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Dyess NF, Palmer C, Soll RF, Clark RH, Abman SH, Kinsella JP. Practices and Outcomes from a Prospective, Multicenter Registry for Preterm Newborns with Pulmonary Hypertension. J Pediatr 2023; 262:113614. [PMID: 37478902 DOI: 10.1016/j.jpeds.2023.113614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/14/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE To describe current treatment practices of preterm infants with early hypoxemic respiratory failure (HRF) and pulmonary hypertension (PH) and their association with patient outcomes. STUDY DESIGN We developed a prospective, observational, multicenter clinical registry of preterm newborns <34 weeks' gestation with HRF and PH, based on either clinical or echocardiographic evidence during the first 72 hours of life, from 28 neonatal intensive care units in the US from 2017 through 2022. The primary end point was mortality among those who did or did not receive PH-targeted treatment, and the secondary end points included comparisons of major morbidities. Variables were compared using t tests, Wilcoxon rank-sum tests, Fisher exact tests, and χ² tests. RESULTS We analyzed the results of 224 preterm infants enrolled in the registry. Of which, 84% (188/224) received PH-targeted treatment, most commonly inhaled nitric oxide (iNO). Early mortality in this cohort was high, as 33% (71/224) of this sample died in the first month of life, and 77% of survivors (105/137) developed bronchopulmonary dysplasia. Infants who received PH-targeted treatment had higher oxygenation indices at the time of enrollment (28.16 [IQR: 13.94, 42.5] vs 15.46 [IQR: 11.94, 26.15]; P = .0064). Patient outcomes did not differ between those who did or did not receive PH-targeted therapy. CONCLUSIONS Early-onset HRF with PH in preterm infants is associated with a high early mortality and a high risk of developing bronchopulmonary dysplasia. iNO is commonly used to treat early-onset PH in preterm infants with HRF. In comparison with untreated infants with lower oxygenation indices, iNO treatment in severe PH may prevent poorer outcomes.
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Affiliation(s)
- Nicolle Fernández Dyess
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, CO.
| | - Claire Palmer
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, CO
| | - Roger F Soll
- Department of Pediatrics, Division of Neonatology, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Reese H Clark
- Pediatrix Center for Research, Education, Quality and Safety (CREQS), Pediatrix Medical Group, Sunrise, FL
| | - Steven H Abman
- Department of Pediatrics, Section of Pulmonology, University of Colorado School of Medicine, Aurora, CO
| | - John P Kinsella
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, CO
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2
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Pizzuto MF, Laughon MM, Jackson WM. Current and emerging pharmacotherapies for the treatment of pulmonary arterial hypertension in infants. Expert Opin Pharmacother 2023; 24:1875-1886. [PMID: 37707346 PMCID: PMC10843401 DOI: 10.1080/14656566.2023.2257598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a complex condition that encompasses an array of underlying disease processes and affects a diverse population of infants, including those with congenital heart disease, congenital diaphragmatic hernia, persistent PH of the newborn, and those with lung disease such as bronchopulmonary dysplasia. While there are treatments available to adults with PH, limited data exists for infants, especially for the newer medications. Therapies that target the three main pathophysiologic pathways of pulmonary hypertension appear to benefit infants, but which are best for each individual disease process is unclear. AREAS COVERED A review of the therapies to treat pulmonary hypertension is covered in this article including the prostacyclin pathway, endothelin pathway, and the nitric oxide pathway. Other adjunctive treatments are also discussed. Findings are based on a PubMed literature search of research papers spanning 1990-2023 and a search of ongoing trials registered with clinicaltrials.gov. EXPERT OPINION Overall therapies seem to improve outcomes with most infants with PH. However, given the diverse population of infants with PH, it is imperative to understand the basis for the PH in individual patients and understand which therapies can be applicable. Further research into tailored therapy for the specific populations is warranted.
