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Qiu J, Di Fiore JM, Krishnamurthi N, Indic P, Carroll JL, Claure N, Kemp JS, Dennery PA, Ambalavanan N, Weese-Mayer DE, Maria Hibbs A, Martin RJ, Bancalari E, Hamvas A, Randall Moorman J, Lake DE. Highly comparative time series analysis of oxygen saturation and heart rate to predict respiratory outcomes in extremely preterm infants. Physiol Meas 2024; 45:055025. [PMID: 38772400 DOI: 10.1088/1361-6579/ad4e91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/21/2024] [Indexed: 05/23/2024]
Abstract
Objective.Highly comparative time series analysis (HCTSA) is a novel approach involving massive feature extraction using publicly available code from many disciplines. The Prematurity-Related Ventilatory Control (Pre-Vent) observational multicenter prospective study collected bedside monitor data from>700extremely preterm infants to identify physiologic features that predict respiratory outcomes.Approach. We calculated a subset of 33 HCTSA features on>7 M 10 min windows of oxygen saturation (SPO2) and heart rate (HR) from the Pre-Vent cohort to quantify predictive performance. This subset included representatives previously identified using unsupervised clustering on>3500HCTSA algorithms. We hypothesized that the best HCTSA algorithms would compare favorably to optimal PreVent physiologic predictor IH90_DPE (duration per event of intermittent hypoxemia events below 90%).Main Results.The top HCTSA features were from a cluster of algorithms associated with the autocorrelation of SPO2 time series and identified low frequency patterns of desaturation as high risk. These features had comparable performance to and were highly correlated with IH90_DPE but perhaps measure the physiologic status of an infant in a more robust way that warrants further investigation. The top HR HCTSA features were symbolic transformation measures that had previously been identified as strong predictors of neonatal mortality. HR metrics were only important predictors at early days of life which was likely due to the larger proportion of infants whose outcome was death by any cause. A simple HCTSA model using 3 top features outperformed IH90_DPE at day of life 7 (.778 versus .729) but was essentially equivalent at day of life 28 (.849 versus .850).Significance. These results validated the utility of a representative HCTSA approach but also provides additional evidence supporting IH90_DPE as an optimal predictor of respiratory outcomes.
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Affiliation(s)
- Jiaxing Qiu
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America
| | - Narayanan Krishnamurthi
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX, United States of America
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, United States of America
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Department of Pediatrics, Providence, RI, United States of America
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Aaron Hamvas
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Department of Pediatrics, Chicago, IL, United States of America
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Hellström A, Smith LEH, Hård AL. ROP: 80 Years after Its Detection - Where Do We Stand and How Long Will We Continue to Laser? Neonatology 2024:1-8. [PMID: 38776885 DOI: 10.1159/000538907] [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: 03/21/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Retinopathy of prematurity (ROP), a potentially blinding disease, is increasing worldwide because of the increased survival of extremely preterm and preterm infants born where oxygen monitoring and ROP screening programs are insufficient. Repeated retinal examinations are stressful for infants, and laser photocoagulation treatment for sight-threatening ROP is destructive. The use of anti-VEGF agents instead of lasers is widespread but requires a long-term follow-up because of late recurrence of the disease. In addition, the optimal anti-VEGF agent dosage and long-term systemic effects require further study. SUMMARY Interventions preventing ROP would be far preferable, and systemic interventions might promote better development of the brain and other organs. Interventions such as improved oxygen control, provision of fresh maternal milk, supplementation with arachidonic acid and docosahexaenoic acid, and fetal hemoglobin preservation by reducing blood sample volumes may help prevent ROP and reduce the need for treatment. Free readily available online tools to predict severe ROP may reduce unnecessary eye examinations and select, for screening, those at a high risk of needing treatment. KEY MESSAGES Treatment warranting ROP is a sign of impaired neurovascular development in the central nervous system. Preventative measures to improve the outcomes are available. Screening can be refined using tools that can predict severe ROP. Laser treatment and anti-VEGF agents are valuable treatment modalities that may complement each other in recurrent ROP.
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Affiliation(s)
- Ann Hellström
- Department of Clinical Neuroscience, Institution of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lois E H Smith
- The Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna-Lena Hård
- Department of Clinical Neuroscience, Institution of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,
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Rabienia Haratbar S, Chen L, Cheng Q, Singh D, Fathi F, Mohtasebi M, Liu X, Patwardhan A, Bhandary P, Bada HS, Yu G, Abu Jawdeh EG. The impact of intermittent hypoxemia on type 1 retinopathy of prematurity in preterm infants. Pediatr Res 2024:10.1038/s41390-024-03169-5. [PMID: 38600299 DOI: 10.1038/s41390-024-03169-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Intermittent hypoxemia (IH) may influence retinopathy of prematurity (ROP) development in preterm infants, however, previous studies had mixed results. This study tests the hypothesis that increased IH is associated with Type 1 ROP; a stage beyond which treatment is indicated. METHODS IH was quantified by continuously monitoring oxygen saturation (SpO2) using high-resolution pulse oximeters during the first 10 weeks of life. Statistical analyses assessed the relationship and predictive ability of weekly and cumulative IH for Type 1 ROP development. RESULTS Most analyses showed no association between IH and Type 1 ROP adjusting for gestational age (GA) and birth weight (BW). However, cumulative IH of longer duration during weeks 5-10, 6-10, and 7-10 were significantly associated with Type 1 ROP adjusting for GA and BW, e.g., the adjusted odds ratio of Type 1 ROP was 2.01 (p = 0.03) for every 3.8 seconds increase in IH duration from week 6-10. IH did not provide statistically significant added predictive ability above GA and BW. CONCLUSIONS For most analyses there was no significant association between IH and Type 1 ROP adjusting for GA and BW. However, infants with longer IH duration during the second month of life had higher risk for Type 1 ROP. IMPACT The relationship and predictive ability of intermittent hypoxemia (IH) on retinopathy of prematurity (ROP) is controversial. This study shows no significant association between IH events and Type 1 ROP after adjusting for gestational age (GA) and birth weight (BW), except for cumulative IH of longer duration in the second month of life. In this cohort, IH does not provide a statistically significant improvement in ROP prediction over GA and BW. This study is the first to assess the cumulative impact of IH measures on Type 1 ROP. Interventions for reducing IH duration during critical postnatal periods may improve ROP outcomes.
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Affiliation(s)
| | - Li Chen
- Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Qiang Cheng
- Institute for Biomedical Informatics, Department of Internal Medicine and Department of Computer Science, Lexington, Kentucky, USA
| | - Dara Singh
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Faraneh Fathi
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Mehrana Mohtasebi
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Xuhui Liu
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Abhijit Patwardhan
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Prasad Bhandary
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA.
| | - Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA.
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Kausch SL, Lake DE, Di Fiore JM, Weese-Mayer DE, Claure N, Ambalavanan N, Vesoulis ZA, Fairchild KD, Dennery PA, Hibbs AM, Martin RJ, Indic P, Travers CP, Bancalari E, Hamvas A, Kemp JS, Carroll JL, Moorman JR, Sullivan BA. Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Infants Born Extremely Preterm. J Pediatr 2024; 271:114042. [PMID: 38570031 DOI: 10.1016/j.jpeds.2024.114042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The objective of this study was to examine the association of cardiorespiratory events, including apnea, periodic breathing, intermittent hypoxemia (IH), and bradycardia, with late-onset sepsis for extremely preterm infants (<29 weeks of gestational age) on vs off invasive mechanical ventilation. STUDY DESIGN This is a retrospective analysis of data from infants enrolled in Pre-Vent (ClinicalTrials.gov identifier NCT03174301), an observational study in 5 level IV neonatal intensive care units. Clinical data were analyzed for 737 infants (mean gestational age: 26.4 weeks, SD 1.71). Monitoring data were available and analyzed for 719 infants (47 512 patient-days); of whom, 109 had 123 sepsis events. Using continuous monitoring data, we quantified apnea, periodic breathing, bradycardia, and IH. We analyzed the relationships between these daily measures and late-onset sepsis (positive blood culture >72 hours after birth and ≥5-day antibiotics). RESULTS For infants not on a ventilator, apnea, periodic breathing, and bradycardia increased before sepsis diagnosis. During times on a ventilator, increased sepsis risk was associated with longer events with oxygen saturation <80% (IH80) and more bradycardia events before sepsis. IH events were associated with higher sepsis risk but did not dynamically increase before sepsis, regardless of ventilator status. A multivariable model including postmenstrual age, cardiorespiratory variables (apnea, periodic breathing, IH80, and bradycardia), and ventilator status predicted sepsis with an area under the receiver operator characteristic curve of 0.783. CONCLUSION We identified cardiorespiratory signatures of late-onset sepsis. Longer IH events were associated with increased sepsis risk but did not change temporally near diagnosis. Increases in bradycardia, apnea, and periodic breathing preceded the clinical diagnosis of sepsis.
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Affiliation(s)
- Sherry L Kausch
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA.
| | - Douglas E Lake
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Debra E Weese-Mayer
- Division of Autonomic Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Providence, RI
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James S Kemp
- Division of Pediatric Pulmonology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - J Randall Moorman
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
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Bashir S, Cai CL, Marcelino M, Aranda JV, Beharry KD. Comparison of Glutathione Nanoparticles, CoEnzyme Q10, and Fish Oil for Prevention of Oxygen-Induced Retinopathy in Neonatal Rats. Pharmaceuticals (Basel) 2024; 17:381. [PMID: 38543167 PMCID: PMC10975314 DOI: 10.3390/ph17030381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 04/01/2024] Open
Abstract
Notch ligands and receptors are important for cell specification and angiogenesis, but their role in oxygen-induced retinopathy (OIR) is not well studied. Delta-like ligand (DLL)-4/Notch inhibits angiogenesis, while Jagged-1/Notch promotes angiogenesis. We tested the hypothesis that early supplementation with antioxidants and/or fish oil curtails severe OIR by inducing DLL-4/Notch and reducing Jagged-1/Notch. Newborn rats were exposed to brief intermittent hypoxia (IH) during hyperoxia, during which they received daily oral supplements of (1) fish oil, (2) coenzyme Q10 (CoQ10) in olive oil (OO), (3) glutathione nanoparticles (nGSH), (4) fish oil + CoQ10, or (5) OO (controls) from birth (P0) to P14. At P14, the pups were placed in room air (RA) until P21, with no further treatment. Oxidative stress, apoptosis, ocular histopathology, and Notch signaling were assessed. Neonatal IH resulted in severe retinal damage consistent with retinopathy of prematurity (ROP). Retinal damage was associated with induced oxidative stress and Jagged-1/Notch signaling, as well as reduced DLL-4/Notch signaling. All treatments reversed these outcomes, but nGSH produced the most beneficial outcomes. Severe OIR promoted the induction of Jagged-1/Notch and curtailed DLL-4/Notch, which was an effect that could be reversed with nGSH supplementation. These findings may indicate a potential alternate pathway for ROP treatment and/or prevention.
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Affiliation(s)
- Sidra Bashir
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA; (S.B.); (C.L.C.); (J.V.A.)
| | - Charles L. Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA; (S.B.); (C.L.C.); (J.V.A.)
| | - Matthew Marcelino
- Medical School, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA;
| | - Jacob V. Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA; (S.B.); (C.L.C.); (J.V.A.)
- Department of Ophthalmology, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA
- SUNY Eye Institute, Brooklyn, NY 11203, USA
| | - Kay D. Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA; (S.B.); (C.L.C.); (J.V.A.)
- Department of Ophthalmology, State University of New York Downstate Health Sciences University, Brooklyn, NY 11203, USA
- SUNY Eye Institute, Brooklyn, NY 11203, USA
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Hibbs AM, Chen Z, Minich NM, Martin RJ, Raffay TM, MacFarlane PM, Di Fiore JM. Association between Intermittent Hypoxemia and NICU Length of Stay in Preterm Infants. Neonatology 2024; 121:327-335. [PMID: 38437802 PMCID: PMC11147692 DOI: 10.1159/000535264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/14/2023] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Length of hospitalization varies widely in preterm infants and can be affected by multiple maternal and neonatal factors including respiratory instability. Therefore, we aimed to determine the association between postnatal intermittent hypoxemia (IH) and prolonged hospitalization. METHODS This prospective single-center cohort study followed infants born at <31 weeks of gestational age through 2 years corrected age with detailed oxygen saturation data captured from days 7 to 30 of age. RESULTS 51/164 (31%) of infants were discharged after 400/7 weeks of corrected gestational age (CGA). A greater average daily number of IH events (OR per 10 events/day 1.33 [95% CI 1.03-1.72]), duration of events (OR per minute 1.14 [1.07-1.21]), and percent time with oxygen saturation <80% (OR per percent 1.88 [1.25-2.85]) on days 7-30 of age were all significantly associated with prolonged hospitalization past 400/7 weeks CGA. In survival analyses, infants with a greater average daily number of IH events (HR per 10 events/day 0.89 [0.81-0.98]), percent time with oxygen saturation <80% (HR per percent 0.79 [0.67-0.94]), and duration of events (HR per minute 0.93 [0.91-0.95]) on days 7-30 of age all had significantly lower probability of earlier discharge. In addition, there was a significant interaction with gestational age; the association between IH and prolonged hospitalization was stronger in more mature infants (p = 0.024). CONCLUSIONS Physiological instability on days 7-30 of age, as manifested by IH, is significantly associated with prolonged hospitalization. IH likely represents both a marker of initial severity of illness and the beginning of biological cascades, leading to prematurity-associated morbidities.
