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Duport O, Rolle VL, Guerrero G, Beuchée A, Hernández AI. Parametric analysis of an integrated cardio-respiratory model in preterm newborns during apnea. Comput Biol Med 2024; 173:108343. [PMID: 38513388 DOI: 10.1016/j.compbiomed.2024.108343] [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: 11/07/2023] [Revised: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Abstract
The analysis of the complex interactions involved in the acute physiological response to apnea-bradycardia events in preterm newborns remains a challenging task. This paper presents a novel integrated model of cardio-respiratory interactions, adapted to preterm newborns. A sensitivity analysis, based Morris' screening method, was applied to study the effects of physiological parameters on heart rate and desaturation, during the simulation of a 15-seconds apnea-bradycardia episode. The most sensitive parameters are associated with fundamental, integrative physiological mechanisms involving: (i) respiratory mechanics (intermediate airways and lung compliance), (ii) fraction of inspired oxygen, (iii) metabolic rates (oxygen consumption rate), (iv) heart rate regulation and (v) chemoreflex (gain). Results highlight the relevant influence of physiological variables, involved in preterm apnea-bradycardia events.
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Affiliation(s)
- Orlane Duport
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Virginie Le Rolle
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France.
| | - Gustavo Guerrero
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Alain Beuchée
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
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2
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Weese-Mayer DE, Di Fiore JM, Lake DE, Hibbs AM, Claure N, Qiu J, Ambalavanan N, Bancalari E, Kemp JS, Zimmet AM, Carroll JL, Martin RJ, Krahn KN, Hamvas A, Ratcliffe SJ, Krishnamurthi N, Indic P, Dormishian A, Dennery PA, Moorman JR. Maturation of cardioventilatory physiological trajectories in extremely preterm infants. Pediatr Res 2024; 95:1060-1069. [PMID: 37857848 DOI: 10.1038/s41390-023-02839-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND In extremely preterm infants, persistence of cardioventilatory events is associated with long-term morbidity. Therefore, the objective was to characterize physiologic growth curves of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants during the first few months of life. METHODS The Prematurity-Related Ventilatory Control study included 717 preterm infants <29 weeks gestation. Waveforms were downloaded from bedside monitors with a novel sharing analytics strategy utilized to run software locally, with summary data sent to the Data Coordinating Center for compilation. RESULTS Apnea, periodic breathing, and intermittent hypoxemia events rose from day 3 of life then fell to near-resolution by 8-12 weeks of age. Apnea/intermittent hypoxemia were inversely correlated with gestational age, peaking at 3-4 weeks of age. Periodic breathing was positively correlated with gestational age peaking at 31-33 weeks postmenstrual age. Females had more periodic breathing but less intermittent hypoxemia/bradycardia. White infants had more apnea/periodic breathing/intermittent hypoxemia. Infants never receiving mechanical ventilation followed similar postnatal trajectories but with less apnea and intermittent hypoxemia, and more periodic breathing. CONCLUSIONS Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. IMPACT Physiologic curves of cardiorespiratory events in extremely preterm-born infants offer (1) objective measures to assess individual patient courses and (2) guides for research into control of ventilation, biomarkers and outcomes. Presented are updated maturational trajectories of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in 717 infants born <29 weeks gestation from the multi-site NHLBI-funded Pre-Vent study. Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. Different time courses for apnea and periodic breathing suggest different maturational mechanisms.
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Affiliation(s)
- Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
| | - Douglas E Lake
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jiaxing Qiu
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James S Kemp
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Amanda M Zimmet
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Katy N Krahn
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aaron Hamvas
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Neonatology, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Narayanan Krishnamurthi
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas Tyler, Tyler, TX, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phyllis A Dennery
- Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - J Randall Moorman
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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Yee AK, Siriwardhana LS, Nixson GM, Walter LM, Wong FY, Horne RSC. Developmental consequences of short apneas and periodic breathing in preterm infants. J Perinatol 2023; 43:1420-1428. [PMID: 37558750 PMCID: PMC10615736 DOI: 10.1038/s41372-023-01748-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/12/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE We investigated the relationship between respiratory events experienced before and after hospital discharge and developmental outcomes at 6 months corrected age (CA). STUDY DESIGN Preterm infants born between 28-32 weeks gestational age (GA) were studied at 32-36 weeks postmenstrual age (PMA), 36-40 weeks PMA, 3- and 6-months CA. Percentage total sleep time (%TST) with respiratory events (isolated apneas, sequential apneas and periodic breathing (PB)) at each study was calculated. Stepwise multiple linear regressions determined significant predictors of developmental outcomes at 6 months. RESULT %TST with respiratory events at term were significant predictors of language (R2 = 0.165, β = -0.416) and motor (R2 = 0.180, β = -0.485) composite scores of the Bayley Scales of Infant Development at 6 months, independent of GA, birth weight and sex. CONCLUSIONS In clinically stable very preterm infants at term equivalent age, time spent having respiratory events, was related to a reduction in language and motor outcomes at 6 months.
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Affiliation(s)
- Alicia K Yee
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | | | - Gillian M Nixson
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Lisa M Walter
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Flora Y Wong
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Rosemary S C Horne
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.
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Varisco G, Peng Z, Kommers D, Zhan Z, Cottaar W, Andriessen P, Long X, van Pul C. Central apnea detection in premature infants using machine learning. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 226:107155. [PMID: 36215858 DOI: 10.1016/j.cmpb.2022.107155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/13/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Apnea of prematurity is one of the most common diagnosis in neonatal intensive care units. Apneas can be classified as central, obstructive or mixed. According to the current international standards, minimal fluctuations or absence of fluctuations in the chest impedance (CI) suggest a central apnea (CA). However, automatic detection of reduced CI fluctuations leads to a high number of central apnea-suspected events (CASEs), the majority being false alarms. We aim to improve automatic detection of CAs by using machine learning to optimize detection of CAs among CASEs. METHODS Using an optimized algorithm for automated detection, all CASEs were detected in a population of 10 premature infants developing late-onset sepsis and 10 age-matched control patients. CASEs were inspected by two clinical experts and annotated as CAs or rejections in two rounds of annotations. A total of 47 features were extracted from the ECG, CI and oxygen saturation signals considering four 30 s-long moving windows, from 30 s before to 15 s after the onset of each CASE, using a moving step size of 5 s. Consecutively, new CA detection models were developed based on logistic regression with elastic net penalty, random forest and support vector machines. Performance was evaluated using both leave-one-patient-out and 10-fold cross-validation considering the mean area under the receiver-operating-characteristic curve (AUROC). RESULTS The CA detection model based on logistic regression with elastic net penalty returned the highest mean AUROC when features extracted from all four time windows were included, both using leave-one-patient-out and 10-fold cross-validation (mean AUROC of 0.88 and 0.90, respectively). Feature relevance was found to be the highest for features derived from the CI. A threshold for the false positive rate in the mean receiver-operating-characteristic curve equal to 0.3 led to a high percentage of correct detections for all CAs (78.2%) and even higher for CAs followed by a bradycardia (93.4%) and CAs followed by both a bradycardia and a desaturation (95.2%), which are more critical for the well-being of premature infants. CONCLUSIONS Models based on machine learning can lead to improved CA detection with fewer false alarms.
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Affiliation(s)
- Gabriele Varisco
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands.
| | - Zheng Peng
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Deedee Kommers
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Zhuozhao Zhan
- Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Ward Cottaar
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter Andriessen
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Xi Long
- Philips Research, Eindhoven, the Netherlands; Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.
| | - Carola van Pul
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands
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Contactless radar-based breathing monitoring of premature infants in the neonatal intensive care unit. Sci Rep 2022; 12:5150. [PMID: 35338172 PMCID: PMC8956695 DOI: 10.1038/s41598-022-08836-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/03/2022] [Indexed: 01/18/2023] Open
Abstract
Vital sign monitoring systems are essential in the care of hospitalized neonates. Due to the immaturity of their organs and immune system, premature infants require continuous monitoring of their vital parameters and sensors need to be directly attached to their fragile skin. Besides mobility restrictions and stress, these sensors often cause skin irritation and may lead to pressure necrosis. In this work, we show that a contactless radar-based approach is viable for breathing monitoring in the Neonatal intensive care unit (NICU). For the first time, different scenarios common to the NICU daily routine are investigated, and the challenges of monitoring in a real clinical setup are addressed through different contributions in the signal processing framework. Rather than just discarding measurements under strong interference, we present a novel random body movement mitigation technique based on the time-frequency decomposition of the recovered signal. In addition, we propose a simple and accurate frequency estimator which explores the harmonic structure of the breathing signal. As a result, the proposed radar-based solution is able to provide reliable breathing frequency estimation, which is close to the reference cabled device values most of the time. Our findings shed light on the strengths and limitations of this technology and lay the foundation for future studies toward a completely contactless solution for vital signs monitoring.