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Affiliation(s)
- Matthew F. Pizzuto
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Matthew M. Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Wesley M. Jackson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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3
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Mullaly R, McCallion N, El-Khuffash A. Inhaled nitric oxide in preterm neonates with preterm prelabour rupture of membranes, a systematic review. Acta Paediatr 2023; 112:358-371. [PMID: 36377399 DOI: 10.1111/apa.16596] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 11/16/2022]
Abstract
AIM To perform a systematic literature review to determine the effect of inhaled nitric oxide (iNO) on oxygenation, mortality and morbidity in preterm neonates with preterm prelabour rupture of membranes (PPROM) and early hypoxaemic respiratory failure (HRF). METHODS MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Web of Science, Zetoc and ProQuest were searched. Studies including neonates <34 weeks' gestation with PPROM, oligohydramnios or pulmonary hypoplasia and HRF in the first 28 days of life treated with iNO were included. Studies were critically appraised and assessed for potential risk of bias using standardised checklists. RESULTS Six hundred and two records remained after duplicates were removed. Seven studies were included in the critical appraisal process. Quality of available evidence was very low to low. Six studies described an improvement in oxygenation after commencement of iNO. One hundred and three of 284 (36%) neonates exposed to iNO died. Seventy-seven of 92 (84%) neonates that had an echocardiogram performed before commencement of iNO had pulmonary hypertension (PH) present. CONCLUSION iNO may improve oxygenation when standard care fails. Improvement in oxygenation is likely associated with increase in survival. Survival may lead to an increase in morbidity. Efficacy of iNO in this cohort is likely secondary to relatively high prevalence of PH.
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Affiliation(s)
- Rachel Mullaly
- The Rotunda Hospital, Dublin, Ireland.,School of Health Sciences, University of Southampton, Southampton, UK.,Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Naomi McCallion
- The Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Afif El-Khuffash
- The Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
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4
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Peluso AM, Othman HF, Karnati S, Sammour I, Aly HZ. Epidemiologic evaluation of inhaled nitric oxide use among neonates with gestational age less than 35 weeks. Pediatr Pulmonol 2022; 57:427-434. [PMID: 34842352 DOI: 10.1002/ppul.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/16/2021] [Accepted: 11/26/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of inhaled nitric oxide (iNO) in +late preterm and term infants with pulmonary hypertension is Food and Drug Administration (FDA) approved and has improved outcomes and survival. iNO use is not FDA approved for preterm infants and previous studies show no mortality benefit. The objectives were 1) to determine the usage of iNO among preterm neonates <35 weeks before and after the 2010 National Institutes of Health consensus statement and 2) to evaluate characteristics and outcomes among preterm neonates who received iNO. METHODS This is a population-based cross-sectional study. Billing and procedure codes were used to determine iNO usage. Data were queried from the National Inpatient Sample from 2004 to 2016. Neonates were included if gestational age was <35 weeks. The epochs were spilt into 2004-2010 (Epoch 1) and 2011-2016 (Epoch 2). Prevalence of iNO use, mortality, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage, length of stay, mechanical ventilation, and cost of hospitalization. RESULTS There were 4865 preterm neonates <35 weeks who received iNO. There was a significant increase in iNO use during Epoch 2 (p < 0.001). There was significantly higher use in Epoch 2 among neonates small for gestational age (SGA) 2.3% versus 7.2%, congenital heart disease (CHD) 11.1% versus 18.6%, and BPD 35.2% versus 46.8%. Mortality was significantly lower in Epoch 2 19.8% versus 22.7%. CONCLUSION Usage of iNO was higher after the release of the consensus statement. The increased use of iNO among preterm neonates may be targeted at specific high-risk populations such as SGA and CHD neonates. There was lower mortality in Epoch 2; however, the cost was doubled.
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Affiliation(s)
- Allison M Peluso
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Hasan F Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, Michigan, USA
| | - Sreenivas Karnati
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Ibrahim Sammour
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Hany Z Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
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5
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Chandrasekharan P, Lakshminrusimha S, Abman SH. When to say no to inhaled nitric oxide in neonates? Semin Fetal Neonatal Med 2021; 26:101200. [PMID: 33509680 DOI: 10.1016/j.siny.2021.101200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Inhaled nitric oxide (iNO) was approved for use in critically ill term and near-term neonates (>34 weeks gestational age) in 1999 for hypoxic respiratory failure (HRF) with evidence of pulmonary hypertension. In 2011 and 2014, the National Institutes of Health and American Academy of Pediatrics respectively recommended against the use of iNO in preterm infants <34 weeks. However, these guidelines were based on trials conducted with varying inclusion criteria and outcomes. Recent guidelines from the American Thoracic Society/American Heart Association, the Pediatric Pulmonary Hypertension Network (PPHNet) and European Pediatric Pulmonary Vascular Disease Network recommend the use of iNO in preterm neonates with HRF with confirmed pulmonary hypertension. This review discusses the available evidence for off-label use of iNO. Preterm infants with prolonged rupture of membranes and pulmonary hypoplasia appear to respond to iNO. Similarly, preterm infants with physiology of pulmonary hypertension with extrapulmonary right-to-left shunts may potentially have an oxygenation response to iNO. An overview of relative and absolute contraindications for iNO use in neonates is provided. Absolute contraindications to iNO use include a ductal dependent congenital heart disease where systemic circulation is supported by a right-to-left ductal shunt, severe left ventricular dysfunction and severe congenital methemoglobinemia. In preterm infants, we do not recommend the routine use of iNO in HRF due to parenchymal lung disease without pulmonary hypertension and prophylactic use to prevent bronchopulmonary dysplasia. Future randomized trials evaluating iNO in preterm infants with pulmonary hypertension and/or pulmonary hypoplasia are warranted. (233/250 words).
