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Stafford IG, Perkins EJ, Marshall AP, Gale TJ, Otahal P, Tingay DG, Dargaville PA. Automated oxygen titration in term newborns and young infants: A randomised crossover study. Acta Paediatr 2024; 113:1270-1272. [PMID: 38482960 DOI: 10.1111/apa.17208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/06/2024] [Indexed: 06/09/2024]
Affiliation(s)
- Isabella G Stafford
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Andrew P Marshall
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Timothy J Gale
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Chang YT, Liu JR, Chen WM, Tseng CN, See LC. First-year outcomes of very low birth weight preterm singleton infants with hypoxemic respiratory failure treated with milrinone and inhaled nitric oxide (iNO) compared to iNO alone: A nationwide retrospective study. PLoS One 2024; 19:e0297137. [PMID: 38722851 PMCID: PMC11081351 DOI: 10.1371/journal.pone.0297137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/28/2023] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) has a beneficial effect on hypoxemic respiratory failure. The increased use of concurrent iNO and milrinone was observed. We aimed to report the trends of iNO use in the past 15 years in Taiwan and compare the first-year outcomes of combining iNO and milrinone to the iNO alone in very low birth weight preterm (VLBWP) infants under mechanical ventilation. METHODS This nationwide cohort study enrolled preterm singleton infants with birth weight <1500g treated with iNO from 2004 to 2019. Infants were divided into two groups, with a combination of intravenous milrinone (Group 2, n = 166) and without milrinone (Group 1, n = 591). After propensity score matching (PSM), each group's sample size is 124. The primary outcomes were all-cause mortality and the respiratory condition, including ventilator use and duration. The secondary outcomes were preterm morbidities within one year after birth. RESULTS After PSM, more infants in Group 2 needed inotropes. The mortality rate was significantly higher in Group 2 than in Group 1 from one month after birth till 1 year of age (55.1% vs. 13.5%) with the adjusted hazard ratio of 4.25 (95%CI = 2.42-7.47, p <0.001). For infants who died before 36 weeks of postmenstrual age (PMA), Group 2 had longer hospital stays compared to Group 1. For infants who survived after 36 weeks PMA, the incidence of moderate and severe bronchopulmonary dysplasia (BPD) was significantly higher in Group 2 than in Group 1. For infants who survived until one year of age, the incidence of pneumonia was significantly higher in Group 2 (28.30%) compared to Group 1 (12.62%) (p = 0.0153). CONCLUSION Combined treatment of iNO and milrinone is increasingly applied in VLBWP infants in Taiwan. This retrospective study did not support the benefits of combining iNO and milrinone on one-year survival and BPD prevention. A future prospective study is warranted.
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Affiliation(s)
- Ya-Ting Chang
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wei-Min Chen
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chi-Nan Tseng
- Department of Cardiac Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, Taiwan
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3
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Lakshminrusimha S, Abman SH. Oxygen Targets in Neonatal Pulmonary Hypertension: Individualized, "Precision-Medicine" Approach. Clin Perinatol 2024; 51:77-94. [PMID: 38325948 PMCID: PMC10857735 DOI: 10.1016/j.clp.2023.12.003] [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] [Indexed: 02/09/2024]
Abstract
Oxygen is a specific pulmonary vasodilator. Hypoxemia causes pulmonary vasoconstriction, and normoxia leads to pulmonary vasodilation. However, hyperoxia does not enhance pulmonary vasodilation but causes oxidative stress. There are no clinical trials evaluating optimal oxygen saturation or Pao2 in pulmonary hypertension. Data from translational studies and case series suggest that oxygen saturation of 90% to 97% or Pao2 between 50 and 80 mm Hg is associated with the lowest pulmonary vascular resistance.
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Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, University of California, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, University of Colorado Anschutz Medical Campus, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Holmes H, Saini BS, Moir OJ, Darby JRT, Morrison JL, Sun L, Seed M. Pulmonary Vascular Regulation in the Fetal and Transitional Lung. Clin Perinatol 2024; 51:1-19. [PMID: 38325936 DOI: 10.1016/j.clp.2023.11.003] [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] [Indexed: 02/09/2024]
Abstract
Fetal lungs have fewer and smaller arteries with higher pulmonary vascular resistance (PVR) than a newborn. As gestation advances, the pulmonary circulation becomes more sensitive to changes in pulmonary arterial oxygen tension, which prepares them for the dramatic drop in PVR and increase in pulmonary blood flow (PBF) that occur when the baby takes its first few breaths of air, thus driving the transition from fetal to postnatal circulation. Dynamic and intricate regulatory mechanisms control PBF throughout development and are essential in supporting gas exchange after birth. Understanding these concepts is crucial given the role the pulmonary vasculature plays in the development of complications with transition, such as in the setting of persistent pulmonary hypertension of the newborn and congenital heart disease. An improved understanding of pulmonary vascular regulation may reveal opportunities for better clinical management.
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Affiliation(s)
- Hannah Holmes
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Brahmdeep S Saini
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Olivia J Moir
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, South Australia, 5001, Australia; Department of Physiology, Faculty of Medicine, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8 Canada; Translational Medicine Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8 Canada
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada; Department of Physiology, Faculty of Medicine, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8 Canada; Translational Medicine Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8 Canada; Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8 Canada; Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8 Canada.
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5
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Maneenil G, Premprat N, Janjindamai W, Dissaneevate S, Phatigomet M, Thatrimontrichai A. Correlation and Prediction of Oxygen Index from Oxygen Saturation Index in Neonates with Acute Respiratory Failure. Am J Perinatol 2024; 41:180-186. [PMID: 34666386 DOI: 10.1055/a-1673-5251] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this article was to evaluate the correlation between the oxygen index (OI) and the oxygen saturation index (OSI, measured by pulse oximetry and noninvasively) in neonates with acute respiratory failure and to predict the OI from the OSI. STUDY DESIGN A retrospective cohort study was conducted in neonates requiring invasive mechanical ventilation who had arterial blood gas between 2018 and 2019 at a neonatal intensive care unit. The correlation between OI and OSI was analyzed by using the Pearson correlation coefficient. RESULTS A total of 636 measurements from 68 neonates (35 preterm and 33 terms) were recruited into the study. There was a strong correlation between the OI and the OSI (r = 0.90) in all neonates. The correlation between the OI and the OSI in persistent pulmonary hypertension of the newborn, congenital cyanotic heart disease, and other causes of respiratory failure also showed a strong correlation (r = 0.88, 0.93, and 0.88, respectively). The correlation was strong in neonates with an oxygen saturation less than 85% (r = 0.88), those with oxygen saturation ranging from 85 to 95% (r = 0.87), and also in preterm and term infants (gestational age < 28, 28 - 34, 34 - 36, and ≥37 weeks, r = 0.87, 0.92, 0.89, and 0.90, respectively). There were strong accuracy measures of the OI for OI cutoffs of 5, 10, 15, and 20 (area under the curve > 0.85). The equation relating the OI and OSI was represented by: OI = (2.3 × OSI) - 4. CONCLUSION The OSI has a strong correlation with the OI, is a reliable assessor of the severity of respiratory failure in neonates without arterial sampling, and has high accuracy when the OI is less than 40. KEY POINTS · OSI is calculated as (FiO2 × mean airway pressure × 100)/SpO2.. · OSI is as effective tool as OI for assessing the severity of pediatric acute respiratory distress syndrome.. · OSI has a strong correlation with OI in neonatal respiratory failure..
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Affiliation(s)
- Gunlawadee Maneenil
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Nutchana Premprat
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Waricha Janjindamai
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Supaporn Dissaneevate
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Manapat Phatigomet
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Anucha Thatrimontrichai
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Osman A, Halling C, Crume M, Al Tabosh H, Odackal N, Ball MK. Meconium aspiration syndrome: a comprehensive review. J Perinatol 2023; 43:1211-1221. [PMID: 37543651 DOI: 10.1038/s41372-023-01708-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 08/07/2023]
Abstract
Meconium aspiration syndrome (MAS) is a complex respiratory disease that continues to be associated with significant morbidities and mortality. The pathophysiological mechanisms of MAS include airway obstruction, local and systemic inflammation, surfactant inactivation and persistent pulmonary hypertension of the newborn (PPHN). Supplemental oxygen and non-invasive respiratory support are the main therapies for many patients. The management of the patients requiring invasive mechanical ventilation could be challenging because of the combination of atelectasis and air trapping. While studies have explored various ventilatory modalities, evidence to date does not clearly support any singular modality as superior. Patient's pathophysiology, symptom severity, and clinician/unit expertise should guide the respiratory management. Early identification and concomitant management of PPHN is critically important as it contributes significantly to mortality and morbidities.
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Affiliation(s)
- Ahmed Osman
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA.
| | - Cecilie Halling
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Mary Crume
- Neonatal-Perinatal Fellowship Program, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Hayat Al Tabosh
- Pediatrics Residency Program, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Namrita Odackal
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
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Ball MK, Seabrook RB, Bonachea EM, Chen B, Fathi O, Nankervis CA, Osman A, Schlegel AB, Magers J, Kulpa T, Sharpin P, Snyder ML, Gajarski RJ, Nandi D, Backes CH. Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2023; 40:1495-1508. [PMID: 34852367 DOI: 10.1055/a-1711-0778] [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] [Indexed: 10/19/2022]
Abstract
Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..