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Efficacy and safety of mydriatic microdrops for retinopathy of prematurity screening: an external pilot crossover randomized controlled trial. J Perinatol 2022; 42:371-377. [PMID: 34654903 DOI: 10.1038/s41372-021-01229-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/08/2021] [Accepted: 10/01/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To study the efficacy and safety of mydriatic microdrops compared with standard drops for retinopathy of prematurity (ROP) screening. STUDY DESIGN Preterm infants undergoing ROP screening received microdrops and standard drops of phenylephrine 1.67% and tropicamide 0.33% in a random allocation sequence at two consecutive weekly examinations. Primary outcome was pupil diameter measured by two masked observers at 45 (T45) and 90 (T90) minutes after instillation. RESULTS Twenty-five infants were randomized. No differences observed in mean pupil diameter after either administration technique at all time points (T45 Mean Difference: -0.14; 95% Confidence Interval: -0.38, 0.09; p = 0.23). Heart rate values at T120 were lower after microdrop instillation (p = 0.046). Otherwise, adverse events did not differ after either administration technique. CONCLUSION This pilot study provides evidence of microdrops mydriasis efficacy, while justifying a full-scale trial to confirm their non-inferiority compared with standard drops and provide more data about safety. TRIAL REGISTRATION ClinicalTrials.gov: NCT04623684.
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Mammel D, Kemp J. Prematurity, the diagnosis of bronchopulmonary dysplasia, and maturation of ventilatory control. Pediatr Pulmonol 2021; 56:3533-3545. [PMID: 34042316 DOI: 10.1002/ppul.25519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022]
Abstract
Infants born before 32 weeks gestational age and receiving respiratory support at 36 weeks postmenstrual age (PMA) are diagnosed with bronchopulmonary dysplasia (BPD). This label suggests that their need for supplemental oxygen (O2 ) is primarily due to acquired dysplasia of airways and airspaces, and that the supplemental O2 is treating residual parenchymal lung disease. However, emerging evidence suggests that immature ventilatory control may also contribute to the need for supplemental O2 at 36 weeks PMA. In all newborns, maturation of ventilatory control continues ex utero and is a plastic process. Among premature infants, supplemental O2 mitigates the hypoxemic effects of delayed maturation of ventilatory control, as well as reduces the duration and frequency of periodic breathing events. Nevertheless, prematurity is associated with altered and occasionally aberrant maturation of ventilatory control. Infants born prematurely, with or without a diagnosis of BPD, are more prone to long-lasting effects of dysfunctional ventilatory control. This review addresses normal and abnormal maturation of ventilatory control and suggests how aberrant maturation complicates assigning the diagnosis of BPD. Greater awareness of the interaction between parenchymal lung disease and delayed maturation of ventilatory control is essential to understanding why a given premature infant requires and is benefitting from supplemental O2 at 36 weeks PMA.
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Affiliation(s)
- Daniel Mammel
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - James Kemp
- Department of Pediatrics, Allergy and Pulmonary Medicine, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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Nagraj VP, Lake DE, Kuhn L, Moorman JR, Fairchild KD. Central Apnea of Prematurity: Does Sex Matter? Am J Perinatol 2021; 38:1428-1434. [PMID: 32578186 DOI: 10.1055/s-0040-1713405] [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] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Apnea is common among infants in the neonatal intensive care unit (NICU). Our group previously developed an automated algorithm to quantitate central apneas with associated bradycardia and desaturation (ABDs). Sex differences in lung disease are well described in preterm infants, but the influence of sex on apnea has not been established. STUDY DESIGN This study includes infants < 34 weeks' gestation admitted to the University of Virginia NICU from 2009 to 2014 with at least 1 day of bedside monitor data available when not on mechanical ventilation. Waveform and vital sign data were analyzed using a validated algorithm to detect ABD events of low variance in chest impedance signal lasting at least 10 seconds with associated drop in heart rate to < 100 beats/minute and drop in oxygen saturation to < 80%. Male and female infants were compared for prevalence of at least one ABD event during the NICU stay, treatment with caffeine, occurrence of ABDs at each week of postmenstrual age, and number of events per day. RESULTS Of 926 infants studied (median gestational age 30 weeks, 53% male), median days of data analyzed were 19 and 22 for males and females, respectively. There was no sex difference in prevalence of at least one ABD event during the NICU stay (males 62%, females 64%, p = 0.47) or in the percentage of infants treated with caffeine (males 64%, females 67%, p = 0.40). Cumulative prevalence of ABDs from postmenstrual ages 24 to 36 weeks was comparable between sexes. Males had 18% more ABDs per day of data, but this difference was not statistically significant (p = 0.16). CONCLUSION In this large cohort of infants < 34 weeks' gestation, we did not detect a sex difference in prevalence of central ABD events. There was a nonsignificant trend toward a greater number of ABDs per day in male infants. KEY POINTS · Central apnea is pervasive among preterm infants in the NICU, but potential disparities between males and females have not been thoroughly studied.. · Identification of risk factors for central apnea can lead to improved treatment protocols.. · The rate and prevalence of central apnea events accompanied by bradycardia and desaturation does not significantly differ between male and female preterm infants..
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Affiliation(s)
| | - Douglas E Lake
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
| | - J Randall Moorman
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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Williamson M, Poorun R, Hartley C. Apnoea of Prematurity and Neurodevelopmental Outcomes: Current Understanding and Future Prospects for Research. Front Pediatr 2021; 9:755677. [PMID: 34760852 PMCID: PMC8573333 DOI: 10.3389/fped.2021.755677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Infants who are born prematurely are at significant risk of apnoea. In addition to the short-term consequences such as hypoxia, apnoea of prematurity has been associated with long-term morbidity, including poor neurodevelopmental outcomes. Clinical trials have illustrated the importance of methylxanthine drugs, in particular caffeine, in reducing the risk of long term adverse neurodevelopmental outcomes. However, the extent to which apnoea is causative of this secondary neurodevelopmental delay or is just associated in a background of other sequelae of prematurity remains unclear. In this review, we first discuss the pathophysiology of apnoea of prematurity, previous studies investigating the relationship between apnoea and neurodevelopmental delay, and treatment of apnoea with caffeine therapy. We propose a need for better methods of measuring apnoea, along with improved understanding of the neonatal brain's response to consequent hypoxia. Only then can we start to disentangle the effects of apnoea on neurodevelopment in preterm infants. Moreover, by better identifying those infants who are at risk of apnoea, and neurodevelopmental delay, we can work toward a risk stratification system for these infants that is clinically actionable, for example, with doses of caffeine tailored to the individual. Optimising treatment of apnoea for individual infants will improve neonatal care and long-term outcomes for this population.
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Affiliation(s)
- Max Williamson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ravi Poorun
- Department of Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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Guerrero G, Le Rolle V, Loiodice C, Amblard A, Pepin JL, Hernandez A. Modeling patient-specific desaturation patterns in sleep apnea. IEEE Trans Biomed Eng 2021; 69:1502-1511. [PMID: 34665719 DOI: 10.1109/tbme.2021.3121170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The physiological mechanisms involved in cardio-respiratory responses to sleep apnea events are not yet fully elucidated. A model-based approach is proposed to analyse the acute desaturation response to obstructive apneas. METHODS An integrated model of cardio-respiratory interactions was proposed and parameters were identified, using an evolutionary algorithm, on a database composed of 107 obstructive apneas acquired from 10 patients (HYPNOS clinical study). Unsupervised clustering was applied to the identified parameters in order to characterize the phenotype of each response to obstructive apneas. RESULTS A close match was observed between simulated oxygen saturation (SaO2) and experimental SaO2 in all identifications (median RMSE = 1.3892%). Two clusters of parameters, associated with different dynamics related to sleep apnea and periodic breathing were obtained. CONCLUSION AND SIGNIFICANCE The proposed patient and event-specific model-based analysis provides understanding on specific desaturation patterns, consequent to apnea events, with potential applications for personalized diagnosis and treatment.
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Parametric Analysis of an Integrated Model of Cardio-respiratory Interactions in Adults in the Context of Obstructive Sleep Apnea. Ann Biomed Eng 2021; 49:3374-3387. [PMID: 34467512 DOI: 10.1007/s10439-021-02828-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
An original integrated model of cardio-respiratory interactions is presented in this paper with the objective of studying the acute physiological responses evoked by obstructive sleep apnea events in adults. A comprehensive sensitivity analysis of the model is proposed during the simulation of a 20 s obstructive apnea episode using the Morris' screening method and local sensitivity analysis. The more relevant parameters are related to the following mechanisms of the physiology: (i) the fraction of oxygen in inspired air, (ii) metabolic rates (oxygen consumption rate, CO2 production rate); (iii) chemoreflex (gains and time constants) (iv) respiratory mechanics (lung compliance and unstressed volume of air in the alveoli). These results highlight significant physiological variables that may be particularly useful for the development of novel diagnostic and therapeutic strategies, integrating a virtual patient approach.
