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Bhatt DR, Braun D, Dizon RA, Shi JM, Weerasinghe S, Sabio A, Reddy S, Lee HC, Ramanathan R, Lakshminrusimha S. Retrospective study of preterm infants exposed to inhaled nitric oxide in Kaiser Permanente Southern California: morbidity, mortality and follow-up. J Perinatol 2024:10.1038/s41372-024-02051-w. [PMID: 39025953 DOI: 10.1038/s41372-024-02051-w] [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: 02/27/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE Describe characteristics of preterm infants exposed to inhaled nitric oxide (iNO) in Kaiser Permanente Southern California. STUDY DESIGN Case review of preterm infants <34-weeks exposed to iNO during 2010-2020 including respiratory and echocardiographic status, NICU course, and 12-month follow-up. RESULTS 270 infants, 2.63% of births<34 weeks, (median, range: 26.1, 225/7-336/7 weeks gestation) were exposed to iNO. Median FiO2 at iNO initiation was 1.0 (IQR 0.94-1.0). Pulmonary hypertension (PH) was not associated with risk-adjusted 2 h oxygenation response or improved survival. Mortality to NICU discharge was 37.4%. Median cost of iNO was $7,695/patient. Discharged survivors experienced frequent rehospitalization (34.9%), use of supplemental oxygen, sildenafil, diuretics, bronchodilators, and steroids. Four infants had persistent PH. Five infants died after NICU discharge. CONCLUSIONS Preterm infants receiving iNO have high mortality and 1st year morbidity. As currently used, iNO may be an indicator of respiratory disease severity rather than mediator of improved outcomes.
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Affiliation(s)
- Dilip R Bhatt
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - David Braun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Roman Angelo Dizon
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Jiaxiao M Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Alex Sabio
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Siva Reddy
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Henry C Lee
- University of California, San Diego, CA, USA
| | - Rangasamy Ramanathan
- Division of Neonatology, Cedars Sinai Guerin Children's, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Schroeder L, Soltesz L, Leyens J, Strizek B, Berg C, Mueller A, Kipfmueller F. Vasoactive Management of Pulmonary Hypertension and Ventricular Dysfunction in Neonates Following Complicated Monochorionic Twin Pregnancies: A Single-Center Experience. CHILDREN (BASEL, SWITZERLAND) 2024; 11:548. [PMID: 38790543 PMCID: PMC11120423 DOI: 10.3390/children11050548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVES Twins resulting from a complicated monochorionic (MC) twin pregnancy are at risk for postnatal evolution of pulmonary hypertension (PH) and cardiac dysfunction (CD). Both pathologies are important contributors to short- and long-term morbidity in these infants. The aim of the present retrospective single-center cohort study was to evaluate the need for vasoactive treatment for PH and CD in these neonates. METHODOLOGY In-born neonates following a complicated MC twin pregnancy admitted to the department of neonatology of the University Children's Hospital Bonn (UKB) between October 2019 and December 2023 were screened for study inclusion. Finally, 70 neonates were included in the final analysis, with 37 neonates subclassified as recipient twins (group A) and 33 neonates as donor twins (group B). RESULTS The overall PH incidence at day of life (DOL) 1 was 17% and decreased to 6% at DOL 7 (p = 0.013), with no PH findings at DOL 28. The overall incidence of CD was 56% at DOL 1 and decreased strongly until DOL 7 (10%, p = 0.015), with no diagnosis of CD at DOL 28. The use of dobutamine, norepinephrine, and vasopressin at DOL 1 until DOL 7 did not differ between the subgroups, whereas the dosing of milrinone was significantly higher in Group B at DOL 1 (p = 0.043). Inhaled nitric oxide (iNO) was used in 16% of the cohort, and a levosimendan therapy was administered in 34% of the neonates. One-third of the cohort was treated with oral beta blockers, and in 10%, an intravenous beta blockade (landiolol) was administered. The maximum levosimendan vasoactive-inotropic score (LVISmax) increased from DOL 1 (12.4 [3/27]) to DOL 2 (14.6 [1/68], p = 0.777), with a significant decrease thereafter as measured at DOL 7 (9.5 [2/30], p = 0.011). CONCLUSION Early PH and CD are frequent diagnoses in neonates following a complicated MC twin pregnancy, and an individualized vasoactive treatment strategy is required in the management of these infants.