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Affiliation(s)
- Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ruth B Seabrook
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Elizabeth M Bonachea
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Bernadette Chen
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics Pulmonary Hypertension Group, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Omid Fathi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Craig A Nankervis
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ahmed Osman
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy B Schlegel
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jacqueline Magers
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Taylor Kulpa
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Paula Sharpin
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Mary Lindsay Snyder
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Robert J Gajarski
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Deipanjan Nandi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Carl H Backes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Department of Pediatrics, Columbus, Ohio
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Breinig S, Ehlinger V, Rozé JC, Storme L, Torchin H, Durrmeyer X, Cambonie G, Delacourt C, Jarreau PH, Berthomieu L, Brissaud O, Benhammou V, Gascoin G, Arnaud C, Ancel PY. Pulmonary hypertension among preterm infants born at 22 through 32 weeks gestation in France: Prevalence, survival, morbidity and management in the EPIPAGE-2 cohort study. Early Hum Dev 2023; 184:105837. [PMID: 37595540 DOI: 10.1016/j.earlhumdev.2023.105837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/16/2023] [Accepted: 07/30/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To determine the prevalence, short-term prognosis and pharmacologic management of pulmonary hypertension (PH) among very preterm infants born before 32 weeks gestation (WG). STUDY DESIGN In the EPIPAGE-2 French national prospective population-based cohort of preterm infants born in 2011, those presenting with PH were identified and prevalence was estimated using multiple imputation. The primary outcome was survival without severe morbidity at discharge and was compared between infants with or without PH after adjusting for confounders, using generalized estimating equations models. Subgroup analysis was performed according to gestational age (GA) groups. RESULTS Among 3383 eligible infants, 3222 were analyzed. The prevalence of PH was 6.0 % (95 % CI, 5.2-6.9), 14.5 % in infants born at 22-27+6 WG vs 2.7 % in infants born at 28-31+6 WG (P < .001). The primary outcome (survival without severe morbidity at discharge) occurred in 30.2 % of infants with PH vs 80.2 % of infants without PH (P < .001). Adjusted incidence rate ratios for survival without severe morbidity among infants with PH were 0.42 (0.32-0.57) and 0.52 (0.39-0.69) in infants born at 22-27+6 weeks gestation and those born at 28-31+6 weeks, respectively. Among infants with PH, 92.2 % (95 % CI, 87.7-95.2) received sedation and/or analgesia, 63.5 % (95 % CI, 56.6-69.9) received inhaled NO and 57.6 % (95 % CI, 50.9-64.0) received hemodynamic treatments. CONCLUSION In this population-based cohort of very preterm infants, the prevalence of PH was 6 %. PH was associated with a significant decrease of survival without severe morbidity in this population.
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Affiliation(s)
- Sophie Breinig
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France; Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France.
| | - Virginie Ehlinger
- Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France
| | | | - Laurent Storme
- Neonatal Intensive Care Unit, Lille University Hospital, Lille, France
| | - Heloise Torchin
- Neonatal Intensive Care Unit, Maternité Cochin-Port Royal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Gilles Cambonie
- Neonatal and Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Christophe Delacourt
- Department of Pediatric Pneumology, Necker Children's Hospital, Paris University Hospital, Paris, France
| | - Pierre-Henri Jarreau
- Neonatal Intensive Care Unit, Maternité Cochin-Port Royal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Berthomieu
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Olivier Brissaud
- Neonatal and Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Valérie Benhammou
- INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris, France
| | - Geraldine Gascoin
- Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France; Neonatal Intensive Care Unit, Children's Hospital, Toulouse University Hospital, Toulouse, France
| | - Catherine Arnaud
- Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France; Clinical Epidemiology Unit, Toulouse University Hospital, Toulouse, France
| | - Pierre-Yves Ancel
- INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris, France
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Kaltsogianni O, Dassios T, Harris C, Jenkinson A, Lee RA, Sugino M, Greenough A. Closed-loop oxygen system in late preterm/term, ventilated infants with different severities of respiratory disease. Acta Paediatr 2023; 112:1185-1189. [PMID: 36656138 DOI: 10.1111/apa.16678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023]
Abstract
AIM To evaluate closed-loop automated oxygen control (CLAC) in ventilated infants >33 weeks of gestation with different respiratory disease severities. METHODS Infants were studied on two consecutive days for 6 h each day. They were randomised to receive standard care or standard care with CLAC (Oxygenie) first. Analyses were performed of the results of infants with or without an FiO2 ≥ 0.3 and infants with congenital diaphragmatic hernia (CDH). RESULTS Thirty-one infants with a median (IQR) gestational age of 37.9 (37.1-38.9) weeks were studied at a median postmenstrual age (IQR) of 38.9 (37.4-39.8) weeks. In infants with an FiO2 ≥ 0.3 (n = 8), CLAC increased the time spent in target oxygen range (92-96%) by 61.6% (p = 0.018), whereas in infants with an FiO2 < 0.3, the time in target was increased by 3.8% (p = 0.019). During CLAC, only infants with an FiO2 ≥ 0.3 spent less time in hyperoxemia (SpO2 > 96%) (p = 0.012) and hyperoxemic episodes were shorter (p = 0.012). In both groups, CLAC reduced the duration of desaturations (SpO2 < 92%, p < 0.001). In CDH infants, CLAC increased the time spent in target oxygen range by 34% (p = 0.036) and the median duration of desaturations was reduced (p = 0.028). CONCLUSION CLAC may be more useful in infants with more severe respiratory distress.
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Affiliation(s)
- Ourania Kaltsogianni
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- 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
| | - Christopher Harris
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Allan Jenkinson
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rebecca Ann Lee
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Klymenko T, Kononovych M. Clinical significance of correlation between persistent pulmonary hypertension and 8-hydroxy-2-desoxyguanosine level in premature newborns. J Neonatal Perinatal Med 2022; 16:81-85. [PMID: 36530094 DOI: 10.3233/npm-221005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Persistent pulmonary hypertension is a problem that leads to high morbidity and mortality in preterm infants. In clinical studies, oxidative stress (OS) contributes to the development of pulmonary hypertension (PH). The most specific biomarker of OS in preterm infants is urinary 8-hydroxy-2-deoxyguanosine (8-OHdG). The aim of the study was to determine the clinical correlation between the value of 8-OHdG and the level of a mean pressure in the pulmonary artery (mPAP) in premature infants with respiratory distress syndrome (RDS) and asphyxia in the early neonatal period. METHODS: Determination of the urinary 8-OHdG value and PH in 96 premature infants born at gestational age of 26–32 weeks on the 1st and the 3rd–5th days of life in two groups: group I –52 children with respiratory distress syndrome; II –44 children with RDS associated with perinatal asphyxia. RESULTS: The 2nd group of children had higher average mPAP level, mmHg, both in the 1st and in the 3rd–5th day of life compared with the 1st group. The value of the urinary 8-OHdG correlated with the manifestation of PH that required prolonged respiratory support in group II. CONCLUSION: Perinatal asphyxia in preterm infants with RDS on the 1st day of life complicates the course of PH, as indicated by a higher level of the urinary 8-OHdG and correlated to mPAP. Gender characteristics of the dynamics of 8-OHdG levels in children with perinatal pathology reveal reduced adaptability and reactivity of boys to OS at birth.
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Affiliation(s)
- T.M. Klymenko
- Kharkiv Medical Academy of Postgraduate Education, Kharkiv, Ukraine
| | - M.I. Kononovych
- Municipal Non-Profit Enterprise City Perinatal Center of Kharkiv city, Kharkiv, Ukraine
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11
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Maneenil G, Janjindamai W, Dissaneevate S, Thatrimontrichai A. Risk factors of transient tachypnea of the newborn developing into pulmonary hypertension of the newborn: a case-control study. ASIAN BIOMED 2022; 16:310-315. [PMID: 37551353 PMCID: PMC10392143 DOI: 10.2478/abm-2022-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Background Transient tachypnea of the newborn (TTN) is the consequence of delayed resorption of lung fluid. When TTN develops, the infant may develop severe hypoxemia and progress to persistent pulmonary hypertension of the newborn (PPHN). Objectives To examine factors associated with the development of PPHN in TTN infants. Methods This retrospective study comprised 23 infants in whom a diagnosis of TTN with PPHN (TTN-PPHN) was confirmed and 59 infants with severe TTN without PPHN who required mechanical ventilation between 2009 and 2018 at Songklanagarind Hospital, Thailand. Logistic regression was used to assess factors associated with TTN and PPHN. Results The factors identified by univariate analysis that were associated with development of PPHN were oxygen saturation (SpO2) <90% and respiratory rate (RR) ≥70 breaths/min at the time of admission, mean airway pressure (MAP) ≥8 cmH2O, oxygen index (OI) ≥10, partial pressure of oxygen (PaO2) ≤60, partial pressure of carbon dioxide (PCO2) ≥45 mmHg, and infants who did not receive positive pressure ventilation (PPV). In multivariate analyses, RR ≥70 breaths/min (adjusted odds ratio [aOR] 9.96, 95% confidence interval [CI] 2.1-47.29, P < 0.001) and OI ≥10 (aOR 29.22, 95% CI 4.46-191.23, P < 0.001) remained statistically significantly associated with PPHN. Conclusions High RR and high OI were factors associated with PPHN in TTN infants.
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Affiliation(s)
- Gunlawadee Maneenil
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla90110, Thailand
| | - Waricha Janjindamai
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla90110, Thailand
| | - Supaporn Dissaneevate
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla90110, Thailand
| | - Anucha Thatrimontrichai
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla90110, Thailand
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12
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Stewart DL, Elsayed Y, Fraga MV, Coley BD, Annam A, Milla SS. Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics 2022; 150:190110. [PMID: 37154781 DOI: 10.1542/peds.2022-060053] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/29/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes.
In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation.
Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved.
This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.
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Affiliation(s)
- Dan L Stewart
- Department of Pediatrics and International Pediatrics, Norton Children's Neonatology Affiliated with University of Louisville School of Medicine, Louisville, Kentucky
| | - Yasser Elsayed
- Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba-Canada, Health Sciences Centre-Winnipeg, Winnipeg, Manitoba, Canada
| | - María V Fraga
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian D Coley
- Departments of Radiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aparna Annam
- Departments of Radiology and Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Vascular Anomalies Center, Aurora, Colorado
| | - Sarah Sarvis Milla
- Departments of Radiology and Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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13
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Saikia Q, Hazarika A, Mishra R. A Review on the Pharmacological Importance of PDE5 and Its Inhibition to Manage Biomedical Conditions. J Pharmacol Pharmacother 2022. [DOI: 10.1177/0976500x221129008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Phosphodiesterase type 5 (PDE5) is a cyclic GMP (cGMP) specific protein. It hydrolyzes the phosphodiesterase linkage and catalyzes the conversion of cGMP to 5’ GMP, which controls different physiological activities of the body. PDE5 is associated with biomedical conditions like neurological disorders, pulmonary arterial hypertension, cardiomyopathy, cancer, erectile dysfunction, and lower urinary tract syndrome. Inhibition of PDE5 has now been proven pharmaceutically effective in a variety of therapeutic conditions. Avanafil, tadalafil, sildenafil, and vardenafil are the most commonly used PDE5 inhibitors (PDE5i) today which are often used for the management of erectile dysfunction, lower urinary tract syndromes, malignancy, and pulmonary arterial hypertension. However, these synthetic PDE5i come with a slew of negative effects. Some of the most common side effects include mild headaches, flushing, dyspepsia, altered color vision, back discomfort, priapism, melanoma, hypotension and dizziness, non-arteritic anterior ischemic optic neuropathy (NAION), and hearing loss. In light of the potential negative effects of this class of medications, there is a lot of room for new, selective PDE5 inhibitors to be discovered. We have found 25 plant botanical compounds effectively inhibiting PDE5 which might be useful in treating a variety of disorders with minimal or no adverse effects.