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Tenorio-Lopes L, Kinkead R. Sex-Specific Effects of Stress on Respiratory Control: Plasticity, Adaptation, and Dysfunction. Compr Physiol 2021; 11:2097-2134. [PMID: 34107062 DOI: 10.1002/cphy.c200022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As our understanding of respiratory control evolves, we appreciate how the basic neurobiological principles of plasticity discovered in other systems shape the development and function of the respiratory control system. While breathing is a robust homeostatic function, there is growing evidence that stress disrupts respiratory control in ways that predispose to disease. Neonatal stress (in the form of maternal separation) affects "classical" respiratory control structures such as the peripheral O2 sensors (carotid bodies) and the medulla (e.g., nucleus of the solitary tract). Furthermore, early life stress disrupts the paraventricular nucleus of the hypothalamus (PVH), a structure that has emerged as a primary determinant of the intensity of the ventilatory response to hypoxia. Although underestimated, the PVH's influence on respiratory function is a logical extension of the hypothalamic control of metabolic demand and supply. In this article, we review the functional and anatomical links between the stress neuroendocrine axis and the medullary network regulating breathing. We then present the persistent and sex-specific effects of neonatal stress on respiratory control in adult rats. The similarities between the respiratory phenotype of stressed rats and clinical manifestations of respiratory control disorders such as sleep-disordered breathing and panic attacks are remarkable. These observations are in line with the scientific consensus that the origins of adult disease are often found among developmental and biological disruptions occurring during early life. These observations bring a different perspective on the structural hierarchy of respiratory homeostasis and point to new directions in our understanding of the etiology of respiratory control disorders. © 2021 American Physiological Society. Compr Physiol 11:1-38, 2021.
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Affiliation(s)
- Luana Tenorio-Lopes
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, The University of Calgary, Calgary, Alberta, Canada
| | - Richard Kinkead
- Département de Pédiatrie, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
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Doyen M, Hernández AI, Flamant C, Defontaine A, Favrais G, Altuve M, Laviolle B, Beuchée A, Carrault G, Pladys P. Early bradycardia detection and therapeutic interventions in preterm infant monitoring. Sci Rep 2021; 11:10486. [PMID: 34006917 PMCID: PMC8131388 DOI: 10.1038/s41598-021-89468-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 04/13/2021] [Indexed: 11/09/2022] Open
Abstract
In very preterm infants, cardio-respiratory events and associated hypoxemia occurring during early postnatal life have been associated with risks of retinopathy, growth alteration and neurodevelopment impairment. These events are commonly detected by continuous cardio-respiratory monitoring in neonatal intensive care units (NICU), through the associated bradycardia. NICU nurse interventions are mainly triggered by these alarms. In this work, we acquired data from 52 preterm infants during NICU monitoring, in order to propose an early bradycardia detector which is based on a decentralized fusion of three detectors. The main objective is to improve automatic detection under real-life conditions without altering performance with respect to that of a monitor commonly used in NICU. We used heart rate lower than 80 bpm during at least 10 sec to define bradycardia. With this definition we observed a high rate of false alarms (64%) in real-life and that 29% of the relevant alarms were not followed by manual interventions. Concerning the proposed detection method, when compared to current monitors, it provided a significant decrease of the detection delay of 2.9 seconds, without alteration of the sensitivity (97.6% vs 95.2%) and false alarm rate (63.7% vs 64.1%). We expect that such an early detection will improve the response of the newborn to the intervention and allow for the development of new automatic therapeutic strategies which could complement manual intervention and decrease the sepsis risk.
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Affiliation(s)
- Matthieu Doyen
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, 35000, Rennes, France
| | | | - Cyril Flamant
- Univ-Nantes, CHU Nantes, Inserm, CIC 0004, F-44000, Nantes, France
| | - Antoine Defontaine
- Polyclinic Quimper, Dpt Thoracic Surgery, Campus de Beaulieu, Bat 22, F-29000, Quimper, France
| | - Géraldine Favrais
- Univ-Tours, CHU Tours, Inserm, Imagerie et Cerveau UMR930, F-37000, Tours, France
| | - Miguel Altuve
- Faculty of Electrical and Electronic Engineering, Pontifical Bolivarian University, Bucaramanga, Colombia
| | - Bruno Laviolle
- Univ-Rennes, CHU Rennes, Inserm, CIC 1414, F-35000, Rennes, France
| | - Alain Beuchée
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, 35000, Rennes, France
| | - Guy Carrault
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, 35000, Rennes, France
| | - Patrick Pladys
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, 35000, Rennes, France
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14
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Immature control of breathing and apnea of prematurity: the known and unknown. J Perinatol 2021; 41:2111-2123. [PMID: 33712716 PMCID: PMC7952819 DOI: 10.1038/s41372-021-01010-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
This narrative review provides a broad perspective on immature control of breathing, which is universal in infants born premature. The degree of immaturity and severity of clinical symptoms are inversely correlated with gestational age. This immaturity presents as prolonged apneas with associated bradycardia or desaturation, or brief respiratory pauses, periodic breathing, and intermittent hypoxia. These manifestations are encompassed within the clinical diagnosis of apnea of prematurity, but there is no consensus on minimum criteria required for diagnosis. Common treatment strategies include caffeine and noninvasive respiratory support, but other therapies have also been advocated with varying effectiveness. There is considerable variability in when and how to initiate and discontinue treatment. There are significant knowledge gaps regarding effective strategies to quantify the severity of clinical manifestations of immature breathing, which prevent us from better understanding the long-term potential adverse outcomes, including neurodevelopment and sudden unexpected infant death.
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15
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Montazeri Ghahjaverestan N, Shamsollahi MB, Ge D, Beuchée A, Hernández AI. Apnea bradycardia detection based on new coupled hidden semi Markov model. Med Biol Eng Comput 2020; 59:1-11. [DOI: 10.1007/s11517-020-02277-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
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16
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Lavanga M, Bollen B, Jansen K, Ortibus E, Naulaers G, Van Huffel S, Caicedo A. A Bradycardia-Based Stress Calculator for the Neonatal Intensive Care Unit: A Multisystem Approach. Front Physiol 2020; 11:741. [PMID: 32670096 PMCID: PMC7332774 DOI: 10.3389/fphys.2020.00741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
Early life stress in the neonatal intensive care unit (NICU) can predispose premature infants to adverse health outcomes and neurodevelopment delays. Hands-on-care and procedural pain might induce apneas, hypoxic events, and sleep-wake disturbances, which can ultimately impact maturation, but a data-driven method based on physiological fingerprints to quantify early-life stress does not exist. This study aims to provide an automatic stress detector by investigating the relationship between bradycardias, hypoxic events and perinatal stress in NICU patients. EEG, ECG, and SpO 2 were recorded from 136 patients for at least 3 h in three different monitoring groups. In these subjects, the stress burden was assessed using the Leuven Pain Scale. Different subspace linear discriminant analysis models were designed to detect the presence or the absence of stress based on information in each bradycardic spell. The classification shows an area under the curve in the range [0.80-0.96] and a kappa score in the range [0.41-0.80]. The results suggest that stress seems to increase SpO 2 desaturations and EEG regularity as well as the interaction between the cardiovascular and neurological system. It might be possible that stress load enhances the reaction to respiratory abnormalities, which could ultimately impact the neurological and behavioral development.
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Affiliation(s)
- Mario Lavanga
- Division STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Bieke Bollen
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Katrien Jansen
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Els Ortibus
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Sabine Van Huffel
- Division STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Applied Mathematics and Computer Science, School of Engineering, Science and Technology, Universidad del Rosario, Bogotá, Colombia
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17
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van der Heijden ME, Zoghbi HY. Development of the brainstem respiratory circuit. WILEY INTERDISCIPLINARY REVIEWS-DEVELOPMENTAL BIOLOGY 2019; 9:e366. [PMID: 31816185 DOI: 10.1002/wdev.366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/01/2023]
Abstract
The respiratory circuit is comprised of over a dozen functionally and anatomically segregated brainstem nuclei that work together to control respiratory rhythms. These respiratory rhythms emerge prenatally but only acquire vital importance at birth, which is the first time the respiratory circuit faces the sole responsibility for O2 /CO2 homeostasis. Hence, the respiratory circuit has little room for trial-and-error-dependent fine tuning and relies on a detailed genetic blueprint for development. This blueprint is provided by transcription factors that have specific spatiotemporal expression patterns along the rostral-caudal or dorsal-ventral axis of the developing brainstem, in proliferating precursor cells and postmitotic neurons. Studying these transcription factors in mice has provided key insights into the functional segregation of respiratory control and the vital importance of specific respiratory nuclei. Many studies converge on just two respiratory nuclei that each have rhythmogenic properties during the prenatal period: the preBötzinger complex (preBötC) and retrotrapezoid nucleus/parafacial nucleus (RTN/pF). Here, we discuss the transcriptional regulation that guides the development of these nuclei. We also summarize evidence showing that normal preBötC development is necessary for neonatal survival, and that neither the preBötC nor the RTN/pF alone is sufficient to sustain normal postnatal respiratory rhythms. Last, we highlight several studies that use intersectional genetics to assess the necessity of transcription factors only in subregions of their expression domain. These studies independently demonstrate that lack of RTN/pF neurons weakens the respiratory circuit, yet these neurons are not necessary for neonatal survival because developmentally related populations can compensate for abnormal RTN/pF function at birth. This article is categorized under: Nervous System Development > Vertebrates: Regional Development.
