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Noh CY, Chock VY, Bhombal S, Danzer E, Patel N, Dahlen A, Harting MT, Lally KP, Ebanks AH, Van Meurs KP. Early nitric oxide is not associated with improved outcomes in congenital diaphragmatic hernia. Pediatr Res 2023; 93:1899-1906. [PMID: 36725908 DOI: 10.1038/s41390-023-02491-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is widely used for the management of infants with congenital diaphragmatic hernia (CDH); however, evidence of benefit is limited. METHODS This is a multicenter cohort study using data from the Congenital Diaphragmatic Hernia Study Group between 2015 and 2020. The impact of early iNO use in the first 3 days of life prior to ECLS use on mortality or ECLS use was explored using multivariate logistic regression models and subgroup analyses. RESULTS Of the 1777 infants, 863 (48.6%) infants received early iNO treatment. Infants receiving iNO had lower birth weight, larger defect size, more severe pulmonary hypertension, and abnormal ventricular size and function. After controlling for these factors, early iNO use was associated with increased mortality (aOR 2.06, 95% CI 1.05-4.03, P = 0.03) and increased ECLS use (aOR 3.44, 95% CI 2.11-5.60, P < 0.001). Subgroup analyses after stratification by echocardiographic characteristics and defect size revealed no subgroup with a reduction in mortality or ECLS use. CONCLUSIONS Use of iNO in the first 3 days of life prior to ECLS was not associated with a reduction in mortality or ECLS use in either the regression models or the subgroup analyses. The widespread use of iNO in this vulnerable population requires reconsideration. IMPACT Evidence to support widespread use of iNO for infants with congenital diaphragmatic hernia is limited. The use of iNO in the first 3 days of life was associated with significantly increased mortality and ECLS use. Stratification by echocardiographic characteristics and defect size did not reveal a subgroup that benefited from iNO. Even the subset of patients with R-to-L shunts at both ductal and atrial levels, a surrogate for elevated pulmonary arterial pressures in the absence of significantly decreased LV compliance, did not benefit from early iNO use. Early iNO therapy was of no benefit in the management of acute pulmonary hypertension in infants with congenital diaphragmatic hernia, supporting reconsideration of its use in this population.
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Affiliation(s)
- Caroline Y Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Enrico Danzer
- Division of Pediatric Surgery, Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil Patel
- Royal Hospital for Children Glasgow, Glasgow, UK
| | - Alex Dahlen
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 PMCID: PMC8289457 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
| | - Girija G. Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, 53226 USA
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3
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Abstract
Congenital diaphragmatic hernia (CDH) is a neonatal pathology in which intrathoracic herniation of abdominal viscera via diaphragmatic defect results in aberrant pulmonary and cardiovascular development. Despite decades of study and many advances in the diagnosis and treatment of CDH, morbidity and mortality remain high, largely due to pulmonary hypertension (PH), along with pulmonary hypoplasia and cardiac dysfunction. In patients with CDH, hypoplastic pulmonary vasculature and alterations in multiple molecular pathways lead to pathophysiologic pulmonary vasculopathy and, for severe CDH, sustained, elevated pulmonary arterial pressures. This review addresses the multiple anatomic and physiologic changes that underlie CDH-associated PH (CDH-PH), along with the multimodal treatment strategies that exist currently and future therapies currently under investigation.
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Affiliation(s)
- Vikas S Gupta
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX 77030, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX 77030, USA.
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Montalva L, Antounians L, Zani A. Pulmonary hypertension secondary to congenital diaphragmatic hernia: factors and pathways involved in pulmonary vascular remodeling. Pediatr Res 2019; 85:754-768. [PMID: 30780153 DOI: 10.1038/s41390-019-0345-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/10/2019] [Indexed: 02/06/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth defect that is characterized by pulmonary hypoplasia and pulmonary hypertension (PHTN). PHTN secondary to CDH is a result of vascular remodeling, a structural alteration in the pulmonary vessel wall that occurs in the fetus. Factors involved in vascular remodeling have been reported in several studies, but their interactions remain unclear. To help understand PHTN pathophysiology and design novel preventative and treatment strategies, we have conducted a systematic review of the literature and comprehensively analyzed all factors and pathways involved in the pathogenesis of pulmonary vascular remodeling secondary to CDH in the nitrofen model. Moreover, we have linked the dysregulated factors with pathways involved in human CDH. Of the 358 full-text articles screened, 75 studies reported factors that play a critical role in vascular remodeling secondary to CDH. Overall, the impairment of epithelial homeostasis present in pulmonary hypoplasia results in altered signaling to endothelial cells, leading to endothelial dysfunction. This causes an impairment of the crosstalk between endothelial cells and pulmonary artery smooth muscle cells, resulting in increased smooth muscle cell proliferation, resistance to apoptosis, and vasoconstriction, which clinically translate into PHTN.