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Affiliation(s)
- Anna Maria Hibbs
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nori M Minich
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Martin
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas M Raffay
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Peter M MacFarlane
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Juliann M Di Fiore
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
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Lin WC, Jordan BK, Scottoline B, Ostmo SR, Coyner AS, Singh P, Kalpathy-Cramer J, Erdogmus D, Chan RP, Chiang MF, Campbell JP. Oxygenation Fluctuations Associated with Severe Retinopathy of Prematurity: Insights from a Multimodal Deep Learning Approach. OPHTHALMOLOGY SCIENCE 2024; 4:100417. [PMID: 38059124 PMCID: PMC10696464 DOI: 10.1016/j.xops.2023.100417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/27/2023] [Accepted: 10/18/2023] [Indexed: 12/08/2023]
Abstract
Purpose Retinopathy of prematurity (ROP) is one of the leading causes of blindness in children. Although the role of oxygen in the pathophysiology of ROP is well established, a precise understanding of the dynamic relationship between oxygen exposure ROP incidence and severity is lacking. The purpose of this study was to evaluate the correlation between time-dependent oxygen variables and the onset of ROP. Design Retrospective cohort study. Participants Two hundred thirty infants who were born at a single academic center and met the inclusion criteria were included. Infants are mainly born between January 2011 and October 2022. Methods Patient data were extracted from electronic health records (EHRs), with sufficient time-dependent oxygen data. Clinical outcomes for ROP were recorded as none/mild or moderate/severe (defined as type II or worse). Mixed-effects linear models were used to compare the 2 groups in terms of dynamic oxygen variables, such as daily average and the coefficient of variation (COV) fraction of inspired oxygen (FiO2). Support vector machine (SVM) and long-short-term memory (LSTM)-based multimodal models were trained with fivefold cross-validation to predict which infants would develop moderate/severe ROP. Gestational age (GA), birth weight, and time-dependent oxygen variables were used to develop predictive models. Main Outcome Measures Model cross-validation performance was evaluated by computing the mean area under the receiver operating characteristic (AUROC) curve, precision, recall, and F1 score. Results We found that both daily average and COV of FiO2 were associated with more severe ROP (adjusted P < 0.001). With fivefold cross-validation, the multimodal LSTM models had higher performance than the best static models (SVM using GA and 3 average FiO2 features) and SVM models trained on GA alone (mean AUROC = 0.89 ± 0.04 vs. 0.86 ± 0.05 vs. 0.83 ± 0.04). Conclusions The development of severe ROP might not only be influenced by oxygen exposure but also by its fluctuation, which provides direction for future study of pathophysiological factors associated with severe ROP development. Additionally, we demonstrated that multimodal neural networks can be a method to extract useful information from time-series data, which may be a valuable methodology for the investigation of other diseases using EHR data. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Wei-Chun Lin
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
| | - Brian K. Jordan
- Department of Neonatology, Oregon Health and Science University, Portland, Oregon
| | - Brian Scottoline
- Department of Neonatology, Oregon Health and Science University, Portland, Oregon
| | - Susan R. Ostmo
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
| | - Aaron S. Coyner
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
| | - Praveer Singh
- Department of Ophthalmology, University of Colorado (CU) School of Medicine, Denver, Colorado
| | | | - Deniz Erdogmus
- Department of Electrical and Computer Engineering, Northeastern University, Boston, Massachusetts
| | - R.V. Paul Chan
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Michael F. Chiang
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland
| | - J. Peter Campbell
- Department of Ophthalmology, Oregon Health & Science University, Portland, Oregon
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8
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Weese-Mayer DE, Di Fiore JM, Lake DE, Hibbs AM, Claure N, Qiu J, Ambalavanan N, Bancalari E, Kemp JS, Zimmet AM, Carroll JL, Martin RJ, Krahn KN, Hamvas A, Ratcliffe SJ, Krishnamurthi N, Indic P, Dormishian A, Dennery PA, Moorman JR. Maturation of cardioventilatory physiological trajectories in extremely preterm infants. Pediatr Res 2024; 95:1060-1069. [PMID: 37857848 DOI: 10.1038/s41390-023-02839-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND In extremely preterm infants, persistence of cardioventilatory events is associated with long-term morbidity. Therefore, the objective was to characterize physiologic growth curves of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants during the first few months of life. METHODS The Prematurity-Related Ventilatory Control study included 717 preterm infants <29 weeks gestation. Waveforms were downloaded from bedside monitors with a novel sharing analytics strategy utilized to run software locally, with summary data sent to the Data Coordinating Center for compilation. RESULTS Apnea, periodic breathing, and intermittent hypoxemia events rose from day 3 of life then fell to near-resolution by 8-12 weeks of age. Apnea/intermittent hypoxemia were inversely correlated with gestational age, peaking at 3-4 weeks of age. Periodic breathing was positively correlated with gestational age peaking at 31-33 weeks postmenstrual age. Females had more periodic breathing but less intermittent hypoxemia/bradycardia. White infants had more apnea/periodic breathing/intermittent hypoxemia. Infants never receiving mechanical ventilation followed similar postnatal trajectories but with less apnea and intermittent hypoxemia, and more periodic breathing. CONCLUSIONS Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. IMPACT Physiologic curves of cardiorespiratory events in extremely preterm-born infants offer (1) objective measures to assess individual patient courses and (2) guides for research into control of ventilation, biomarkers and outcomes. Presented are updated maturational trajectories of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in 717 infants born <29 weeks gestation from the multi-site NHLBI-funded Pre-Vent study. Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. Different time courses for apnea and periodic breathing suggest different maturational mechanisms.
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Affiliation(s)
- Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
| | - Douglas E Lake
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jiaxing Qiu
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James S Kemp
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Amanda M Zimmet
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Katy N Krahn
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aaron Hamvas
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Neonatology, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Narayanan Krishnamurthi
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas Tyler, Tyler, TX, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phyllis A Dennery
- Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - J Randall Moorman
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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9
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Kausch SL, Lake DE, Di Fiore JM, Weese-Mayer DE, Claure N, Ambalavanan N, Vesoulis ZA, Fairchild KD, Dennery PA, Hibbs AM, Martin RJ, Indic P, Travers CP, Bancalari E, Hamvas A, Kemp JS, Carroll JL, Moorman JR, Sullivan BA. Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Extremely Preterm Infants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.26.24301820. [PMID: 38343825 PMCID: PMC10854335 DOI: 10.1101/2024.01.26.24301820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Objectives Detection of changes in cardiorespiratory events, including apnea, periodic breathing, intermittent hypoxemia (IH), and bradycardia, may facilitate earlier detection of sepsis. Our objective was to examine the association of cardiorespiratory events with late-onset sepsis for extremely preterm infants (<29 weeks' gestational age (GA)) on versus off invasive mechanical ventilation. Study Design Retrospective analysis of data from infants enrolled in Pre-Vent (ClinicalTrials.gov identifier NCT03174301), an observational study in five level IV neonatal intensive care units. Clinical data were analyzed for 737 infants (mean GA 26.4w, SD 1.71). Monitoring data were available and analyzed for 719 infants (47,512 patient-days), of whom 109 had 123 sepsis events. Using continuous monitoring data, we quantified apnea, periodic breathing, bradycardia, and IH. We analyzed the relationships between these daily measures and late-onset sepsis (positive blood culture >72h after birth and ≥5d antibiotics). Results For infants not on a ventilator, apnea, periodic breathing, and bradycardia increased before sepsis diagnosis. During times on a ventilator, increased sepsis risk was associated with longer IH80 events and more bradycardia events before sepsis. IH events were associated with higher sepsis risk, but did not dynamically increase before sepsis, regardless of ventilator status. A multivariable model predicted sepsis with an AUC of 0.783. Conclusion We identified cardiorespiratory signatures of late-onset sepsis. Longer IH events were associated with increased sepsis risk but did not change temporally near diagnosis. Increases in bradycardia, apnea, and periodic breathing preceded the clinical diagnosis of sepsis.
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Affiliation(s)
- Sherry L Kausch
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Karen D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Department of Pediatrics, Providence, RI
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - Colm P Travers
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Department of Pediatrics, Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Brynne A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
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10
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Qiu J, Di Fiore JM, Krishnamurthi N, Indic P, Carroll JL, Claure N, Kemp JS, Dennery PA, Ambalavanan N, Weese-Mayer DE, Hibbs AM, Martin RJ, Bancalari E, Hamvas A, Randall Moorman J, Lake DE. Highly comparative time series analysis of oxygen saturation and heart rate to predict respiratory outcomes in extremely preterm infants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.24.24301724. [PMID: 38343830 PMCID: PMC10854343 DOI: 10.1101/2024.01.24.24301724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Objective Highly comparative time series analysis (HCTSA) is a novel approach involving massive feature extraction using publicly available code from many disciplines. The Prematurity-Related Ventilatory Control (Pre-Vent) observational multicenter prospective study collected bedside monitor data from > 700 extremely preterm infants to identify physiologic features that predict respiratory outcomes. We calculated a subset of 33 HCTSA features on > 7M 10-minute windows of oxygen saturation (SPO2) and heart rate (HR) from the Pre-Vent cohort to quantify predictive performance. This subset included representatives previously identified using unsupervised clustering on > 3500 HCTSA algorithms. Performance of each feature was measured by individual area under the receiver operating curve (AUC) at various days of life and binary respiratory outcomes. These were compared to optimal PreVent physiologic predictor IH90 DPE, the duration per event of intermittent hypoxemia events with threshold of 90%. Main Results The top HCTSA features were from a cluster of algorithms associated with the autocorrelation of SPO2 time series and identified low frequency patterns of desaturation as high risk. These features had comparable performance to and were highly correlated with IH90_DPE but perhaps measure the physiologic status of an infant in a more robust way that warrants further investigation. The top HR HCTSA features were symbolic transformation measures that had previously been identified as strong predictors of neonatal mortality. HR metrics were only important predictors at early days of life which was likely due to the larger proportion of infants whose outcome was death by any cause. A simple HCTSA model using 3 top features outperformed IH90_DPE at day of life 7 (.778 versus .729) but was essentially equivalent at day of life 28 (.849 versus .850). These results validated the utility of a representative HCTSA approach but also provides additional evidence supporting IH90_DPE as an optimal predictor of respiratory outcomes.
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Affiliation(s)
- Jiaxing Qiu
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Narayanan Krishnamurthi
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO
| | - Phyllis A Dennery
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Department of Pediatrics, Chicago, IL
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
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11
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Sullivan BA, Beam K, Vesoulis ZA, Aziz KB, Husain AN, Knake LA, Moreira AG, Hooven TA, Weiss EM, Carr NR, El-Ferzli GT, Patel RM, Simek KA, Hernandez AJ, Barry JS, McAdams RM. Transforming neonatal care with artificial intelligence: challenges, ethical consideration, and opportunities. J Perinatol 2024; 44:1-11. [PMID: 38097685 PMCID: PMC10872325 DOI: 10.1038/s41372-023-01848-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
Artificial intelligence (AI) offers tremendous potential to transform neonatology through improved diagnostics, personalized treatments, and earlier prevention of complications. However, there are many challenges to address before AI is ready for clinical practice. This review defines key AI concepts and discusses ethical considerations and implicit biases associated with AI. Next we will review literature examples of AI already being explored in neonatology research and we will suggest future potentials for AI work. Examples discussed in this article include predicting outcomes such as sepsis, optimizing oxygen therapy, and image analysis to detect brain injury and retinopathy of prematurity. Realizing AI's potential necessitates collaboration between diverse stakeholders across the entire process of incorporating AI tools in the NICU to address testability, usability, bias, and transparency. With multi-center and multi-disciplinary collaboration, AI holds tremendous potential to transform the future of neonatology.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kristyn Beam
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Khyzer B Aziz
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Ameena N Husain
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lindsey A Knake
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Alvaro G Moreira
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Thomas A Hooven
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elliott M Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA, USA
| | - Nicholas R Carr
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - George T El-Ferzli
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi M Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelsey A Simek
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Antonio J Hernandez
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - James S Barry
- Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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12
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Kim F, Bateman DA, Garey D, Goldshtrom N, Isler JR, Sahni R, Wallman-Stokes A. Association between intermittent hypoxemia and neurodevelopmental outcomes in extremely premature infants: A single-center experience. Early Hum Dev 2024; 188:105919. [PMID: 38118389 DOI: 10.1016/j.earlhumdev.2023.105919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/03/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVE To describe the association between intermittent hypoxemic events (IHEs) and severe neurodevelopmental impairment (SNDI) or death in extremely premature infants. STUDY DESIGN Retrospective study of extremely premature infants 230/7-276/7 weeks gestational age (GA) and birthweight (BW) ≤1250 grams (g) admitted to a level IV neonatal intensive care unit (NICU) from 2013 to 2017. IHEs, defined as events with SpO2 ≤ 80 % lasting 10 s to 5 min, were algorithmically identified using data extracted from bedside monitors at 2 s intervals (0.5 Hz). The primary outcome was SNDI at 18-24 months corrected age (CA), defined as a Bayley-III motor, language or cognitive composite score ≤69, or death before discharge while the secondary outcome was SNDI alone. We used mixed-effects regression models to evaluate the relationship between mean daily IHE rate per postnatal week of life for the first 12 weeks and the outcomes, and logistic regression models to assess the association between outcomes and summary measures of hypoxic burden for the entire NICU hospitalization. RESULTS The mortality rate was 7 % (18/249) during NICU hospitalization. Of 249 infants born during this time period, IHE and neurodevelopmental outcome data were fully available for 65 infants (mean GA 26 ± 1.4 weeks, mean birth weight (BW) 738 ± 199 g. The outcome of SNDI alone occurred in 34 % (22/65) with a majority demonstrating motor or language delay on the Bayley-III. Although mean daily IHE rate/week was not associated with SNDI or death, total IHE duration was associated with increased odds of SNDI (OR (95 % CI) 1.03 (1.01, 1.05), p = 0.008) in models adjusted for GA. CONCLUSIONS In a cohort of extremely premature infants 23-27 weeks GA, each hour of total IHE duration (SpO2 ≤ 80 %) was associated with a 2.7 % (0.7 %, 4.8 %) increase in the odds of SNDI at 18-24 months CA.