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Affiliation(s)
- Queen Saikia
- Department of Zoology, Gauhati University, Guwahati, Assam, India
| | - Ajit Hazarika
- Tyagbir Hem Baruah College, Jamugurihat, Sonitpur, Assam, India
| | - Ritu Mishra
- Department of Zoology, Gauhati University, Guwahati, Assam, India
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14
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Mahmood B. Persistent pulmonary hypertension of newborn. Semin Pediatr Surg 2022; 31:151202. [PMID: 36038220 DOI: 10.1016/j.sempedsurg.2022.151202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Burhan Mahmood
- Division of Newborn Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pennsylvania, USA.
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15
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Cookson MW, Abman SH, Kinsella JP, Mandell EW. Pulmonary vasodilator strategies in neonates with acute hypoxemic respiratory failure and pulmonary hypertension. Semin Fetal Neonatal Med 2022; 27:101367. [PMID: 35688685 PMCID: PMC10329862 DOI: 10.1016/j.siny.2022.101367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The management of acute hypoxemic respiratory failure (AHRF) in newborns continues to be a clinical challenge with elevated risk for significant morbidities and mortality, especially when accompanied with persistent pulmonary hypertension of the newborn (PPHN). PPHN is a syndrome characterized by marked hypoxemia secondary to extrapulmonary right-to-left shunting across the ductus arteriosus and/or foramen ovale with high pulmonary artery pressure and increased pulmonary vascular resistance (PVR). After optimizing respiratory support, cardiac performance and systemic hemodynamics, targeting persistent elevations in PVR with inhaled nitric oxide (iNO) therapy has improved outcomes of neonates with PPHN physiology. Despite aggressive cardiopulmonary management, a significant proportion of patients have an inadequate response to iNO therapy, prompting consideration for additional pulmonary vasodilator therapy. This article reviews the pathophysiology and management of PPHN in term newborns with AHRF while highlighting both animal and human data to inform a physiologic approach to the use of PH-targeted therapies.
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Affiliation(s)
- Michael W Cookson
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States; Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States.
| | - Steven H Abman
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States; Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States; Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Erica W Mandell
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States; Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
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16
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Jain A, Giesinger RE, Dakshinamurti S, ElSayed Y, Jankov RP, Weisz DE, Lakshminrusimha S, Mitra S, Mazwi ML, Ting J, Narvey M, McNamara PJ. Care of the critically ill neonate with hypoxemic respiratory failure and acute pulmonary hypertension: framework for practice based on consensus opinion of neonatal hemodynamics working group. J Perinatol 2022; 42:3-13. [PMID: 35013586 DOI: 10.1038/s41372-021-01296-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/17/2021] [Accepted: 12/02/2021] [Indexed: 11/09/2022]
Abstract
Circulatory transition after birth presents a critical period whereby the pulmonary vascular bed and right ventricle must adapt to rapidly changing loading conditions. Failure of postnatal transition may present as hypoxemic respiratory failure, with disordered pulmonary and systemic blood flow. In this review, we present the biological and clinical contributors to pathophysiology and present a management framework.
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Affiliation(s)
- Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | | | - Yasser ElSayed
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Robert P Jankov
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Souvik Mitra
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Mjaye L Mazwi
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Joseph Ting
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Michael Narvey
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
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17
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Elsayed YN, Dakshinamurti S. Titration of inspired oxygen in preterm infants with hypoxemic respiratory failure using near-infrared spectroscopy and pulse oximetry: A new approach. Pediatr Pulmonol 2021; 56:3870-3878. [PMID: 34549553 DOI: 10.1002/ppul.25673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/13/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Titration of inspired oxygen is a challenge in preterm infants with hypoxemic respiratory failure (HRF). Monitoring of brain oxygen by near-infrared spectroscopy (NIRS) has been proven to minimize the burden of hyperoxia and hypoxemia; with a better understanding of cerebral autoregulation, integrating NIRS and pulse oximetry for titrating inspired oxygen in preterm infants is a novel approach. METHODS We studied the impact of integrated monitoring of oxygen saturation by pulse oximetry (SpO2 ) and cerebral regional tissue oxygen (crRTO) by NIRS during a stepwise oxygen reduction test (ORT) on reducing oxygen requirement in preterm infants with HRF. The correlation between SpO2 with crRTO, and fractional oxygen extraction (FOE) was assessed, concordance levels (r > 0.5) were determined during the assessment period and were considered as a sign of impaired autoregulation. The primary outcome was the achievement of significantly lower FiO2 at 72 h after the start of the integrated monitoring. RESULTS A total of 38 preterm infants were included, 27 had normal cerebral autoregulation (CAR) (Group 1) in whom SpO2 was poorly correlating with crRTO with (r < 0.5) and had a significantly greater percentage of reduction below baseline in FiO2 (mean: 34%). Eleven infants had impaired CAR (Group 2) with SpO2 significantly correlating with crRTO (r > 0.5) and had a linear trend of FOE inverse to SpO2 and crRTO; this was considered as an arterial saturation dependent oxygen delivery (SadDO2 ). CONCLUSION Integrated monitoring of preterm infants by SpO2 and crRTO was associated with easier weaning of oxygen with less burden of both hyperoxia and hypoxemia.
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Affiliation(s)
- Yasser N Elsayed
- Section of Neonatology, University of Manitoba, Winnipeg, Canada
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18
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Arshad MS, Adnan M, Anwar-Ul-Haq HM, Zulqarnain A. Postnatal causes and severity of persistent pulmonary Hypertension of Newborn. Pak J Med Sci 2021; 37:1387-1391. [PMID: 34475917 PMCID: PMC8377898 DOI: 10.12669/pjms.37.5.2218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/10/2020] [Accepted: 05/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background & Objective: Persistent pulmonary hypertension of the newborn (PPHN) is described as severe respiratory failure along with hypoxaemia. PPHN is known to be linked with high morbidity and mortality around the world. This study was planned to determine the postnatal causes and assess the severity of persistent pulmonary hypertension of newborn in babies presenting to the Children’s Hospital, Multan. Methods: This observational study was conducted at the Department of Paediatric Cardiology, The Children Hospital &Institute of Child Health, Multan, Pakistan from July to December 2019. A total of 122 confirmed cases of PPHN admitted having gestational age above 34 weeks were enrolled. Demographic data of the newborns was recorded along with maternal medical history, pregnancy status and postnatal causes of PPHN. Severity of PPHN was also recorded. Results: Out of a total of 122 cases of PPHN, 81 (66.3%) were male. Majority, 78 (64.0%) had gestational age above 37 weeks. Mode of delivery as cesarean section was noted in 70 (57.4%). Meconium aspiration syndrome 52 (42.6%), birth asphyxia 48 (39.3%), respiratory distress syndrome 23 (18.8%) and sepsis 33 (27.0%) were found to be the commonest causes of PPHN. Severe PPHN was found to be the most frequent, noted among 63 (51.6%) while Moderate PPHN was observed in 40 (32.8%) and Mild PPHN in 19 (15.6%). Morality was noted among 26 (21.3%) of cases. Conclusion: Meconium aspiration syndrome, birth asphyxia and respiratory distress syndrome were the commonest postnatal causes of PPHN. Severe PPHN was found to be the most frequent form of PPHN.
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Affiliation(s)
- Muhammad Sohail Arshad
- Dr. Muhammad Sohail Arshad, FCPS (Paeds Cardiology) Department of Paediatric Cardiology, The Children's Hospital & the Institute of Child Health, Multan, Pakistan
| | - Mudasser Adnan
- Dr. Mudasser Adnan, FCPS (Paeds Medicine) Department of Paediatric Cardiology, The Children's Hospital & the Institute of Child Health, Multan, Pakistan
| | - Hafiz Muhammad Anwar-Ul-Haq
- Dr. Hafiz Muhammad Anwar-ul-Haq, FCPS (Paeds Medicine) Department of Paediatric Cardiology, The Children's Hospital & the Institute of Child Health, Multan, Pakistan
| | - Arif Zulqarnain
- Dr. Arif Zulqarnain, FCPS (Paeds Medicine) Department of Paediatric Cardiology, The Children's Hospital & the Institute of Child Health, Multan, Pakistan
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19
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Hemodynamic response to milrinone for refractory hypoxemia during therapeutic hypothermia for neonatal hypoxic ischemic encephalopathy. J Perinatol 2021; 41:2345-2354. [PMID: 33850285 DOI: 10.1038/s41372-021-01049-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/24/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Characterize the impact of milrinone on arterial pressure of neonates with persistent hypoxemic respiratory failure (HRF) and hypoxic ischemic encephalopathy (HIE) treated with inhaled nitric oxide and therapeutic hypothermia (TH). STUDY DESIGN Retrospective cohort study. Arterial pressure was assessed hourly for 24 h. The primary outcome was change in diastolic arterial pressure (DAP). RESULTS 56 patients were included [(i) cases: HIE/TH who received milrinone (n = 9), (ii) Milrinone controls (n = 17), (iii) HIE controls (n = 30)]. Baseline demographics, severity of HRF and arterial pressure were comparable between groups. Only milrinone treated patients with HIE/TH had a marked drop in DAP in the first hour, which persisted for more than 12 h despite escalation in inotropes (p = 0.008). CONCLUSION Milrinone treated patients with HRF and HIE/TH develop profound reduction in DAP and require escalation of cardiovascular support. The risk benefit profile of milrinone should be considered and pharmacological studies are warranted to evaluate drug metabolism and clearance in this population.