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Affiliation(s)
- Meike E van der Heijden
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas.,Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, Texas
| | - Huda Y Zoghbi
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas.,Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, Texas.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Howard Hughes Medical Institute, Baylor College of Medicine, Houston, Texas
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18
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Heart rate fluctuation after birth predicts subsequent cardiorespiratory stability in preterm infants. Pediatr Res 2019; 86:348-354. [PMID: 31086292 DOI: 10.1038/s41390-019-0424-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/27/2019] [Accepted: 04/18/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiorespiratory stability of preterm infants is a prerequisite for discharge from the neonatal intensive care unit (NICU) but very difficult to predict. We aimed to assess whether characterizing heart rate fluctuation (HRF) within the first days of life has prognostic utility. METHODS We conducted a prospective cohort study in 90 preterm infants using a previously validated surface diaphragmatic electromyography (sEMG) method to derive interbeat intervals. We characterized HRF by time series parameters including sample entropy (SampEn) and scaling exponent alpha (ScalExp) obtained from daily 3-h measurements. Data were analyzed by multivariable, multilevel linear regression. RESULTS We obtained acceptable raw data from 309/330 sEMG measurements in 76/90 infants born at a mean (range) of 30.2 (24.7-34.0) weeks gestation. We found a significant negative association of SampEn with duration of respiratory support (R2 = 0.53, p < 0.001) and corrected age at discontinuation of caffeine therapy (R2 = 0.35, p < 0.001) after adjusting for sex, gestational age, birth weight z-score, and sepsis. CONCLUSIONS Baseline SampEn calculated over the first 5 days of life carries prognostic utility for an estimation of subsequent respiratory support and pre-discharge cardiorespiratory stability in preterm infants, both important for planning of treatment and utilization of health care resources.
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19
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Daftary AS, Jalou HE, Shively L, Slaven JE, Davis SD. Polysomnography Reference Values in Healthy Newborns. J Clin Sleep Med 2019; 15:437-443. [PMID: 30853051 DOI: 10.5664/jcsm.7670] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/12/2018] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVES Polysomnography (PSG) is increasingly used in the assessment of infants. Newborn PSG reference values based on recent standardization are not available. This study provides reference values for PSG variables in healthy newborn infants. METHODS Cross-sectional study of normal term newborn infants using standardized PSG collection and American Academy of Sleep Medicine interpretation criteria. RESULTS Thirty infants born between 37 and 42 weeks gestation underwent PSG testing before 30 days of age (mean 19.6 days). The infants had a mean sleep efficiency of 71% with average proportions of transitional, NREM and REM sleep estimated at 16.1%, 43.3% and 40.6% respectively. Mean arousal index was 14.7 events/h with respiratory arousal index of 1.2 events/h. Mean apnea-hypopnea index (AHI) was 14.9 events/h. Central, obstructive, and mixed apnea indices were 5.4, 2.3, and 1.2 events/h respectively. Mean oxygen saturation in sleep was 97.9% with a nadir of 84.4%. Mean end tidal CO2 was 35.4 mmHg with an average of 6.2% of sleep time spent above end-tidal CO2 45 mmHg and 0.6% above 50 mmHg. CONCLUSIONS The sleep efficiency was significantly lower and the AHI was significantly higher compared to healthy children older than 1 year. The AHI was also higher than reported in healthy infants older than 1 month. These findings suggest current severity classifications of sleep apnea may not apply to newborn infants.
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Affiliation(s)
- Ameet S Daftary
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Hasnaa E Jalou
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Lori Shively
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephanie D Davis
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
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20
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Hasenstab KA, Nawaz S, Lang IM, Shaker R, Jadcherla SR. Pharyngoesophageal and cardiorespiratory interactions: potential implications for premature infants at risk of clinically significant cardiorespiratory events. Am J Physiol Gastrointest Liver Physiol 2019; 316:G304-G312. [PMID: 30543445 PMCID: PMC6397335 DOI: 10.1152/ajpgi.00303.2018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aims of this study were to 1) examine pharyngoesophageal and cardiorespiratory responses to provoking pharyngeal stimuli, and 2) to determine potential contributory factors impacting heart rate (HR) changes to provide insight into cardiorespiratory events occurring in preterm infants. Forty-eight neonates (19 females and 29 males, born at 27.7 ± 0.5 wk; mean ± SE) pending discharge on full oral feeds were studied at 38.7 ± 0.2 wk postmenstrual age using concurrent pharyngoesophageal manometry, electrocardiography, respiratory inductance plethysmography, and nasal airflow thermistor. Pharyngoesophageal and cardiorespiratory responses (prevalence, latency, and duration) were quantified upon abrupt pharyngeal water stimuli (0.1, 0.3, and 0.5 ml in triplicate). Mixed linear models and generalized estimating equations were used for comparisons between HR changes. Contributory factors included stimulus characteristics and subject characteristics. Of 338 pharyngeal stimuli administered, HR increased in 23 (7%), decreased in 108 (32%), and remained stable in 207 (61%) neonates. HR decrease resulted in repetitive swallowing, increased respiratory-rhythm disturbance, and decreased esophageal propagation rates (all, P < 0.05). HR responses were related to stimulus volume, stimulus flow rate, and extreme prematurity (all, P < 0.05). In preterm infants, HR remains stable in a majority of pharyngeal provocations. HR decrease, due to pharyngeal stimulation, is related to aberrant pharyngoesophageal motility and respiratory dysregulation and is magnified by prematurity. We infer that the observed aberrant responses across digestive, respiratory, and cardiovascular systems are related to maladaptive maturation of the parasympathetic nervous system. These aberrant responses may provide diagnostic clues for risk stratification of infants with troublesome cardiorespiratory events and swallowing difficulty. NEW & NOTEWORTHY Cardiorespiratory rhythms concurrent with pharyngeal, upper esophageal sphincter, and esophageal body responses were examined upon pharyngeal provocation in preterm-born infants who were studied at full-term maturation. Decreased heart rate (HR) was associated with extreme preterm birth and stimulus flow/volume. With HR decrease responses, aerodigestive reflex abnormalities were present, characterized by prolonged respiratory rhythm disturbance, repetitive multiple swallowing, and poor esophageal propagation. Promoting esophageal peristalsis may be a potential therapeutic target.
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Affiliation(s)
- Kathryn A. Hasenstab
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Saira Nawaz
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Ivan M. Lang
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sudarshan R. Jadcherla
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,4Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
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21
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Gottlob S, Gille C, Poets CF. Randomized Controlled Trial on the Effects of Morning versus Evening Primary Vaccination on Episodes of Hypoxemia and Bradycardia in Very Preterm Infants. Neonatology 2019; 116:315-320. [PMID: 31394525 DOI: 10.1159/000501338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hypoxemia and bradycardia occur frequently in preterm infants, but are incompletely understood. They are more prevalent during infections and following immunization. Data on adults suggested an increased immune response if subjects slept following vaccination, suggesting an interaction between circadian rhythm and the immune system. Whether this holds true for preterm infants with their less well-established circadian rhythm is unclear. OBJECTIVE Do infants born at 26-30 weeks' gestation and having received their first routine hexavalent vaccination in the morning have a lower cardiorespiratory event rate (CER) after vaccination than those receiving it in the evening? METHODS Twenty-six infants were randomized to an evening versus morning vaccination group in a pilot and main study with 10 and 16 participants, respectively. Pulse oximeter saturation, actigraphy, and rectal temperature were obtained for 24 h before and after vaccination. Blood samples for vaccination titers were taken before vaccination and during a follow-up examination in our outpatient clinic; another blood sample was taken 24 h after vaccination to determine inflammatory markers. RESULTS Vaccination led to an increase in CER in both groups, but there was no difference in CER between the morning and evening groups. Vaccination titers for Bordetella pertussis were increased in both groups, with no difference in inflammatory markers 24 h after vaccination. Body temperature increased in both groups after vaccination. Participants in the evening group slept longer after vaccination. CONCLUSIONS We did not identify a difference in CER between morning and evening vaccination but could confirm increased body temperatures and vaccination titers following vaccination.
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Affiliation(s)
- Stefan Gottlob
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
| | - Christian Gille
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital, Tübingen, Germany,
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22
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Cramer SJE, Dekker J, Dankelman J, Pauws SC, Hooper SB, Te Pas AB. Effect of Tactile Stimulation on Termination and Prevention of Apnea of Prematurity: A Systematic Review. Front Pediatr 2018; 6:45. [PMID: 29552548 PMCID: PMC5840648 DOI: 10.3389/fped.2018.00045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 02/15/2018] [Indexed: 11/16/2022] Open
Abstract
Apnea of prematurity (AOP) is one of the most common diagnoses in preterm infants. Severe and recurrent apneas are associated with cerebral injury and adverse neurodevelopmental outcome. Despite pharmacotherapy and respiratory support to prevent apneas, a proportion of infants continue to have apneas and often need tactile stimulation, mask, and bag ventilation and/or extra oxygen. The duration of the apnea and the concomitant hypoxia and bradycardia depends on the response time of the nurse. We systematically reviewed the literature with the aim of providing an overview of what is known about the effect of manual and mechanical tactile stimulation on AOP. Tactile stimulation, manual or mechanical, has been shown to shorten the duration of apnea, hypoxia, and or bradycardia or even prevent an apnea. Automated stimulation, using closed-loop pulsating or vibrating systems, has been shown to be effective in terminating apneas, but data are scarce. Several studies used continuous mechanical stimulation, with pulsating, vibrating, or oscillating stimuli, to prevent apneas, but the reported effect varied. More studies are needed to confirm whether automated stimulation using a closed loop is more effective than manual stimulation, how and where the automated stimulation should be performed and the potential side effects.