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Affiliation(s)
- Faith Kim
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America.
| | - David A Bateman
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Donna Garey
- Department of Pediatrics, Phoenix Children's Medical Group, Phoenix, AZ, United States of America
| | - Nimrod Goldshtrom
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Joseph R Isler
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Rakesh Sahni
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Aaron Wallman-Stokes
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT, United States of America
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13
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Dormishian A, Schott A, Aguilar AC, Jimenez V, Bancalari E, Tolosa J, Claure N. Etiology and Mechanism of Intermittent Hypoxemia Episodes in Spontaneously Breathing Extremely Premature Infants. J Pediatr 2023; 262:113623. [PMID: 37473988 PMCID: PMC10794559 DOI: 10.1016/j.jpeds.2023.113623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To evaluate the mechanisms leading to intermittent hypoxemia (IH) episodes in spontaneously breathing extremely premature infants at 32 weeks and 36 weeks postmenstrual age (PMA). METHODS We studied spontaneously breathing premature infants born at 23-28 weeks of gestational age who presented with IH episodes while on noninvasive respiratory support at 32 or 36 weeks PMA. Daytime recordings of arterial oxygen saturation (SpO2), esophageal pressure, respiratory inductive plethysmography of the abdomen, chest wall, and their sum were obtained during 4 hours at 32 weeks and 36 weeks PMA. IH episodes (SpO2 <90% for ≥5 seconds) and severe IH episodes (SpO2 < 80% for ≥5 seconds) were classified as resulting from apnea, active exhalation and breath holding, reduced tidal volume (VT), or reduced respiratory rate (RR) during the preceding 60 seconds. RESULTS Fifty-one infants with a mean gestational age of 25.9 ± 1.5 weeks and a mean birth weight of 846 ± 185 g were included. Of these, 31 and 41 were included in the analysis at 32 weeks and 36 weeks PMA, respectively. At both 32 weeks and 36 weeks PMA, greater proportions of all IH episodes and severe IH episodes were associated with active exhalation and breath holding than with apnea, reduced RR, or reduced VT. The severity and duration of the IH episodes did not differ between mechanisms. CONCLUSIONS In this group of premature infants, the predominant mechanism associated with daytime IH was active exhalation and breath holding. This etiology is more closely associated with behavioral factors than abnormal respiratory control and can have implications for prevention.
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Affiliation(s)
- Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL; Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL
| | - Alini Schott
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Ana Cecilia Aguilar
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Vicente Jimenez
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Jose Tolosa
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL; Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL.
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14
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Alarcon-Martinez T, Latremouille S, Kovacs L, Kearney RE, Sant'Anna GM, Shalish W. Clinical usefulness of reintubation criteria in extremely preterm infants: a cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 108:643-648. [PMID: 37193586 DOI: 10.1136/archdischild-2022-325245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To describe the thresholds of instability used by clinicians at reintubation and evaluate the accuracy of different combinations of criteria in predicting reintubation decisions. DESIGN Secondary analysis using data obtained from the prospective observational Automated Prediction of Extubation Readiness study (NCT01909947) between 2013 and 2018. SETTING Multicentre (three neonatal intensive care units). PATIENTS Infants with birth weight ≤1250 g, mechanically ventilated and undergoing their first planned extubation were included. INTERVENTIONS After extubation, hourly O2 requirements, blood gas values and occurrence of cardiorespiratory events requiring intervention were recorded for 14 days or until reintubation, whichever came first. MAIN OUTCOME MEASURES Thresholds at reintubation were described and grouped into four categories: increased O2, respiratory acidosis, frequent cardiorespiratory events and severe cardiorespiratory events (requiring positive pressure ventilation). An automated algorithm was used to generate multiple combinations of criteria from the four categories and compute their accuracies in capturing reintubated infants (sensitivity) without including non-reintubated infants (specificity). RESULTS 55 infants were reintubated (median gestational age 25.2 weeks (IQR 24.5-26.1 weeks), birth weight 750 g (IQR 640-880 g)), with highly variable thresholds at reintubation. After extubation, reintubated infants had significantly greater O2 needs, lower pH, higher pCO2 and more frequent and severe cardiorespiratory events compared with non-reintubated infants. After evaluating 123 374 combinations of reintubation criteria, Youden indices ranged from 0 to 0.46, suggesting low accuracy. This was primarily attributable to the poor agreement between clinicians on the number of cardiorespiratory events at which to reintubate. CONCLUSIONS Criteria used for reintubation in clinical practice are highly variable, with no combination accurately predicting the decision to reintubate.
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Affiliation(s)
- Tugba Alarcon-Martinez
- Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia
| | | | - Lajos Kovacs
- Department of Neonatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Robert E Kearney
- Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | | | - Wissam Shalish
- Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
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15
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Poppe JA, Flint RB, Smits A, Willemsen SP, Storm KK, Nuytemans DH, Onland W, Poley MJ, de Boode WP, Carkeek K, Cassart V, Cornette L, Dijk PH, Hemels MAC, Hermans I, Hütten MC, Kelen D, de Kort EHM, Kroon AA, Lefevere J, Plaskie K, Stewart B, Voeten M, van Weissenbruch MM, Williams O, Zonnenberg IA, Lacaze-Masmonteil T, Pas ABT, Reiss IKM, van Kaam AH, Allegaert K, Hutten GJ, Simons SHP. Doxapram versus placebo in preterm newborns: a study protocol for an international double blinded multicentre randomized controlled trial (DOXA-trial). Trials 2023; 24:656. [PMID: 37817255 PMCID: PMC10566117 DOI: 10.1186/s13063-023-07683-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Apnoea of prematurity (AOP) is one of the most common diagnoses among preterm infants. AOP often leads to hypoxemia and bradycardia which are associated with an increased risk of death or disability. In addition to caffeine therapy and non-invasive respiratory support, doxapram might be used to reduce hypoxemic episodes and the need for invasive mechanical ventilation in preterm infants, thereby possibly improving their long-term outcome. However, high-quality trials on doxapram are lacking. The DOXA-trial therefore aims to investigate the safety and efficacy of doxapram compared to placebo in reducing the composite outcome of death or severe disability at 18 to 24 months corrected age. METHODS The DOXA-trial is a double blinded, multicentre, randomized, placebo-controlled trial conducted in the Netherlands, Belgium and Canada. A total of 396 preterm infants with a gestational age below 29 weeks, suffering from AOP unresponsive to non-invasive respiratory support and caffeine will be randomized to receive doxapram therapy or placebo. The primary outcome is death or severe disability, defined as cognitive delay, cerebral palsy, severe hearing loss, or bilateral blindness, at 18-24 months corrected age. Secondary outcomes are short-term neonatal morbidity, including duration of mechanical ventilation, bronchopulmonary dysplasia and necrotising enterocolitis, hospital mortality, adverse effects, pharmacokinetics and cost-effectiveness. Analysis will be on an intention-to-treat principle. DISCUSSION Doxapram has the potential to improve neonatal outcomes by improving respiration, but the safety concerns need to be weighed against the potential risks of invasive mechanical ventilation. It is unknown if the use of doxapram improves the long-term outcome. This forms the clinical equipoise of the current trial. This international, multicentre trial will provide the needed high-quality evidence on the efficacy and safety of doxapram in the treatment of AOP in preterm infants. TRIAL REGISTRATION ClinicalTrials.gov NCT04430790 and EUDRACT 2019-003666-41. Prospectively registered on respectively June and January 2020.
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Affiliation(s)
- Jarinda A Poppe
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Sten P Willemsen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kelly K Storm
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Debbie H Nuytemans
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Marten J Poley
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Katherine Carkeek
- Neonatal Intensive Care Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Vincent Cassart
- Department of Neonatology, Grand hôpital de Charleroi, Charleroi, Belgium
| | - Luc Cornette
- Department Neonatology, AZ St-Jan, Bruges, Belgium
| | - Peter H Dijk
- Division of Neonatology, Department of Paediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, the Netherlands
| | | | - Isabelle Hermans
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Matthias C Hütten
- Division of Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Dorottya Kelen
- Neonatal Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ellen H M de Kort
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - André A Kroon
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Julie Lefevere
- Neonatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Katleen Plaskie
- Department of Neonatology, GasthuisZusters Antwerpen, Antwerp, Belgium
| | - Breanne Stewart
- Quality Management in Clinical Research (QMCR), University of Alberta, Edmonton, AB, Canada
| | - Michiel Voeten
- Department of Neonatal Intensive Care, University Hospital Antwerp, Edegem, Belgium
| | - Mirjam M van Weissenbruch
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Olivia Williams
- Neonatology and Neonatal Intensive Care Unit, CHIREC-Delta Hospital, Brussels, Belgium
| | - Inge A Zonnenberg
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thierry Lacaze-Masmonteil
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Maternal Infant Child & Youth Research Network (MICYRN), Vancouver, Canada
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Irwin K M Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Sinno H P Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus University Medical Center Sophia Children's Hospital, Room Sk-4113, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands.
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Raffay TM, Di Fiore JM, Chen Z, Sánchez-Illana Á, Vento M, Piñeiro-Ramos JD, Kuligowski J, Martin RJ, Tatsuoka C, Minich NM, MacFarlane PM, Hibbs AM. Hypoxemia events in preterm neonates are associated with urine oxidative biomarkers. Pediatr Res 2023; 94:1444-1450. [PMID: 37188801 DOI: 10.1038/s41390-023-02646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intermittent hypoxemia (IH) events are common in preterm neonates and are associated with adverse outcomes. Animal IH models can induce oxidative stress. We hypothesized that an association exists between IH and elevated peroxidation products in preterm neonates. METHODS Time in hypoxemia, frequency of IH, and duration of IH events were assessed from a prospective cohort of 170 neonates (<31 weeks gestation). Urine was collected at 1 week and 1 month. Samples were analyzed for lipid, protein, and DNA oxidation biomarkers. RESULTS At 1 week, adjusted multiple quantile regression showed positive associations between several hypoxemia parameters with various individual quantiles of isofurans, neurofurans, dihomo-isoprostanes, dihomo-isofurans, and ortho-tyrosine and a negative correlation with dihomo-isoprostanes and meta-tyrosine. At 1 month, positive associations were found between several hypoxemia parameters with quantiles of isoprostanes, dihomo-isoprostanes and dihomo-isofurans and a negative correlation with isoprostanes, isofurans, neuroprostanes, and meta-tyrosine. CONCLUSIONS Preterm neonates experience oxidative damage to lipids, proteins, and DNA that can be analyzed from urine samples. Our single-center data suggest that specific markers of oxidative stress may be related to IH exposure. Future studies are needed to better understand mechanisms and relationships to morbidities of prematurity. IMPACT Hypoxemia events are frequent in preterm infants and are associated with poor outcomes. The mechanisms by which hypoxemia events result in adverse neural and respiratory outcomes may include oxidative stress to lipids, proteins, and DNA. This study begins to explore associations between hypoxemia parameters and products of oxidative stress in preterm infants. Oxidative stress biomarkers may assist in identifying high-risk neonates.
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Affiliation(s)
- Thomas M Raffay
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Ángel Sánchez-Illana
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Analytical Chemistry, Universtitat de València, Burjassot, Spain
| | - Maximo Vento
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Division of Neonatology, University & Polytechnic Hospital La Fe (HULAFE), Valencia, Spain
| | | | - Julia Kuligowski
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Richard J Martin
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Nori M Minich
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Peter M MacFarlane
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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Haratbar SR, Chen L, Cheng Q, Singh D, Fathi F, Mohtasebi M, Liu X, Patwardhan A, Bhandary P, Bada HS, Yu G, Abu Jawdeh EG. The Impact of Intermittent Hypoxemia on Type 1 Retinopathy of Prematurity in Preterm Infants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.25.23295922. [PMID: 37808800 PMCID: PMC10557831 DOI: 10.1101/2023.09.25.23295922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Intermittent hypoxemia (IH) may influence retinopathy of prematurity (ROP) development in preterm infants, however, previous studies had mixed results. This study aims to assess the influence and evaluate the predictive ability of IH measures on Type 1 ROP, a stage beyond which ROP treatment is indicated. Methods IH was quantified by continuously monitoring oxygen saturation (SpO2) using high-resolution pulse oximeters during the first 10 weeks of life. Statistical analyses assessed the relationship and predictive ability of weekly and cumulative IH variables for Type 1 ROP development. Results Univariate analyses suggested that IH measures are greater in infants with Type 1 ROP and are predictive of Type 1 ROP development. Multivariable logistic regression analyses revealed that cumulative IH of longer duration during certain postnatal periods are associated with Type 1 ROP development after adjusting for gestational age (GA) or birth weight (BW). Although area under the curve (AUC) analyses revealed added predictivity of cumulative IH variables above GA or BW, these increments in AUC were not statistically significant. Conclusions The duration of IH events was associated with Type 1 ROP development. Interventions for reducing the duration of IH events may potentially improve ROP outcomes.