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20
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Kawasumi T, Takeno S, Ishikawa C, Takahara D, Taruya T, Takemoto K, Hamamoto T, Ishino T, Ueda T. The Functional Diversity of Nitric Oxide Synthase Isoforms in Human Nose and Paranasal Sinuses: Contrasting Pathophysiological Aspects in Nasal Allergy and Chronic Rhinosinusitis. Int J Mol Sci 2021; 22:ijms22147561. [PMID: 34299181 PMCID: PMC8304068 DOI: 10.3390/ijms22147561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
The human paranasal sinuses are the major source of intrinsic nitric oxide (NO) production in the human airway. NO plays several roles in the maintenance of physiological homeostasis and the regulation of airway inflammation through the expression of three NO synthase (NOS) isoforms. Measuring NO levels can contribute to the diagnosis and assessment of allergic rhinitis (AR) and chronic rhinosinusitis (CRS). In symptomatic AR patients, pro-inflammatory cytokines upregulate the expression of inducible NOS (iNOS) in the inferior turbinate. Excessive amounts of NO cause oxidative damage to cellular components, leading to the deposition of cytotoxic substances. CRS phenotype and endotype classifications have provided insights into modern treatment strategies. Analyses of the production of sinus NO and its metabolites revealed pathobiological diversity that can be exploited for useful biomarkers. Measuring nasal NO based on different NOS activities is a potent tool for specific interventions targeting molecular pathways underlying CRS endotype-specific inflammation. We provide a comprehensive review of the functional diversity of NOS isoforms in the human sinonasal system in relation to these two major nasal disorders' pathologies. The regulatory mechanisms of NOS expression associated with the substrate bioavailability indicate the involvement of both type 1 and type 2 immune responses.
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Affiliation(s)
| | - Sachio Takeno
- Correspondence: ; Tel.: +81-82-257-5252; Fax: +81-82-257-5254
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21
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Inhaled Nitric Oxide at Birth Reduces Pulmonary Vascular Resistance and Improves Oxygenation in Preterm Lambs. CHILDREN-BASEL 2021; 8:children8050378. [PMID: 34064629 PMCID: PMC8150344 DOI: 10.3390/children8050378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022]
Abstract
Resuscitation with 21% O2 may not achieve target oxygenation in preterm infants and in neonates with persistent pulmonary hypertension of the newborn (PPHN). Inhaled nitric oxide (iNO) at birth can reduce pulmonary vascular resistance (PVR) and improve PaO2. We studied the effect of iNO on oxygenation and changes in PVR in preterm lambs with and without PPHN during resuscitation and stabilization at birth. Preterm lambs with and without PPHN (induced by antenatal ductal ligation) were delivered at 134 d gestation (term is 147–150 d). Lambs without PPHN were ventilated with 21% O2, titrated O2 to maintain target oxygenation or 21% O2 + iNO (20 ppm) at birth for 30 min. Preterm lambs with PPHN were ventilated with 50% O2, titrated O2 or 50% O2 + iNO. Resuscitation with 21% O2 in preterm lambs and 50%O2 in PPHN lambs did not achieve target oxygenation. Inhaled NO significantly decreased PVR in all lambs and increased PaO2 in preterm lambs ventilated with 21% O2 similar to that achieved by titrated O2 (41 ± 9% at 30 min). Inhaled NO increased PaO2 to 45 ± 13, 45 ± 20 and 76 ± 11 mmHg with 50% O2, titrated O2 up to 100% and 50% O2 + iNO, respectively, in PPHN lambs. We concluded that iNO at birth reduces PVR and FiO2 required to achieve target PaO2.
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22
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Figueroa EG, Gonzaléz-Candia A, Villanueva CA, Ebensperger G, Reyes RV, Llanos AJ, Herrera EA. Beneficial effects of melatonin on prostanoids pathways in pulmonary hypertensive neonates. Vascul Pharmacol 2021; 138:106853. [PMID: 33766627 DOI: 10.1016/j.vph.2021.106853] [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: 09/28/2020] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 01/04/2023]
Abstract
Pulmonary arterial hypertension of the newborn (PAHN) is a syndrome caused by chronic hypoxia, characterized by decreased vasodilator function, a marked vasoconstrictor activity, proliferation of smooth muscle cells (SMC) and thickening of the extracellular matrix in the pulmonary circulation, among other characteristics. Prostaglandins are derived from the arachidonic acid (AA) metabolism and are important regulators of pulmonary vascular tone. Since hypoxia induces oxidative stress and has been related to PAHN, a postnatal treatment with melatonin has been proposed due to its antioxidant properties. Here, we determined the effects of melatonin on pulmonary vascular homeostasis given by prostanoids. Ten PAHN newborn lambs were divided in two groups and treated either with vehicle or melatonin. After 1 week of treatment, we assessed pulmonary vascular prostanoids function and expression by wire myography, RT-PCR, Western Blot and immunohistochemistry. Melatonin improved in vivo and ex vivo pulmonary vasodilation. This was associated with an increased function and expression of vasodilator prostanoids at the expense of vasoconstrictor prostanoids. Our study demonstrates for the first time that melatonin may enhance the vasodilator prostanoid pathway in PAHN.
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Affiliation(s)
- Esteban G Figueroa
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile
| | - Alejandro Gonzaléz-Candia
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile; Institute of Health Sciences, University of O'Higgins, Rancagua, Chile
| | - Cristian A Villanueva
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile
| | - Germán Ebensperger
- Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile
| | - Roberto V Reyes
- Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile
| | - Aníbal J Llanos
- Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile; International Center for Andean Studies (INCAS), Universidad de Chile, Chile
| | - Emilio A Herrera
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile; Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Chile; International Center for Andean Studies (INCAS), Universidad de Chile, Chile.
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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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Abed NT, Abdelhaie OM, Almonaem ERA, Mansour AI. Relation of asymmetric dimethylarginine with pulmonary morbidities in neonatal respiratory distress syndrome. J Neonatal Perinatal Med 2021; 14:511-517. [PMID: 33646184 DOI: 10.3233/npm-200604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Asymmetric Dimethyl Arginine (ADMA) is an endogenous inhibitor of nitric oxide synthase (NOS) is important in different diseases characterized by decreased nitric oxide (NO) availability. We aimed to assess the serum ADMA level in preterm infants suffering from respiratory distress syndrome (RDS) and its relationship with pulmonary outcomes. METHODS This prospective study included 50 preterm neonates suffering from RDS aging≤32 weeks and weighing≤1500 gm. Serum ADMA levels were estimated in the 1st and 28th day of life by ELISA, and its correlation with surfactant requirement, duration of ventilation, and development of BPD was assessed. RESULTS Fifty preterm infants with RDS were included, 30 infants were treated with surfactant within 12 hours after birth, the 1stday ADMA level was higher significantly in infants who required surfactant treatment than infants without surfactant treatment, At 36 weeks postmenstrual age, 16 infants were diagnosed with BPD, the 28th day ADMA level was significantly higher in infants with BPD than others without BPD. 1st-day ADMA level was significantly correlated with days on mechanical ventilation but there were no significant correlations between 1st day ADMA and days on CPAP and days on supplemental O2. CONCLUSION Elevated serum ADMA level in preterm neonates with RDS estimated in the 1st and 28th day of life is a good predictor for pulmonary morbidities such as surfactant requirement, duration of mechanical ventilation, and development of BPD.
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Affiliation(s)
- N T Abed
- Pediatric Department, Faculty of Medicine, Benha University, Egypt
| | - O M Abdelhaie
- Pediatric Department, Faculty of Medicine, Benha University, Egypt
| | - E R A Almonaem
- Pediatric Department, Faculty of Medicine, Benha University, Egypt
| | - A I Mansour
- Clinical Pathology Department, Faculty of Medicine, Benha University, Egypt
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Hamza W, AbdElaal N, Awad H, Tawfik S, Elsayed Y. The impact of targeted oxygen reduction test in preterm infants on reducing the oxygen exposure. J Neonatal Perinatal Med 2021; 14:61-65. [PMID: 32538878 DOI: 10.3233/npm-200459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Caring for infants on respiratory support is a challenge in the middle-income countries, applying a protocol of targeted oxygen reduction test (tORT) guided by daily assessment of oxygen histograms is novel and practical approach. OBJECTIVE To study the impact of tORT guided by daily assessment of oxygen histograms as a quality improvement project aiming to decrease days on oxygen support, and duration of hospital admission in preterm infants. STUDY DESIGN A quality project conducted in neonatal intensive care units (NICU) of two hospitals, from 2017- 2018 (Epochs II). After a period of observation of a cohort of preterm Infants, 2016-2017 (Epoch I). The main aims were to reduce days on oxygen and hospital admission days. All infants in Epoch II underwent daily assessment of oxygen histograms and a trial of oxygen reduction if applicable as per a predefined protocol. Comparison was made between these two Epochs, and the primary outcome was the time to successful discontinuation of oxygen support. RESULTS Fifty-nine infants were included; 30 underwent the protocolized tORT (Epoch II) with a median (IQR) of 4 (2-6) tORC per infant. Postanal age at presentation (time of initial tORT assessment was performed at the postnatal age of 8 (5, 13) days. Days on oxygen and total numbers of hospital days were significantly less in Epoch II. Oxygen histograms significantly improved after tORT. CONCLUSIONS Applying tORT guided by oxygen histograms may have a significant impact on oxygen exposure and hospitalization days of patients admitted to the NICU.
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Affiliation(s)
| | | | - H Awad
- Ain Shams University, Egypt
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Qasim A, Jain SK. Milrinone Use in Persistent Pulmonary Hypertension of the Newborn. Neoreviews 2021; 21:e165-e178. [PMID: 32123121 DOI: 10.1542/neo.21-3-e165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Failure of the normal transition from in utero to ex utero physiology leads to "persistent" pulmonary hypertension of the newborn (PPHN). PPHN is frequently associated with low systemic blood pressure and low cardiac output because of increased right ventricular afterload and myocardial dysfunction. The general management of newborns with PPHN is geared toward maintenance of normothermia, normal serum electrolytes, normal intravascular volume, correction of acidosis, adequate sedation/analgesia, adequate ventilation and oxygenation with optimal lung recruitment, and avoidance of hyperoxia. Inotropic and vasoactive agents are commonly initiated early to increase cardiac output, maintain adequate systemic blood pressure, and enhance oxygen delivery to the tissue. Unfortunately, there is not much evidence on the choice, timing of initiation, dosing, monitoring, and titrating of vasoactive agents in this patient population. In this review, we will discuss the pathophysiology of PPHN and review the use of inotropic, lusitropic, and vasoactive agents in the management of PPHN, with particular attention to milrinone.