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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6
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Mandell E, Kinsella JP, Abman SH. Persistent pulmonary hypertension of the newborn. Pediatr Pulmonol 2021; 56:661-669. [PMID: 32930508 DOI: 10.1002/ppul.25073] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/07/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a significant clinical problem characterized by refractory and severe hypoxemia secondary to elevated pulmonary vascular resistance resulting in right-to-left extrapulmonary shunting of deoxygenated blood. PPHN is associated with diverse cardiopulmonary disorders and a high early mortality rate for infants with severe PPHN. Surviving infants with PPHN have an increased risk of long-term morbidities. PPHN physiology can be categorized by (1) maladaptation: pulmonary vessels have normal structure and number but have abnormal vasoreactivity; (2) excessive muscularization: increased smooth muscle cell thickness and increased distal extension of muscle to vessels that are usually not muscularized; and (3) underdevelopment: lung hypoplasia associated with decreased pulmonary artery number. Treatment involves adequate lung recruitment, optimization of cardiac output and left ventricular function, and pulmonary vasodilators such as inhaled nitric oxide. Infants who fail to respond to conventional therapy should be evaluated for lethal lung disorders including alveolar-capillary dysplasia, T-box transcription factor 4 gene, thyroid transcription factor-1, ATP-binding cassette A3 gene, and surfactant protein diseases.
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Affiliation(s)
- Erica Mandell
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John P Kinsella
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Pulmonary Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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7
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Cho JY, Lee BS, Oh MY, Cha T, Jeong J, Jung E, Kim AR, Kim KS. Response to Inhaled Nitric Oxide and Clinical Outcome in Very Low Birth Weight Infants with Early Pulmonary Hypertension. NEONATAL MEDICINE 2020. [DOI: 10.5385/nm.2020.27.3.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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8
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Dassios T, Ambulkar H, Greenough A. Treatment and respiratory support modes for neonates with respiratory distress syndrome. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1769598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Theodore Dassios
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
| | - Hemant Ambulkar
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Anne Greenough
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
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9
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Garrido F, Gonzalez‐Caballero JL, Lomax R, Dady I. The immediate efficacy of inhaled nitric oxide treatment in preterm infants with acute respiratory failure during neonatal transport. Acta Paediatr 2020; 109:309-313. [PMID: 31373038 DOI: 10.1111/apa.14958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/16/2019] [Accepted: 07/31/2019] [Indexed: 02/02/2023]
Abstract
AIM The aim of our review was to describe the clinical response to inhaled nitric oxide (iNO) in a series of preterm babies in respiratory failure during uplift transfers to a neonatal intensive care unit. METHODS We performed a retrospective review of critical newborns with gestational age <34+0 weeks transferred from January 2013 to December 2018. Data were extracted from our Clinical Information System for transport. The primary measure of this review was to assess whether a significant improvement in the oxygenation saturation index (OSI) occurred following the use of iNO. RESULTS Thirty preterm babies <34+0 weeks were included in our review. OSI, as a measure of oxygenation, did not statistically improve as an immediate response to iNO from referral to receiving hospital (17.1 vs 16.4; P = .7). We found that pH (7.15 vs 7.29; P = .004) and pCO2 (8.1 vs 6.3; P = .05) significantly improved probably based on ventilation management. CONCLUSION Following the recommendations of the American Academy of Paediatrics and other organizations, iNO should not routinely be used during the neonatal transfer of preterm babies <34+0 in respiratory failure. We need to conduct further studies to establish which selected preterm patients would benefit from being treated with iNO.
