Screening for pulmonary hypertension in preterm infants-not ready for prime time

Short and long-term outcomes of chronic pulmonary hypertension in preterm infants managed using a standardized algorithm

BACKGROUND

There is limited data on management strategies for chronic pulmonary hypertension (cPH) in chronic lung disease (CLD) of prematurity. Our objective was to evaluate clinical outcomes following a standardized policy, wherein only cPH with right-ventricular (RV) dilatation was treated and diuretics were employed as first-line therapy; cPH without RV-dilatation was managed expectantly.

METHOD

In this retrospective cohort study, all infants with CLD were categorized as "CLD-only" or "CLD-cPH," using echocardiography at ≥36 weeks postmenstrual age. Intergroup comparison was performed. Regression analysis examined the association between cPH and primary outcome of death or disability at 18-24 months.

RESULTS

Of 128 CLD infants, 48 (38%) had cPH, of which 29 (60%) received diuretics. Symptomatic improvement within 1-week was recorded in 90%. Although CLD-cPH had worse in-hospital respiratory course than CLD-only, all post-discharge respiratory and neurodevelopmental outcomes were similar. cPH was not associated with death or disability (adjusted odds ratio, 1.02; 95% confidence interval, 0.32-3.27). Disease progression treated with sildenafil occurred in 2 (4%) cases. There was no death from respiratory or RV failure.

CONCLUSION

Primary treatment of CLD-cPH with diuretics using RV-dilatation as therapeutic threshold, may result in symptomatic improvement, disease stabilization and post-discharge outcomes comparable to infants without cPH.

Cost of clinician-driven tests and treatments in very low birth weight and/or very preterm infants

OBJECTIVE

To rank clinician-driven tests and treatments (CTTs) by their total cost during the birth hospitalization for preterm infants.

STUDY DESIGN

Retrospective cohort of very low birth weight (<1500 g) and/or very preterm (<32 weeks) subjects admitted to US children's hospital Neonatal Intensive Care Units (2012-2018). CTTs were defined as pharmaceutical, laboratory and imaging services and ranked by total cost.

RESULTS

24,099 infants from 51 hospitals were included. Parenteral nutrition ($85M, 32% of pharmacy costs), blood gas analysis ($34M, 29% of laboratory costs), and chest radiographs ($18M, 31% of imaging costs) were the costliest CTTs overall. More than half of CTT-related costs occurred during 10% of hospital days.

CONCLUSIONS

The majority of CTT-related costs were from commonly used tests and treatments. Targeted efforts to improve value in neonatal care may benefit most from focusing on reducing unnecessary utilization of common tests and treatments, rather than infrequently used ones.

Late onset of pulmonary hypertension in very low birth weight infants

INTRODUCTION

Pulmonary hypertension (PH) is a recognized complication of bronchopulmonary dysplasia (BPD). Recent guidelines recommend evaluating all infants with BPD for PH via echocardiogram, but the specific timing of this screening is controversial. We aimed to identify the timing of PH diagnosis in a cohort of very low birthweight infants (VLBW) to determine appropriate age at screening.

METHODS

We retrospectively reviewed data on 455 VLBW infants undergoing echocardiography at our institution. The timing of all echocardiograms, PH diagnosis on echocardiography, and BPD diagnosis at 36 weeks corrected age were extracted. PH was defined as dilation of the right sided chambers or RVH, flattening or leftward deviation of the septum, TR >25 mmHg, or 2/3 systemic pressures, or right to left shunting.

RESULTS

Fifteen VLBW infants had PH identified on echocardiography, of whom 11 had BPD and 2 died before BPD status at 36 weeks could be ascertained. PH was most often identified on echocardiography after 36 weeks corrected age, and typically around 40 weeks. Ten of the infants ultimately diagnosed with PH had previous echocardiograms performed that were negative for PH at 25-46 weeks.

CONCLUSIONS

In our cohort of VLBW infants, onset of PH was typically found later than the 36-38 week range used by recently described screening programs. These findings suggest a need to examine echocardiograms obtained after 36 weeks for evidence of late-onset PH in vulnerable infants born at VLBW.

Survey of practices in relation to chronic pulmonary hypertension in neonates in the Canadian Neonatal Network and the National Institute of Child Health and Human Development Neonatal Research Network

Current knowledge gaps pertaining to diagnosis and management of neonatal chronic pulmonary hypertension (cPH) may result in significant variability in clinical practice. The objective of the study is to understand cPH management practices in neonatal intensive care units affiliated with the Canadian Neonatal Network (CNN) and National Institute of Child Health and Human Development Neonatal Research Network (NRN). A 32-question survey seeking practice details for cPH evaluation, diagnostic criteria, conservative measures, pharmacotherapeutics, and follow-up was e-mailed to a designated physician at each center. Responses were described as frequency (percentage) and compared between CNN and NRN, where appropriate. Overall response rate was 67% (CNN 20/28 (71%), NRN 9/15 (60%)). While 8 (28%) centers had standardized management protocols, 17 (59%) routinely evaluate high-risk patients; moderate-severe chronic lung disease being the commonest indication. While interventricular septal flattening on echocardiography was the commonest listed diagnostic criterion, several adjunctive indices were also identified. Asymptomatic neonates with cPH were managed expectantly (routine care) in 50% of sites, and using various conservative measures in others. Pulmonary vasodilators were prescribed for symptomatic cases, with 60% of sites using them early (86% reporting any use). Seventy-five percent of sites use inhaled nitric oxide and sildenafil citrate as first- and second-line agents, respectively. Use of standard protocols, cardiac catheterization, and conservative measures for asymptomatic cases was more common in NRN units (p < 0.05). While there is relative homogeneity in patient identification and diagnostic criteria used for neonatal cPH, significant interunit inconsistencies still exists in routine evaluation, use of additional investigations, management of asymptomatic cases, frequency and type of conservative measures, and choice of pulmonary vasodilators.