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Affiliation(s)
- Amna Qasim
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Sunil K Jain
- Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch, Galveston, TX
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Vieira F, Makoni M, Szyld E, Sekar K. The Controversy Persists: Is There a Qualification Criterion to Utilize Inhaled Nitric Oxide in Pre-term Newborns? Front Pediatr 2021; 9:631765. [PMID: 33869113 PMCID: PMC8044816 DOI: 10.3389/fped.2021.631765] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/01/2021] [Indexed: 11/22/2022] Open
Abstract
Inhaled nitric oxide (iNO) use in premature newborns remains controversial among clinicians. In 2014, the American Academy of Pediatrics, Committee on Fetus and Newborn released a statement that the available data do not support routine iNO use in pre-term newborns. Despite the absence of significant benefits, 2016 California data showed that clinicians continue to utilize iNO in pre-term infants. With studies as recent as January 2017, the Cochrane review confirmed no major advantages of iNO in pre-term newborns. Still, it recognized that a subset of pre-term infants with pulmonary hypertension (PHTN) had not been separately investigated. Furthermore, recent non-randomized controlled trials have suggested that iNO may benefit specific subgroups of pre-term newborns, especially those with PHTN, prolonged rupture of membranes, and antenatal steroid exposure. Those pre-term infants who showed a clinical response to iNO had increased survival without disability. These findings underscore the need for future studies in pre-term newborns with hypoxemic respiratory failure and PHTN. This review will discuss the rationale for using iNO, controversies regarding the diagnosis of PHTN, and additional novel approaches of iNO treatment in perinatal asphyxia and neonatal resuscitation in the pre-term population < 34 weeks gestation.
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Affiliation(s)
- Frederico Vieira
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Marjorie Makoni
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Edgardo Szyld
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Abstract
Oxidative stress (OS) plays a key role in the pathophysiology of preterm infants. Accurate assessment of OS remains an analytical challenge that has been partially addressed during the last few decades. A plethora of approaches have been developed to assess preterm biofluids to demonstrate a link postnatally with preterm OS, giving rise to a set of widely employed biomarkers. However, the vast number of different analytic methods and lack of standardization hampers reliable comparison of OS-related biomarkers. In this chapter, we discuss approaches for the study of OS in prematurity with respect to methodologic considerations, the metabolic source of different biomarkers and their role in clinical studies.
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Rawat M, Chandrasekharan P, Gugino SF, Koenigsknecht C, Nielsen L, Wedgwood S, Mathew B, Nair J, Steinhorn R, Lakshminrusimha S. Optimal Oxygen Targets in Term Lambs with Meconium Aspiration Syndrome and Pulmonary Hypertension. Am J Respir Cell Mol Biol 2020; 63:510-518. [PMID: 32609558 PMCID: PMC7528912 DOI: 10.1165/rcmb.2019-0449oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/01/2020] [Indexed: 12/13/2022] Open
Abstract
Optimal oxygen saturation as measured by pulse oximetry (SpO2) in neonatal lung injury, such as meconium aspiration syndrome (MAS) and persistent pulmonary hypertension of newborn (PPHN), is not known. Our goal was to determine the SpO2 range in lambs with MAS and PPHN that results in the highest brain oxygen delivery (bDO2) and pulmonary blood flow (Qp) and the lowest pulmonary vascular resistance and oxidative stress. Meconium was instilled into endotracheal tubes in 25 near-term gestation lambs, and the umbilical cord was occluded to induce asphyxia and gasping, causing MAS and PPHN. Lambs were randomized into four groups and ventilated for 6 hours with fixed fraction of inspired oxygen (FiO2) = 1.0 irrespective of SpO2, and three groups had FiO2 titrated to keep preductal SpO2 between 85% and 89%, 90% and 94%, and 95% and 99%, respectively. Tissues were collected to measure nitric oxide synthase activity, 3-nitrotyrosine, and 8-isoprostanes. Throughout the 6-hour exposure period, lambs in the 95-99% SpO2 target group had the highest Qp, lowest pulmonary vascular resistance, and highest bDO2 but were exposed to higher FiO2 (0.5 ± 0.21 vs. 0.29 ± 0.17) with higher lung 3-nitrotyrosine (0.67 [interquartile range (IQR), 0.43-0.73] ng/mcg protein vs. 0.1 [IQR, 0.09-0.2] ng/mcg protein) and lower lung nitric oxide synthase activity (196 [IQR, 192-201] mMol nitrite/mg protein vs. 270 [IQR, 227-280] mMol nitrite/mg protein) compared with the 90-94% target group. Brain 3-nitrotyrosine was lower in the 85-89% target group, and brain/lung 8-isoprostane levels were not significantly different. In term lambs with MAS and PPHN, Qp and bDO2 through the first 6 hours are higher with target SpO2 in the 95-99% range. However, the 90-94% target range is associated with significantly lower FiO2 and lung oxidative stress. Clinical trials comparing the 90-94% versus the 95-99% SpO2 target range in term infants with PPHN are warranted.
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Affiliation(s)
| | | | - Sylvia F. Gugino
- Department of Pediatrics and
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | | | - Lori Nielsen
- Department of Pediatrics and
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | - Stephen Wedgwood
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; and
| | | | | | - Robin Steinhorn
- Department of Pediatrics, Rady Children’s Hospital, University of California San Diego, California
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; and
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Abstract
Primary function of cardiovascular system is to meet body's metabolic demands. The aim of inotrope therapy is to minimise adverse impact of cardiovascular compromise. Current use of inotropes is primarily guided by the pathophysiology of cardiovascular compromise and anticipated actions of inotropes. Lack of significant reduction in morbidity and mortality associated with cardiovascular compromise despite inotrope use, highlights major gaps in our understanding of circulatory targets, thresholds and choices of inotrope therapy. Thus far, prevention of cardiovascular compromise remains the most effective strategy to optimize outcomes. Studies of alternative design are needed for further advancement in cardiovascular therapy in neonates.
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Affiliation(s)
- Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia.
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia
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Steinhorn RH, Lakshminrusimha S. Oxygen and pulmonary vasodilation: The role of oxidative and nitrosative stress. Semin Fetal Neonatal Med 2020; 25:101083. [PMID: 31983672 DOI: 10.1016/j.siny.2020.101083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Respiratory failure complicates up to 2% of live births and contributes significantly to neonatal morbidity and mortality. Under these conditions, supplemental oxygen is required to support oxygen delivery to the brain and other organs, and to prevent hypoxic pulmonary vasoconstriction. However, therapeutic oxygen is also a source of reactive oxygen species that produce oxidative stress, along with multiple intracellular systems that contribute to the production of free radicals in pulmonary endothelium and vascular smooth muscle. These free radicals cause vasoconstriction, act on multiple sites of the nitric oxide pathway to reduce cGMP-mediated vasodilation, and nitrate and inactivate essential proteins such as surfactant. In addition to oxygen, antenatal stressors such as placental insufficiency, maternal diabetes, and fetal growth restriction increase pulmonary and vascular oxidant stress and may amplify the adverse effects of oxygen. Moreover, the effects of free radical damage may extend well beyond infancy as suggested by the increased risk of childhood malignancy after neonatal exposure to hyperoxia. Antioxidant therapy is theoretically promising, but there are not yet clinical trials to support this approach. Targeting the abnormal sources of increased oxidant stress that trigger abnormal pulmonary vascular responses may be more effective in treating disease and preventing long term consequences.
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Affiliation(s)
- Robin H Steinhorn
- George Washington University, Senior Vice President, Children's National Hospital, Washington, DC, 20010, USA.
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Chandrasekharan P, Lakshminrusimha S. Oxygen therapy in preterm infants with pulmonary hypertension. Semin Fetal Neonatal Med 2020; 25:101070. [PMID: 31836427 PMCID: PMC9188671 DOI: 10.1016/j.siny.2019.101070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Premature neonates <34 weeks gestation can present with early-onset, late-onset and bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (PHT), with clinical, echocardiographic, and histological features similar to term infants with PHT. Changes in pulmonary vascular resistance (PVR) in response to oxygen are diminished in preterm infants compared to term. Studies from preterm lambs and human infants with BPD have shown that PaO2 > 30-55 mm Hg promotes pulmonary vasodilation. Targeting saturations of 80-85% by 5 min, 85-95% by 10 min during resuscitation and 90-95% during the postnatal course are appropriate targets for routine management of preterm infants. Among preterm infants with PHT, avoiding hypoxia/hyperoxia by titrating supplemental oxygen to maintain saturations in low to mid 90s with alarm limits at 90 and 97% seems to be a reasonable approach pending further studies. Further high-quality evidence generated from randomized trials is required to guide oxygen therapy in preterm PHT.
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
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Kalra VK, Lee HC, Sie L, Ratnasiri AW, Underwood MA, Lakshminrusimha S. Change in neonatal resuscitation guidelines and trends in incidence of meconium aspiration syndrome in California. J Perinatol 2020; 40:46-55. [PMID: 31611615 DOI: 10.1038/s41372-019-0529-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/02/2019] [Accepted: 08/19/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe trends in the incidence and severity of meconium aspiration syndrome (MAS) around the release of revised Neonatal Resuscitation Program (NRP) guidelines in 2016. STUDY DESIGN The California Perinatal Quality Care Collaborative database was queried for years 2013-2017 to describe the incidence and outcomes of infants with MAS. Results were analyzed based on both individual years and pre- vs. post-guideline epochs (2013-15 vs. 2017). RESULT Incidence of MAS decreased significantly from 2013-15 to 2017 (1.02 to 0.78/1000 births, p < 0.001). Among infants with MAS, delivery room intubations decreased from 2013-15 to 2017 (44.3 vs. 35.1%; p = 0.005), but similar proportion of infants required invasive respiratory support (80.1 vs. 80.8%), inhaled nitric oxide (28.8 vs. 28.4%) or extracorporeal membrane oxygenation (0.81 vs. 0.35%). CONCLUSION While the study design precludes confirmation of implementation of the recent NRP recommendation, there was no increase in the incidence or severity of MAS following its release.
