was significantly associated with increased PAI.
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Affiliation(s)
- Justin B Josephsen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA.
| | - Brianna M Hemmann
- Cincinnati Children's Hospital Medical Center, Department of Pharmacy, Cincinnati, OH, USA
| | - Connie D Anderson
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Brett M Hemmann
- The Christ Hospital Health Network, Department of Pharmacy, Cincinnati, OH, USA
| | - Paula M Buchanan
- Department of Health and Clinical Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Howard L Williams
- SSM Health Cardinal Glennon Children's Hospital, Department of Pharmacy, St. Louis, MO, USA
| | - Lisa M Lubsch
- SSM Health Cardinal Glennon Children's Hospital, Department of Pharmacy, St. Louis, MO, USA.,Southern Illinois University Edwardsville School of Pharmacy, Department of Pharmacy Practice, Edwardsville, IL, USA
| | - Noah H Hillman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
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20
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Vento G, Tirone C, Paladini A, Aurilia C, Lio A, Tana M. Weaning from the Ventilator in Bronchopulmonary Dysplasia. Clin Perinatol 2021; 48:895-906. [PMID: 34774216 DOI: 10.1016/j.clp.2021.08.005] [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] [Indexed: 10/19/2022]
Abstract
For the newborns needing respiratory support at 36 weeks postmenstrual age, regardless of the type of ventilation used, it is critical to take into account the mechanics properties of both airways and lungs affected by severe bronchopulmonary dysplasia (sBPD). Ventilator strategies, settings, and weaning must change dramatically after sBPD is established, but to date there is almost no high-quality evidence base supporting a specific approach to guide the optimal ventilator management and weaning in patients with sBPD. Weaning from invasive mechanical ventilation, management of the immediately postextubation period, and weaning from noninvasive ventilation in patients with sBPD are the topics covered in this chapter.
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Affiliation(s)
- Giovanni Vento
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome 00168, Italy.
| | - Chiara Tirone
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome 00168, Italy
| | - Angela Paladini
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome 00168, Italy
| | - Claudia Aurilia
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome 00168, Italy
| | - Alessandra Lio
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome 00168, Italy
| | - Milena Tana
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome 00168, Italy
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21
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Mohiuddin M, Kasahara K. Potential therapeutic role of budesonide to reduce COVID-19 severity. J Infect Public Health 2021; 15:109-111. [PMID: 34802976 PMCID: PMC8585565 DOI: 10.1016/j.jiph.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/04/2021] [Accepted: 11/01/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Md Mohiuddin
- Department of Respiratory Medicine, Kanazawa University, Ishikawa, Japan.
| | - Kazuo Kasahara
- Department of Respiratory Medicine, Kanazawa University, Ishikawa, Japan
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22
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DeMauro SB. Neurodevelopmental outcomes of infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3509-3517. [PMID: 33749169 DOI: 10.1002/ppul.25381] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/15/2021] [Accepted: 02/27/2021] [Indexed: 01/31/2023]
Abstract
Preterm infants with bronchopulmonary dysplasia (BPD), and particularly those who develop the most severe forms of chronic lung disease during the neonatal period, are at high risk for poor developmental outcomes throughout childhood. Infants who require mechanical ventilation at 36 weeks post-menstrual age have significantly increased odds for cerebral palsy, developmental delay at 2 years, and poor academic achievement and low intelligence quotient in adolescence. Over the past several decades, many therapies and care strategies, including steroids, continuous positive airway pressure, surfactant, and other medications have been introduced into clinical practice. These approaches have changed the epidemiology of BPD in very preterm infants. However, BPD remains common and strongly associated with poor development throughout childhood. Only caffeine has been proven to reduce BPD and improve childhood developmental outcomes. In future research, it will be essential to better understand the developmental sequelae of BPD beyond school age and to test interventions to improve developmental trajectories in this population. As new management strategies for BPD are developed, it will be essential to rigorously evaluate both short-term and long-term effects before they are introduced into routine neonatal practice.
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Affiliation(s)
- Sara B DeMauro
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Children's Hospital of Philadelphia-Roberts Center for Pediatric Research, Philadelphia, Pennsylvania, USA
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23
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in infants and is associated with increased mortality, respiratory morbidity, neurodevelopmental impairment, and increased healthcare costs. In parallel with advances made in the field of neonatal intensive care, the phenotype of BPD has evolved from a fibrocystic disease affecting late preterm infants to one of impaired parenchymal development and dysregulated vascular growth predominantly affecting infants born before 29 weeks' gestational age. BPD has been shown to have significant lifelong consequences. Adults with BPD have been found to have abnormal lung function tests, reduced exercise tolerance, and may be at increased risk for developing chronic obstructive pulmonary disease. Evidence shows that BPD occurs secondary to genetic-environmental interactions in an immature lung. In this review, we evaluate the various clinical definitions, imaging modalities, and biomarker data that are helpful in making an early diagnosis of BPD. In addition, we evaluate recent evidence about the prevention and treatment of BPD. We discuss the invasive and non-invasive ventilation strategies and pharmacological agents used in the early, evolving, and established phases of BPD.