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Affiliation(s)
| | - Li Chen
- Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky
| | - Qiang Cheng
- Institute for Biomedical Informatics, Department of Internal Medicine and Department of Computer Science
| | - Dara Singh
- Department of Biomedical Engineering, University of Kentucky
| | - Faraneh Fathi
- Department of Biomedical Engineering, University of Kentucky
| | | | - Xuhui Liu
- Department of Biomedical Engineering, University of Kentucky
| | | | - Prasad Bhandary
- Division of Neonatology, Department of Pediatrics, University of Kentucky
| | - Henrietta S. Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky
| | - Elie G. Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky
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18
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Marcelino M, Cai CL, Wadowski S, Aranda JV, Beharry KD. Biomarkers of lung alveolarization and microvascular maturation in response to intermittent hypoxia and/or early antioxidant/fish oil supplementation in neonatal rats. Pediatr Pulmonol 2023; 58:2352-2363. [PMID: 37265429 PMCID: PMC10463793 DOI: 10.1002/ppul.26495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 04/11/2023] [Accepted: 05/14/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Extremely preterm infants experience frequent intermittent hypoxia (IH) episodes during oxygen therapy which causes significant damage to the lungs and curtails important signaling pathways that regulate normal lung alveolarization and microvascular maturation. We tested the hypothesis that early supplementation with fish oil and/or antioxidants in rats exposed to neonatal IH improves expression of lung biomarkers of alveolarization and microvascular maturation, and reduces IH-induced lung injury. STUDY DESIGN/METHODS From birth (P0) to P14, rat pups were exposed to room air (RA) or neonatal IH during which they received daily oral supplementation with either: (1) olive oil (OO) (control); (2) Coenzyme Q10 (CoQ10) in OO; (3) fish oil; (4) glutathione nanoparticles (nGSH); or (5) fish oil +CoQ10. At P14 pups were placed in RA until P21 with no further treatment. RA controls were similarly treated. Lung growth and alveolarization, histopathology, apoptosis, oxidative stress and biomarkers of alveolarization and microvascular maturation were determined. RESULTS Neonatal IH was associated with reduced lung weights and severe histopathological outcomes. These effects were curtailed with fish oil and nGSH. nGSH was also protective against apoptosis, while CoQ10 prevented IH-induced ROS production. Of all treatments, nGSH and CoQ10 + fish oil-induced vascular endothelial growth factor165 and CD31 (Platelet endothelial cell adhesion molecule-1), which are associated with angiogenesis. CoQ10 + fish oil improved alveolarization in RA and IH despite evidence of hemorrhage. CONCLUSIONS The benefits of nGSH and CoQ10 + fish oil suggest an antioxidant effect which may be required to curtail IH-induced lung injury. Further clinical assessment of the effectiveness of nGSH is warranted.
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Affiliation(s)
- Matthew Marcelino
- State University of New York Downstate Health Sciences University, College of Medicine, Brooklyn, NY 11203
| | - Charles L. Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
| | - Stephen Wadowski
- Department of Pediatrics, Division of Pediatric Pulmonology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
| | - Jacob V. Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
| | - Kay D. Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
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19
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Ambalavanan N, Weese-Mayer DE, Hibbs AM, Claure N, Carroll JL, Moorman JR, Bancalari E, Hamvas A, Martin RJ, Di Fiore JM, Indic P, Kemp JS, Dormishian A, Krahn KN, Qiu J, Dennery PA, Ratcliffe SJ, Troendle JF, Lake DE. Cardiorespiratory Monitoring Data to Predict Respiratory Outcomes in Extremely Preterm Infants. Am J Respir Crit Care Med 2023; 208:79-97. [PMID: 37219236 PMCID: PMC10870840 DOI: 10.1164/rccm.202210-1971oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/01/2023] [Indexed: 05/24/2023] Open
Abstract
Rationale: Immature control of breathing is associated with apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants. However, it is not clear if such events independently predict worse respiratory outcome. Objectives: To determine if analysis of cardiorespiratory monitoring data can predict unfavorable respiratory outcomes at 40 weeks postmenstrual age (PMA) and other outcomes, such as bronchopulmonary dysplasia at 36 weeks PMA. Methods: The Prematurity-related Ventilatory Control (Pre-Vent) study was an observational multicenter prospective cohort study including infants born at <29 weeks of gestation with continuous cardiorespiratory monitoring. The primary outcome was either "favorable" (alive and previously discharged or inpatient and off respiratory medications/O2/support at 40 wk PMA) or "unfavorable" (either deceased or inpatient/previously discharged on respiratory medications/O2/support at 40 wk PMA). Measurements and Main Results: A total of 717 infants were evaluated (median birth weight, 850 g; gestation, 26.4 wk), 53.7% of whom had a favorable outcome and 46.3% of whom had an unfavorable outcome. Physiologic data predicted unfavorable outcome, with accuracy improving with advancing age (area under the curve, 0.79 at Day 7, 0.85 at Day 28 and 32 wk PMA). The physiologic variable that contributed most to prediction was intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <90%. Models with clinical data alone or combining physiologic and clinical data also had good accuracy, with areas under the curve of 0.84-0.85 at Days 7 and 14 and 0.86-0.88 at Day 28 and 32 weeks PMA. Intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <80% was the major physiologic predictor of severe bronchopulmonary dysplasia and death or mechanical ventilation at 40 weeks PMA. Conclusions: Physiologic data are independently associated with unfavorable respiratory outcome in extremely preterm infants.
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Affiliation(s)
| | - Debra E. Weese-Mayer
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anna Maria Hibbs
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - John L. Carroll
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Aaron Hamvas
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard J. Martin
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Juliann M. Di Fiore
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - James S. Kemp
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | | | - Jiaxing Qiu
- University of Virginia, Charlottesville, Virginia
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Atanasov S, Dippel C, Takoulegha D, Windhorst A, Schuler R, Strodthoff C, Frerichs I, Dreyhaupt J, Waitz M, Sohrabi K, Ehrhardt H. Fluctuations in Oxygen Saturation during Synchronized Nasal Intermittent Positive Pressure Ventilation and Nasal High-Frequency Oscillatory Ventilation in Very Low Birth Weight Infants: A Randomized Crossover Trial. Neonatology 2023; 120:598-606. [PMID: 37393894 PMCID: PMC10614494 DOI: 10.1159/000530409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/21/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Very low birth weight (VLBW) infants on noninvasive ventilation (NIV) experience frequent fluctuations in oxygen saturation (SpO2) that are associated with an increased risk for mortality and severe morbidities. METHODS In this randomized crossover trial, VLBW infants (n = 22) born 22+3 to 28+0 weeks on NIV with supplemental oxygen were allocated on two consecutive days in random order to synchronized nasal intermittent positive pressure ventilation (sNIPPV) and nasal high-frequency oscillatory ventilation (nHFOV) for 8 h. nHFOV and sNIPPV were set to equivalent mean airway pressure and transcutaneous pCO2. Primary outcome was the time spent within the SpO2 target (88-95%). RESULTS During sNIPPV, VLBW infants spent significantly more time within the SpO2 target (59.9%) than during nHFOV (54.6%). The proportion of time spent in hypoxemia (22.3% vs. 27.1%) and the mean fraction of supplemental oxygen (FiO2) (29.4% vs. 32.8%) were significantly reduced during sNIPPV, while the respiratory rate (50.1 vs. 42.6) was significantly higher. Mean SpO2, SpO2 above the target, number of prolonged (>1 min) and severe (SpO2 <80%) hypoxemic episodes, parameters of cerebral tissue oxygenation using NIRS, number of FiO2 adjustments, heart rate, number of bradycardias, abdominal distension and transcutaneous pCO2 did not differ between both interventions. CONCLUSIONS In VLBW infants with frequent fluctuations in SpO2, sNIPPV is more efficient than nHFOV to retain the SpO2 target and to reduce FiO2 exposure. These results demand more detailed investigations into cumulative oxygen toxicities during different modes of NIV over the weaning period, particularly with regard to consequences for long-term outcomes.
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Affiliation(s)
- Svilen Atanasov
- Department of General Pediatrics and Neonatology, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Giessen, Germany,
| | - Constanze Dippel
- Department of General Pediatrics and Neonatology, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Giessen, Germany
| | - Dupleix Takoulegha
- Faculty of Health Sciences, University of Applied Sciences Giessen, Giessen, Germany
- Institute of Medical Informatics, Justus-Liebig-University Giessen, Giessen, Germany
| | - Anita Windhorst
- Institute of Medical Informatics, Justus-Liebig-University Giessen, Giessen, Germany
| | - Rahel Schuler
- Department of General Pediatrics and Neonatology, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Giessen, Germany
| | - Claas Strodthoff
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Markus Waitz
- Department of General Pediatrics and Neonatology, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Giessen, Germany
| | - Keywan Sohrabi
- Faculty of Health Sciences, University of Applied Sciences Giessen, Giessen, Germany
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Giessen, Germany
- Division of Neonatology and Pediatric Intensive Care Medicine, Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
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Early prediction of severe retinopathy of prematurity requiring laser treatment using physiological data. Pediatr Res 2023:10.1038/s41390-023-02504-6. [PMID: 36788288 PMCID: PMC10382319 DOI: 10.1038/s41390-023-02504-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Early risk stratification for developing retinopathy of prematurity (ROP) is essential for tailoring screening strategies and preventing abnormal retinal development. This study aims to examine the ability of physiological data during the first postnatal month to distinguish preterm infants with and without ROP requiring laser treatment. METHODS In this cohort study, preterm infants with a gestational age <32 weeks and/or birth weight <1500 g, who were screened for ROP were included. Differences in the physiological data between the laser and non-laser group were identified, and tree-based classification models were trained and independently tested to predict ROP requiring laser treatment. RESULTS In total, 208 preterm infants were included in the analysis of whom 30 infants (14%) required laser treatment. Significant differences were identified in the level of hypoxia and hyperoxia, oxygen requirement, and skewness of heart rate. The best model had a balanced accuracy of 0.81 (0.72-0.87), a sensitivity of 0.73 (0.64-0.81), and a specificity of 0.88 (0.80-0.93) and included the SpO2/FiO2 ratio and baseline demographics (including gestational age and birth weight). CONCLUSIONS Routinely monitored physiological data from preterm infants in the first postnatal month are already predictive of later development of ROP requiring laser treatment, although validation is required in larger cohorts. IMPACT Routinely monitored physiological data from the first postnatal month are predictive of later development of ROP requiring laser treatment, although model performance was not significantly better than baseline characteristics (gestational age, birth weight, sex, multiple birth, prenatal glucocorticosteroids, route of delivery, and Apgar scores) alone. A balanced accuracy of 0.81 (0.72-0.87), a sensitivity of 0.73 (0.64-0.81), and a specificity of 0.88 (0.80-0.93) was achieved with a model including the SpO2/FiO2 ratio and baseline characteristics. Physiological data have potential to play a significant role for future ROP prediction and provide opportunities for early interventions to protect infants from abnormal retinal development.
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Antenatal and Postnatal Sequelae of Oxidative Stress in Preterm Infants: A Narrative Review Targeting Pathophysiological Mechanisms. Antioxidants (Basel) 2023; 12:antiox12020422. [PMID: 36829980 PMCID: PMC9952227 DOI: 10.3390/antiox12020422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
The detrimental effects of oxidative stress (OS) can start as early as after conception. A growing body of evidence has shown the pivotal role of OS in the development of several pathological conditions during the neonatal period, which have been therefore defined as OS-related neonatal diseases. Due to the physiological immaturity of their antioxidant defenses and to the enhanced antenatal and postnatal exposure to free radicals, preterm infants are particularly susceptible to oxidative damage, and several pathophysiological cascades involved in the development of prematurity-related complications are tightly related to OS. This narrative review aims to provide a detailed overview of the OS-related pathophysiological mechanisms that contribute to the main OS-related diseases during pregnancy and in the early postnatal period in the preterm population. Particularly, focus has been placed on pregnancy disorders typically associated with iatrogenic or spontaneous preterm birth, such as intrauterine growth restriction, pre-eclampsia, gestational diabetes, chorioamnionitis, and on specific postnatal complications for which the role of OS has been largely ascertained (e.g., respiratory distress, bronchopulmonary dysplasia, retinopathy of prematurity, periventricular leukomalacia, necrotizing enterocolitis, neonatal sepsis). Knowledge of the underlying pathophysiological mechanisms may increase awareness on potential strategies aimed at preventing the development of these conditions or at reducing the ensuing clinical burden.