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Affiliation(s)
- Vaneet K Kalra
- Department of Pediatrics, UC Davis Health System, Sacramento, CA, USA.
| | - Henry C Lee
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Lillian Sie
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Anura W Ratnasiri
- Department of Cardiovascular medicine, UC Davis Health System, Sacramento, CA, USA
| | - Mark A Underwood
- Department of Pediatrics, UC Davis Health System, Sacramento, CA, USA
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Sekar K, Szyld E, McCoy M, Wlodaver A, Dannaway D, Helmbrecht A, Riley J, Manfredo A, Anderson M, Lakshminrusimha S, Noori S. Inhaled nitric oxide as an adjunct to neonatal resuscitation in premature infants: a pilot, double blind, randomized controlled trial. Pediatr Res 2020; 87:523-528. [PMID: 31666688 PMCID: PMC7223624 DOI: 10.1038/s41390-019-0643-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Nitric oxide (NO) plays an important role in normal postnatal transition. Our aims were to determine whether adding inhaled NO (iNO) decreases supplemental oxygen exposure in preterm infants requiring positive pressure ventilation (PPV) during resuscitation and to study iNO effects on heart rate (HR), oxygen saturation (SpO2), and need for intubation during the first 20 min of life. METHODS This was a pilot, double-blind, randomized, placebo-controlled trial. Infants 25 0/7-31 6/7 weeks' gestational age requiring PPV with supplemental oxygen during resuscitation were enrolled. PPV was initiated with either oxygen (FiO2-0.30) + iNO at 20 ppm (iNO group) or oxygen (FiO2-0.30) + nitrogen (placebo group). Oxygen was titrated targeting defined SpO2 per current guidelines. After 10 min, iNO/nitrogen was weaned stepwise per protocol and terminated at 17 min. RESULTS Twenty-eight infants were studied (14 per group). The mean gestational age in both groups was similar. Cumulative FiO2 and rate of exposure to high FiO2 (>0.60) were significantly lower in the iNO group. There were no differences in HR, SpO2, and need for intubation. CONCLUSIONS Administration of iNO as an adjunct during neonatal resuscitation is feasible without side effects. It diminishes exposure to high levels of supplemental oxygen.
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Affiliation(s)
- Krishnamurthy Sekar
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Edgardo Szyld
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Michael McCoy
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Anne Wlodaver
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Douglas Dannaway
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Ashley Helmbrecht
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Julee Riley
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Amy Manfredo
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Michael Anderson
- 0000 0001 2179 3618grid.266902.9Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK USA
| | - Satyan Lakshminrusimha
- 0000 0004 0413 7653grid.416958.7Department of Pediatrics, UC Davis Health, Sacramento, CA USA
| | - Shahab Noori
- 0000 0001 2156 6853grid.42505.36Fetal and Neonatal Institute, Division of Neonatology, Children’s Hospital of Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
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Wedgwood S, Steinhorn RH, Lakshminrusimha S. Optimal oxygenation and role of free radicals in PPHN. Free Radic Biol Med 2019; 142:97-106. [PMID: 30995536 PMCID: PMC6761018 DOI: 10.1016/j.freeradbiomed.2019.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023]
Abstract
Effective ventilation of the lungs is essential in mediating pulmonary vasodilation at birth to allow effective gas exchange and an increase in systemic oxygenation. Unsuccessful transition prevents the increase in pulmonary blood flow after birth resulting in hypoxemia and persistent pulmonary hypertension of the newborn (PPHN). Management of neonates with PPHN includes ventilation of the lungs with supplemental oxygen to correct hypoxemia. Optimal oxygenation should meet oxygen demand to the tissues and avoid hypoxic pulmonary vasoconstriction (HPV) while preventing oxidative stress. The optimal target for oxygenation in PPHN is not known. Animal models have demonstrated that PaO2<45 mmHg exacerbates HPV. However, there are no practical methods of assessing oxygen levels associated with oxidant stress. Oxidant stress can be due to free radical generation from underlying lung disease or from free radicals generated by supplemental oxygen. Free radicals act on the nitric oxide pathway reducing cGMP and promoting pulmonary vasoconstriction. Antioxidant therapy improves systemic oxygenation in an animal model of PPHN but there are no clinical trials to support such therapy. Targeting preductal SpO2 between 90 and 97% and PaO2 at 50-80 mmHg appears prudent in PPHN but clinical trials to support this practice are lacking. Preterm infants with PPHN present unique challenges due to lack of antioxidant defenses and functional and structural immaturity of the lungs. This review highlights the need for additional studies to mitigate the impact of oxidative stress in the lung and pulmonary vasculature in PPHN.
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Affiliation(s)
- Stephen Wedgwood
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA
| | - Robin H Steinhorn
- Department of Hospitalist Medicine, Children's National Health System, Washington DC, USA
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Perioperative Considerations in Pediatric Patients With Pulmonary Hypertension. Int Anesthesiol Clin 2019; 57:25-41. [PMID: 31503094 DOI: 10.1097/aia.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hsiao HF, Yang MC, Lai MY, Chu SM, Huang HR, Chiang MC, Fu RH, Hsu JF, Tsai MH. The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality. J Clin Med 2019; 8:jcm8081113. [PMID: 31357613 PMCID: PMC6722605 DOI: 10.3390/jcm8081113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/18/2019] [Accepted: 07/24/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The indication of inhaled nitric oxide (iNO) used in preterm infants has not been well defined. Neonates with refractory hypoxemia may benefit from the pulmonary vasodilatory effects of iNO. The aim of this study was to investigate the off-label use of iNO as a rescue therapy. METHODS Between January 2010 and December 2017, all neonates who received iNO as a rescue therapy from a tertiary-level medical center were enrolled, and those who were not diagnosed with persistent pulmonary hypertension of newborn (PPHN) were defined as having received off-label use of iNO. The controls were 636 neonates with severe respiratory failure requiring high-frequency oscillatory ventilation but no iNO. RESULTS A total of 206 neonates who received iNO as a rescue therapy were identified, and 84 (40.8%) had off-label use. The median (interquartile) gestational age was 30.5 (26.3-37.0) weeks. Neonates receiving iNO had significantly more severe respiratory failure and a higher oxygenation index than the controls (p < 0.001). Respiratory distress syndrome and secondary pulmonary hypertension after severe bronchopulmonary dysplasia (BPD) were the most common causes of the off-label iNO prescription. Of the 84 neonates with off-label use of iNO, 53 (63.1%) had initial improvement in oxygenation, but 44 (52.4%) eventually died. The overall mortality rate was 41.7% (86/206). After multivariate logistic regression, extremely preterm (odds ratio [OR] 5.51; p < 0.001), presence of pulmonary hemorrhage (OR 2.51; p = 0.036) and severe hypotension (OR 2.78; p = 0.008) were the independent risk factors for final mortality. CONCLUSIONS iNO is applicable to be an off-label rescue therapy for premature neonates with refractory hypoxemia due to severe pulmonary hypertension and bronchopulmonary dysplasia.
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Affiliation(s)
- Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.
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Abstract
Rates of bronchopulmonary dysplasia (BPD) are increasing. After preterm birth, there are important developmental periods in which neonates are more vulnerable to stressful events. These periods are opportunities for pharmacologic interventions. Many drugs remain inadequately tested and no new drugs have been approved in more than 25 years for BPD prevention or therapy. More progress is needed in defining appropriate end points based on the pathophysiology of BPD and postdischarge chronic pulmonary insufficiency of prematurity and to develop effective new drugs. In addition, much work is needed to better define perinatal factors, early postnatal findings, and physiologic phenotypes or endotypes.
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Abstract
OBJECTIVES Therapeutic hypothermia is standard of care in management of moderate/severe hypoxic-ischemic encephalopathy. Persistent pulmonary hypertension of the newborn is associated with hypoxic-ischemic encephalopathy and is exacerbated by hypoxemia and hypercarbia. Gas exchange is assessed by arterial blood gas analysis (with/without correction for body temperature), pulse oximetry, and end-tidal CO2. DESIGN A retrospective chart review. SETTINGS Regional perinatal center in Western New York. PATIENTS Fifty-eight ventilated neonates with indwelling arterial catheter on therapeutic hypothermia. INTERVENTION None. MEASUREMENT AND MAIN RESULTS We compared pulse oximetry, PaO2, end-tidal CO2, and PaCO2 during hypothermia and normothermia in neonates with hypoxic-ischemic encephalopathy using 1,240 arterial blood gases with simultaneously documented pulse oximetry. During hypothermia, pulse oximetry 92-98% was associated with significantly lower temperature-corrected PaO2 (51 mmHg; interquartile range, 43-51) compared with normothermia (71 mmHg; interquartile range, 61-85). Throughout the range of pulse oximetry values, geometric mean PaO2 was about 23% (95% CI, 19-27%) lower during hypothermia compared with normothermia. In contrast, end-tidal CO2 accurately assessed temperature-corrected PaCO2 during normothermia and hypothermia. CONCLUSIONS Hypothermia shifts oxygen-hemoglobin dissociation curve to the left resulting in lower PaO2 for pulse oximetry. Monitoring oxygenation with arterial blood gas uncorrected for body temperature and pulse oximetry may underestimate hypoxemia in hypoxic-ischemic encephalopathy infants during whole-body hypothermia, while end-tidal CO2 reliably correlates with temperature-corrected PaCO2.
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Pandya S, Baser O, Wan GJ, Lovelace B, Potenziano J, Pham AT, Huang X, Wang L. The Burden of Hypoxic Respiratory Failure in Preterm and Term/Near-term Infants in the United States 2011-2015. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:130-141. [PMID: 32685586 PMCID: PMC7299458 DOI: 10.36469/9682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This study quantified the burden of hypoxic respiratory failure (HRF)/persistent pulmonary hypertension of newborn (PPHN) in preterm and term/near-term infants (T/NTs) by examining health care resource utilization (HRU) and charges in the United States. METHODS Preterms and T/NTs (≤34 and >34 weeks of gestation, respectively) having HRF/PPHN, with/without meconium aspiration in inpatient setting from January 1, 2011-October 31, 2015 were identified from the Vizient database (first hospitalization=index hospitalization). Comorbidities, treatments, HRU, and charges during index hospitalization were evaluated among preterms and T/NTs with HRF/PPHN. Logistic regression was performed to evaluate mortality-related factors. RESULTS This retrospective study included 504 preterms and 414 T/NTs with HRF/PPHN. Preterms were more likely to have respiratory distress syndrome, neonatal jaundice, and anemia of prematurity than T/NTs. Preterms had significantly longer inpatient stays (54.1 vs 29.0 days), time in a neonatal intensive care unit (34.1 vs 17.5 days), time on ventilation (4.7 vs 2.2 days), and higher total hospitalization charges ($613 350 vs $422 558) (all P<0.001). Similar rates were observed for use of antibiotics (96.2% vs 95.4%), sildenafil (9.5% vs 8.2%), or inhaled nitric oxide (93.8% vs 94.2%). Preterms had a significantly higher likelihood of mortality than T/NTs (odds ratio: 3.6, 95% confidence interval: 2.3-5.0). CONCLUSIONS The findings of more severe comorbidities, higher HRU, hospitalization charges, and mortality in preterms than in T/NTs underscore the significant clinical and economic burden of HRF/PPHN among infants. The results show significant unmet medical need; further research is warranted to determine new treatments and real-world evidence for improved patient outcomes.