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Affiliation(s)
- Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Leon Soltesz
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Judith Leyens
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, 50931 Cologne, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
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Nishikawa S, Taki M, Okamoto H, Kawamura Y, Chigusa Y, Tomotaki S, Mandai M, Mogami H. The prognosis of neonatal respiratory status within three years after birth in chronic abruption-oligohydramnios sequence. J Obstet Gynaecol Res 2023; 49:2649-2655. [PMID: 37534531 DOI: 10.1111/jog.15755] [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: 04/13/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023]
Abstract
AIM Chronic abruption-oligohydramnios sequence (CAOS), which is characterized by vaginal bleeding and oligohydramnios, adversely affects the lungs of fetuses due to bloody amniotic fluid and oligohydramnios. The criteria for termination of pregnancy remain controversial. This study aimed to examine respiratory function in infants within 3 years after birth and risk factors for respiratory prognosis, and to clarify the management of CAOS. METHODS This study is a case series of patients with CAOS managed at our institution between 2010 and 2020. The clinical data of the patients and their infants within 3 years after birth were reviewed. The amniotic fluid volume was measured using the maximum vertical pocket (MVP). RESULTS Six of 17 neonates (35.3%) used inhaled nitric oxide (iNO) to improve oxygenation. Women with longer periods of MVP <1 cm delivered more neonates using iNO; however, periods of MVP <2 cm were not associated with iNO use. Almost half of the infants required home oxygen therapy when discharged, regardless of amniotic fluid volume. At 18 months corrected age, only one child needed respiratory support, and the others discontinued. Two neonates, both born at 23 weeks of gestational age, died within 1 month after birth because of extremely preterm birth. CONCLUSIONS The amniotic fluid volume could predict the use of iNO in neonates, but it did not affect the child's respiratory function after the newborn period. Almost all children born to women with CAOS can improve their respiratory function as they grow up.
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Affiliation(s)
- Shoko Nishikawa
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mana Taki
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Haruko Okamoto
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yosuke Kawamura
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitsugu Chigusa
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Seiichi Tomotaki
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Haruta Mogami
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Fraga MV, Dysart KC, Stoller JZ, Huber M, Fedec A, Mercer-Rosa L, Kirpalani H. Echocardiographic Assessment of Pulmonary Arterial Hypertension Following Inhaled Nitric Oxide in Infants with Severe Bronchopulmonary Dysplasia. Neonatology 2023; 120:633-641. [PMID: 37573771 DOI: 10.1159/000531586] [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: 02/06/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is an effective pulmonary vasodilator. However, the efficacy of iNO in former premature infants with established bronchopulmonary dysplasia (BPD) has not been studied. This study aimed to determine the efficacy of iNO in reducing pulmonary artery pressure in infants with severe BPD as measured by echocardiography. STUDY DESIGN Prospective, observational study enrolling infants born at less than 32 weeks gestation and in whom (1) iNO therapy was initiated after admission to our institution, or (2) at the outside institution less than 48 h before transfer and received an echocardiogram prior to iNO initiation, and (3) had severe BPD. Data were collected at three time-points: (1) before iNO; (2) 12-48 h after initiation of iNO; and (3) 48-168 h after initiation of iNO. The primary outcome was the effect of iNO on pulmonary artery pressure measured by echocardiography in patients with severe BPD between 48 and 168 h after initiating iNO therapy. RESULTS Of 37 enrolled, 81% had echocardiographic evidence of pulmonary arterial hypertension (PAH) before iNO and 56% after 48 h of iNO (p = 0.04). FiO2 requirements were significantly different between time-points (1) and (3) (p = 0.05). There were no significant differences between Tricuspid Annular Plane Systolic Excursion (TAPSE) Z-Scores, time to peak velocity: right ventricular ejection time (TPV:RVET), and ventilator changes. CONCLUSIONS Although we found a statistically significant reduction of PAH between time-point (1) and (3), future trials are needed to further guide clinical care.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jason Z Stoller
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew Huber
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anysia Fedec
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Emeritus Professor of Pediatrics, Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Emeritus Professor of Pediatrics, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Dumpa V, Avulakunta I, Bhandari V. Respiratory management in the premature neonate. Expert Rev Respir Med 2023; 17:155-170. [PMID: 36803028 DOI: 10.1080/17476348.2023.2183843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. AREAS COVERED Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. EXPERT OPINION Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Indirapriya Avulakunta
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, the Children's Regional Hospital at Cooper, Camden, NJ, USA
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Abstract
Pulmonary hypertension (PH) because of chronic lung disease is categorized as Group 3 PH in the most recent classification system. Prevalence of these diseases is increasing over time, creating a growing need for effective therapeutic options. Recent approval of the first pulmonary arterial hypertension therapy for the treatment of Group 3 PH related to interstitial lung disease represents an encouraging advancement. This review focuses on molecular mechanisms contributing to pulmonary vasculopathy in chronic hypoxia, the pathology and epidemiology of Group 3 PH, the right ventricular dysfunction observed in this population and clinical trial data that inform the use of pulmonary vasodilators in Group 3 PH.