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Pulse oximetry reliability for detection of hypoxemia under motion in extremely premature infants. Pediatr Res 2023; 93:118-124. [PMID: 35978093 PMCID: PMC9892170 DOI: 10.1038/s41390-022-02258-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Episodes of intermittent hypoxemia (IH) in extremely premature infants are detected by pulse oximetry (SpO2) but motion artifact can cause falsely low readings. OBJECTIVES To evaluate the reliability of SpO2 during IH episodes associated with motion in premature infants of ≤28 weeks GA monitored with 2 pulse oximeters. METHODS IH episodes (defined as SpO2 < 90%, >10 s and SpO2 < 80%, >10 s) were classified by an analytic tool based on distortion caused by motion in the pulse plethysmograph (Pleth) as: A (true hypoxemia), both SpO2 decreased (only one Pleth showed motion); B (false hypoxemia), one SpO2 decreased (Pleth showed motion) and the other didn't (Pleth didn't show motion); C (suspected hypoxemia), both SpO2 decreased (both Pleth showed motion); D (true hypoxemia-motion free), both SpO2 decreased (neither Pleth showed motion). RESULTS In 24-72 h data from 20 infants of 25.4 ± 1.5 weeks GA, 14.1 ± 5.7 episodes with SpO2 < 90% and 7.9 ± 5.5 episodes with SpO2 < 80% per infant were identified. 29 ± 15% of episodes with SpO2 < 90% were type A, 1 ± 2% B, 43 ± 21% C and 27 ± 23% D, while 26 ± 22% of episodes with SpO2 < 80% were type A, 0.3 ± 1.2% B, 45 ± 29% C, and 19 ± 25% D [p < 0.001 type B vs. rest (GLM-repeated measures)]. CONCLUSION In extremely premature infants SpO2 with motion artifact is more likely to indicate true- than false hypoxemia. IMPACT Uncertainty on the effect of motion on SpO2 accuracy during hypoxemia episodes in premature infants can influence the caregiver's trust on SpO2 and influence their response. This study evaluated data from two pulse oximeters used simultaneously in different extremities to determine the reliability of SpO2 during motion artifact in premature infants. Data from this study showed that in extremely premature infants SpO2 is more likely to indicate true- than false hypoxemia during episodes of hypoxemia associated with motion artifact.
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Wilson CG, Altamirano AE, Hillman T, Tan JB. Data analytics in a clinical setting: Applications to understanding breathing patterns and their relevance to neonatal disease. Semin Fetal Neonatal Med 2022; 27:101399. [PMID: 36396542 DOI: 10.1016/j.siny.2022.101399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this review, we focus on the use of contemporary linear and non-linear data analytics as well as machine learning/artificial intelligence algorithms to inform treatment of pediatric patients. We specifically focus on methods used to quantify changes in breathing that can lead to increased risk for apnea of prematurity, retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC) and provide a list of potentially useful algorithms that comprise a suite of software tools to enhance prediction of outcome. Next, we provide a brief overview of machine learning/artificial intelligence methods and applications within the sphere of perinatal care. Finally, we provide an overview of the infrastructure needed to use these tools in a clinical setting for real-time data acquisition, data synchrony, data storage and access, and bedside data visualization to assist in clinical decision making and support the medical informatics mission. Our goal is to provide an overview and inspire other investigators to adopt these tools for their own research and optimization of perinatal patient care.
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Affiliation(s)
- Christopher G Wilson
- Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University, School of Medicine, Loma Linda, CA, 92350, USA; Department of Pediatrics, Loma Linda University, School of Medicine, Loma Linda, CA, 92350, USA.
| | - A Erika Altamirano
- Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University, School of Medicine, Loma Linda, CA, 92350, USA.
| | - Tyler Hillman
- Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University, School of Medicine, Loma Linda, CA, 92350, USA.
| | - John B Tan
- Department of Pediatrics, Loma Linda University, School of Medicine, Loma Linda, CA, 92350, USA; Huckleberry Care, Irvine, CA, 92618, USA.
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Hou X, Faqeeh A, Amjad R, Pardalos J, Fales R. Clinical Evaluation of an Automatic Oxygen Control System for Premature Infants Receiving High-Flow Nasal Cannula for Respiratory Support: A Pilot Study. J Med Device 2022; 16:031005. [PMID: 35646226 PMCID: PMC9125868 DOI: 10.1115/1.4054250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/25/2022] [Indexed: 09/03/2023] Open
Abstract
A pilot clinical study was conducted that compared the peripheral oxygen saturation (SpO2) targeting performance of an automatic oxygen control system with manual oxygen control, which is the standard of care for preterm and low birth weight infants on high-flow nasal cannula (HFNC). The new oxygen control device studied was used to automatically adjust the fraction of inspired oxygen (FiO2) according to a desired SpO2 target setpoint and measured feedback signals including the SpO2 and other signals. A crossover study was designed with several endpoints including the comparison of the percentage of time that the SpO2 was within the target range with the automatic oxygen control device versus manual oxygen control. Other metrics were also compared to assess the performance of the system including the number of bradycardia events. The pilot study included six patients that fit the inclusion criteria. The results showed that there were improvements in all of the measured outcomes considered including statistically significant improvements in the number of bradycardia events during the period when the automatic oxygen control device was used.
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Affiliation(s)
- Xuefeng Hou
- Mechanical and Aerospace Engineering, University of Missouri-Columbia, E2412 Lafferre Hall, Columbia, MO 65211
| | - Akram Faqeeh
- Department of Mechanical Engineering Technology, Yanbu Industrial College, Yanbu 41912, Saudi Arabia
| | - Ramak Amjad
- Neonatology, University of Missouri Health, 400 N. Keene Street, Columbia, MO 65212
| | - John Pardalos
- Neonatology, University of Missouri Health, 400 N. Keene Street, Columbia, MO 65212
| | - Roger Fales
- Mechanical and Aerospace Engineering, University of Missouri-Columbia, E2412 Lafferre Hall, Columbia, MO 65211
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Srivatsa B, Hagan JL, Clark RH, Kupke KG. Oxygenation Factors Associated with Retinopathy of Prematurity in Infants of Extremely Low Birth Weight. J Pediatr 2022; 247:46-52.e4. [PMID: 35427689 DOI: 10.1016/j.jpeds.2022.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/06/2022] [Accepted: 03/21/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To study characteristics of oxygenation during the first 2 postnatal months and correlation with the occurrence and severity of retinopathy of prematurity (ROP) among infants of extremely low birth weight. STUDY DESIGN This retrospective study analyzed the incidence and severity of hyperoxemia and hypoxemia while on respiratory support with or without supplemental oxygen among infants of extremely low birth weight (birth weight <1000 g) admitted to the neonatal intensive care unit during 2016-2020. The findings were correlated with the occurrence and severity of ROP after adjusting for baseline covariates. RESULTS After adjusting for differences in baseline demographic and clinical features, the group with severe ROP was exposed to greater fraction of inspired oxygen (FiO2) (P = .001) and experienced more frequent FiO2 titration adjustments (P = .001) compared with the group without ROP. Ambient air hyperoxemia occurred more frequently in the group without ROP (P = .003), and iatrogenic hyperoxemia occurred more frequently in the group with severe ROP (P = .046). There were no differences in the severity of ambient and iatrogenic hyperoxemia in the study population. The group with severe ROP demonstrated more hypoxemic episodes (P = .01) and longer time spent in the severe hypoxemic range (P = .005) compared with the group without ROP. CONCLUSIONS Severe ROP is associated with greater FiO2 exposure, increased iatrogenic hyperoxemia, decreased ambient air hyperoxemia, and increased hypoxemia in infants of extremely low birth weight despite a greater frequency of FiO2 titration. This study illustrates the need for automated closed loop FiO2 delivery systems to further optimize oxygen saturation targeting in this high-risk population.
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Affiliation(s)
- Bharath Srivatsa
- Neonatology Associates of Atlanta, Atlanta, GA; Northside Hospital, Atlanta, GA; Pediatrix Medical Group, Sunrise, FL.
| | | | | | - Kenneth G Kupke
- Neonatology Associates of Atlanta, Atlanta, GA; Northside Hospital, Atlanta, GA; Pediatrix Medical Group, Sunrise, FL
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Bancalari E, Claure N. Importance and Challenges Associated with Oxygen Control in Premature Infants. J Pediatr 2022; 247:8-9. [PMID: 35640674 DOI: 10.1016/j.jpeds.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida.
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
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Mukherjee R, Indic P, Travers CP, Ambalavanan N, Ramanand P. Stochastic Modeling of Inter-Hypoxemia Intervals in Preterm Infants. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:346-349. [PMID: 36085974 DOI: 10.1109/embc48229.2022.9871320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Hypoxemia, characterized by low blood oxygen levels is pervasive in preterm infants and is associated with development of multiple adverse cardiovascular morbidities. In clinical practice, it is often quantified using frequency, pattern and time spent in it. A predictive tool of hypoxemia occurrence will aid clinicians in risk stratifying infant oxygenation patterns and improving personalized care. As a first step towards this goal in characterizing the underlying temporal processes, we studied inter-hypoxemia interval distributions in preterm infants on oxygen supplementation. We derived regression relationships of characterizing parameters of the distributions with gestational age and birth weight of infants. The modeling and goodness of fit tests of pooled and individual inter-hypoxemia intervals indicated that the inverse Gaussian and Birnbaum Saunders distributions fit well over short time scales and the lognormal at longer time scales. Information from distribution modeling may provide insights into hypoxemia recurrence times and be helpful in developing models to predict severe hypoxemic events that may be translated to personalized care in clinical settings. Clinical relevance - Understanding the stochastic nature of temporal processes underlying hypoxemia in preterm infants is a critical step towards developing predictive models for their occurrence. This may potentially aid in the neonatal care and treatment of these vulnerable infants.
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Neonatal intermittent hypoxia, fish oil, and/or antioxidant supplementation on gut microbiota in neonatal rats. Pediatr Res 2022; 92:109-117. [PMID: 34455420 PMCID: PMC8882692 DOI: 10.1038/s41390-021-01707-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preterm infants frequently experience intermittent hypoxia (IH) episodes, rendering them susceptible to oxidative stress and gut dysbiosis. We tested the hypothesis that early supplementation with antioxidants and/or fish oil promotes gut biodiversity and mitigates IH-induced gut injury. METHODS Newborn rats were exposed to neonatal IH from birth (P0) to P14 during which they received daily oral supplementation with: (1) coenzyme Q10 (CoQ10) in olive oil, (2) fish oil, (3) glutathione nanoparticles (nGSH), (4) CoQ10 + fish oil, or (5) olive oil (placebo control). Pups were placed in room air (RA) from P14 to P21 with no further treatment. RA controls were similarly treated. Stool samples were assessed for microbiota and terminal ileum for histopathology and morphometry, total antioxidant capacity, lipid peroxidation, and biomarkers of gut injury. RESULTS Neonatal IH induced histopathologic changes consistent with necrotizing enterocolitis, which were associated with increased lipid peroxidation, toll-like receptor, transforming growth factor, and nuclear factor kappa B. Combination of CoQ10 + fish oil and nGSH were most effective for preserving gut integrity, reducing biomarkers of gut injury, and increasing commensal organisms. CONCLUSIONS Combination of antioxidants and fish oil may confer synergistic benefits to mitigate IH-induced injury in the terminal ileum. IMPACT Antioxidant and fish oil (PUFA) co-treatment was most beneficial for reducing neonatal IH-induced gut injury. The synergistic effects of antioxidant and fish oil is likely due to prevention of IH-induced ROS attack on lipids, thus preserving and augmenting its therapeutic benefits. Combination treatment was also effective for increasing the abundance of the non-pathogenic Firmicutes phylum, which is associated with a healthy gastrointestinal system of the newborn. Extremely low gestational age neonates who are at high risk for frequent, repetitive neonatal IH and oxidative stress-induced diseases may benefit from this combination therapy.
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Beckstrom AC, Lin G, Ngoche L, Perla S, Clark RH, Kamitsuka M. Effect of an Alternate Definition for a Clinically Significant Cardiopulmonary Event on Discharge. J Pediatr 2022; 242:25-31.e2. [PMID: 34748739 DOI: 10.1016/j.jpeds.2021.10.064] [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: 06/14/2021] [Revised: 10/15/2021] [Accepted: 10/31/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate a precise definition of a clinically significant cardiopulmonary event (CSCPE) on the hospital length of stay (LOS), medical provider satisfaction, and discharge complications. STUDY DESIGN This is a single-center, observational study that included 139 infants before and 134 infants after the new definition was implemented in December 2017. Retrospective data collected November 2015 to November 2017 (before) was compared with prospective data from June 2018 to July 2020 (after). Outcome measures were the proportion of infants waiting to outgrow CSCPE, LOS, provider satisfaction with the definition, and discharge complications. Multivariate regression modeling was used to evaluate variables on LOS and postmenstrual age at discharge. RESULTS The proportion waiting to outgrow CSCPE decreased from 68.4% to 31.7% (P < .0001). The LOS was similar between groups; however, multivariate analysis correcting for gestational age and reason awaiting discharge estimated 3.5 days (95% CI, 1.4-5.8 days; P = .0017) decrease in LOS, and 0.92 weeks (95% CI, 0.29-1.56; P = .005) younger postmenstrual age at discharge in the after group. There was no difference in the number of readmissions or emergency room visits for apnea or deaths. Provider satisfaction improved with discharge planning after the implementation of the definition. CONCLUSIONS We developed an alternate definition for a CSCPE that decreased the proportion of infants waiting to outgrow a CSCPE but not LOS. There was no difference in the number of readmissions or emergency room visits for apnea or deaths, and provider satisfaction in management and discharge planning was greater. CLINICAL TRIAL REGISTRATION INFORMATION This study was registered under the ClinicalTrial.gov Protocol ID: 5892S-15. "The effect of standardizing the definition and approach to a clinically significant cardiopulmonary event in infants less than 30 weeks on length of stay." Recorded Nov 2017.