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Affiliation(s)
- Felipe Garrido
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
- Newborn Intensive Care Unit Clínica Universidad de Navarra Madrid Spain
| | | | - Rachel Lomax
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
| | - Ian Dady
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
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10
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Sherlock LG, Wright CJ, Kinsella JP, Delaney C. Inhaled nitric oxide use in neonates: Balancing what is evidence-based and what is physiologically sound. Nitric Oxide 2019; 95:12-16. [PMID: 31866361 DOI: 10.1016/j.niox.2019.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 12/22/2022]
Abstract
Inhaled nitric oxide is a powerful therapeutic used in neonatology. Its use is evidenced-based for term and near-term infants with persistent pulmonary hypertension; however, it is frequently used off-label both in term and preterm babies. This article reviews the off-label uses of iNO in infants. Rationale is discussed for a selective application of iNO based on physiologically guided principles, and new research avenues are considered.
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Affiliation(s)
- Laurie G Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Cassidy Delaney
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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11
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McPherson C. Pharmacotherapy for the Prevention of Bronchopulmonary Dysplasia: Can Anything Compete with Caffeine and Corticosteroids? Neonatal Netw 2019; 38:242-249. [PMID: 31470395 DOI: 10.1891/0730-0832.38.4.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a morbidity of prematurity with implications for respiratory and neurologic health into adulthood. Multiple risk factors contribute to the development of BPD leading to examination of various prevention strategies. The roles of systemic corticosteroids and caffeine have been addressed by the American Academy of Pediatrics. The place in therapy of other agents commonly utilized in clinical practice remains unclear. Inhaled nitric oxide has been the subject of numerous large, randomized controlled trials in preterm infants. Despite sound rationale, these trials have largely failed to document benefit, suggesting a limited role for inhaled nitric oxide therapy in the preterm population. In contrast, intramuscular vitamin A has been documented to reduce the incidence of BPD in randomized trials. However, the invasiveness and the sporadic availability of this therapy have led to decreased utilization. All macrolide antibiotics do not appear to have a similar impact on the incidence of BPD; however, azithromycin administered to infants colonized with Ureaplasma may have impact. Questions remain about the optimal dosing approach and long-term safety of this intervention. Finally, diuretic therapy is widely used in clinical practice despite significant toxicities and limited data supporting a role in BPD prevention. Taken together, available data suggest that caffeine and selective use of corticosteroids remain the mainstays of pharmacologic BPD prevention.
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12
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Ahmed MS, Giesinger RE, Ibrahim M, Baczynski M, Louis D, McNamara KP, Jain A, Weisz DE, McNamara PJ. Clinical and echocardiography predictors of response to inhaled nitric oxide in hypoxic preterm neonates. J Paediatr Child Health 2019; 55:753-761. [PMID: 30537276 DOI: 10.1111/jpc.14286] [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: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/04/2018] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the clinical and echocardiography modulators of treatment response in hypoxemic preterm infants exposed to inhaled nitric oxide (iNO). METHODS In this multicentre retrospective study, clinical parameters, including oxygenation, ventilation and haemodynamics, were collected for preterm infants <36 weeks gestation before and 2 h after initiation of iNO for acute hypoxemia. Comprehensive echocardiography, performed near the time iNO initiation, was analysed by experts blind to the clinical course. Multiple logistic regression analysis was used to identify factors associated with iNO response as defined by a reduction in the fraction of inspired oxygen by >0.20. RESULTS A total of 213 infants met eligibility criteria, of which 73 had echocardiography data available and formed the study cohort. Response to iNO was demonstrated in 56% of patients. Younger post-natal age (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.89, 0.99) and the presence of pulmonary hypertension (PH) (OR 4.47; 95% CI 1.23-11.9) were independently predictive of iNO response regardless of gestational age. Among neonates <72 h old with documented PH, iNO response was seen in 82%. The onset of a new diagnosis of severe (grade III/IV) intraventricular haemorrhage (IVH) after iNO treatment was seen in 6 of 40 patients <28 weeks' gestational age, with a greater frequency in responders (32 vs. 0%, P = 0.02). CONCLUSIONS Positive response to iNO is greatest in the first 3 days of life and in patients with echo-confirmed PH, independent of gestational age. The association between critical illness, iNO administration and IVH in extremely premature infants may merit prospective delineation.