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Affiliation(s)
- Louise Montalva
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Lina Antounians
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Augusto Zani
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Canada. .,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada.
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5
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Abstract
Congenital diaphragmatic hernia (CDH) is a complex entity wherein a diaphragmatic defect allows intrathoracic herniation of intra-abdominal contents and both pulmonary parenchymal and vascular development are stifled. Pulmonary pathology and pathophysiology, including pulmonary hypoplasia and pulmonary hypertension, are hallmarks of CDH and are associated with disease severity. Pulmonary hypertension (PH) is sustained, supranormal pulmonary arterial pressure, and among patients with CDH (CDH-PH), is driven by hypoplastic pulmonary vasculature, including alterations at the molecular, cellular, and tissue levels, along with pathophysiologic pulmonary vasoreactivity. This review addresses the basic mechanisms, altered anatomy, definition, diagnosis, and management of CDH-PH. Further, emerging therapies targeting CDH-PH and PH are explored.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, Texas 77030.
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6
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Lemus-Varela MDL, Soliz A, Gómez-Meda BC, Zamora-Perez AL, Ornelas-Aguirre JM, Melnikov V, Torres-Mendoza BM, Zúñiga-González GM. Antenatal use of bosentan and/or sildenafil attenuates pulmonary features in rats with congenital diaphragmatic hernia. World J Pediatr 2014; 10:354-9. [PMID: 25515807 DOI: 10.1007/s12519-014-0512-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/26/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lung hypoplasia, pulmonary persistent hypertension of the newborn and its morphological changes are the main features in congenital diaphragmatic hernia (CDH). This study was undertaken to investigate if antenatal use of sildenafil and/or bosentan attenuates vascular remodeling, promotes branching, and improves alveolarization in experimental nitrofeninduced CDH. METHODS Nitrofen (100 mg) was gavage-fed to pregnant rats at post conception day (PCD) 9 to induce CDH. The rats were randomized to 5 groups: 1) control; 2) nitrofen; 3) nitrofen+sildenafil 100 mg/kg per day at PCD 16-20; 4) nitrofen+bosentan 30 mg/kg per day, at PCD 16-20, and 5) nitrofen+bosentan+sildenafil, same doses and administration days. After cesarean delivery, the offsprings were sacrificed. The diaphragmatic defect and pulmonary hypoplasia were identified, and the lungs were dissected. Arterial wall thickness, bronchiolar density and alveolarization were assessed. RESULTS The offsprings with CDH were characterized by severe pulmonary hypoplasia (lung weight-to-body weight ratio: 0.0263 [95% confidence interval (CI) 0.0242-0.0278)] in the nitrofen group versus 0.0385 (95% CI 0.0355-0.0424) in the control group (P=0.0001). Pulmonary arterial wall thickness was decreased to 3.0 (95% CI 2.8-3.7) μm in the nitrofen+sildenafil group versus 5.0 (95% CI 4.1-4.9) μm in the nitrofen group (P=0.02). Terminal bronchioles increased to 13.7 (95% CI 10.7-15.2) μm in the nitrofen+bosentan group in contrast to 8.7 (95% CI 7.2-9.4) μm in the nitrofen group (P=0.002). More significant differences (P=0.0001) were seen in terminal bronchioles in the nitrofen+sildenafil+bosentan group than in the nitrofen group [14.0 (95% CI 12.5-15.4) μm versus 8.5 (95% CI 7.1-9.3) μm]. Pulmonary arterial wall thickness was also decreased in the former group. CONCLUSIONS In this rat model, antenatal treatment with sildenafil attenuates vascular remodeling. Bosentan promotes the development of terminal bronchioles in nitrofen-induced CDH.