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Affiliation(s)
| | - Onur Baser
- Department of Internal Medicine, the University of Michigan, Ann Arbor, MI
| | | | | | | | - An T Pham
- School of Pharmacy, University of California San Francisco, San Francisco, CA
| | | | - Li Wang
- STATinMED Research, Plano, TX
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Intravenous epoprostenol improves oxygenation index in patients with persistent pulmonary hypertension of the newborn refractory to nitric oxide. J Perinatol 2018; 38:1212-1219. [PMID: 30046179 DOI: 10.1038/s41372-018-0179-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/19/2018] [Accepted: 06/26/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Evaluate the short-term effects of IV epoprostenol in neonates with persistent pulmonary hypertension (PPHN) of the newborn. STUDY DESIGN We reviewed 36 patients with inhaled nitric oxide (iNO) refractory PPHN placed on IV epoprostenol from 2010 to 2015. Patients were categorized as responders or non-responders (who either died or required extracorporeal membranous oxygenation). RESULTS There were 15 responders and 21 non-responders. Pulmonary hypoplasia was the etiology of PPHN for 57% of non-responders vs. 13% of responders. Median oxygenation index (OI) was similar at baseline (41.8 non-responders vs. 36.5 responders, p = 0.41) with responders having a significantly lower OI by 4 h of treatment (42.3 vs. 23.1, p = 0.002). Epoprostenol responders had a median OI decrease of 11.6 within 4 h (p = 0.017) with a significant response persisting through 24 h. CONCLUSION In infants with iNO-refractory PPHN, initiation of IV epoprostenol was associated with a significant and rapid OI reduction among responders.
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Antosova M, Mokra D, Pepucha L, Plevkova J, Buday T, Sterusky M, Bencova A. Physiology of nitric oxide in the respiratory system. Physiol Res 2018; 66:S159-S172. [PMID: 28937232 DOI: 10.33549/physiolres.933673] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Nitric oxide (NO) is an important endogenous neurotransmitter and mediator. It participates in regulation of physiological processes in different organ systems including airways. Therefore, it is important to clarify its role in the regulation of both airway and vascular smooth muscle, neurotransmission and neurotoxicity, mucus transport, lung development and in the. surfactant production. The bioactivity of NO is highly variable and depends on many factors: the presence and activity of NO-producing enzymes, activity of competitive enzymes (e.g. arginase), the amount of substrate for the NO production, the presence of reactive oxygen species and others. All of these can change NO primary physiological role into potentially harmful. The borderline between them is very fragile and in many cases not entirely clear. For this reason, the research focuses on a comprehensive understanding of NO synthesis and its metabolic pathways, genetic polymorphisms of NO synthesizing enzymes and related effects. Research is also motivated by frequent use of exhaled NO monitoring in the clinical manifestations of respiratory diseases. The review focuses on the latest knowledge about the production and function of this mediator and understanding the basic physiological processes in the airways.
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Affiliation(s)
- M Antosova
- Biomedical Center Martin, Division of Respirology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia.
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Astorga CR, González-Candia A, Candia AA, Figueroa EG, Cañas D, Ebensperger G, Reyes RV, Llanos AJ, Herrera EA. Melatonin Decreases Pulmonary Vascular Remodeling and Oxygen Sensitivity in Pulmonary Hypertensive Newborn Lambs. Front Physiol 2018; 9:185. [PMID: 29559926 PMCID: PMC5845624 DOI: 10.3389/fphys.2018.00185] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/20/2018] [Indexed: 12/16/2022] Open
Abstract
Background: Chronic hypoxia and oxidative stress during gestation lead to pulmonary hypertension of the neonate (PHN), a condition characterized by abnormal pulmonary arterial reactivity and remodeling. Melatonin has strong antioxidant properties and improves pulmonary vascular function. Here, we aimed to study the effects of melatonin on the function and structure of pulmonary arteries from PHN lambs. Methods: Twelve lambs (Ovis aries) gestated and born at highlands (3,600 m) were instrumented with systemic and pulmonary catheters. Six of them were assigned to the control group (CN, oral vehicle) and 6 were treated with melatonin (MN, 1 mg.kg−1.d−1) during 10 days. At the end of treatment, we performed a graded oxygenation protocol to assess cardiopulmonary responses to inspired oxygen variations. Further, we obtained lung and pulmonary trunk samples for histology, molecular biology, and immunohistochemistry determinations. Results: Melatonin reduced the in vivo pulmonary pressor response to oxygenation changes. In addition, melatonin decreased cellular density of the media and diminished the proliferation marker KI67 in resistance vessels and pulmonary trunk (p < 0.05). This was associated with a decreased in the remodeling markers α-actin (CN 1.28 ± 0.18 vs. MN 0.77 ± 0.04, p < 0.05) and smoothelin-B (CN 2.13 ± 0.31 vs. MN 0.88 ± 0.27, p < 0.05). Further, melatonin increased vascular density by 134% and vascular luminal surface by 173% (p < 0.05). Finally, melatonin decreased nitrotyrosine, an oxidative stress marker, in small pulmonary vessels (CN 5.12 ± 0.84 vs. MN 1.14 ± 0.34, p < 0.05). Conclusion: Postnatal administration of melatonin blunts the cardiopulmonary response to hypoxia, reduces the pathological vascular remodeling, and increases angiogenesis in pulmonary hypertensive neonatal lambs.These effects improve the pulmonary vascular structure and function in the neonatal period under chronic hypoxia.
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Affiliation(s)
- Cristian R Astorga
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Alejandro González-Candia
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Alejandro A Candia
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,Department for the Woman and Newborn Health Promotion, Universidad de Chile, Santiago, Chile
| | - Esteban G Figueroa
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Daniel Cañas
- Department of Mechanical Engineering, Faculty of Engineering, Universidad de Santiago de Chile, Santiago, Chile
| | - Germán Ebensperger
- Perinatal Physiology and Pathophysiology Unit, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,International Center for Andean Studies, Universidad de Chile, Santiago, Chile
| | - Roberto V Reyes
- Perinatal Physiology and Pathophysiology Unit, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,International Center for Andean Studies, Universidad de Chile, Santiago, Chile
| | - Aníbal J Llanos
- Perinatal Physiology and Pathophysiology Unit, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,International Center for Andean Studies, Universidad de Chile, Santiago, Chile
| | - Emilio A Herrera
- Laboratory of Vascular Function & Reactivity, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,Perinatal Physiology and Pathophysiology Unit, Pathophysiology Program, ICBM, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,International Center for Andean Studies, Universidad de Chile, Santiago, Chile
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Maneenil G, Thatrimontrichai A, Janjindamai W, Dissaneevate S. Effect of bosentan therapy in persistent pulmonary hypertension of the newborn. Pediatr Neonatol 2018; 59:58-64. [PMID: 28735030 DOI: 10.1016/j.pedneo.2017.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/28/2016] [Accepted: 02/24/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Persistent pulmonary hypertension of the newborn (PPHN) contributes to neonatal hypoxemia and is associated with a high mortality. Some PPHN patients are unresponsive to inhaled nitric oxide (iNO). Bosentan, an oral endothelin-1 receptor antagonist, reduces pulmonary vascular resistance and hence may play a role in the treatment of PPHN. METHODS A retrospective medical records review was performed in newborns who received oral bosentan as an adjunctive therapy for treatment of PPHN between January 2013 and February 2016 at the neonatal intensive care unit of Songklanagarind Hospital. The main outcomes were the effect of bosentan on oxygenation and hemodynamic status after commencement of treatment and the safety of bosentan. RESULTS Forty neonates at a median (IQR) gestation of 38 (36.8-40) weeks and an initial median (IQR) oxygen index (OI) of 29.2 (13.4-40.1) received bosentan therapy. Oral bosentan was commenced at a median (IQR) age of 27 (14.5-40.2) hours and the mean (SD) duration of treatment was 6.2 (3.1) days. The OI, alveolar-arterial oxygen difference (AaDO2) and oxygen saturation (SpO2) improved significantly at 2 h after treatment (p = 0.002, p = 0.01 and p < 0.001, respectively). In 21 (52.5%) neonates who received iNO and bosentan, the median OI (IQR) was 34.2 (29.0-42.6) with a significant decrease of OI at 6 h (p = 0.005) after treatment. In 19 (47.5%) neonates who received bosentan alone, the median OI (IQR) was 13.0 (9.8-30.9) with a significant decrease of OI in 2 h (p = 0.01) after treatment. The blood pressures before and after bosentan treatment were not statistically significantly different. The mortality rate was 12.5% (5/40). CONCLUSION Oral bosentan may be a safe and effective treatment to improve oxygenation in neonates with PPHN. Bosentan can be used as an adjuvant therapy with iNO and can be an alternative therapy option in mild-to-moderate PPHN.