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Affiliation(s)
- Mohamed Shalabi Ahmed
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Regan E Giesinger
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mohamed Ibrahim
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle Baczynski
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Deepak Louis
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Karl P McNamara
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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13
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Kettle R, Subhedar NV. Nitric Oxide in Pulmonary Hypoplasia: Results from the European iNO Registry. Neonatology 2019; 116:341-346. [PMID: 31581153 DOI: 10.1159/000501800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this work was to describe treatment response and outcome data for preterm infants with pulmonary hypoplasia treated with inhaled nitric oxide (iNO). We hypothesised that an acute oxygenation response to iNO would be associated with survival. DESIGN A retrospective observational study design was used to identify cases of pulmonary hypoplasia in preterm infants <34 weeks' gestation reported to the European iNO Registry. Demographic and clinical data were collected including oxygenation and echocardiographic parameters. The primary outcome was acute oxygenation response defined as a reduction in fractional inspired oxygen of >0.15. Outcome data included chronic lung disease (CLD) and death. RESULTS Seventy-two infants with pulmonary hypoplasia were treated with iNO during a 10-year period (2007-2016). In total, 30/69 (43%) of the infants showed a significant improvement in oxygenation and were categorised as "responders." Thirty-one treated infants died, and 19 survivors developed CLD. Although there were no differences in demographics and baseline cardiorespiratory parameters between responders and non-responders, an acute response was significantly associated with survival. Neither pulmonary hypertension nor PPHN (persistent pulmonary hypertension of the newborn) physiology predicted the acute response to iNO or survival. CONCLUSION Although the acute oxygenation response to iNO therapy in pulmonary hypoplasia is comparable to other respiratory disorders in preterm infants, mortality in this group remains very high. An acute response is associated with survival and suggests that a short therapeutic trial of iNO therapy is warranted in this population. This study underscores the value of registries in evaluating therapies for rare neonatal disorders, although their limitations must be recognised.
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Affiliation(s)
- Rebecca Kettle
- Neonatal Intensive Care Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
| | - Nimish V Subhedar
- Neonatal Intensive Care Unit, Liverpool Women's Hospital, Liverpool, United Kingdom,
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14
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Ellsworth KR, Ellsworth MA, Weaver AL, Mara KC, Clark RH, Carey WA. Association of Early Inhaled Nitric Oxide With the Survival of Preterm Neonates With Pulmonary Hypoplasia. JAMA Pediatr 2018; 172:e180761. [PMID: 29800952 PMCID: PMC6137510 DOI: 10.1001/jamapediatrics.2018.0761] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Pulmonary hypoplasia affects a very small percentage of preterm neonates, but its presence is associated with high rates of mortality. OBJECTIVE To determine whether treatment with inhaled nitric oxide during the first week of life was associated with improved in-hospital survival in a cohort of extremely preterm neonates with pulmonary hypoplasia. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Pediatrix Medical Group's Clinical Data Warehouse, a data set containing information from more than 350 neonatal intensive care units in 35 US states and Puerto Rico. Since inhaled nitric oxide was not randomly prescribed, we used 1-to-1 propensity score matching to reduce the imbalance of measured covariates between the 2 treatment groups. The initial, unmatched cohort included singleton neonates who were born between 22 and 29 weeks' gestation, had a birth weight of 400 g or more, were diagnosed with pulmonary hypoplasia as a cause of their respiratory distress, remained free of major anomalies, and were discharged between January 1, 2000, and December 31, 2014. We defined exposure as the initiation of inhaled nitric oxide on day t in days 0 to 7 of the life of a neonate. Each exposed neonate was matched 1-to-1 to a neonate who had not initiated inhaled nitric oxide on a given day. MAIN OUTCOMES AND MEASURES The primary outcome was mortality defined as death prior to transfer or discharge home. Secondary outcomes were any-stage necrotizing enterocolitis, retinopathy of prematurity requiring treatment, chronic lung disease, and periventricular leukomalacia. RESULTS Among 92 635 neonates in our study sample, we identified 767 (0.8%) with pulmonary hypoplasia who met all study inclusion criteria, of whom 185 (0.2%) were exposed to inhaled nitric oxide. Among 151 matched pairs of exposed and unexposed neonates, we did not identify a significant association between inhaled nitric oxide use and mortality (hazard ratio [HR], 0.79; 95% CI, 0.57-1.11). Subgroup analyses of neonates with and without persistent pulmonary hypertension (PPHN) likewise revealed no significant association between inhaled nitric oxide use and mortality (pulmonary hypoplasia with PPHN: HR, 0.67; 95% CI, 0.45-1.01; pulmonary hypoplasia without PPHN: HR, 1.11; 95% CI, 0.61-2.02), but these findings may have been influenced by ascertainment bias. CONCLUSIONS AND RELEVANCE Early treatment with inhaled nitric oxide is not associated with improved survival among extremely preterm neonates with pulmonary hypoplasia. Clinical trials are warranted to clarify the matter.