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Affiliation(s)
- María de Lourdes Lemus-Varela
- Division of Neonatology, High Specialty Medical Unit, Pediatric Hospital, Western National Medical Center, Mexican Social Security Institute, Guadalajara, Jalisco, México
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Fike CD, Aschner JL. Looking beyond PPHN: the unmet challenge of chronic progressive pulmonary hypertension in the newborn. Pulm Circ 2013; 3:454-66. [PMID: 24618533 DOI: 10.1086/674438] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Abstract Infants with forms of pulmonary hypertension (PH) that persist or develop beyond the first week of life are an understudied group of patients with up to 40%-60% mortality. The clinical management of the progressive PH that develops in these infants is challenging because of the nonspecific signs and symptoms of clinical presentation, the limited diagnostic sensitivity of standard echocardiographic techniques, and the lack of proven therapies. The signaling mechanisms that underlie the structural and functional abnormalities in the pulmonary circulation of these infants are not yet clear. The ability to improve outcomes for these patients awaits technological advances to improve diagnostic capabilities and therapeutic discoveries made in basic science laboratories that can be tested in randomized clinical trials.
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Affiliation(s)
- Candice D Fike
- 1 Department of Pediatrics, Vanderbilt University School of Medicine, and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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8
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van den Hout L, Sluiter I, Gischler S, De Klein A, Rottier R, Ijsselstijn H, Reiss I, Tibboel D. Can we improve outcome of congenital diaphragmatic hernia? Pediatr Surg Int 2009; 25:733-43. [PMID: 19669650 PMCID: PMC2734260 DOI: 10.1007/s00383-009-2425-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This review gives an overview of the disease spectrum of congenital diaphragmatic hernia (CDH). Etiological factors, prenatal predictors of survival, new treatment strategies and long-term morbidity are described. Early recognition of problems and improvement of treatment strategies in CDH patients may increase survival and prevent secondary morbidity. Multidisciplinary healthcare is necessary to improve healthcare for CDH patients. Absence of international therapy guidelines, lack of evidence of many therapeutic modalities and the relative low number of CDH patients calls for cooperation between centers with an expertise in the treatment of CDH patients. The international CDH Euro-Consortium is an example of such a collaborative network, which enhances exchange of knowledge, future research and development of treatment protocols.
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Affiliation(s)
- L. van den Hout
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - I. Sluiter
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - S. Gischler
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - A. De Klein
- Department of Genetics, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - R. Rottier
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - H. Ijsselstijn
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - I. Reiss
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - D. Tibboel
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
- ErasmusMC-Sophia, Room SK-3284, P.O. Box 2060, 3000CB Rotterdam, The Netherlands
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9
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Gosche JR, Islam S, Boulanger SC. Congenital diaphragmatic hernia: searching for answers. Am J Surg 2005; 190:324-32. [PMID: 16023454 DOI: 10.1016/j.amjsurg.2005.05.035] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 04/15/2005] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pulmonary hypoplasia and hypertension are the primary causes of morbidity and mortality in infants with congenital diaphragmatic hernia (CDH). At present, the origin of CDH and the causes of pulmonary hypoplasia and hypertension are unknown. DATA SOURCES This article reviews the available published data regarding the origin of CDH and the pathogenesis of the associated pulmonary hypertension and hypoplasia. These investigations have employed human tissues as well as two types of CDH animal models. CONCLUSIONS Investigations performed to date have not yet provided definitive answers regarding the pathogenesis of CDH. However, they have yielded many new and exciting discoveries and several opportunities for intervention. Ongoing research should open new possibilities to improve the outcome for these unfortunate babies with CDH.
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Affiliation(s)
- John R Gosche
- Division of Pediatric Surgery, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216, USA.