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Affiliation(s)
- Andrew C Beckstrom
- Division of Neonatology, Swedish Medical Center, Seattle, WA; Pediatrix Medical Group, Center for Research and Education, Sunrise, FL.
| | - Grace Lin
- Division of Neonatology, Swedish Medical Center, Seattle, WA; Pediatrix Medical Group, Center for Research and Education, Sunrise, FL
| | - Leah Ngoche
- Division of Neonatology, Swedish Medical Center, Seattle, WA; Pediatrix Medical Group, Center for Research and Education, Sunrise, FL
| | - Sally Perla
- Division of Neonatology, Swedish Medical Center, Seattle, WA
| | - Reese H Clark
- Pediatrix Medical Group, Center for Research and Education, Sunrise, FL
| | - Michael Kamitsuka
- Division of Neonatology, Swedish Medical Center, Seattle, WA; Pediatrix Medical Group, Center for Research and Education, Sunrise, FL
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Kurtom W, Dormishian A, Jain D, Schott A, Aguilar AC, Grieb G, Bancalari E, Claure N. Effect of the Target Range on Arterial Oxygen Saturation Stability in Extremely Premature Infants. Neonatology 2022; 119:638-643. [PMID: 36030769 DOI: 10.1159/000525271] [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: 03/25/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effect of targeting arterial oxygen saturation (SpO2) in the high (93-95%) versus the low portion (90-92%) of the recommended range of 90-95% on oxygenation stability in extremely premature infants. METHODS Premature infants of ≤28 weeks of gestational age who received a fraction of inspired oxygen (FiO2) > 0.21 after day 14 were eligible. FiO2 was adjusted by a dedicated investigator to keep SpO2 between 90-92% and 93-95% for 2 h each in random sequence. Episodes of intermittent hypoxemia (IH) were defined as SpO2 <90% for ≥10 s; severe IH episodes were defined as SpO2 <80% for ≥10 s. Hyperoxemia was defined as SpO2 >95% or >98%. RESULTS Eighteen premature infants were enrolled. Their (mean ± SD) GA was 26 ± 1.5 w. Seven infants were on mechanical ventilation, 4 infants on nasal ventilation, and 7 infants on nasal cannula. They were on a mean FiO2 0.38 ± 0.12 at study entry. Episodes of IH and severe IH were more frequent during the low compared to the high target (36.6 [27.0-41.3] vs. 16.0 [7.8-19.0], p < 0.001; 8.4 ± 9.3 vs. 3.2 ± 4.3, p = 0.002). The proportions of time with SpO2 >95% and >98% were greater with the high target (13.9 ± 11 vs. 34.1 ± 15.4%, p < 0.001; 0.9 [0-5.7] vs. 3.4 [0.5-16.1]%, p = 0.002). CONCLUSION In this group of extremely premature infants, targeting SpO2 at the lower portion of the recommended range resulted in more frequent episodes of IH. However, targeting the higher SpO2 range led to more hyperoxemia. This trade-off warrants further investigation.
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Affiliation(s)
- Waleed Kurtom
- Division of Neonatology, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, Florida, USA
| | - Deepak Jain
- Division of Neonatology, Department of Pediatrics, Pediatrics, Robert W. Johnson School of Medicine Rutgers University, New Brunswick, New Jersey, USA
| | - Alini Schott
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ana Cecilia Aguilar
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gavin Grieb
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, Florida, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, Florida, USA
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Free Radicals and Neonatal Brain Injury: From Underlying Pathophysiology to Antioxidant Treatment Perspectives. Antioxidants (Basel) 2021; 10:antiox10122012. [PMID: 34943115 PMCID: PMC8698308 DOI: 10.3390/antiox10122012] [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] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 01/23/2023] Open
Abstract
Free radicals play a role of paramount importance in the development of neonatal brain injury. Depending on the pathophysiological mechanisms underlying free radical overproduction and upon specific neonatal characteristics, such as the GA-dependent maturation of antioxidant defenses and of cerebrovascular autoregulation, different profiles of injury have been identified. The growing evidence on the detrimental effects of free radicals on the brain tissue has led to discover not only potential biomarkers for oxidative damage, but also possible neuroprotective therapeutic approaches targeting oxidative stress. While a more extensive validation of free radical biomarkers is required before considering their use in routine neonatal practice, two important treatments endowed with antioxidant properties, such as therapeutic hypothermia and magnesium sulfate, have become part of the standard of care to reduce the risk of neonatal brain injury, and other promising therapeutic strategies are being tested in clinical trials. The implementation of currently available evidence is crucial to optimize neonatal neuroprotection and to develop individualized diagnostic and therapeutic approaches addressing oxidative brain injury, with the final aim of improving the neurological outcome of this population.
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Claure N, Bancalari E. New Modes of Respiratory Support for the Premature Infant: Automated Control of Inspired Oxygen Concentration. Clin Perinatol 2021; 48:843-853. [PMID: 34774212 DOI: 10.1016/j.clp.2021.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most extremely premature infants have respiratory instability that can manifest as frequent episodes of intermittent hypoxemia. Although caregivers target clinically recommended ranges of arterial oxygen saturation (oxygen saturation as measured by pulse oximetry [Spo2]), consistent maintenance of these ranges is not always achieved. Excessive administration of supplemental oxygen combined with limited staff resources increases exposure to extreme Spo2 levels. In this population, exposure to hyperoxemia and prolonged episodes of intermittent hypoxemia have been associated with damage to the eye and lung and impaired neurodevelopment. To improve Spo2 targeting, various systems for automated control of inspired oxygen have been developed recently.
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Affiliation(s)
- Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
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Williamson M, Poorun R, Hartley C. Apnoea of Prematurity and Neurodevelopmental Outcomes: Current Understanding and Future Prospects for Research. Front Pediatr 2021; 9:755677. [PMID: 34760852 PMCID: PMC8573333 DOI: 10.3389/fped.2021.755677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Infants who are born prematurely are at significant risk of apnoea. In addition to the short-term consequences such as hypoxia, apnoea of prematurity has been associated with long-term morbidity, including poor neurodevelopmental outcomes. Clinical trials have illustrated the importance of methylxanthine drugs, in particular caffeine, in reducing the risk of long term adverse neurodevelopmental outcomes. However, the extent to which apnoea is causative of this secondary neurodevelopmental delay or is just associated in a background of other sequelae of prematurity remains unclear. In this review, we first discuss the pathophysiology of apnoea of prematurity, previous studies investigating the relationship between apnoea and neurodevelopmental delay, and treatment of apnoea with caffeine therapy. We propose a need for better methods of measuring apnoea, along with improved understanding of the neonatal brain's response to consequent hypoxia. Only then can we start to disentangle the effects of apnoea on neurodevelopment in preterm infants. Moreover, by better identifying those infants who are at risk of apnoea, and neurodevelopmental delay, we can work toward a risk stratification system for these infants that is clinically actionable, for example, with doses of caffeine tailored to the individual. Optimising treatment of apnoea for individual infants will improve neonatal care and long-term outcomes for this population.
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Affiliation(s)
- Max Williamson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ravi Poorun
- Department of Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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Behnke J, Dippel CM, Choi Y, Rekers L, Schmidt A, Lauer T, Dong Y, Behnke J, Zimmer KP, Bellusci S, Ehrhardt H. Oxygen Toxicity to the Immature Lung-Part II: The Unmet Clinical Need for Causal Therapy. Int J Mol Sci 2021; 22:10694. [PMID: 34639034 PMCID: PMC8508961 DOI: 10.3390/ijms221910694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022] Open
Abstract
Oxygen toxicity continues to be one of the inevitable injuries to the immature lung. Reactive oxygen species (ROS) production is the initial step leading to lung injury and, subsequently, the development of bronchopulmonary dysplasia (BPD). Today, BPD remains the most important disease burden following preterm delivery and results in life-long restrictions in lung function and further important health sequelae. Despite the tremendous progress in the pathomechanistic understanding derived from preclinical models, the clinical needs for preventive or curative therapies remain unmet. This review summarizes the clinical progress on guiding oxygen delivery to the preterm infant and elaborates future directions of research that need to take into account both hyperoxia and hypoxia as ROS sources and BPD drivers. Many strategies have been tested within clinical trials based on the mechanistic understanding of ROS actions, but most have failed to prove efficacy. The majority of these studies were tested in an era before the latest modes of non-invasive respiratory support and surfactant application were introduced or were not appropriately powered. A comprehensive re-evaluation of enzymatic, antioxidant, and anti-inflammatory therapies to prevent ROS injury is therefore indispensable. Strategies will only succeed if they are applied in a timely and vigorous manner and with the appropriate outcome measures.
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Affiliation(s)
- Judith Behnke
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Constanze M. Dippel
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Yesi Choi
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Lisa Rekers
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Annesuse Schmidt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Tina Lauer
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Ying Dong
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Jonas Behnke
- Department of Internal Medicine V, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Klinikstrasse 33, 35392 Giessen, Germany;
| | - Klaus-Peter Zimmer
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Saverio Bellusci
- Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center (UGMLC), Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Aulweg 130, 35392 Giessen, Germany;
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
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Guzel S, Cai CL, Aranda JV, Beharry KD. Dose Response of Bumetanide on Aquaporins and Angiogenesis Biomarkers in Human Retinal Endothelial Cells Exposed to Intermittent Hypoxia. Pharmaceuticals (Basel) 2021; 14:ph14100967. [PMID: 34681190 PMCID: PMC8538009 DOI: 10.3390/ph14100967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022] Open
Abstract
Aquaporins (AQPs) are important for regulating cellular water, solute transport, and balance. Recently, AQPs have also been recognized as playing a key role in cell migration and angiogenesis. In the retina, hypoxia induces vascular endothelial growth factor (VEGF), a potent angiogenic and vascular permeability factor, resulting in retinal edema, which is facilitated by AQPs. Bumetanide is a diuretic agent and AQP 1–4 blocker. We tested the hypothesis that bumetanide suppression of AQPs ameliorates intermittent hypoxia (IH)-induced angiogenesis and oxidative stress in human microvascular retinal endothelial cells (HMRECs). HMRECs were treated with a low-dose (0.05 µg/mL) or high-dose (0.2 µg/mL) of bumetanide and were exposed to normoxia (Nx), hyperoxia (50% O2), or IH (50% O2 with brief hypoxia 5% O2) for 24, 48, and 72 h. Angiogenesis and oxidative stress biomarkers were determined in the culture media, and the cells were assessed for tube formation capacity and AQP-1 and -4 expression. Both doses of bumetanide significantly decreased oxidative stress and angiogenesis biomarkers. This response was reflected by reductions in tube formation capacity and AQP expression. These findings confirm the role of AQPs in retinal angiogenesis. Therapeutic targeting of AQPs with bumetanide may be advantageous for IH-induced aberrant retinal development.
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Affiliation(s)
- Sibel Guzel
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA; (S.G.); (C.L.C.); (J.V.A.)
| | - Charles L. Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA; (S.G.); (C.L.C.); (J.V.A.)
| | - Jacob V. Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA; (S.G.); (C.L.C.); (J.V.A.)
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
- State University of New York Eye Institute, Brooklyn, NY 11203, USA
| | - Kay D. Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA; (S.G.); (C.L.C.); (J.V.A.)
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
- State University of New York Eye Institute, Brooklyn, NY 11203, USA
- Correspondence: ; Tel.: +1-(718)-270-1475
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Zangaladze A, Cai CL, Marcelino M, Aranda JV, Beharry KD. Renal biomarkers of acute kidney injury in response to increasing intermittent hypoxia episodes in the neonatal rat. BMC Nephrol 2021; 22:299. [PMID: 34481475 PMCID: PMC8418040 DOI: 10.1186/s12882-021-02507-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/19/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We tested the hypotheses that: 1) early exposure to increasing episodes of clinically relevant intermittent hypoxia (IH) is detrimental to the developing kidneys; and 2) there is a critical number of daily IH episodes which will result in irreparable renal damage that may involve angiotensin (Ang) II and endothelin (ET)-1. METHODS At birth (P0), neonatal rat pups were exposed to brief IH episodes from the first day of life (P0) to P7 or from P0-P14. Pups were either euthanized immediately or placed in room air (RA) until P21. RA littermates served as controls. Kidneys were harvested at P7, P14, and P21 for histopathology; angiotensin converting enzyme (ACE), ACE-2, ET-1, big ET-1, and malondialdehyde (MDA) levels; immunoreactivity of ACE, ACE-2, ET-1, ET-2, ET receptors (ETAR, ETBR), and hypoxia inducible factor (HIF)1α; and apoptosis (TUNEL stain). RESULTS Histopathology showed increased renal damage with 8-12 IH episodes/day, and was associated with Ang II, ACE, HIF1α, and apoptosis. ACE-2 was not expressed at P7, and minimally increased at P14. However, a robust ACE-2 response was seen during recovery with maximum levels noted in the groups recovering from 8 IH episodes/day. ET-1, big ET-1, ETAR, ETBR, and MDA increased with increasing levels of neonatal IH. CONCLUSIONS Chronic neonatal IH causes severe damage to the developing kidney with associated elevations in vasoconstrictors, suggesting hypertension, particularly with 8 neonatal IH episodes. ACE-2 is not activated in early postnatal life, and this may contribute to IH-induced vasoconstriction. Therapeutic targeting of ACE and ET-1 may help decrease the risk for kidney injury in the developing neonate to prevent and/or treat neonatal acute kidney injury and/or chronic kidney disease.
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Affiliation(s)
- Anano Zangaladze
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Matthew Marcelino
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- SUNY Eye Institute, New York, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.
- SUNY Eye Institute, New York, NY, USA.
- Department of Pediatrics & Ophthalmology, Neonatal-Perinatal Medicine Clinical & Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA.