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Affiliation(s)
- Sophie J E Cramer
- Department of Instrumental Affairs, Leiden University Medical Center, Leiden, Netherlands.,Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny Dankelman
- Department of Biomedical Engineering, Delft University of Technology, Delft, Netherlands
| | - Steffen C Pauws
- Tilburg center for Cognition and Communication (TiCC), Tilburg University, Tilburg, Netherlands
| | - Stuart B Hooper
- The Ritchie Center, MIMR-PHI Institute of Medical Research, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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Gauda EB, Master Z. Contribution of relative leptin and adiponectin deficiencies in premature infants to chronic intermittent hypoxia: Exploring a new hypothesis. Respir Physiol Neurobiol 2017; 256:119-127. [PMID: 29246449 DOI: 10.1016/j.resp.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/08/2017] [Accepted: 12/06/2017] [Indexed: 12/15/2022]
Abstract
Chronic intermittent hypoxia (CIH) occurs frequently in premature infants who have apnea of prematurity. Immaturity of the respiratory network from low central respiratory drive and the greater contribution of the carotid body on baseline breathing leads to respiratory instability in premature infants presenting as apnea and periodic breathing. During the 2nd week after birth, the smallest and the youngest premature infants have increased frequency of apnea and periodic breathing and associated oxygen desaturations that can persist for weeks after birth. CIH increases the production of reactive oxygen species that causes tissue damage. Premature infants have decreased capacity to scavenge reactive oxygen species. Oxidative injury is the cause of many of the co-morbidities that are seen in premature infants. In this review we discuss who low fat mass and the resulting relative deficiencies in leptin and adiponectin could contribute to the increase frequency of oxygen desaturations that occurs days after birth in the smallest and youngest premature infants. Leptin is a central respiratory stimulant and adiponectin protects the lung from vascular leak, oxidative injury and vascular remodeling.
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Affiliation(s)
- Estelle B Gauda
- The Hospital for Sick Children, Division of Neonatology, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada.
| | - Zankhana Master
- Department of Pediatrics, Division of Neonatology, University of Missouri, Columbia, MO 65211, United States.
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24
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Rousseau JP, Tenorio-Lopes L, Baldy C, Janes TA, Fournier S, Kinkead R. On the origins of sex-based differences in respiratory disorders: Lessons and hypotheses from stress neuroendocrinology in developing rats. Respir Physiol Neurobiol 2017; 245:105-121. [DOI: 10.1016/j.resp.2017.03.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/28/2017] [Accepted: 03/31/2017] [Indexed: 12/31/2022]
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25
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Maloney PR, Murphy ME, Sullan MJ, Van Abel KM, Cofer SA, Cheville JC, Wetjen NM. Clinical and surgical management of a congenital Type II split cord malformation presenting with progressive cranial neuropathies: case report. J Neurosurg Pediatr 2017; 19:349-353. [PMID: 28009225 DOI: 10.3171/2016.9.peds15661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Split cord malformation (SCM) is a rare abnormality of notochord development. The majority of cases occur in the thoracolumbar region, with more than 30 cases of cervical SCM reported. The clinical impact of SCMs involving the cervical cord is therefore largely unknown. In addition, the concomitant finding of brainstem involvement is presumably incompatible with life in the majority of patients, resulting in a paucity of data regarding this clinical scenario. In this paper the authors present the first case, to their knowledge, of an incomplete cervical SCM involving the brainstem and discuss its clinical impact, diagnosis, and management.
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Affiliation(s)
| | | | | | | | | | - John C Cheville
- Pathology, Mayo Clinic School of Medicine, Rochester, Minnesota
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26
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Tenorio-Lopes L, Baldy C, Jochmans-Lemoine A, Mercier O, Pothier-Piccinin O, Seaborn T, Joseph V, Marc I, Kinkead R. Consequences of maternal omega-3 polyunsaturated fatty acid supplementation on respiratory function in rat pups. J Physiol 2016; 595:1637-1655. [PMID: 27861919 DOI: 10.1113/jp273471] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/04/2016] [Indexed: 01/22/2023] Open
Abstract
KEY POINTS Incomplete development of the neural circuits that control breathing contributes to respiratory disorders in pre-term infants. Manifestations include respiratory instability, prolonged apnoeas and poor ventilatory responses to stimuli. Based on evidence suggesting that omega-3 polyunsaturated fatty acids (n-3 PUFA) improves brain development, we determined whether n-3 PUFA supplementation (via the maternal diet) improves respiratory function in 10-11-day-old rat pups. n-3 PUFA treatment prolonged apnoea duration but augmented the relative pulmonary surface area and the ventilatory response to hypoxia. During hypoxia, the drop in body temperature measured in treated pups was 1 °C less than in controls. n-3 PUFA treatment also reduced microglia cell density in the brainstem. Although heterogeneous, the results obtained in rat pups constitute a proof of concept that n-3 PUFA supplementation can have positive effects on neonatal respiration. This includes a more sustained hypoxic ventilatory response and a decreased respiratory inhibition during laryngeal chemoreflex. ABSTRACT Most pre-term infants present respiratory instabilities and apnoeas as a result of incomplete development of the neural circuits that control breathing. Because omega-3 polyunsaturated fatty acids (n-3 PUFA) benefit brain development, we hypothesized that n-3 PUFA supplementation (via the maternal diet) improves respiratory function in rat pups. Pups received n-3 PUFA supplementation from an enriched diet (13 g kg-1 of n-3 PUFA) administered to the mother from birth until the experiments were performed (postnatal days 10-11). Controls received a standard diet (0.3 g kg-1 of n-3 PUFA). Breathing was measured in intact pups at rest and during hypoxia (FiO2 = 0.12; 20 min) using whole body plethysmography. The duration of apnoeas induced by stimulating the laryngeal chemoreflex (LCR) was measured under anaesthesia. Lung morphology was compared between groups. Maternal n-3 PUFA supplementation effectively raised n-3 PUFA levels above control levels both in the blood and brainstem of pups. In intact, resting pups, n-3 PUFA increased the frequency and duration of apnoeas, especially in females. During hypoxia, n-3 PUFA supplemented pups hyperventilated 23% more than controls; their anapyrexic response was 1 °C less than controls. In anaesthetized pups, n-3 PUFA shortened the duration of LCR-induced apnoeas by 32%. The relative pulmonary surface area of n-3 PUFA supplemented pups was 12% higher than controls. Although n-3 PUFA supplementation augments apnoeas, there is no clear evidence of deleterious consequences on these pups. Based on the improved lung architecture and responses to respiratory challenges, this neonatal treatment appears to be beneficial to the offspring. However, further experiments are necessary to establish its overall safety.
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Affiliation(s)
- Luana Tenorio-Lopes
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Cécile Baldy
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | | | - Océane Mercier
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Olivier Pothier-Piccinin
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Tommy Seaborn
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Vincent Joseph
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Isabelle Marc
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Richard Kinkead
- Department of Pediatrics, Université Laval, Centre de Recherche du CHU de Québec, Québec, QC, Canada
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Automated control of inspired oxygen for preterm infants: What we have and what we need. Biomed Signal Process Control 2016. [DOI: 10.1016/j.bspc.2016.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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de Waal K, Phad N, Collins N, Boyle A. Myocardial function during bradycardia events in preterm infants. Early Hum Dev 2016; 98:17-21. [PMID: 27351349 DOI: 10.1016/j.earlhumdev.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/11/2016] [Accepted: 05/12/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transient bradycardia episodes are common in preterm infants and often secondary to apnea. Decreased ventilation with resultant hypoxemia is believed to be the predominant mechanism. Sudden bradycardias without apnea are also reported, possibly due to vagal stimulation. Point of care ultrasound is used to diagnose and follow cardiovascular complications in preterm infants. Inadvertently, the operator would sometimes capture bradycardia events. This study reports on left ventricular function during such events. METHODS We retrospectively reviewed our cardiac ultrasound database for bradycardia events. Apical four or three chamber images before, during and after a bradycardia event were analysed with speckle tracking software which provides systolic and diastolic parameters of myocardial motion, deformation and volume. RESULTS Over a 2year period, 15 bradycardia events were noted in 14 patients with a median gestational age of 26weeks (range 23 to 29). Heart rate decreased by an average of 43% (171/min to 98/min). Myocardial velocity and longitudinal strain rate during the atrial component of diastole were reduced during bradycardia. Longitudinal strain during systole was increased and radial deformation was unchanged. Ventricular volumes and ejection fraction did not change. Most parameters returned to baseline values after the event. Longitudinal systolic strain rate remained lower and stroke volume was 12% higher compared to baseline. CONCLUSION Parameters of systolic contractility and stroke volume were maintained and parameters of atrial contractility were reduced during mild to moderate bradycardia in preterm infants. Bradycardia reduces total cardiac output with a compensatory increase detected following the event.
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Affiliation(s)
- Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia.