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Affiliation(s)
- Gunlawadee Maneenil
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand.
| | - Anucha Thatrimontrichai
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Waricha Janjindamai
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Supaporn Dissaneevate
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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45
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Joynt C, Cheung PY. Treating Hypotension in Preterm Neonates With Vasoactive Medications. Front Pediatr 2018; 6:86. [PMID: 29707527 PMCID: PMC5908904 DOI: 10.3389/fped.2018.00086] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/19/2018] [Indexed: 12/23/2022] Open
Abstract
Preterm neonates often have hypotension which may be due to various etiologies. While it is controversial to define hypotension in preterm neonates, various vasoactive medications are commonly used to provide the cardiovascular support to improve the blood pressure, cardiac output, or to treat shock. However, the literature on the systemic and regional hemodynamic effects of these antihypotensive medications in neonates is deficient and incomplete, and cautious translation of findings from other clinical populations and animal studies is required. Based on a literature search on published reports, meta-analytic reviews, and selected abstracts, this review discusses the current available information on pharmacologic actions, clinical effects, and side effects of commonly used antihypotensive medications including dopamine, dobutamine, epinephrine, norepinephrine, vasopressin, and milrinone in preterm neonates.
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Affiliation(s)
- Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pharmacology and Surgery, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Edmonton, AB, Canada
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46
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Joynt C, Cheung PY. Cardiovascular Supportive Therapies for Neonates With Asphyxia - A Literature Review of Pre-clinical and Clinical Studies. Front Pediatr 2018; 6:363. [PMID: 30619782 PMCID: PMC6295641 DOI: 10.3389/fped.2018.00363] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022] Open
Abstract
Asphyxiated neonates often have hypotension, shock, and poor tissue perfusion. Various "inotropic" medications are used to provide cardiovascular support to improve the blood pressure and to treat shock. However, there is incomplete literature on the examination of hemodynamic effects of these medications in asphyxiated neonates, especially in the realm of clinical studies (mostly in late preterm or term populations). Although the extrapolation of findings from animal studies and other clinical populations such as children and adults require caution, it seems appropriate that findings from carefully conducted pre-clinical studies are important in answering some of the fundamental knowledge gaps. Based on a literature search, this review discusses the current available information, from both clinical studies and animal models of neonatal asphyxia, on common medications used to provide hemodynamic support including dopamine, dobutamine, epinephrine, milrinone, norepinephrine, vasopressin, levosimendan, and hydrocortisone.
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Affiliation(s)
- Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pharmacology, University of Alberta, Edmonton, AB, Canada.,Centre for the Study of Asphyxia and Resuscitation, Edmonton, AB, Canada
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Ahmed M, VanPatten S, Lakshminrusimha S, Patel H, Coleman TR, Al-Abed Y. Effects of novel muscarinic M3 receptor ligand C1213 in pulmonary arterial hypertension models. Physiol Rep 2017; 4:4/24/e13069. [PMID: 28039410 PMCID: PMC5210380 DOI: 10.14814/phy2.13069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/07/2016] [Accepted: 11/13/2016] [Indexed: 11/24/2022] Open
Abstract
Pulmonary hypertension (PH) is a complex disease comprising a pathologic remodeling and thickening of the pulmonary vessels causing an after load on the right heart ventricle that can result in ventricular failure. Triggered by oxidative stress, episodes of hypoxia, and other undetermined causes, PH is associated with poor outcomes and a high rate of morbidity. In the neonate, this disease has a similar etiology but is further complicated by the transition to breathing after birth, which requires a reduction in vascular resistance. Persistent pulmonary hypertension of the newborn (PPHN) is one form of PH that is frequently unresponsive to current therapies including inhaled nitric oxide (due to lack of proper absorption and diffusion), and other therapeutics targeting signaling mediators in vascular endothelium and smooth muscle. The need for novel agents, which target distinct pathways in pulmonary hypertension, remains. Herein, we investigated the therapeutic effects of novel muscarinic receptor ligand C1213 in models of PH We demonstrated that via M3 muscarinic receptors, C1213 induced activating- eNOS phosphorylation (serine-1177), which is known to lead to nitric oxide (NO) production in endothelial cells. Using signaling pathway inhibitors, we discovered that AKT and calcium signaling contributed to eNOS phosphorylation induced by C1213. As expected for an eNOS-stimulating agent, in ex vivo and in vivo models, C1213 triggered pulmonary vasodilation and induced both pulmonary artery and systemic blood pressure reductions demonstrating its potential value in PH and PPHN In brief, this proof-of-concept study provides evidence that an M3 muscarinic receptor functionally selective ligand stimulates downstream pathways leading to antihypertensive effects using in vitro, ex vivo, and in vivo models of PH.
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Affiliation(s)
- Mohamed Ahmed
- Northwell Health, Pediatrics Department - Neonatology Division, Cohens Children's Medical Center, Manhasset, New York
| | - Sonya VanPatten
- Department of Medicinal Chemistry, Center for Molecular Innovation, Manhasset, New York
| | - Satyan Lakshminrusimha
- Departments of Pediatrics, Physiology and Biophysics, State University of New York at Buffalo, Buffalo, New York
| | - Hardik Patel
- Northwell Health, Pediatrics Department - Neonatology Division, Cohens Children's Medical Center, Manhasset, New York
| | - Thomas R Coleman
- The Feinstein Institute for Medical Research, Manhasset, New York
| | - Yousef Al-Abed
- Department of Medicinal Chemistry, Center for Molecular Innovation, Manhasset, New York
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Schwingshackl A, Lopez B, Teng B, Luellen C, Lesage F, Belperio J, Olcese R, Waters CM. Hyperoxia treatment of TREK-1/TREK-2/TRAAK-deficient mice is associated with a reduction in surfactant proteins. Am J Physiol Lung Cell Mol Physiol 2017; 313:L1030-L1046. [PMID: 28839101 DOI: 10.1152/ajplung.00121.2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/15/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022] Open
Abstract
We previously proposed a role for the two-pore domain potassium (K2P) channel TREK-1 in hyperoxia (HO)-induced lung injury. To determine whether redundancy among the three TREK isoforms (TREK-1, TREK-2, and TRAAK) could protect from HO-induced injury, we now examined the effect of deletion of all three TREK isoforms in a clinically relevant scenario of prolonged HO exposure and mechanical ventilation (MV). We exposed WT and TREK-1/TREK-2/TRAAK-deficient [triple knockout (KO)] mice to either room air, 72-h HO, MV [high and low tidal volume (TV)], or a combination of HO + MV and measured quasistatic lung compliance, bronchoalveolar lavage (BAL) protein concentration, histologic lung injury scores (LIS), cellular apoptosis, and cytokine levels. We determined surfactant gene and protein expression and attempted to prevent HO-induced lung injury by prophylactically administering an exogenous surfactant (Curosurf). HO treatment increased lung injury in triple KO but not WT mice, including an elevated LIS, BAL protein concentration, and markers of apoptosis, decreased lung compliance, and a more proinflammatory cytokine phenotype. MV alone had no effect on lung injury markers. Exposure to HO + MV (low TV) further decreased lung compliance in triple KO but not WT mice, and HO + MV (high TV) was lethal for triple KO mice. In triple KO mice, the HO-induced lung injury was associated with decreased surfactant protein (SP) A and SPC but not SPB and SPD expression. However, these changes could not be explained by alterations in the transcription factors nuclear factor-1 (NF-1), NKX2.1/thyroid transcription factor-1 (TTF-1) or c-jun, or lamellar body levels. Prophylactic Curosurf administration did not improve lung injury scores or compliance in triple KO mice.
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Affiliation(s)
| | - Benjamin Lopez
- Department of Pediatrics, University of California, Los Angeles, California
| | - Bin Teng
- Department of Physiology, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Charlean Luellen
- Department of Physiology, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Florian Lesage
- Université Côte d'Azur, Institut de Pharmacologie Moléculaire et Cellulaire, Centre National de la Recherche Scientifique, Laboratory of Excellence "Ion Channel Science and Therapeutics," Valbonne, France
| | - John Belperio
- Department of Pulmonary and Critical Care, University of California, Los Angeles, California
| | - Riccardo Olcese
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, California
| | - Christopher M Waters
- Department of Physiology, University of Tennessee Health Science Center, Memphis, Tennessee; and
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The Fetus Can Teach Us: Oxygen and the Pulmonary Vasculature. CHILDREN-BASEL 2017; 4:children4080067. [PMID: 28771211 PMCID: PMC5575589 DOI: 10.3390/children4080067] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/22/2017] [Accepted: 07/31/2017] [Indexed: 11/17/2022]
Abstract
Neonates suffering from pulmonary hypertension of the newborn (PPHN) continue to represent an important proportion of patients requiring intensive neonatal care, and have an increased risk of morbidity and mortality. The human fetus has evolved to maintain a high pulmonary vascular resistance (PVR) in utero to allow the majority of the fetal circulation to bypass the lungs, which do not participate in gas exchange, towards the low resistance placenta. At birth, oxygen plays a major role in decreasing PVR to enhance pulmonary blood flow and establish the lungs as the organ of gas exchange. The failure of PVR to fall following birth results in PPHN, and oxygen remains the mainstay therapeutic intervention in the management of PPHN. Knowledge gaps on what constitutes the optimal oxygenation target leads to a wide variation in practices, and often leads to excessive oxygen use. Owing to the risk of oxygen toxicity, avoiding hyperoxemia is as important as avoiding hypoxemia in the management of PPHN. Current evidence supports maintaining arterial oxygen tension in the range of 50–80 mm Hg, and oxygen saturation between 90–97% in term infants with hypoxemic respiratory failure. Clinical studies evaluating the optimal oxygenation in the treatment of PPHN will be enthusiastically awaited.
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50
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Abstract
Failure of the normal circulatory adaptation to extrauterine life results in persistent pulmonary hypertension of the newborn (PPHN). Although this condition is most often secondary to parenchymal lung disease or lung hypoplasia, it may also be idiopathic. PPHN is characterized by elevated pulmonary vascular resistance with resultant right-to-left shunting of blood and hypoxemia. Although the preliminary diagnosis of PPHN is often based on differential cyanosis and labile hypoxemia, the diagnosis is confirmed by echocardiography. Management strategies include optimal lung recruitment and use of surfactant in patients with parenchymal lung disease, maintaining optimal oxygenation and stable blood pressures, avoidance of respiratory and metabolic acidosis and alkalosis, and pulmonary vasodilator therapy. Extracorporeal membrane oxygenation is considered when medical management fails. Although mortality associated with PPHN has decreased significantly with improvements in medical care, there remains the potential risk for neurodevelopmental disability which warrants close follow-up of affected infants after discharge.
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Affiliation(s)
- Mamta Fuloria
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY, USA
| | - Judy L Aschner
- Departments of Pediatrics and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY, USA.
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