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Affiliation(s)
- Navneet Singh
- Division of Pulmonary, Critical Care and Sleep Medicine (N.S., C.E.V.), Brown University, Providence, RI
| | - Peter Dorfmüller
- Department of Pathology, Universities of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University, Germany (P.D.).,German Center for Lung Research (DZL), Giessen, Germany (P.D.)
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA (O.A.S.)
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care and Sleep Medicine (N.S., C.E.V.), Brown University, Providence, RI.,Department of Health Services, Policy and Practice (C.E.V.), Brown University, Providence, RI
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7
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Hussain WA, Bondi DS, Shah P, Morgan SE, Sriram S, Schreiber MD. Implementation of an Inhaled Nitric Oxide Weaning Protocol and Stewardship in a Level 4 NICU to Decrease Inappropriate Use. J Pediatr Pharmacol Ther 2022; 27:284-291. [PMID: 35350163 DOI: 10.5863/1551-6776-27.3.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension in newborns, with limited data regarding weaning. Our institution implemented a multidisciplinary iNO weaning protocol and stewardship to reduce inappropriate use of iNO. The objective of this study was to evaluate our institutional iNO usage before and after implementation. METHODS Single-center study comparing a retrospective control group to a prospective cohort after implementation of an iNO weaning protocol. All infants in the neonatal intensive care unit (NICU) who received iNO during the study timeframe were included. The primary outcome was duration of iNO per course. RESULTS A total of 47 courses of iNO occurred during the pre-protocol timeframe compared with 37 courses in the post-protocol timeframe. Median iNO usage per course was 149 hours (IQR, 63-243) in the pre-protocol group versus 59 hours (IQR, 37-122) in the post-protocol group (p = 0.008). Length of stay was significantly longer in the pre-protocol group (p = 0.02), likely related to significantly longer ventilator days in the pre-protocol group (p = 0.02). Compliance with initiation of weaning when recommended per the protocol was 72%, and the incidence of successful weaning was 74%. CONCLUSIONS The implementation of an iNO weaning protocol in the NICU significantly decreased iNO usage by approximately 60% with no notable negative effects.
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Affiliation(s)
- Walid A Hussain
- Section of Neonatology, Department of Pediatrics (WAH), Loyola University Medical Center, Maywood, IL
| | - Deborah S Bondi
- Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Pooja Shah
- Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Sherwin E Morgan
- Department of Respiratory Care Services (SEM), University of Chicago Medicine, Chicago, IL
| | - Sudhir Sriram
- Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Michael D Schreiber
- Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
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Ramos-Navarro C, Maderuelo-Rodríguez E, Concheiro-Guisán A, Pérez-Tarazona S, Rueda-Esteban S, Sánchez-Torres A, Sánchez-Solís M, Sanz-López E, Sánchez-Luna M. Risk factors and bronchopulmonary dysplasia severity: data from the Spanish Bronchopulmonary Dysplasia Research Network. Eur J Pediatr 2022; 181:789-799. [PMID: 34596741 DOI: 10.1007/s00431-021-04248-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/12/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022]
Abstract
GEIDIS is a national-based research-net registry of patients with bronchopulmonary dysplasia (BPD) from public and private Spanish hospitals. It was created to provide data on the clinical characterization and follow-up of infants with BPD until adulthood. The purpose of this observational study was to analyze the characteristics and the impact of perinatal risk factors on BPD severity. The study included 1755 preterm patients diagnosed with BPD. Of the total sample, 90.6% (n = 1591) were less than 30 weeks of gestation. The median gestational age was 27.1 weeks (25.8-28.5) and median birth weight 885 g (740-1,070 g). A total of 52.5% (n = 922) were classified as mild (type 1), 25.3% (n = 444) were moderate (type 2), and 22.2% (n = 389) were severe BPD (type 3). In patients born at under 30 weeks' gestation, most pre-and postnatal risk factors for type 2/3 BPD were associated with the length of exposure to mechanical ventilation (MV). Independent prenatal risk factors were male gender, oligohydramnios, and intrauterine growth restriction. Postnatal risk factors included the need for FiO2 of > 0.30 in the delivery room, nosocomial pneumonia, and the length of exposure to MV. Conclusion: In this national-based research-net registry of BPD patients, the length of MV is the most important risk factor associated with type 2/3 BPD. Among type 3 BPD patients, those who required an FiO2 > .30 at 36 weeks' postmenstrual age had a higher morbidity, during hospitalization and at discharge, compared to those with nasal positive pressure but FiO2 < .30. What is Known: • BPD is a highly complex multifactorial disease associated with preterm birth. What is New: • The length of exposure to mechanical ventilation is the most important postnatal risk factor associated to bronchopulmonary severity which modulate the effect of most pre and postnatal risk factors. • Among patients with BPD, the requirement for FiO2 >.30% at 36 weeks of postmenstrual age is associated with greater morbidity during hospitalization and at discharge.