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Nick Collins
- Department of Cardiology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Boyle
- Department of Cardiology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
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29
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Montazeri Ghahjaverestan N, Masoudi S, Shamsollahi MB, Beuchee A, Pladys P, Ge D, Hernandez AI. Coupled Hidden Markov Model-Based Method for Apnea Bradycardia Detection. IEEE J Biomed Health Inform 2016; 20:527-38. [DOI: 10.1109/jbhi.2015.2405075] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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30
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den Boer SL, Joosten KFM, van den Berg S, Backx APCM, Tanke RB, du Marchie Sarvaas GJ, Helbing WA, Rammeloo LAJ, ten Harkel ADJ, van Iperen GG, Dalinghaus M. Prospective Evaluation of Sleep Apnea as Manifestation of Heart Failure in Children. Pediatr Cardiol 2016; 37:248-54. [PMID: 26474863 PMCID: PMC4770058 DOI: 10.1007/s00246-015-1269-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/09/2015] [Indexed: 11/23/2022]
Abstract
In adults with heart failure, central sleep apnea (CSA), often manifested as Cheyne-Stokes respiration, is common, and has been associated with adverse outcome. Heart failure in children is commonly caused by dilated cardiomyopathy (DCM). It is unknown whether children with heart failure secondary to DCM have CSA, and whether CSA is related to the severity of heart failure. In this prospective observational study, 37 patients (<18 year) with heart failure secondary to DCM were included. They underwent polysomnography, clinical and laboratory evaluation and echocardiographic assessment. After a median follow-up time of 2 years, eight patients underwent heart transplantation. CSA (apnea-hypopnea index [AHI] ≥1) was found in 19 % of the patients. AHI ranged from 1.2 to 4.5/h. The occurrence of CSA was not related to the severity of heart failure. Three older patients showed a breathing pattern mimicking Cheyne-Stokes respiration, two of whom required heart transplantation. CSA was found in 19 % of the children with heart failure secondary to DCM. No relation was found with the severity of heart failure. In a small subset of children with severe DCM, a pattern mimicking Cheyne-Stokes respiration was registered.
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Affiliation(s)
- Susanna L. den Boer
- Department of Pediatrics, Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, Dr. Molewaterplein 60, Room Sp-2433, 3000 CB Rotterdam, The Netherlands
| | - Koen F. M. Joosten
- Department of Pediatrics, Pediatric Intensive Care, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sandra van den Berg
- Department of Pediatrics, Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Ad P. C. M. Backx
- Department of Pediatrics, Division of Pediatric Cardiology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Ronald B. Tanke
- Department of Pediatrics, Division of Pediatric Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gideon J. du Marchie Sarvaas
- Department of Pediatrics, Division of Pediatric Cardiology, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Willem A. Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, Dr. Molewaterplein 60, Room Sp-2433, 3000 CB Rotterdam, The Netherlands
| | - Lukas A. J. Rammeloo
- Department of Pediatrics, Division of Pediatric Cardiology, Free University Medical Center, Amsterdam, The Netherlands
| | - Arend D. J. ten Harkel
- Department of Pediatrics, Division of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gabriëlle G. van Iperen
- Department of Pediatrics, Division of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Dalinghaus
- Department of Pediatrics, Division of Pediatric Cardiology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, Dr. Molewaterplein 60, Room Sp-2433, 3000 CB, Rotterdam, The Netherlands.
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Mohr MA, Fairchild KD, Patel M, Sinkin RA, Clark MT, Moorman JR, Lake DE, Kattwinkel J, Delos JB. Quantification of periodic breathing in premature infants. Physiol Meas 2015; 36:1415-27. [PMID: 26012526 DOI: 10.1088/0967-3334/36/7/1415] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Periodic breathing (PB), regular cycles of short apneic pauses and breaths, is common in newborn infants. To characterize normal and potentially pathologic PB, we used our automated apnea detection system and developed a novel method for quantifying PB. We identified a preterm infant who died of sudden infant death syndrome (SIDS) and who, on review of her breathing pattern while in the neonatal intensive care unit (NICU), had exaggerated PB.We analyzed the chest impedance signal for short apneic pauses and developed a wavelet transform method to identify repetitive 10-40 second cycles of apnea/breathing. Clinical validation was performed to distinguish PB from apnea clusters and determine the wavelet coefficient cutoff having optimum diagnostic utility. We applied this method to analyze the chest impedance signals throughout the entire NICU stays of all 70 infants born at 32 weeks' gestation admitted over a two-and-a-half year period. This group includes an infant who died of SIDS and her twin.For infants of 32 weeks' gestation, the fraction of time spent in PB peaks 7-14 d after birth at 6.5%. During that time the infant that died of SIDS spent 40% of each day in PB and her twin spent 15% of each day in PB.This wavelet transform method allows quantification of normal and potentially pathologic PB in NICU patients.
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Affiliation(s)
- Mary A Mohr
- Department of Physics, College of William and Mary, Williamsburg, VA 23187-8795, USA
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32
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Poets CF. Intermittent hypoxemia/bradycardia and the developing brain: how much is too much? Commentary on M.B. Schmid et al.: Cerebral oxygenation during intermittent hypoxemia and bradycardia in preterm infants (Neonatology 2015;107:137-146). Neonatology 2015; 107:147-9. [PMID: 25531535 DOI: 10.1159/000369775] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/10/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Christian F Poets
- Department of Neonatology, Tuebingen University Hospital, Tuebingen, Germany
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Gizzi C, Montecchia F, Panetta V, Castellano C, Mariani C, Campelli M, Papoff P, Moretti C, Agostino R. Is synchronised NIPPV more effective than NIPPV and NCPAP in treating apnoea of prematurity (AOP)? A randomised cross-over trial. Arch Dis Child Fetal Neonatal Ed 2015; 100:F17-23. [PMID: 25318667 DOI: 10.1136/archdischild-2013-305892] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Apnoea, desaturations and bradycardias are common problems in preterm infants which can be treated with nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV). It is unclear whether synchronised NIPPV (SNIPPV) would be even more effective. OBJECTIVE To assess the effects of flow-SNIPPV, NIPPV and NCPAP on the rate of desaturations and bradycardias in preterm infants and, secondarily, to evaluate their influence on pattern of breathing and gas exchange. PATIENTS AND METHODS Nineteen infants (mean gestational age at study 30 weeks, 9 boys) with apnoeic spells were enrolled in a randomised controlled trial with a cross-over design. They received flow-SNIPPV, NIPPV and NCPAP for 4 h each. All modes were provided by a nasal conventional ventilator able to provide synchronisation by a pneumotachograph. The primary outcome was the event rate of desaturations (≤80% arterial oxygen saturation) and bradycardias (≤80 bpm) per hour, obtained from cardiorespiratory recordings. The incidence of central apnoeas (≥10 s) as well as baseline heart rate, FiO2, SpO2, transcutaneous blood gases and respiratory rate were also evaluated. RESULTS The median event rate per hour during flow-SNIPPV, NIPPV and NCPAP was 2.9, 6.1 and 5.9, respectively (p<0.001 and 0.009, compared with flow-SNIPPV). Central apnoeas per hour were 2.4, 6.3 and 5.4, respectively (p=0.001, for both compared with flow-SNIPPV), while no differences in any other parameter studied were recorded. CONCLUSIONS Flow-SNIPPV seems more effective than NIPPV and NCPAP in reducing the incidence of desaturations, bradycardias and central apnoea episodes in preterm infants.
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Affiliation(s)
- Camilla Gizzi
- Neonatal Intensive Care Unit, Pediatric and Neonatal Department, "S.Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy
| | - Francesco Montecchia
- Medical Engineering Laboratory, Department of Civil Engineering and Computer Science Engineering, "Tor Vergata" University of Rome, Rome, Italy
| | - Valentina Panetta
- SeSMIT-A.Fa.R., Medical Statistics & Information Technology, Fatebenefratelli Association for Biomedical and Sanitary Research, Rome, Italy
| | - Chiara Castellano
- Neonatal Intensive Care Unit, Pediatric and Neonatal Department, "S.Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy
| | - Chiara Mariani
- Neonatal Intensive Care Unit, Pediatric and Neonatal Department, "S.Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy
| | - Maristella Campelli
- Neonatal Intensive Care Unit, Pediatric and Neonatal Department, "S.Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy
| | - Paola Papoff
- Pediatric Emergency and Intensive Care, Department of Pediatrics, Policlinico "Umberto I," Sapienza University of Rome, Rome, Italy
| | - Corrado Moretti
- Pediatric Emergency and Intensive Care, Department of Pediatrics, Policlinico "Umberto I," Sapienza University of Rome, Rome, Italy
| | - Rocco Agostino
- Neonatal Intensive Care Unit, Pediatric and Neonatal Department, "S.Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy
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Mohr MA, Vergales BD, Lee H, Clark MT, Lake DE, Mennen AC, Kattwinkel J, Sinkin RA, Moorman JR, Fairchild KD, Delos JB. Very long apnea events in preterm infants. J Appl Physiol (1985) 2014; 118:558-68. [PMID: 25549762 DOI: 10.1152/japplphysiol.00144.2014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Apnea is nearly universal among very low birth weight (VLBW) infants, and the associated bradycardia and desaturation may have detrimental consequences. We describe here very long (>60 s) central apnea events (VLAs) with bradycardia and desaturation, discovered using a computerized detection system applied to our database of over 100 infant years of electronic signals. Eighty-six VLAs occurred in 29 out of 335 VLBW infants. Eighteen of the 29 infants had a clinical event or condition possibly related to the VLA. Most VLAs occurred while infants were on nasal continuous positive airway pressure, supplemental oxygen, and caffeine. Apnea alarms on the bedside monitor activated in 66% of events, on average 28 s after cessation of breathing. Bradycardia alarms activated late, on average 64 s after cessation of breathing. Before VLAs oxygen saturation was unusually high, and during VLAs oxygen saturation and heart rate fell unusually slowly. We give measures of the relative severity of VLAs and theoretical calculations that describe the rate of decrease of oxygen saturation. A clinical conclusion is that very long apnea (VLA) events with bradycardia and desaturation are not rare. Apnea alarms failed to activate for about one-third of VLAs. It appears that neonatal intensive care unit (NICU) personnel respond quickly to bradycardia alarms but not consistently to apnea alarms. We speculate that more reliable apnea detection systems would improve patient safety in the NICU. A physiological conclusion is that the slow decrease of oxygen saturation is consistent with a physiological model based on assumed high values of initial oxygen saturation.