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Affiliation(s)
| | | | - Amy L. Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Reese H. Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - William A. Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
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15
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Controversies in the identification and management of acute pulmonary hypertension in preterm neonates. Pediatr Res 2017; 82:901-914. [PMID: 28820870 DOI: 10.1038/pr.2017.200] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 08/05/2017] [Indexed: 12/22/2022]
Abstract
It is increasingly recognized that the abnormal physiologic consequences of pulmonary hypertension (PH) may contribute to poor cardiopulmonary health in premature babies. Conflicting literature has led to clinical uncertainty, pathological misinterpretation, and variability in treatment approaches among practitioners. There are several disorders with overlapping and interrelated presentations, and other disorders with a similar clinical phenotype but diverse pathophysiological contributors. In this review, we provide a diagnostic approach for acute hypoxemic respiratory failure in the preterm neonate, outline the pathophysiological conditions that may present as acute PH, and discuss the implications of high pulmonary vascular resistance (PVR) on the cardiovascular system. Although PVR and respiratory management are highly interrelated, there may be a population of preterm neonates in whom inhaled nitric oxide may improve illness severity and may relate to outcomes. A management approach based on physiology that considers common clinical conundrums is provided. A more comprehensive understanding of the physiology may help in informed decision-making in clinical situations where conclusive scientific evidence is lacking. Regardless, high-quality research is required, and appropriate definition of the target population is paramount. A thoughtful approach to cardiovascular therapy may also provide an avenue to improve neurodevelopmental outcomes while awaiting more clear answers.
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16
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Baczynski M, Ginty S, Weisz DE, McNamara PJ, Kelly E, Shah P, Jain A. Short-term and long-term outcomes of preterm neonates with acute severe pulmonary hypertension following rescue treatment with inhaled nitric oxide. Arch Dis Child Fetal Neonatal Ed 2017; 102:F508-F514. [PMID: 28483819 DOI: 10.1136/archdischild-2016-312409] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe short-term and long-term outcomes of preterm neonates with severe acute pulmonary hypertension (aPHT) in relation to response to rescue inhaled nitric oxide (iNO) therapy. DESIGN Retrospective cohort studyover a 6 year period. SETTING Tertiary neonatal intensive care unit. PATIENTS 89 neonates <35 weeks gestational age (GA) who received rescue iNO for aPHT, including 62 treated at ≤3 days of age (early aPHT). INTERVENTIONS iNO ≥ 1 hour. MAIN OUTCOME MEASURES Positive responders (reduction in fraction of inspired oxygen (FiO2) ≥0.20 within 1 hour of iNO) were compared with non-responders. Primary outcome was survival without moderate-to-severe disability at 18 months of age. RESULTS Mean (SD) GA and birth weight was 27.7 (3.0) weeks and 1077 (473) gm, respectively. Median (IQR) pre-iNO FiO2 was 1.0 (1.0, 1.0). Positive response rate to iNO was 46%. Responders showed improved survival without disability (51% vs 15%; p<0.01), lower mortality (34% vs 71%; p<0.01) and disability among survivors (17% vs 50%; p=0.06). Higher GA (adjusted OR: 1.44 (95% CI 1.10 to 1.89)), aPHT in context of preterm prolonged rupture of membranes (6.26 (95% CI 1.44 to 27.20)) and positive response to rescue iNO (5.81 (95% CI 1.29 to, 26.18)) were independently associated with the primary outcome. Compared with late cases (>3 days of age), early aPHT had a higher response rate to iNO (61% vs 11%; p<0.01) and lower mortality (43% vs 78%; p<0.01). CONCLUSION A positive response to rescue iNO in preterm infants with aPHT is associated with survival benefit, which is not offset by long-term disability.