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10
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Belik J, Davidge ST, Zhang W, Pan J, Greer JJ. Airway smooth muscle changes in the nitrofen-induced congenital diaphragmatic hernia rat model. Pediatr Res 2003; 53:737-43. [PMID: 12612200 DOI: 10.1203/01.pdr.0000057986.74037.7b] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the fetal rat, nitrofen induces congenital diaphragmatic hernia (CDH) and pulmonary vascular remodeling similar to what is observed in the human condition. Airway hyperactivity is common in infants with CDH and attributed to the ventilator-induced airway damage. The purpose of this study was to test the hypothesis that airway smooth muscle mechanical properties are altered in the nitrofen-induced CDH rat model. Lungs from nitrofen-exposed fetuses with hernias (CDH) or intact diaphragm (nitrofen) and untreated fetuses (control) were studied on gestation d 21. The left intrapulmonary artery and bronchi were removed and mounted on a wire myograph, and lung expression, content, and immunolocalization of cyclooxygenases COX-1 and COX-2 were evaluated. Pulmonary artery muscle in the CDH group had significantly (p < 0.01) lower force generation compared with control and nitrofen groups. In contrast, the same generation bronchial smooth muscle of the CDH and nitrofen groups developed higher force compared with control. Whereas no differences were found in endothelium-dependent pulmonary vascular muscle tone, the epithelium-dependent airway muscle relaxation was significantly decreased (p < 0.01) in the CDH and nitrofen groups. The lung mRNA levels of COX-1 and COX-2 were increased in the CDH and nitrofen groups. COX-1 vascular and airway immunostaining, as well as COX-1 and COX-2 lung protein content, were increased in the CDH group. This is the first report of airway smooth muscle abnormalities in the nitrofen-induced fetal rat model of CDH. We speculate that congenital airway muscle changes may be present in the human form of this disease.
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MESH Headings
- 15-Hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5,13-dienoic Acid/pharmacology
- Acetylcholine/pharmacology
- Airway Obstruction/congenital
- Airway Obstruction/physiopathology
- Animals
- Cyclooxygenase 1
- Cyclooxygenase 2
- Disease Models, Animal
- Female
- Hernia, Diaphragmatic/chemically induced
- Hernia, Diaphragmatic/physiopathology
- Hernias, Diaphragmatic, Congenital
- Isoenzymes/genetics
- Isoenzymes/metabolism
- Membrane Proteins
- Muscle, Smooth/drug effects
- Muscle, Smooth/physiology
- Muscle, Smooth/physiopathology
- Pesticides
- Phenyl Ethers
- Potassium Chloride/pharmacology
- Pregnancy
- Prostaglandin-Endoperoxide Synthases/genetics
- Prostaglandin-Endoperoxide Synthases/metabolism
- Pulmonary Artery/physiology
- RNA, Messenger/analysis
- Rats
- Rats, Sprague-Dawley
- Vasoconstrictor Agents/pharmacology
- Vasodilator Agents/pharmacology
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Affiliation(s)
- Jaques Belik
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada.
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11
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Abstract
Congenital diaphragmatic hernia occurs in approximately 1 in every 2500 live births and is associated with a reported mortality of almost 35% in live-born patients and a higher mortality when in utero deaths are counted. Ventilator-induced lung injury, pulmonary hypoplasia, and other associated anomalies account for the high death rate. Numerous adjunctive measures have been used to treat these patients. Inhaled vasodilators (nitric oxide), intravenous vasodilators, and fetal therapy have no proven benefit. While animal models of congenital diaphragmatic hernia are surfactant deficient, controversy remains over the use of surfactant in infants. There has been no clinical trial showing any clear benefit with the use of exogenous surfactant in these patients. Similarly, prenatal corticosteroids show some improvements in animal models, but again, there is a complete absence of supportive data to show benefit in humans. Mechanical ventilator strategies that limit ventilator-induced lung injury by avoiding hyperventilation and lung over inflation are the strategies currently in use that have been associated with improved survival. Long-term follow-up of these patients is quite important since gastroesophageal reflux, developmental delay, chronic lung disease, and chest wall deformity are all seen with increased frequency in these children.
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Affiliation(s)
- Kevin P Lally
- Department of Surgery, The University of Texas Houston Medical School, Houston, Texas, USA.
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