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Affiliation(s)
- Mary A Mohr
- Department of Physics, College of William and Mary, Williamsburg, Virginia;
| | - Brooke D Vergales
- Department of Pediatrics (Neonatology), University of Virginia, Charlottesville, Virginia
| | - Hoshik Lee
- Department of Physics, College of William and Mary, Williamsburg, Virginia; Samsung Advanced Institute of Technology, Suwon, South Korea
| | - Matthew T Clark
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Douglas E Lake
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia; Department of Statistics, University of Virginia, Charlottesville, Virginia
| | - Anne C Mennen
- Department of Physics, College of William and Mary, Williamsburg, Virginia
| | - John Kattwinkel
- Department of Pediatrics (Neonatology), University of Virginia, Charlottesville, Virginia
| | - Robert A Sinkin
- Department of Pediatrics (Neonatology), University of Virginia, Charlottesville, Virginia
| | - J Randall Moorman
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia; Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia; and Department of Molecular Physiology, University of Virginia, Charlottesville, Virginia
| | - Karen D Fairchild
- Department of Pediatrics (Neonatology), University of Virginia, Charlottesville, Virginia
| | - John B Delos
- Department of Physics, College of William and Mary, Williamsburg, Virginia
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35
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Abstract
Breathing movements have been demonstrated in the fetuses of every mammalian species investigated and are a critical component of normal fetal development. The classic sheep preparations instrumented for chronic fetal monitoring determined that fetal breathing movements (FBMs) occur in aggregates interspersed with long periods of quiescence that are strongly associated with neurophysiological state. The fetal sheep model also provided data regarding the neurochemical modulation of behavioral state and FBMs under a variety of in utero conditions. Subsequently, in vitro rodent models have been developed to advance our understanding of cellular, synaptic, network, and more detailed neuropharmacological aspects of perinatal respiratory neural control. This includes the ontogeny of the inspiratory rhythm generating center, the preBötzinger complex (preBötC), and the anatomical and functional development of phrenic motoneurons (PMNs) and diaphragm during the perinatal period. A variety of newborn animal models and studies of human infants have provided insights into age-dependent changes in state-dependent respiratory control, responses to hypoxia/hypercapnia and respiratory pathologies.
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Affiliation(s)
- John J Greer
- Department of Physiology, Centre for Neuroscience, Women and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
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36
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Prell C, Koletzko S. Gastroösophageale Refluxkrankheit im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2013. [DOI: 10.1007/s00112-013-3049-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Schmid MB, Hopfner RJ, Lenhof S, Hummler HD, Fuchs H. Cerebral desaturations in preterm infants: a crossover trial on influence of oxygen saturation target range. Arch Dis Child Fetal Neonatal Ed 2013; 98:F392-8. [PMID: 23457220 DOI: 10.1136/archdischild-2012-303136] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test the hypothesis that a higher pulsoximetric arterial oxygen saturation (SpO2) target range is associated with reduced cerebral tissue oxygen desaturations from baseline during events of hypoxaemia or bradycardia. DESIGN Randomised crossover trial. SETTING Single tertiary care neonatal intensive care unit. PATIENTS Sixteen preterm infants with severe intermittent hypoxaemia or bradycardia. INTERVENTIONS SpO2 target was set to 80-92% and 85-96% for 4 h each in random sequence. On a subsequent day, the target sequence was reversed and the study was repeated. MAIN OUTCOME MEASURES We simultaneously recorded cerebral tissue oxygen saturation (cerebral StO2), SpO2 and heart rate. Cerebral StO2 was measured by near infrared spectroscopy. The primary outcome was the cumulative cerebral StO2 desaturation score representing the area below a cerebral StO2 baseline value before onset of each hypoxaemic or bradycardic event. RESULTS During low SpO2 target range the median (IQR) cumulative cerebral StO2 desaturation score was higher (27384 (15825-37396) vs 18103 (6964-32946), p=0.011) and the mean (±SD) number of events was higher (29.1 (±15.3) vs 21.1 (±11.4), p=0.001). More time was spent with SpO2 below 80% (57.2 (±24.8) min vs 34.0 (±29.6) min, p=0.006). Total time of hyperoxaemia (defined as SpO2 ≥97% and ≥99%, respectively) and total time with cerebral StO2 <60% and <55% were similar. CONCLUSIONS A lower SpO2 target range was associated with a greater cumulative cerebral StO2 desaturation score, caused by more frequent SpO2 desaturations. However, time at very low cerebral StO2 was not affected. Episodes of hyperoxaemia were not reduced.
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Affiliation(s)
- Manuel B Schmid
- Division of Neonatology and Pediatric Critical Care, Department for Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany.
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Forecasting respiratory collapse: theory and practice for averting life-threatening infant apneas. Respir Physiol Neurobiol 2013; 189:223-31. [PMID: 23735485 DOI: 10.1016/j.resp.2013.05.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/28/2013] [Accepted: 05/28/2013] [Indexed: 11/22/2022]
Abstract
Apnea of prematurity is a common disorder of respiratory control among preterm infants, with potentially serious adverse consequences on infant development. We review the capability for automatically assessing apnea risk and predicting apnea episodes from multimodal physiological measurements, and for using this knowledge to provide timely therapeutic intervention. We also review other, similar clinical domains of respiratory distress assessment and prediction in the hope of gaining useful insights. We propose an algorithmic framework for constructing discriminative feature vectors from physiological measurements, and for building robust and effective statistical models for apnea assessment and prediction.
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39
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Apnea of prematurity--perfect storm. Respir Physiol Neurobiol 2013; 189:213-22. [PMID: 23727228 DOI: 10.1016/j.resp.2013.05.026] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 05/17/2013] [Accepted: 05/21/2013] [Indexed: 12/23/2022]
Abstract
With increased survival of preterm infants as young as 23 weeks gestation, maintaining adequate respiration and corresponding oxygenation represents a clinical challenge in this unique patient cohort. Respiratory instability characterized by apnea and periodic breathing occurs in premature infants because of immature development of the respiratory network. While short respiratory pauses and apnea may be of minimal consequence if oxygenation is maintained, they can be problematic if accompanied by chronic intermittent hypoxemia. Underdevelopment of the lung and the resultant lung injury that occurs in this population concurrent with respiratory instability creates the perfect storm leading to frequent episodes of profound and recurrent hypoxemia. Chronic intermittent hypoxemia contributes to the immediate and long term co-morbidities that occur in this population. In this review we discuss the pathophysiology leading to the perfect storm, diagnostic assessment of breathing instability in this unique population and therapeutic interventions that aim to stabilize breathing without contributing to tissue injury.
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Gestational stress promotes pathological apneas and sex-specific disruption of respiratory control development in newborn rat. J Neurosci 2013; 33:563-73. [PMID: 23303936 DOI: 10.1523/jneurosci.1214-12.2013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Recurrent apneas are important causes of hospitalization and morbidity in newborns. Gestational stress (GS) compromises fetal brain development. Maternal stress and anxiety during gestation are linked to respiratory disorders in newborns; however, the mechanisms remain unknown. Here, we tested the hypothesis that repeated activation of the neuroendocrine response to stress during gestation is sufficient to disrupt the development of respiratory control and augment the occurrence of apneas in newborn rats. Pregnant dams were displaced and exposed to predator odor from days 9 to 19 of gestation. Control dams were undisturbed. Experiments were performed on male and female rats aged between 0 and 4 d old. Apnea frequency decreased with age but was consistently higher in stressed pups than controls. At day 4, GS augmented the proportion of apneas with O(2) desaturations by 12%. During acute hypoxia (12% O(2)), the reflexive increase in breathing augmented with age; however, this response was lower in stressed pups. Instability of respiratory rhythm recorded from medullary preparations decreased with age but was higher in stressed pups than controls. GS reduced medullary serotonin (5-HT) levels in newborn pups by 32%. Bath application of 5-HT and injection of 8-OH-DPAT [(±)-8-hydroxy-2-di-(n-propylamino) tetralin hydrobromide; 5-HT(1A) agonist; in vivo] reduced respiratory instability and apneas; these effects were greater in stressed pups than controls. Sex-specific effects were observed. We conclude that activation of the stress response during gestation is sufficient to disrupt respiratory control development and promote pathological apneas in newborn rats. A deficit in medullary 5-HT contributes to these effects.