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Zhong DJ, Zhang Y, Zhang S, Ge YY, Tong M, Feng Y, You F, Zhao X, Wang K, Zhang L, Liu X, Chen JF. Adenosine A 2A receptor antagonism protects against hyperoxia-induced retinal vascular loss via cellular proliferation. FASEB J 2021; 35:e21842. [PMID: 34418159 DOI: 10.1096/fj.202100414rr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022]
Abstract
Retinopathy of prematurity (ROP) remains one of the major causes of blindness in children worldwide. While current ROP treatments are mostly disruptive to reduce proliferative neovascularization by targeting the hypoxic phase, protection against early hyperoxia-induced retinal vascular loss represents an effective therapeutic window, but no such therapeutic strategy is available. Built upon our recent demonstration that the protection against oxygen-induced retinopathy by adenosine A2A receptor (A2A R) antagonists is most effective when administered at the hyperoxia (not hypoxic) phase, we here uncovered the cellular mechanism underlying the A2A R-mediated protection against early hyperoxia-induced retinal vascular loss by reversing the inhibition of cellular proliferation via possibly multiple signaling pathways. Specifically, we revealed two distinct stages of the hyperoxia phase with greater cellular proliferation and apoptosis activities and upregulation of adenosine signaling at postnatal 9 day (P9) but reduced cellular activities and adenosine-A2A R signaling at P12. Importantly, the A2A R-mediated protection at P9 was associated with the reversal of hyperoxia-induced inhibition of progenitor cells at the peripheral retina at P9 and of retinal endothelial proliferation at P9 and P12. The critical role of cellular proliferation in the hyperoxia-induced retinal vascular loss was validated by the increased avascular areas by siRNA knockdown of the multiple signaling molecules involved in modulation of cellular proliferation, including activin receptor-like kinase 1, DNA-binding protein inhibitor 1, and vascular endothelial growth factor-A.
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Affiliation(s)
- Ding-Juan Zhong
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China.,Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yu Zhang
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Shuya Zhang
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yuan-Yuan Ge
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Mengyun Tong
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yijia Feng
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Feng You
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xinyue Zhao
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Ke Wang
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Liping Zhang
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xiaoling Liu
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Jiang-Fan Chen
- State Key Laboratory of Optometry, Ophthalmology and Vision Science, The Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, China
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D'Agrosa C, Cai CL, Siddiqui F, Deslouches K, Wadowski S, Aranda JV, Beharry KD. Comparison of coenzyme Q10 or fish oil for prevention of intermittent hypoxia-induced oxidative injury in neonatal rat lungs. Respir Res 2021; 22:196. [PMID: 34225702 PMCID: PMC8256540 DOI: 10.1186/s12931-021-01786-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal intermittent hypoxia (IH) results in oxidative distress in preterm infants with immature antioxidant systems, contributing to lung injury. Coenzyme Q10 (CoQ10) and fish oil protect against oxidative injury. We tested the hypothesis that CoQ10 is more effective than fish oil for prevention of IH-induced lung injury in neonatal rats. METHODS Newborn rats were exposed to two clinically relevant IH paradigms at birth (P0): (1) 50% O2 with brief hypoxia (12% O2); or (2) room air (RA) with brief hypoxia (12% O2), until P14 during which they were supplemented with daily oral CoQ10, fish oil, or olive oil from P0 to P14. Pups were studied at P14 or placed in RA until P21 with no further treatment. Lungs were assessed for histopathology and morphometry; biomarkers of oxidative stress and lipid peroxidation; and antioxidants. RESULTS Of the two neonatal IH paradigms 21%/12% O2 IH resulted in the most severe outcomes, evidenced by histopathology and morphometry. CoQ10 was effective for preserving lung architecture and reduction of IH-induced oxidative stress biomarkers. In contrast, fish oil resulted in significant adverse outcomes including oversimplified alveoli, hemorrhage, reduced secondary crest formation and thickened septae. This was associated with elevated oxidants and antioxidants activities. CONCLUSIONS Data suggest that higher FiO2 may be needed between IH episodes to curtail the damaging effects of IH, and to provide the lungs with necessary respite. The negative outcomes with fish oil supplementation suggest oxidative stress-induced lipid peroxidation.
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Affiliation(s)
- Christina D'Agrosa
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA
| | - Charles L Cai
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA
| | - Faisal Siddiqui
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA
| | - Karen Deslouches
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA
| | - Stephen Wadowski
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA
| | - Jacob V Aranda
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, 11203, USA.,State University of New York Eye Institute, New York, NY, USA
| | - Kay D Beharry
- Department of Pediatrics and Ophthalmology, Division of Neonatal-Perinatal Medicine Clinical and Translational Research Labs, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY, 11203, USA. .,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, 11203, USA. .,State University of New York Eye Institute, New York, NY, USA.
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40
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Conlon S, Di Fiore JM, Martin RJ. Are we over-treating hypoxic spells in preterm infants? Semin Fetal Neonatal Med 2021; 26:101227. [PMID: 33736905 DOI: 10.1016/j.siny.2021.101227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.
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Affiliation(s)
- Steven Conlon
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Richard J Martin
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
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41
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Mustafa G, Cai CL, Bodkin D, Aranda JV, Beharry KD. Antioxidants and/or fish oil reduce intermittent hypoxia-induced inflammation in the neonatal rat terminal ileum. Prostaglandins Other Lipid Mediat 2021; 155:106565. [PMID: 34051366 DOI: 10.1016/j.prostaglandins.2021.106565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/29/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022]
Abstract
Intermittent hypoxia (IH) is associated with the pathogenesis of necrotizing enterocolitis (NEC). We tested the hypothesis that early supplementation with antioxidants and/or fish oil protects the terminal ileum from oxidative injury induced by neonatal IH. Newborn rats were exposed to neonatal IH from birth (P0) until P14 during which they received daily fish oil, coenzyme Q10 (CoQ10), glutathione nanoparticles (nGSH), fish oil + CoQ10, or olive oil. Pups were then placed in room air from P14 to P21 with no further supplementation. Terminal ileum was assessed for IH-induced injury and inflammatory biomarkers. Neonatal IH induced severe damage consistent with NEC, and was associated with oxidative stress and elevations in PGE2, PGF2α, TxB2, NOS-2 and TLR-4, effects that were ameliorated with nGSH and combination CoQ10+fish oil. Early postnatal supplementation with antioxidants and/or fish oil during neonatal IH may be favorable for preserving gut integrity and reducing oxidative injury.
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Affiliation(s)
- Ghassan Mustafa
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Darren Bodkin
- Department of Pediatrics, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA; Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.
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42
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Manlapaz-Mann A, Cai CL, Bodkin D, Mustafa G, Aranda JV, Beharry KD. Effects of omega 3 polyunsaturated fatty acids, antioxidants, and/or non-steroidal inflammatory drugs in the brain of neonatal rats exposed to intermittent hypoxia. Int J Dev Neurosci 2021; 81:448-460. [PMID: 33969544 DOI: 10.1002/jdn.10120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
Preterm infants experience frequent arterial oxygen desaturations during oxygen therapy, or intermittent hypoxia (IH). Neonatal IH increases oxidative distress which contributes to neuroinflammation and brain injury. We tested the hypotheses that exposure to neonatal IH is detrimental to the immature brain and that early supplementation with antioxidants and/or omega 3 polyunsaturated fatty acids (n-3 PUFAs) combined with non-steroidal anti-inflammatory drugs (NSAIDs) is protective. Newborn rats were exposed to brief hypoxia (12% O2 ) during hyperoxia (50% O2 ) from the first day of life (P0) until P14 during which they received daily oral supplementation with antioxidants, namely coenzyme Q10 (CoQ10) or glutathione nanoparticles (nGSH), n-3 PUFAs and/or topical ocular ketorolac. Placebo controls received daily oral olive oil and topical ocular saline. Room air (RA) littermates remained in 21% O2 from birth to P21 with all treatments identical. At P14 animals were allowed to recover in RA until P21 with no further treatment. Whole brains were harvested for histopathology and morphometric analyses, and assessed for biomarkers of oxidative stress and inflammation, as well as myelin injury. Neonatal IH resulted in higher brain/body weight ratios, an effect that was reversed with n-3 PUFAs and n-3 PUFAs+CoQ10 with or without ketorolac. Neonatal IH was also associated with hemorrhage, oxidative stress, and elevations in inflammatory prostanoids. Supplementation with n-3 PUFAs and nGSH with and without ketorolac were most beneficial for myelin growth and integrity when administered in RA. However, the benefit of n-3 PUFAs was significantly curtailed in neonatal IH. Neonatal IH during a critical time of brain development causes inflammation and oxidative injury. Loss of therapeutic benefits of n-3 PUFAs suggest its susceptibility to oxidation in neonatal IH and therefore indicate that co-administration with antioxidants may be necessary to sustain its efficacy.
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Affiliation(s)
- Alex Manlapaz-Mann
- Department of Pediatrics, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Darren Bodkin
- Department of Pediatrics, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Ghassan Mustafa
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.,SUNY Eye Institute, Brooklyn, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.,SUNY Eye Institute, Brooklyn, NY, USA
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Di Fiore JM, Raffay TM. The relationship between intermittent hypoxemia events and neural outcomes in neonates. Exp Neurol 2021; 342:113753. [PMID: 33984336 DOI: 10.1016/j.expneurol.2021.113753] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 04/06/2021] [Accepted: 05/07/2021] [Indexed: 12/20/2022]
Abstract
This brief review examines 1) patterns of intermittent hypoxemia in extremely preterm infants during early postnatal life, 2) the relationship between neonatal intermittent hypoxemia exposure and outcomes in both human and animal models, 3) potential mechanistic pathways, and 4) future alterations in clinical care that may reduce morbidity. Intermittent hypoxemia events are pervasive in extremely preterm infants (<28 weeks gestation at birth) during early postnatal life. An increased frequency of intermittent hypoxemia events has been associated with a range of poor neural outcomes including language and cognitive delays, motor impairment, retinopathy of prematurity, impaired control of breathing, and intraventricular hemorrhage. Neonatal rodent models have shown that exposure to short repetitive cycles of hypoxia induce a pathophysiological cascade. However, not all patterns of intermittent hypoxia are deleterious and some may even improve neurodevelopmental outcomes. Therapeutic interventions include supplemental oxygen, pressure support and pharmacologic drugs but prolonged hyperoxia and pressure exposure have been associated with cardiopulmonary morbidity. Therefore, it becomes imperative to distinguish high risk from neutral and/or even beneficial patterns of intermittent hypoxemia during early postnatal life. Identification of such patterns could improve clinical care with targeted interventions for high-risk patterns and minimal or no exposure to treatment modalities for low-risk patterns.
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Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America
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Zuzarte I, Paydarfar D, Sternad D. Effect of spontaneous movement on respiration in preterm infants. Exp Physiol 2021; 106:1285-1302. [PMID: 33675125 DOI: 10.1113/ep089143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 03/03/2021] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? The respiratory centres in the brainstem that control respiration receive inputs from various sources, including proprioceptors in muscles and joints and suprapontine centres, which all affect limb movements. What is the effect of spontaneous movement on respiration in preterm infants? What is the main finding and its importance? Apnoeic events tend to be preceded by movements. These activity bursts can cause respiratory instability that leads to an apnoeic event. These findings show promise that infant movements might serve as potential predictors of life-threatening apnoeic episodes, but more research is required. ABSTRACT A common condition in preterm infants (<37 weeks' gestational age) is apnoea resulting from immaturity and instability of the respiratory system. As apnoeas are implicated in several acute and long-term complications, prediction of apnoeas may preempt their onset and subsequent complications. This study tests the hypothesis that infant movements are a predictive marker for apnoeic episodes and examines the relation between movement and respiration. Movement was detected using a wavelet algorithm applied to the photoplethysmographic signal. Respiratory activity was measured in nine infants using respiratory inductance plethysmography; in an additional eight infants, respiration and partial pressure of airway carbon dioxide ( P C O 2 ) were measured by a nasal cannula with side-stream capnometry. In the first cohort, the distribution of movements before and after the onset of 370 apnoeic events was compared. Results showed that apnoeic events were associated with longer movement duration occurring before apnoea onsets compared to after. In the second cohort, respiration was analysed in relation to movement, comparing standard deviation of inter-breath intervals (IBI) before and after apnoeas. Poincaré maps of the respiratory activity quantified variability of airway P C O 2 in phase space. Movement significantly increased the variability of IBI and P C O 2 . Moreover, destabilization of respiration was dependent on the duration of movement. These findings support that bodily movements of the infants precede respiratory instability. Further research is warranted to explore the predictive value of movement for life-threatening events, useful for clinical management and risk stratification.