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Affiliation(s)
- Margaret Gilfillan
- Division of Neonatology, St Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anita Bhandari
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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24
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Tsao PC, Lin CH, Lee YS, Chen WY, Jeng MJ, Kou YR. Efficacy of intratracheal budesonide-surfactant combined therapy in surfactant-insufficient rat lungs with lipopolysaccharide insult. J Chin Med Assoc 2021; 84:783-790. [PMID: 34155174 DOI: 10.1097/jcma.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Intratracheal steroid therapy for lipopolysaccharide (LPS)-induced acute lung injury (ALI) remains challenging particularly in surfactant-insufficient lungs, a common problem of neonatal or pediatric ALI. Surfactant has been used as a vehicle for intratracheal steroid in the treatment of other types of ALI. This study investigated the efficacy of intratracheal budesonide (BUD) delivered by two concentrations of surfactant in the treatment of LPS-induced ALI in surfactant-insufficient rat lungs. METHODS Male adult rats were anesthetized and ventilated. Our ALI model was established by repeated saline lavage to produce surfactant insufficiency, followed by intratracheal LPS instillation. Five study groups (n = 5 for each) with different intratracheal treatments following ALI were used: control (no treatment), BUD (NS-BUD; BUD in saline), DS-BUD (BUD in diluted surfactant), FS-BUD (BUD in full-strength surfactant), FS (full-strength surfactant). Cardiopulmonary variables were monitored 4 hours post injury. Histological and immunohistochemical assessments of the lungs were performed. RESULTS The FS-BUD and FS groups presented better gas exchange, less metabolic acidosis, less oxygen index, and more stable hemodynamic changes than the DS-BUD, NS-BUD, and control groups. The total lung injury scores assessed by histological examination were ordered as follows: FS-BUD < DS-BUD or FS < NS-BUD < control. The immunostaining intensities of lung myeloperoxidase showed the following order: NS-BUD, DS-BUD, or FS-BUD < control or FS. Only the FS-BUD group displayed a smaller immunostaining intensity of lung tumor necrosis factor (TNF)-α than the control group. CONCLUSION Among our therapeutic strategies, intratracheal BUD delivered by full-strength surfactant confers an optimal protection against LPS-induced ALI in surfactant-insufficient rat lungs.
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Affiliation(s)
- Pei-Chen Tsao
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department and Institute of Physiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chih-Hsueh Lin
- Department and Institute of Physiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Nutrition, Hung-Kuang University, Taichung, Taiwan, ROC
| | - Yu-Sheng Lee
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wei-Yu Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Mei-Jy Jeng
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu Ru Kou
- Department and Institute of Physiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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25
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Moschino L, Nardo D, Bonadies L, Stocchero M, Res G, Priante E, Salvadori S, Baraldi E. Intra-tracheal surfactant/budesonide versus surfactant alone: Comparison of two consecutive cohorts of extremely preterm infants. Pediatr Pulmonol 2021; 56:2114-2124. [PMID: 33942570 PMCID: PMC8251959 DOI: 10.1002/ppul.25415] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the efficacy of intra-tracheal (IT) surfactant/budesonide (SB) with that of surfactant alone (S) in reducing the rate of bronchopulmonary dysplasia (BPD) at 36 weeks post-menstrual age (PMA), we included extremely preterm very low birth weight (VLBW) infants with severe respiratory distress syndrome (RDS) in our tertiary neonatal level of care unit (Padua, Italy). STUDY DESIGN A retrospective chart review of two cohorts of extremely preterm VLBW neonates (<28+0 gestation weeks, birth weight [BW] < 1500 g) born in two consequent epochs (2017-2018/2018-2019) were compared. The SB group received surfactant (200 mg/kg 1st dose) and budesonide (0.25 mg/kg), while the S group received surfactant alone. RESULTS Among 68 neonates with RDS Grades III-IV, FiO2 ≥ 0.3 within 12 h of life, 18 were included in each group after matching for perinatal, clinical, and laboratory characteristics. IT SB did not affect the rate of BPD (Vermont Oxford Network, Jensen's, and National Institute of Child Health and Human Development BPD Workshop 2018 definitions), death, BPD, or death at 36 weeks PMA. Hypotension requiring inotropic support within the first 5 days was lower in those receiving the combined treatment (p = .03). The SB group had fewer admissions to pediatric ward due to respiratory causes up to 12 months of corrected age (p = .03). CONCLUSION The preliminary results of this retrospective study suggest that in extremely preterm VLBW infants, IT SB for severe RDS did not affect the incidence of BPD, death, and BPD or death at 36 weeks PMA, compared to surfactant alone. The combined therapy proved to be safe in this population. Further studies are warranted to explore the role of early IT steroids on respiratory morbidity in preterm infants.
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Affiliation(s)
- Laura Moschino
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy
| | - Daniel Nardo
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy
| | - Luca Bonadies
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy
| | - Matteo Stocchero
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy.,Institute of Pediatric Research, Città della Speranza, Padova, Italy
| | - Giulia Res
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy
| | - Elena Priante
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy
| | - Sabrina Salvadori
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy
| | - Eugenio Baraldi
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University of Padua School of Medicine, Padua, Italy.,Institute of Pediatric Research, Città della Speranza, Padova, Italy
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26