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Affiliation(s)
- Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Canada
| | - Shannon Ginty
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Canada
| | - Dany E Weisz
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Science Center, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Patrick J McNamara
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Neonatology, Hospital for Sick Children, Toronto, Canada.,Physiology, University of Toronto, Toronto, Canada
| | - Edmond Kelly
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Prakeshkumar Shah
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
| | - Amish Jain
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Physiology, University of Toronto, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
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17
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18
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Sokol GM, Konduri GG, Van Meurs KP. Inhaled nitric oxide therapy for pulmonary disorders of the term and preterm infant. Semin Perinatol 2016; 40:356-369. [PMID: 27480246 PMCID: PMC5065760 DOI: 10.1053/j.semperi.2016.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The 21st century began with the FDA approval of inhaled nitric oxide therapy for the treatment of neonatal hypoxic respiratory failure associated with pulmonary hypertension in recognition of the 2 randomized clinical trials demostrating a significant reduction in the need for extracorporeal support in the term and near-term infant. Inhaled nitric oxide is one of only a few therapeutic agents approved for use through clinical investigations primarily in the neonate. This article provides an overview of the pertinent biology and chemistry of nitric oxide, discusses potential toxicities, and reviews the results of pertinent clinical investigations and large randomized clinical trials including neurodevelopmental follow-up in term and preterm neonates. The clinical investigations conducted by the Eunice Kennedy Shriver NICHD Neonatal Research Network will be discussed and placed in context with other pertinent clinical investigations exploring the efficacy of inhaled nitric oxide therapy in neonatal hypoxic respiratory failure.
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Affiliation(s)
- Gregory M. Sokol
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46254
| | - G. Ganesh Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304
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19
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Abstract
Pulmonary hypertension in the perinatal period can present acutely (persistent pulmonary hypertension of the newborn) or chronically. Clinical and echocardiographic diagnosis of acute pulmonary hypertension is well accepted but there are no broadly validated criteria for echocardiographic diagnosis of pulmonary hypertension later in the clinical course, although there are significant populations of infants with lung disease at risk for this diagnosis. Contributing cardiovascular comorbidities are common in infants with pulmonary hypertension and lung disease. It is not clear who should be treated without confirmation of pulmonary vascular disease by cardiac catheterization, with concurrent evaluation of any contributing cardiovascular comorbidities.
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Affiliation(s)
- Roberta L Keller
- Neonatology, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, Box 0734, 550 16th Street, 5th Floor, San Francisco, CA 94143, USA.
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20
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Kinsella JP, Steinhorn RH, Krishnan US, Feinstein JA, Adatia I, Austin ED, Rosenzweig EB, Everett AD, Fineman JR, Hanna BD, Hopper RK, Humpl T, Ivy DD, Keller RL, Mullen MP, Raj JU, Wessel DL, Abman SH. Recommendations for the Use of Inhaled Nitric Oxide Therapy in Premature Newborns with Severe Pulmonary Hypertension. J Pediatr 2016; 170:312-4. [PMID: 26703869 DOI: 10.1016/j.jpeds.2015.11.050] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/30/2015] [Accepted: 11/17/2015] [Indexed: 12/27/2022]
Affiliation(s)
- John P Kinsella
- Section of Neonatology, University of Colorado School of Medicine-Children's Hospital Colorado, Aurora, CO.
| | | | - Usha S Krishnan
- New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Ian Adatia
- University of Alberta-Edmonton, Edmonton, Alberta, Canada
| | - Eric D Austin
- Vanderbilt University Medical Center-Vanderbilt Children's Hospital, Nashville, TN
| | | | | | - Jeffrey R Fineman
- Section of Pediatric Critical Care, University of California San Francisco-Benioff Children's Hospital, San Francisco, CA
| | - Brian D Hanna
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rachel K Hopper
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tilman Humpl
- The Hospital for Sick Children-University of Toronto, Toronto, Ontario, Canada
| | - D Dunbar Ivy
- Section of Cardiology, University of Colorado School of Medicine-Children's Hospital Colorado, Aurora, CO
| | - Roberta L Keller
- Section of Neonatology, University of California San Francisco-Benioff Children's Hospital, San Francisco, CA
| | | | - J Usha Raj
- University of Illinois-Chicago, Chicago, IL
| | | | - Steven H Abman
- Section of Pulmonary Medicine, University of Colorado School of Medicine-Children's Hospital Colorado, Aurora, CO
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