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Affiliation(s)
- Ian Zuzarte
- Department of Bioengineering, Northeastern University, Boston, MA, USA
| | - David Paydarfar
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA.,Oden Institute for Computational Sciences and Engineering, University of Texas at Austin, Austin, TX, USA
| | - Dagmar Sternad
- Departments of Biology, Electrical and Computer Engineering & Physics, Northeastern University, Boston, MA, USA
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Qadri A, Cai CL, Deslouches K, Siddiqui F, Aranda JV, Beharry KD. Ocular Versus Oral Propranolol for Prevention and/or Treatment of Oxygen-Induced Retinopathy in a Rat Model. J Ocul Pharmacol Ther 2021; 37:112-130. [PMID: 33535016 DOI: 10.1089/jop.2020.0092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose: Propranolol, a nonselective B1/B2 adrenoceptor antagonist, promotes the regression of infantile hemangiomas likely through suppression of vascular endothelial growth factor (VEGF), which prompted its use for the prevention of retinopathy of prematurity. We tested the hypothesis that topical ocular propranolol is safe and effective for reducing the severity of oxygen-induced retinopathy (OIR) in the neonatal rat intermittent hypoxia (IH) model. Methods: At birth (P0), rat pups were randomly assigned to room air or neonatal intermittent hypoxia (IH) consisting of 50% O2 with brief episodes of hypoxia (12% O2) from P0 to P14, during which they received a single daily dose of oral propranolol (1 mg/kg/day in 50 μL in sterile normal saline) or topical ocular propranolol (0.2% in 10 μL in normal saline) from P5 to P14. Placebo-controlled littermates received 50 μL oral or 10 μL topical ocular sterile normal saline. Retinal vascular and astrocyte integrity; retinal histopathology and morphometry; and angiogenesis biomarkers were determined. Results: Topical ocular propranolol improved retinal vascular damage and preserved the astrocytic template, but did not completely prevent OIR. The beneficial effects of propranolol were associated with reduced ocular VEGF and increased endogenous soluble inhibitor, sVEGFR-1, when administered topically. Conclusions: Propranolol failed to completely prevent severe OIR, however, it prevented astrocyte degeneration resulting from neonatal IH-induced damage. We conclude that the mechanisms of propranolol's beneficial effects in neonatal IH may involve in part, astrocyte preservation.
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Affiliation(s)
- Areej Qadri
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, State University of New York, Brooklyn, New York, USA
| | - Charles L Cai
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, State University of New York, Brooklyn, New York, USA
| | - Karen Deslouches
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, State University of New York, Brooklyn, New York, USA
| | - Faisal Siddiqui
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, State University of New York, Brooklyn, New York, USA
| | - Jacob V Aranda
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, State University of New York, Brooklyn, New York, USA.,Department of Ophthalmology, Downstate Medical Center, State University of New York, Brooklyn, New York, USA.,State University of New York Eye Institute, New York, New York, USA
| | - Kay D Beharry
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, State University of New York, Brooklyn, New York, USA.,Department of Ophthalmology, Downstate Medical Center, State University of New York, Brooklyn, New York, USA.,State University of New York Eye Institute, New York, New York, USA
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46
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Duggan TJ, Cai CL, Aranda JV, Beharry KD. Acute and chronic effects of intravitreal bevacizumab on lung biomarkers of angiogenesis in the rat exposed to neonatal intermittent hypoxia. Exp Lung Res 2020; 47:121-135. [PMID: 33377400 DOI: 10.1080/01902148.2020.1866712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE/AIM Intravitreal bevacizumab (Avastin) is an irreversible vascular endothelial growth factor (VEGF) inhibitor used to treat severe retinopathy of prematurity (ROP) in extremely low gestational age neonates (ELGANs). ELGANs who are at the highest risk for developing severe ROP often experience brief intermittent hypoxia (IH) episodes which may cause oxidative damage. We tested the hypothesis that intravitreal Avastin leaks into the systemic circulation during exposure to IH and has adverse effects on biomarkers of pulmonary microvascular maturation, thus leading to pulmonary hemorrhage and long-term pulmonary sequelae. METHODS Neonatal rats at postnatal day (PN) 0 (birth) were exposed to either: 1) hyperoxia (50% O2) or 2) neonatal IH (50% O2 with brief episodes of 12% O2) from PN0 to PN14. Room air (RA) littermates served as controls. At PN14, the time of eye opening in rats, a single dose of Avastin (0.125 mg in 5 µL) was injected into the vitreous cavity of the left eyes. A control group received equivalent volume saline. At PN23 and PN45, blood gases, lung-to-body weight ratios, histology, immunofluorescence, and lung biomarkers of angiogenesis were examined. RESULTS At PN23, Avastin increased lung VEGF, nitric oxide derivatives (NOx), and hypoxia-inducible factor (HIF)1a in the hyperoxia-exposed groups, but decreased soluble VEGFR-1 (sVEGFR-1). At PN45, lungs from animals exposed to neonatal IH and treated with Avastin were severely hemorrhagic with morphologic changes in lung architecture consistent with chronic lung disease. This was associated with higher VEGF and NOx levels, and lower insulin-like growth factor (IGF)-I and sVEGFR-1. CONCLUSIONS These findings prove our hypothesis that intravitreal Avastin penetrates the blood-ocular barrier in IH and alters lung biomarkers of angiogenesis. Avastin targeting of VEGF could affect normal lung development which may be exaggerated under pathologic conditions such as IH, ultimately leading to vascular permeability, vessel rupture, and pulmonary hemorrhage.
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Affiliation(s)
- Thomas J Duggan
- aDepartment of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Charles L Cai
- aDepartment of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, USA
| | - Jacob V Aranda
- aDepartment of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA.,State University of New York Eye Institute, Brooklyn, New York, USA
| | - Kay D Beharry
- aDepartment of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, USA.,Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, New York, USA.,State University of New York Eye Institute, Brooklyn, New York, USA
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47
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Kovatis KZ, Di Fiore JM, Martin RJ, Abbasi S, Chaundhary AS, Hoover S, Zhang Z, Kirpalani H. Effect of Blood Transfusions on Intermittent Hypoxic Episodes in a Prospective Study of Very Low Birth Weight Infants. J Pediatr 2020; 222:65-70. [PMID: 32423683 DOI: 10.1016/j.jpeds.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/18/2020] [Accepted: 03/09/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To compare the number of intermittent hypoxia events before and after packed red blood cell (pRBC) and non-pRBC transfusions in very low birth weight infants, and to compare the time spent with saturations of ≤85% before and after transfusions in the same population. STUDY DESIGN This prospective observational study was conducted from April 2014 to August 2017. It included 92 transfusions (81 pRBC, 11 non-pRBC) from 41 very low birth weight infants between 230/7 and 286/7 weeks of gestation. The primary outcome was number of intermittent hypoxia events. Secondary outcomes included the percent time of Peripheral capillary oxygen saturation (SpO2)of ≤85%, ≤80%, and ≤75%. A mixed ANOVA model was used to examine the relationship between event rate and covariates. RESULTS The mean number of intermittent hypoxia events per hour decreased from 5.27 ± 5.02 events per hour before pRBC transfusion to 3.61 ± 3.17 per hour after pRBC transfusions (P < .01) and intermittent hypoxia did not change after non-RBC transfusions (before, 4.45 ± 3.19 vs after, 4.47 ± 2.78; P = NS). The percent time with saturations of ≤80% and ≤75% significantly decreased after pRBC transfusions (P = .01). The time with saturations of ≤85% did not significantly change after non-pRBC transfusion. CONCLUSIONS In very low birth weight infants with a hematocrit of 20%-42%, pRBC transfusions are associated with decreased frequency of intermittent hypoxia. No such diminution of intermittent hypoxia events was observed in infants who had received a non-pRBC transfusion. This finding suggests that the observed beneficial effects of RBC transfusions on apnea and its clinical manifestations of intermittent hypoxia are mediated through an enhanced oxygen carrying capacity.
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Affiliation(s)
- Kelley Z Kovatis
- Department of Neonatology, Christiana Care Health System, Newark, DE.
| | - Juliann M Di Fiore
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Soraya Abbasi
- Division of Neonatology, Pennsylvania Hospital, Philadelphia, PA; Division of Neonatology, University of Pennsylvania, Philadelphia, PA
| | | | - Stephen Hoover
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Zugui Zhang
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
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48
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Jensen EA, Zhang H, Feng R, Dysart K, Nilan K, Munson DA, Kirpalani H. Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding. Arch Dis Child Fetal Neonatal Ed 2020; 105:399-404. [PMID: 31685527 PMCID: PMC7453998 DOI: 10.1136/archdischild-2019-317148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 09/26/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Compare rates of hypoxaemia during transpyloric and gastric feedings in very preterm infants with severe bronchopulmonary dysplasia. DESIGN N-of-1 multiple crossover trials with individual patient and pooled data analyses. SETTING Level IV intensive care nursery. PATIENTS Infants receiving positive airway pressure between 36 and 55 weeks postmenstrual age were enrolled between December 2014-July 2016. INTERVENTION N-of-1 trial consisting of two blocks, each with a 4-day gastric and 4-day transpyloric feeding period assigned in random order. MAIN OUTCOME MEASURES The primary outcome was the frequency of daily intermittent hypoxaemic events (SpO2 ≤80% lasting 10-180 s). Secondary outcomes included the daily proportion of time with an SpO2 ≤80% and mean daily fraction of inspired oxygen. RESULTS Of 15 infants, 13 completed the trial and 2 stopped early for transient worsening in respiratory status during gastric feedings. In the intention-to-treat analyses, transpyloric feedings resulted in increased rates of intermittent hypoxaemia in five infants, greater time per day in hypoxaemia in three infants and more supplemental oxygen use in three infants. One infant received more supplemental oxygen during gastric feedings. The remaining study outcomes were similar between the feeding routes in all other infants. Pooling all data, transpyloric feedings resulted in a higher frequency of intermittent hypoxaemic events (median 7.5/day (IQR 1-23.5) vs 3/day (1-11); adjusted incidence rate ratio 1.8, 95% CI 1.3 to 2.5) and a greater proportion of daily hypoxaemia time (median 0.8% (IQR 0.1-2.3) vs 0.4% (0.07-1.8); adjusted mean difference 1.6, 95% CI 1.1 to 2.5). CONCLUSIONS Transpyloric compared with gastric feedings modestly increased rates of hypoxaemia among study participants. TRIAL REGISTRATION NUMBER NCT02142621.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Huayan Zhang
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rui Feng
- Department of Biostatistics and Epidemiology, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Kevin Dysart
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen Nilan
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David A Munson
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Martini S, Frabboni G, Rucci P, Czosnyka M, Smielewski P, Galletti S, Vitali F, Faldella G, Austin T, Corvaglia L. Cardiorespiratory Events in Infants Born Preterm during the Transitional Period. J Pediatr 2020; 221:32-38.e2. [PMID: 32446489 DOI: 10.1016/j.jpeds.2020.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/22/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate the features of cardiorespiratory events in infants born preterm during the transitional period, and to evaluate whether different neonatal characteristics may correlate with event type, duration, and severity. STUDY DESIGN Infants with gestational age (GA) <32 weeks and/or birth weight <1500 g were enrolled in this observational prospective study. Heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded continuously over the first 72 hours. Cardiorespiratory events of ≥10 seconds were clustered into isolated desaturation (SpO2 <85%), isolated bradycardia (HR <100 bpm or <70% of baseline), or combined desaturation/bradycardia and classified as mild, moderate, or severe. The daily incidences of isolated desaturation, isolated bradycardia, and combined desaturation and bradycardia were analyzed. The effects of relevant clinical variables on cardiorespiratory event type and severity were assessed using generalized estimating equations. RESULTS Among the 1050 events analyzed, isolated desaturations were the most frequent (n = 625) and isolated bradycardias the least common (n = 171). The number of cardiorespiratory events increased significantly from day 1 to day 2 (P = .028). One in 5 events had severe characteristics; event severity was highest for combined desaturation and bradycardia (P < .001). Compared with other event types, the incidence of combined desaturation and bradycardia was inversely correlated with GA (P = .029) and was higher with the use of continuous positive airway pressure (P = .002). The presence of a hemodynamically significant patent ductus arteriosus was associated with the occurrence of isolated desaturations (P = .001) and with a longer duration of cardiorespiratory events (P = .003). CONCLUSIONS Cardiorespiratory events during transition exhibit distinct types, duration, and severity. Neonatal characteristics are associated with the clinical features of these events, indicating that a tailored clinical approach may reduce the hypoxic burden in preterm infants aged 0-72 hours.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC).
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Paola Rucci
- Division of Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Silvia Galletti
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
| | - Francesca Vitali
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
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Bumetanide Suppression of Angiogenesis in a Rat Model of Oxygen-Induced Retinopathy. Int J Mol Sci 2020; 21:ijms21030987. [PMID: 32024231 PMCID: PMC7037744 DOI: 10.3390/ijms21030987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/24/2020] [Accepted: 01/29/2020] [Indexed: 12/18/2022] Open
Abstract
Aquaporins (AQPs) are involved in hypoxia-induced angiogenesis and retinal damage. Bumetanide is a diuretic agent, Na+/K+/Cl− cotransporter (NKCC1), and AQP 1–4 inhibitor. We tested the hypothesis that early postnatal treatment with bumetanide suppresses biomarkers of angiogenesis and decreases severe retinopathy oxygen-induced retinopathy (OIR). Neonatal rats were exposed at birth (P0) to either (1) room air (RA); (2) hyperoxia (50% O2); or (3) intermittent hypoxia (IH) consisting of 50% O2 with brief, clustered episodes of 12% O2 from P0 to postnatal day 14 (P14), during which they were treated intraperitoneally (IP) with bumetanide (0.1 mg/kg/day) or an equivalent volume of saline, on P0–P2. Pups were examined at P14 or allowed to recover in RA from P14–P21. Retinal angiogenesis, morphometry, pathology, AQPs, and angiogenesis biomarkers were determined at P14 and P21. Bumetanide reduced vascular abnormalities associated with severe OIR. This was associated with reductions in AQP-4 and VEGF. Bumetanide suppressed sVEGFR-1 in the serum and vitreous fluid, but levels were increased in the ocular tissues during recovery. Similar responses were noted for IGF-I. In this model, early systemic bumetanide administration reduces severe OIR, the benefits of which appear to be mediated via suppression of AQP-4 and VEGF. Further studies are needed to determine whether bumetanide at the right doses may be considered a potential pharmacologic agent to treat retinal neovascularization.
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