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Fallon BP, Mychaliska GB. Development of an artificial placenta for support of premature infants: narrative review of the history, recent milestones, and future innovation. Transl Pediatr 2021; 10:1470-1485. [PMID: 34189106 PMCID: PMC8192990 DOI: 10.21037/tp-20-136] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Over 50 years ago, visionary researchers began work on an extracorporeal artificial placenta to support premature infants. Despite rudimentary technology and incomplete understanding of fetal physiology, these pioneering scientists laid the foundation for future work. The research was episodic, as medical advances improved outcomes of premature infants and extracorporeal life support (ECLS) was introduced for the treatment of term and near-term infants with respiratory or cardiac failure. Despite ongoing medical advances, extremely premature infants continue to suffer a disproportionate burden of mortality and morbidity due to organ immaturity and unintended iatrogenic consequences of medical treatment. With advancing technology and innovative approaches, there has been a resurgence of interest in developing an artificial placenta to further diminish the mortality and morbidity of prematurity. Two related but distinct platforms have emerged to support premature infants by recreating fetal physiology: a system based on arteriovenous (AV) ECLS and one based on veno-venous (VV) ECLS. The AV-ECLS approach utilizes only the umbilical vessels for cannulation. It requires immediate transition of the infant at the time of birth to a fluid-filled artificial womb to prevent umbilical vessel spasm and avoid gas ventilation. In contradistinction, the VV-ECLS approach utilizes the umbilical vein and the internal jugular vein. It would be applied after birth to infants failing maximal medical therapy or preemptively if risk stratified for high mortality and morbidity. Animal studies are promising, demonstrating prolonged support and ongoing organ development in both systems. The milestones for clinical translation are currently being evaluated.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
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27
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN-BASEL 2021; 8:children8040298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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28
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De Luca D, Cogo P, Kneyber MC, Biban P, Semple MG, Perez-Gil J, Conti G, Tissieres P, Rimensberger PC. Surfactant therapies for pediatric and neonatal ARDS: ESPNIC expert consensus opinion for future research steps. Crit Care 2021; 25:75. [PMID: 33618742 PMCID: PMC7898495 DOI: 10.1186/s13054-021-03489-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/04/2021] [Indexed: 12/14/2022] Open
Abstract
Pediatric (PARDS) and neonatal (NARDS) acute respiratory distress syndrome have different age-specific characteristics and definitions. Trials on surfactant for ARDS in children and neonates have been performed well before the PARDS and NARDS definitions and yielded conflicting results. This is mainly due to heterogeneity in study design reflecting historic lack of pathobiology knowledge. We reviewed the available clinical and preclinical data to create an expert consensus aiming to inform future research steps and advance the knowledge in this area. Eight trials investigated the use of surfactant for ARDS in children and ten in neonates, respectively. There were improvements in oxygenation (7/8 trials in children, 7/10 in neonates) and mortality (3/8 trials in children, 1/10 in neonates) improved. Trials were heterogeneous for patients' characteristics, surfactant type and administration strategy. Key pathobiological concepts were missed in study design. Consensus with strong agreement was reached on four statements: 1. There are sufficient preclinical and clinical data to support targeted research on surfactant therapies for PARDS and NARDS. Studies should be performed according to the currently available definitions and considering recent pathobiology knowledge. 2. PARDS and NARDS should be considered as syndromes and should be pre-clinically studied according to key characteristics, such as direct or indirect (primary or secondary) nature, clinical severity, infectious or non-infectious origin or patients' age. 3. Explanatory should be preferred over pragmatic design for future trials on PARDS and NARDS. 4. Different clinical outcomes need to be chosen for PARDS and NARDS, according to the trial phase and design, trigger type, severity class and/or surfactant treatment policy. We advocate for further well-designed preclinical and clinical studies to investigate the use of surfactant for PARDS and NARDS following these principles.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, 157 Rue de la Porte de Trivaux, 92140, Clamart (Paris-IDF), France.
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France.
| | - Paola Cogo
- Department of Pediatrics, University of Udine, Udine, Italy
| | - Martin C Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital Groningen, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Critical Care, Anesthesiology, Peri-Operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Paolo Biban
- Department of Neonatal and Pediatric Critical Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Malcolm Grace Semple
- Health Protection Research Unit in Emerging and Zoonotic Infections, Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Jesus Perez-Gil
- Department of Biochemistry and Molecular Biology and Research Institute "Hospital 12 de Octubre", Complutense University, Madrid, Spain
| | - Giorgio Conti
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Pierre Tissieres
- Division of Pediatric Critical Care and Neonatal Medicine, "Kremlin-Bicetre" Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
- Integrative Cellular Biology Institute-UMR 9198, Host-Pathogen Interactions Team, Paris Saclay University, Paris, France
| | - Peter C Rimensberger
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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29
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Doyle LW. Postnatal Corticosteroids to Prevent or Treat Bronchopulmonary Dysplasia. Neonatology 2021; 118:244-251. [PMID: 33975319 DOI: 10.1159/000515950] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/19/2022]
Abstract
Bronchopulmonary dysplasia (BPD) remains a major morbidity for infants born preterm. Postnatal corticosteroids might reduce the risk of developing BPD, or reduce its severity when it occurs, because of their powerful anti-inflammatory effects. However, corticosteroids have adverse effects, including on the developing brain. There have been numerous randomized clinical trials of corticosteroids given via various routes, of varying types, and started at different postnatal ages. There is some evidence that inhaled corticosteroids started earlier in the postnatal period may reduce BPD, but increase mortality. Inhaled corticosteroids started after the first week of age have little effect, but data are sparse. Systemic corticosteroids started in the first week after birth reduce BPD but increase cerebral palsy. Systemic corticosteroids started after the first week of age reduce both BPD and mortality, without evidence of long-term neurological harm. However, no studies have been powered to look for important adverse long-term neurological effects. Of the 2 systemic corticosteroids assessed, most effects relate to dexamethasone and not to hydrocortisone, but hydrocortisone in the first week after birth may reduce mortality, and is worthy of further study. There are limited data directly comparing inhaled versus systemic corticosteroids, with no evidence of superiority of one mode over the other. Corticosteroids instilled into the trachea using surfactant as a vehicle to distribute the drug through the lungs offer promise in preventing BPD. For current clinical practice, systemic corticosteroids should be avoided in the first week of life, and thereafter used only in infants at high risk of BPD.