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Abstract
Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. It is a frequently experienced physiologic condition occurring several times a day, mostly postprandial and causes no symptoms. These infants are also called 'happy spitters'. GER disease (GERD) occurs when reflux of the gastric contents causes symptoms that affect the quality of life or pathologic complications, such as failure to thrive, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, apnea, and apparent life-threatening events. About 70-85 % of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95 % of infants by 1 year of age. The predominant mechanism causing GERD is transient lower esophageal sphincter (LES) relaxation, which is defined as an abrupt decrease in LES pressure to the level of intragastric pressure, unrelated to swallowing and of relatively longer duration than the relaxation triggered by a swallow. Regurgitation and vomiting are the most common symptoms of infant reflux. A thorough history and physical examination with attention to warning signals suggesting other causes is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER. Choking, gagging, coughing with feedings or significant irritability can be warning signs for GERD or other diagnoses. If there is forceful vomiting, laboratory and radiographic investigation (upper gastrointestinal series) are warranted to exclude other causes of vomiting. Irritability coupled with back arching in infants is thought to be a non-verbal equivalent of heartburn in older children. Other causes of irritability, including cow's milk protein allergy, neurologic disorders, constipation and infection, should be ruled out. The presentation of cow's milk protein allergy overlaps with GERD, and both conditions may co-exist in 42-58 % of infants. In these infants, symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein from the diet. For non-complicated reflux, no intervention is required for most infants. Effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux. Sandifer syndrome, apnea and apparent life-threatening events are the extraesophageal manifestations of GERD in infants. Pharmacotherapeutic agents used to treat GERD encompass antisecretory agents, antacids, surface barrier agents and prokinetics. Currently, North American Society for Pediatric Gasroenterology, Hepatology and Nutrition (NASPGHAN) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) practice guidelines concluded that there is insufficient evidence to justify the routine use of prokinetic agents. Esomeprazole (Nexium) is now approved in the US for short-term treatment of GERD with erosive esophagitis in infants aged from 1 to 12 months. Although Nissen fundoplication is now well established as a treatment option in selected cases of GERD in children, its role in neonates and young infants is unclear and is only reserved for selective infants who did not respond to medical therapy and have life-threatening complications of GERD.
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Boudaa N, Samson N, Carrière V, Germim PS, Pasquier JC, Bairam A, Praud JP. Effects of caffeine and/or nasal CPAP treatment on laryngeal chemoreflexes in preterm lambs. J Appl Physiol (1985) 2013; 114:637-46. [PMID: 23305977 DOI: 10.1152/japplphysiol.00599.2012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Current knowledge suggests that laryngeal chemoreflexes (LCR) are involved in the occurrence of certain neonatal apneas/bradycardias, especially in the preterm newborn. While caffeine and/or nasal continuous positive airway pressure (nCPAP) are the most frequent options used for treating apneas in preterm newborns, their effects on LCR-related apneas/bradycardias are virtually unknown. The aim of the present study was to test the hypothesis that caffeine and/or nCPAP decreases LCR-related cardiorespiratory inhibition in a preterm ovine model. Seven preterm lambs were born vaginally on gestational day 133 (normal gestation: 147 days) after intramuscular injections of betamethasone and mifepristone. Five days after birth, a chronic surgical instrumentation was performed to record states of alertness, electrocardiogram, systemic arterial pressure, and electromyographic activity of a laryngeal constrictor muscle, as well as to insert a transcutaneous supraglottal catheter. LCR were induced in quiet sleep under four conditions: 1) control (without caffeine or nCPAP); 2) nCPAP (5 cmH2O, without caffeine); 3) caffeine (10 mg/kg infused intravenously for 30 min, without nCPAP); and 4) nCPAP + caffeine. Our results showed that nCPAP consistently blunted LCR-related cardiorespiratory inhibition vs. control condition, contrary to caffeine whose overall effect was nonsignificant. In addition, nCPAP condition was characterized by a more consistent and rapid arousal after HCl injection. No significant differences were observed between all tested conditions with regard to swallowing and cough. It is concluded that nCPAP should be further assessed for its usefulness in treating neonatal apneas linked to LCR.
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Affiliation(s)
- Nadia Boudaa
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Physiology, Université de Sherbrooke, Quebec, Canada J1H 5N4
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Monasterio V, Burgess F, Clifford GD. Robust classification of neonatal apnoea-related desaturations. Physiol Meas 2012; 33:1503-16. [PMID: 22902971 DOI: 10.1088/0967-3334/33/9/1503] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Respiratory signals monitored in the neonatal intensive care units are usually ignored due to the high prevalence of noise and false alarms (FA). Apneic events are generally therefore indicated by a pulse oximeter alarm reacting to the subsequent desaturation. However, the high FA rate in the photoplethysmogram may desensitize staff, reducing the reaction speed. The main reason for the high FA rates of critical care monitors is the unimodal analysis behaviour. In this work, we propose a multimodal analysis framework to reduce the FA rate in neonatal apnoea monitoring. Information about oxygen saturation, heart rate, respiratory rate and signal quality was extracted from electrocardiogram, impedance pneumogram and photoplethysmographic signals for a total of 20 features in the 5 min interval before a desaturation event. 1616 desaturation events from 27 neonatal admissions were annotated by two independent reviewers as true (physiologically relevant) or false (noise-related). Patients were divided into two independent groups for training and validation, and a support vector machine was trained to classify the events as true or false. The best classification performance was achieved on a combination of 13 features with sensitivity, specificity and accuracy of 100% in the training set, and a sensitivity of 86%, a specificity of 91% and an accuracy of 90% in the validation set.
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Affiliation(s)
- Violeta Monasterio
- CIBER de Bioingenieria, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain.
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Driessen C, Mathijssen I, De Groot M, Joosten K. Does central sleep apnea occur in children with syndromic craniosynostosis? Respir Physiol Neurobiol 2012; 181:321-5. [DOI: 10.1016/j.resp.2012.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 03/22/2012] [Accepted: 03/23/2012] [Indexed: 11/25/2022]
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Lee H, Rusin CG, Lake DE, Clark MT, Guin L, Smoot TJ, Paget-Brown AO, Vergales BD, Kattwinkel J, Moorman JR, Delos JB. A new algorithm for detecting central apnea in neonates. Physiol Meas 2011; 33:1-17. [PMID: 22156193 DOI: 10.1088/0967-3334/33/1/1] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Apnea of prematurity is an important and common clinical problem, and is often the rate-limiting process in NICU discharge. Accurate detection of episodes of clinically important neonatal apnea using existing chest impedance (CI) monitoring is a clinical imperative. The technique relies on changes in impedance as the lungs fill with air, a high impedance substance. A potential confounder, however, is blood coursing through the heart. Thus, the cardiac signal during apnea might be mistaken for breathing. We report here a new filter to remove the cardiac signal from the CI that employs a novel resampling technique optimally suited to remove the heart rate signal, allowing improved apnea detection. We also develop an apnea detection method that employs the CI after cardiac filtering. The method has been applied to a large database of physiological signals, and we prove that, compared to the presently used monitors, the new method gives substantial improvement in apnea detection.
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Affiliation(s)
- Hoshik Lee
- Department of Physics, College of William and Mary, Williamsburg, VA 23187, USA
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Annual review of selected scientific literature: Report of the committee on scientific investigation of the American Academy of Restorative Dentistry. J Prosthet Dent 2011; 106:224-65. [DOI: 10.1016/s0022-3913(11)60127-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Apnea of prematurity (AOP) is a common problem affecting premature infants, likely secondary to a "physiologic" immaturity of respiratory control that may be exacerbated by neonatal disease. These include altered ventilatory responses to hypoxia, hypercapnia, and altered sleep states, while the roles of gastroesophageal reflux and anemia remain controversial. Standard clinical management of the obstructive subtype of AOP includes prone positioning and continuous positive or nasal intermittent positive pressure ventilation to prevent pharyngeal collapse and alveolar atelectasis, while methylxanthine therapy is a mainstay of treatment of central apnea by stimulating the central nervous system and respiratory muscle function. Other therapies, including kangaroo care, red blood cell transfusions, and CO(2) inhalation, require further study. The physiology and pathophysiology behind AOP are discussed, including the laryngeal chemoreflex and sensitivity to inhibitory neurotransmitters, as are the mechanisms by which different therapies may work and the potential long-term neurodevelopmental consequences of AOP and its treatment.
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Affiliation(s)
- Jing Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Fernando Gonzalez
- Departments of Neurology and Pediatrics, Newborn Brain Research Institute, University of California, San Francisco, CA USA
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China ,Departments of Neurology and Pediatrics, Newborn Brain Research Institute, University of California, San Francisco, CA USA
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