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Affiliation(s)
- Lex W Doyle
- Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Departments of Obstetrics and Gynaecology, and of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Centre, Parkville, Victoria, Australia
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30
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Hillman NH, Abugisisa L, Royse E, Fee E, Kemp MW, Kramer BW, Schmidt AF, Salomone F, Clarke MW, Musk GC, Jobe AH. Dose of budesonide with surfactant affects lung and systemic inflammation after normal and injurious ventilation in preterm lambs. Pediatr Res 2020; 88:726-732. [PMID: 32066138 PMCID: PMC8717708 DOI: 10.1038/s41390-020-0809-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/30/2020] [Accepted: 02/07/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The addition of budesonide (Bud) 0.25 mg/kg to surfactant decreased the lung and systemic responses to mechanical ventilation in preterm sheep and the rates and severity of bronchopulmonary dysplasia (BPD) in preterm infants. We hypothesized that lower budesonide concentrations in surfactant will decrease injury while decreasing systemic corticosteroid exposure. METHODS Preterm lambs received either (1) protective tidal volume (VT) ventilation with surfactant from birth or (2) injurious VT ventilation for 15 min and then surfactant treatment. Lambs were further assigned to surfactant mixed with (i) Saline, (ii) Bud 0.25 mg/kg, (iii) Bud 0.1 mg/kg, or (iv) Bud 0.04 mg/kg. All lambs were then ventilated with protective VT for 6 h. RESULTS Plasma Bud levels were proportional to the dose received and decreased throughout ventilation. In both protective and injurious VT ventilation, <4% of Bud remained in the lung at 6 h. Some of the improvements in physiology and markers of injury with Bud 0.25 mg/kg were also found with 0.1 mg/kg, whereas 0.04 mg/kg had only minimal effects. CONCLUSIONS Lower doses of Bud were less effective at decreasing lung and systemic inflammation from mechanical ventilation. The plasma Bud levels were proportional to dose given and the majority left the lung.
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Affiliation(s)
- Noah H Hillman
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, MO, 63104, USA.
| | - Leenah Abugisisa
- Division of Neonatology, Cardinal Glennon Children’s Hospital, Saint Louis University, Saint Louis, MO 63104
| | - Emily Royse
- Division of Neonatology, Cardinal Glennon Children’s Hospital, Saint Louis University, Saint Louis, MO 63104
| | - Erin Fee
- School of Women’s and Infants’ Health, University of Western Australia, Perth, WA, Australia 6009
| | - Matthew W Kemp
- School of Women’s and Infants’ Health, University of Western Australia, Perth, WA, Australia 6009
| | | | - Augusto F Schmidt
- Department of Pediatrics, Univ. Miami Miller School of Medicine, Miami, FL 33136
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - Michael W Clarke
- Metabolomics Australia, Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, WA 6009, Australia
| | - Gabrielle C Musk
- School of Women’s and Infants’ Health, University of Western Australia, Perth, WA, Australia 6009,Animal Care Services, University of Western Australia, Perth, WA, Australia 6009
| | - Alan H Jobe
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH 45229,School of Women’s and Infants’ Health, University of Western Australia, Perth, WA, Australia 6009
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31
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Baer B, McCaig L, Yamashita C, Veldhuizen R. Exogenous Surfactant as a Pulmonary Delivery Vehicle for Budesonide In Vivo. Lung 2020; 198:909-916. [PMID: 33106891 PMCID: PMC7587541 DOI: 10.1007/s00408-020-00399-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/14/2020] [Indexed: 12/19/2022]
Abstract
Background Lung inflammation is associated with many respiratory conditions. Consequently, anti-inflammatory medications, like glucocorticoids, have become mainstay intrapulmonary therapeutics. However, their effectiveness for treating inflammation occurring in the alveolar regions of the lung is limited by suboptimal delivery. To improve the pulmonary distribution of glucocorticoids, such as budesonide to distal regions of the lung, exogenous surfactant has been proposed as an ideal delivery vehicle for such therapies. It was therefore hypothesized that fortifying an exogenous surfactant (BLES) with budesonide would enhance efficacy for treating pulmonary inflammation in vivo. Methods An intratracheal instillation of heat-killed bacteria was used to elicit an inflammatory response in the lungs of male and female rats. Thirty minutes after this initial instillation, either budesonide or BLES combined with budesonide was administered intratracheally. To evaluate the efficacy of surfactant delivery, various markers of inflammation were measured in the bronchoalveolar lavage and lung tissue. Results Although budesonide exhibited anti-inflammatory effects when administered alone, delivery with BLES enhanced those effects by lowering the lavage neutrophil counts and myeloperoxidase activity in lung tissue. Combining budesonide with BLES was also shown to reduce several other pro-inflammatory mediators. These results were shown across both sexes, with no observed sex differences. Conclusion Based on these findings, it was concluded that exogenous surfactant can enhance the delivery and efficacy of budesonide in vivo.
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Affiliation(s)
- Brandon Baer
- Department of Physiology and Pharmacology, Western University, London, ON, Canada.
| | - Lynda McCaig
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Cory Yamashita
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
| | - Ruud Veldhuizen
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
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Wang SH, Tsao PN. Phenotypes of Bronchopulmonary Dysplasia. Int J Mol Sci 2020; 21:ijms21176112. [PMID: 32854293 PMCID: PMC7503264 DOI: 10.3390/ijms21176112] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/18/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic morbidity in preterm infants. In the absence of effective interventions, BPD is currently a major therapeutic challenge. Several risk factors are known for this multifactorial disease that results in disrupted lung development. Inflammation plays an important role and leads to persistent airway and pulmonary vascular disease. Since corticosteroids are potent anti-inflammatory agents, postnatal corticosteroids have been used widely for BPD prevention and treatment. However, the clinical responses vary to a great degree across individuals, and steroid-related complications remain major concerns. Emerging studies on the molecular mechanism of lung alveolarization during inflammatory stress will elucidate the complicated pathway and help discover novel therapeutic targets. Moreover, with the advances in metabolomics, there are new opportunities to identify biomarkers for early diagnosis and prognosis prediction of BPD. Pharmacometabolomics is another novel field aiming to identify the metabolomic changes before and after a specific drug treatment. Through this "metabolic signature," a more precise treatment may be developed, thereby avoiding unnecessary drug exposure in non-responders. In the future, more clinical, genetic, and translational studies would be required to improve the classification of BPD phenotypes and achieve individualized care to enhance the respiratory outcomes in preterm infants.
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Affiliation(s)
- Shih-Hsin Wang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan;
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100225, Taiwan
- Center for Developmental Biology & Regenerative Medicine, National Taiwan University, Taipei 100226, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71013)
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Chiu HY, Chu SM, Lin HY, Tsai ML, Chen YT, Lin HC. Evidence base multi-discipline critical strategies toward better tomorrow for very preterm infants. Pediatr Neonatol 2020; 61:371-377. [PMID: 32201157 DOI: 10.1016/j.pedneo.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/30/2019] [Accepted: 01/21/2020] [Indexed: 12/15/2022] Open
Abstract
Despite advances in neonatal intensive care in the recent decade, a large number of very preterm infants (VPIs) remain at risk for significant neurodevelopmental impairment (NDI). Given that there are many interventions need to be implemented during the critical perinatal period so that complications of these vulnerable VPIs could be minimized, it is urgent to develop multi-discipline strategies based on evidence to be carried out. The objective of this new term evidence-based perinatal critical strategies (EBPCS), is to provide beneficial intervention towards better neurodevelopmental outcomes, specifically for preterm infants below 28 weeks gestational age. EBPCS is defined as the management of the VPIs during the perinatal period which would include antenatal counseling with team briefing and share decision making, treat the chorioamnionitis, antenatal MgS04, antenatal steroid, delayed cord clamping/milking, neonatal resuscitation team preparation, prevention of hypothermia, immediate respiratory support with continuous positive airway pressure at delivery room, less invasive surfactant administration, early surfactant with budesonide therapy, support of cardiovascular system, early initiate of probiotics administration, early caffeine, early parenteral and enteral nutrition, promptly initiating antibiotics. These critical strategies will be discussed detail in the text; nonetheless, standardized protocols, technical skills and repeated training are the cornerstones of successful of EBPCS. Further experience from different NICU is needed to prove whether these very complicate and comprehensive perinatal critical strategies could translate into daily practice to mitigate the incidence of NDI in high-risk VPIs.
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Affiliation(s)
- Hsiao-Yu Chiu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Hsiang-Yu Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Ming-Luen Tsai
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Yin-Ting Chen
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chih Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Asia University Hospital, Asia University, Taichung, Taiwan.
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Foligno S, Loi B, Pezza L, Piastra M, Autilio C, De Luca D. Extrapulmonary Surfactant Therapy: Review of Available Data and Research/Development Issues. J Clin Pharmacol 2020; 60:1561-1572. [PMID: 32578234 DOI: 10.1002/jcph.1675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/21/2020] [Indexed: 11/07/2022]
Abstract
Since the discovery of surfactant, a large amount of knowledge has been accumulated about its biology and pharmacology. Surfactant is the cornerstone of neonatal respiratory critical care, but its proteins and phospholipids are produced in various tissues and organs, with possible roles only partially similar to that played in the alveoli. As surfactant research is focused mainly on its respiratory applications, knowledge about the possible role of surfactant in extrapulmonary disorders has never been summarized. Here we aim to comprehensively review the data about surfactant biology and pharmacology in organs other than the lung, especially focusing in the more promising surfactant extrapulmonary roles. We also review any preclinical or clinical data available about the therapeutic use of surfactant in these contexts. We offer a summary of knowledge and research/development milestones, as possible useful guidance for researchers of multidisciplinary background.
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Affiliation(s)
- Silvia Foligno
- Division of Pediatrics and Neonatal Critical Care, Medical Center, "A. Béclère," South Paris University Hospitals, Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - Barbara Loi
- Division of Pediatrics and Neonatal Critical Care, Medical Center, "A. Béclère," South Paris University Hospitals, Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - Lucilla Pezza
- Pediatric Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital "A.Gemelli"-IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital "A.Gemelli"-IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research Institut-Hospital "12 de Octubre,", Complutense University, Madrid, Spain
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center, "A. Béclère," South Paris University Hospitals, Assistance Publique-Hopitaux de Paris (APHP), Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris/Saclay University, Paris, France
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Dassios T, Ambulkar H, Greenough A. Treatment and respiratory support modes for neonates with respiratory distress syndrome. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1769598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- 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
| | - Hemant Ambulkar
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, 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
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
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Kothe TB, Sadiq FH, Burleyson N, Williams HL, Anderson C, Hillman NH. Surfactant and budesonide for respiratory distress syndrome: an observational study. Pediatr Res 2020; 87:940-945. [PMID: 31715622 DOI: 10.1038/s41390-019-0663-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 09/03/2019] [Accepted: 10/05/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND In preterm infants on moderately high ventilator support, the addition of budesonide to surfactant lowered bronchopulmonary dysplasia (BPD) rates by 20% without increased morbidity or mortality. The aim of this cohort comparison was to determine the safety and efficacy of the combination in infants with milder respiratory distress syndrome (RDS). METHODS In August 2016 we began administering budesonide (0.25 mg/kg) mixed with surfactant (Survanta 4 mL/kg) to all infants ≤ 1250 g who failed CPAP and required intubation. Infants were compared to a historical cohort (2013-2016) who received surfactant alone. RESULTS BPD or death did not change between the historical surfactant cohort (71%, n = 294) and the budesonide cohort (69%, n = 173). Budesonide was associated with a decrease in the need for continued mechanical ventilation, severe BPD type II or death (19-12%), grade III BPD or death (31-21%), and the median gestational age at discharge was 1 week earlier. Histologic chorioamnionitis was associated with decreased budesonide effects. Secondary morbidities (NEC, IVH, ROP, Sepsis) were similar. CONCLUSION Overall BPD rates remained unchanged with the addition of budesonide. Budesonide was associated with decreased severity of BPD, decreased mechanical ventilation use, earlier discharge, and similar short-term outcomes.
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Affiliation(s)
- T Brett Kothe
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Hospital, St. Louis, MO, USA.,Division of Neonatology, Department of Obstetrics and Gynecology, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Farouk H Sadiq
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Nikki Burleyson
- SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | | | - Connie Anderson
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Noah H Hillman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Hospital, St. Louis, MO, USA.
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Hillman NH, Kothe TB, Schmidt AF, Kemp MW, Royse E, Fee E, Salomone F, Clarke MW, Musk GC, Jobe AH. Surfactant plus budesonide decreases lung and systemic responses to injurious ventilation in preterm sheep. Am J Physiol Lung Cell Mol Physiol 2020; 318:L41-L48. [PMID: 31617728 PMCID: PMC6985873 DOI: 10.1152/ajplung.00203.2019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/09/2019] [Accepted: 09/30/2019] [Indexed: 11/22/2022] Open
Abstract
Mechanical ventilation from birth with normal tidal volumes (VT) causes lung injury and systemic responses in preterm sheep. The addition of budesonide to surfactant therapy decreases these injury markers. Budesonide and surfactant will decrease the injury from injurious VT ventilation in preterm sheep. Lambs at 126 ± 1 day gestational age were ventilated from birth with either: 1) Normal VT [surfactant 200 mg/kg before ventilation, positive end expiratory pressure (PEEP) 5 cmH2O, VT 8 mL/kg] or 2) Injury VT (high pressure, 100% oxygen, no PEEP) for 15 min, then further randomized to surfactant + saline or surfactant + 0.25 mg/kg budesonide with Normal VT for 6 h. Lung function and lung, liver, and brain tissues were evaluated for indicators of injury. Injury VT + saline caused significant injury and systemic responses, and Injury VT + budesonide improved lung physiology. Budesonide decreased lung inflammation and decreased pro-inflammatory cytokine mRNA in the lung, liver, and brain to levels similar to Normal VT + saline. Budesonide was present in plasma within 15 min of treatment in both ventilation groups, and less than 5% of the budesonide remained in the lung at 6 h. mRNA sequencing of liver and periventricular white matter demonstrated multiple pathways altered by both Injury VT and budesonide and the combination exposure. In lambs receiving Injury VT, the addition of budesonide to surfactant improved lung physiology and decreased pro-inflammatory cytokine responses in the lung, liver, and brain to levels similar to lambs receiving Normal VT.
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Affiliation(s)
- Noah H Hillman
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, Missouri
| | - T Brett Kothe
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, Missouri
| | - Augusto F Schmidt
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Matthew W Kemp
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
| | - Emily Royse
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, Missouri
| | - Erin Fee
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - Michael W Clarke
- Metabolomics Australia, Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, Western Australia, Australia
| | - Gabrielle C Musk
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
- Animal Care Services, University of Western Australia, Perth, Western Australia, Australia
| | - Alan H Jobe
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
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Deliloglu B, Tuzun F, Cengiz MM, Ozkan H, Duman N. Endotracheal Surfactant Combined With Budesonide for Neonatal ARDS. Front Pediatr 2020; 8:210. [PMID: 32432062 PMCID: PMC7214613 DOI: 10.3389/fped.2020.00210] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 04/08/2020] [Indexed: 11/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a clinical condition characterized by acute diffuse inflammatory lung injury and severe hypoxemia. In 2017, the Montreux Consensus defined diagnostic criteria for ARDS in the neonatal period. The management of ARDS includes strict adherence to lung-protective ventilation strategies and therapeutic agents to improve gas exchange. We report two similar cases of premature infants with gestational ages of 23 and 24 weeks diagnosed with neonatal ARDS according to the Montreux definition. These patients developed acute worsening of oxygenation on the 30th and 28th day of life, respectively, while they were ventilated on volume-guarantee assist/control mode. Chest X-rays revealed bilateral diffuse opacity, there were no cardiogenic origins for pulmonary edema, and their oxygenation indexes were >8. Both cases fulfilled the neonatal ARDS criteria and the patients' clinical conditions were associated with late onset neonatal sepsis. After lung recruitment maneuver, the infants began HFO volume-guarantee ventilation and received surfactant treatment. Since they showed a poor short-term response, intratracheal surfactant of 100 mg/kg plus budesonide of 0.25 mg/kg were administered and their oxygenation indexes were reduced stepwise. Both patients survived and were discharged home with spontaneous breathing of room air. Neonatal ARDS is generally an underdiagnosed condition associated with sepsis, pneumonia, and meconium aspiration. Impaired surfactant activity and reduced lung compliance play important roles in its pathophysiology. To our knowledge, this is the first case report indicating the possible therapeutic role of budesonide plus surfactant in ARDS treatment. Since ARDS is an entity not recognized in newborns, we want to emphasize neonatal ARDS diagnosis and underline that the combination of budesonide and surfactant may be a novel therapeutic option in the treatment of ARDS.
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Affiliation(s)
- Burak Deliloglu
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Funda Tuzun
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Merve Meryem Cengiz
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Hasan Ozkan
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Nuray Duman
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
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Zheng Y, Xiu W, Lin Y, Ren Y, Zhang B, Yang C. Long-term effects of the intratracheal administration of corticosteroids for the prevention of bronchopulmonary dysplasia: A meta-analysis. Pediatr Pulmonol 2019; 54:1722-1734. [PMID: 31397120 DOI: 10.1002/ppul.24452] [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] [Received: 04/20/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is one of the most common complications in premature infants. Since inflammation plays a crucial role in the pathogenesis of BPD, anti-inflammatory drugs, such as corticosteroids, have long been the focus of prevention research. In this meta-analysis, we aim to explore the long-term effects of the intratracheal administration of corticosteroids (IAC) in preventing BPD. METHODS EMBASE, MEDLINE, the Cochrane Library, Web of Science, CINAHL, Clinicaltrials.gov, the ISRCTN registry, and gray literature were searched to identify randomized controlled trials (RCTs) that evaluated the long-term effects of IAC for the prevention of BPD in premature infants. RESULTS Five RCTs (n = 1515) were eligible for further analysis. The meta-analysis revealed that the incidence of neurodevelopmental impairment (NDI) did not significantly differ between the IAC group and the control group (relative risk [RR] 0.9, 95% confidence interval [CI] 0.79 to 1.03, P = .14). There was no significant reduction in long-term mortality (RR, 1.13; 95% CI, 0.9 to 1.41; P = .3) or the incidence of rehospitalization (RR, 0.99; 95% CI, 0.89 to 1.09, P = .82). No significant differences were observed between the IAC group and the control group with regard to height, weight and head circumference at the age of 18 to 36 months of postmenstrual age (PMA) (mean difference [MD], 0.14; 95% CI, -0.26 to 0.54, P = .48). CONCLUSIONS Our study suggests that IAC in preterm infants does not have significant long-term benefits or adverse outcomes. However, before routine use, well-designed studies and studies involving large sample sizes are needed to confirm the pharmacokinetics and long-term effects of IAC.
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Affiliation(s)
- Yirong Zheng
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wenlong Xiu
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yunfeng Lin
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanli Ren
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Baoquan Zhang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Changyi Yang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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Early Intratracheal Administration of Corticosteroid and Pulmonary Surfactant for Preventing Bronchopulmonary Dysplasia in Preterm Infants with Neonatal Respiratory Distress Syndrome: A Meta-analysis. Curr Med Sci 2019; 39:493-499. [DOI: 10.1007/s11596-019-2064-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 03/07/2019] [Indexed: 10/26/2022]
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41
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Rüegger CM, Bassler D. Alternatives to systemic postnatal corticosteroids: Inhaled, nebulized and intratracheal. Semin Fetal Neonatal Med 2019; 24:207-212. [PMID: 30992184 DOI: 10.1016/j.siny.2019.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Concern about adverse outcomes with the use of systemic postnatal corticosteroids (PCS) for bronchopulmonary dysplasia (BPD) have led to the widespread use of alternative methods of administration in research and clinical care. Theoretically, administration of topical (directly to the lung) corticosteroids may allow for beneficial effects on the pulmonary system with a lower risk of undesirable side effects compared with systemic administration. Current evidence suggests that inhaled corticosteroids may be an effective therapy in the management of developing BPD in preterm infants, but questions about their safety remain. An alternative to inhalation is the intratracheal administration of corticosteroids using surfactant as a vehicle, but this approach has only been studied in a limited number of infants. We review the evidence for the short-term clinical efficacy and safety of inhaled, nebulized and intratracheal PCS for the prevention and treatment of BPD.
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Affiliation(s)
- Christoph M Rüegger
- Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland.
| | - Dirk Bassler
- Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
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Baer B, Souza LMP, Pimentel AS, Veldhuizen RA. New insights into exogenous surfactant as a carrier of pulmonary therapeutics. Biochem Pharmacol 2019; 164:64-73. [DOI: 10.1016/j.bcp.2019.03.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/26/2019] [Indexed: 01/03/2023]
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43
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Long-term effects of postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia: Balancing the risks and benefits. Semin Fetal Neonatal Med 2019; 24:197-201. [PMID: 30962159 DOI: 10.1016/j.siny.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Postnatal corticosteroids are effective in preventing or treating bronchopulmonary dysplasia (BPD) in preterm newborns, but their benefits need to exceed their risks. Several types of corticosteroids, and different timing and administration modes have been trialed. Systemic corticosteroids, given either early or late, have proven efficacy for reducing BPD and the combined outcome of death or BPD. Inhaled corticosteroids are less effective. However, systemic dexamethasone given early is associated with more neurosensory disability and cerebral palsy in survivors. The risk of adverse neurodevelopment is highest if dexamethasone is given to preterm infants at low risk of BPD. Current trials focus on corticosteroids, mixed with surfactant, delivered intratracheally directly to the lung, which may avoid some systemic adverse effects of corticosteroids. Early trials of intratracheal corticosteroids are encouraging, but more data are needed to determine whether this method of administration is preferable to systemic corticosteroids for preventing or treating BPD.
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Sung TJ. Bronchopulmonary dysplasia: how can we improve its outcomes? KOREAN JOURNAL OF PEDIATRICS 2019; 62:367-373. [PMID: 31122011 PMCID: PMC6801196 DOI: 10.3345/kjp.2019.00178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/17/2019] [Indexed: 01/01/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease of preterm infants with multiple factors affected from prenatal to postnatal periods. Despite significant advances in neonatal care over almost 50 years, BPD rates have not decreased; in fact, they may have even increased. Since more preterm infants, even at periviable gestational age, survive today, different stages of lung development affect the pathogenesis of BPD. Hence, the definition of BPD has changed from “old” to “new.” In this review, we discuss the various definitions of BPD, risk factors from the prenatal to postnatal periods, management strategies by phase, and future directions for research.
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Affiliation(s)
- Tae-Jung Sung
- Department of Pediatrics, Hallym University Medical Center, Seoul, Korea
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45
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology 2019; 115:432-450. [PMID: 30974433 PMCID: PMC6604659 DOI: 10.1159/000499361] [Citation(s) in RCA: 643] [Impact Index Per Article: 128.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, United Kingdom,
| | - Virgilio Carnielli
- Department of Neonatology, Polytechnic University of Marche, and Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Pediatrics and Adolescence, Oulu University Hospital, and PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan Te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C Roehr
- Department of Paediatrics, University of Oxford, Medical Sciences Division, Newborn Services, John Radcliffe Hospitals, Oxford, United Kingdom
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
| | - Umberto Simeoni
- Division of Pediatrics, CHUV & University of Lausanne, Lausanne, Switzerland
| | - Christian P Speer
- Department of Pediatrics, University Children's Hospital, Würzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerhard H A Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, United Kingdom
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46
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic complication associated with extremely preterm birth. Although BPD is now an uncommon condition in infants born with birthweights higher than 1,500 g, among infants born at or near the current limits of viability, BPD rates have not improved over the past 2 to 3 decades and may be increasing. No single therapeutic intervention is effective at preventing BPD. As such, clinicians must use multiple evidence-based strategies to help reduce BPD rates. This review examines current evidence-based approaches to BPD prevention, primarily focusing on data obtained from randomized controlled trials.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics; Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
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47
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Delara M, Chauhan BF, Le ML, Abou-Setta AM, Zarychanski R, 'tJong GW. Efficacy and safety of pulmonary application of corticosteroids in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2019; 104:F137-F144. [PMID: 29666203 DOI: 10.1136/archdischild-2017-314046] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 03/06/2018] [Accepted: 03/10/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Systemic corticosteroids as the frontline treatment of respiratory distress syndrome (RDS) in preterm infants are associated with adverse effects on growth and neurodevelopmental outcome, but the pulmonary administration of steroids may help prevent the development of bronchopulmonary dysplasia (BPD) without these side effects. OBJECTIVES To evaluate the efficacy and safety of pulmonary application of corticosteroids in preterm infants with RDS. METHODS MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, the WHO's International Clinical Trials Registry and grey literature were searched with no restriction on date and language of publication from inception to May 2016. Using a random-effect model, we pooled data from randomised controlled trials (RCTs) comparing inhaled or endotracheal corticosteroids with the standard of care, placebo or no other intervention in preterm infants with RDS. RESULTS We identified 873 potential citations and included 12 unique RCTs. Pulmonary corticosteroid therapy was associated with a significant reduction in the composite outcome of BPD or death (relative risk (RR) 0.85, 95% CI 0.76 to 0.96). Pulmonary application of corticosteroids significantly reduced the incidence of patent ductus arteriosus (PDA) (RR 0.82, 95% CI 0.74 to 0.92) and pneumonia (RR 0.57, 95% CI 0.35 to 0.92). There was no evidence of a significant difference regarding the risk of neurodevelopmental impairment or other side effects. CONCLUSIONS Pulmonary administration of corticosteroids reduces the incidence of BPD or death, pneumonia, PDA without causing any major side effects in preterm infants with RDS.
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Affiliation(s)
- Mahin Delara
- Clinical Research Unit, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,College of Human Ecology, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bhupendrasinh F Chauhan
- Clinical Research Unit, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Soham Research Group Inc, Winnipeg, Manitoba, Canada
| | - Mê-Linh Le
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmed M Abou-Setta
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Haematology and Medical Oncology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Geert W 'tJong
- Clinical Research Unit, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,Department of Pediatrics, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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48
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Özkan H, Erdeve Ö, Kutman HGK. Turkish Neonatal Society guideline on the management of respiratory distress syndrome and surfactant treatment. Turk Arch Pediatr 2018; 53:S45-S54. [PMID: 31236018 PMCID: PMC6568291 DOI: 10.5152/turkpediatriars.2018.01806] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Respiratory distress syndrome is the leading cause of respiratory failure in preterm infants. The incidence and severity of respiratory distress syndrome are inversely related to the gestational age of the newborn. The major underlying pathophysiologic mechanisms are surfactant deficiency and anatomic, structural immaturity of the lung. Recent improvements such as antenatal steroid treatment to enhance pulmonary maturity, appropriate resuscitation facilitated by placental transfusion and immediate use of continuous positive airway pressure for alveolar recruitment, early rescue administration of surfactant, ventilation with gentler modes to minimize damage to the immature lungs, and the other supportive therapies have significantly decreased respiratory distress syndrome-related morbidity and mortality. This guideline was addressed to overview the mentioned improvements in order to standardize respiratory distress syndrome management in neonatal intensive care units in Turkey.
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Affiliation(s)
- Hasan Özkan
- Division of Neonatology, Department of Pediatrics, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Ömer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - H Gözde Kanmaz Kutman
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Zekai Tahir Burak Womens' Health Training and Research Hospital, Ankara, Turkey
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49
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Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease which develops as a result of neonatal/perinatal lung injury. It is the commonest cause of chronic lung disease in infancy and the most frequent morbidity associated with prematurity. The incidence of BPD has continued to rise despite many advances in neonatal care and this increase has been attributed to the increased survival of younger and more premature babies. There have been many advances in the care of patients with early and evolving BPD, yet there is a paucity of data regarding outpatient management of patients with established BPD. There are limited adequately-powered high-quality studies/randomized controlled trials which assess commonly used therapies such as supplemental oxygen, bronchodilators, steroids and diuretics in patients with BPD, beyond short-term effects. Further research is needed to improve our understanding of the role of currently used treatments on the long-term outcomes of patients with established BPD, post-discharge from the neonatal intensive care unit.
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Affiliation(s)
- Anita Bhandari
- Division of Pulmonary Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 11th floor Colket Building, 3501 Civic Center Boulevard, Philadelphia, PA 19446, United States.
| | - Howard Panitch
- Division of Pulmonary Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 11th floor Colket Building, 3501 Civic Center Boulevard, Philadelphia, PA 19446, United States
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50
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Abstract
Bronchopulmonary dysplasia (BPD) is a complex disorder with multiple factors implicated in its etiopathogenesis. Despite the scientific advances in the field of neonatology, the incidence of BPD has remained somewhat constant due to increased survival of extremely premature infants. Surfactant deficiency in the immature lung, exposure to invasive mechanical ventilation leading to volutrauma, barotrauma and lung inflammation are some of the critical contributing factors to the pathogenesis of BPD. Hence, strategies to prevent BPD in the postnatal period revolve around mitigation of this injury and inflammation. This article reviews the progress made in the last 5 years in the development of new preparations of surfactant, use of corticosteroids and non-invasive ventilation in the prevention of BPD. Emerging techniques of surfactant delivery through minimally invasive and non-invasive routes are also discussed.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, NYU Winthrop Hospital, 259 First Street, Mineola, NY 11501, United States
| | - Vineet Bhandari
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA 19134, United States.
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