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Affiliation(s)
- Cristina Ramos-Navarro
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, O'Donnell 48 street, 28009, Madrid, Spain.
| | - Elena Maderuelo-Rodríguez
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, O'Donnell 48 street, 28009, Madrid, Spain
| | - Ana Concheiro-Guisán
- Neonatologist at Neonatology Department, Álvaro Cunqueiro University Hospital, Vigo, Spain
| | | | - Santiago Rueda-Esteban
- Pediatric Pulmonologist at Pulmonology Department, San Carlos University Hospital, Madrid, Spain
| | - Ana Sánchez-Torres
- Neonatologist at Neonatology Department, La Paz University Hospital, Madrid, Spain
| | - Manuel Sánchez-Solís
- Pediatric Pulmonologist at Pulmonology Department, Virgen Arrixaca University Hospital Murcia, Murcia, Spain
| | - Ester Sanz-López
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, O'Donnell 48 street, 28009, Madrid, Spain
| | - Manuel Sánchez-Luna
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, O'Donnell 48 street, 28009, Madrid, Spain
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Go H, Ohto H, Nollet KE, Sato K, Ichikawa H, Kume Y, Kanai Y, Maeda H, Kashiwabara N, Ogasawara K, Sato M, Hashimoto K, Hosoya M. Red cell distribution width as a predictor for bronchopulmonary dysplasia in premature infants. Sci Rep 2021; 11:7221. [PMID: 33790386 PMCID: PMC8012706 DOI: 10.1038/s41598-021-86752-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/19/2021] [Indexed: 01/21/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common morbidity complicating preterm birth. Red blood cell distribution width (RDW), a measure of the variation of red blood cell size, could reflect oxidative stress and chronic inflammation in many diseases such as cardiovascular, pulmonary, and other diseases. The objectives of the present study were to evaluate perinatal factors affecting RDW and to validate whether RDW could be a potential biomarker for BPD. A total of 176 preterm infants born at < 30 weeks were included in this study. They were categorized into BPD (n = 85) and non-BPD (n = 91) infants. RDW at birth and 14 days and 28 days of life (DOL 14, DOL 28) were measured. Clinical data were obtained from all subjects at Fukushima Medical University (Fukushima, Japan). The mean RDW at birth, DOL 14 and DOL 28 were 16.1%, 18.6%, 20.1%, respectively. Small for gestational age (SGA), chorioamnionitis (CAM), hypertensive disorders of pregnancy (HDP), gestational age and birth weight were significantly associated with RDW at birth. SGA, BPD and red blood cell (RBC) transfusion before DOL 14 were associated with RDW at DOL 14. BPD and RBC transfusion before DOL 14 were associated with RDW at DOL 28. Compared with non-BPD infants, mean RDW at DOL 14 (21.1% vs. 17.6%, P < 0.001) and DOL 28 (22.2% vs. 18.2%, P < 0.001) were significantly higher in BPD infants. Multivariate analysis revealed that RDW at DOL 28 was significantly higher in BPD infants (P = 0.001, odds ratio 1.63; 95% CI 1.22–2.19). Receiver operating characteristic analysis for RDW at DOL 28 in infants with and without BPD yielded an area under the curve of 0.87 (95% CI 0.78–0.91, P < 0.001). RDW at DOL 28 with mild BPD (18.1% vs. 21.3%, P < 0.001), moderate BPD (18.1% vs. 21.2%, P < 0.001), and severe BPD (18.1% vs. 24.0%, P < 0.001) were significantly higher than those with non-BPD, respectively. Furthermore, there are significant differences of RDW at DOL 28 among mild, moderate, and severe BPD. In summary, we conclude that RDW at DOL 28 could serve as a biomarker for predicting BPD and its severity. The mechanism by which RDW at DOL 28 is associated with the pathogenesis of BPD needs further elucidation.
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Affiliation(s)
- Hayato Go
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan.
| | | | - Kenneth E Nollet
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenichi Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Hirotaka Ichikawa
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Yohei Kume
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Yuji Kanai
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Hajime Maeda
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Nozomi Kashiwabara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Kei Ogasawara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Maki Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Koichi Hashimoto
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Japan
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10
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Vieira F, Makoni M, Szyld E, Sekar K. The Controversy Persists: Is There a Qualification Criterion to Utilize Inhaled Nitric Oxide in Pre-term Newborns? Front Pediatr 2021; 9:631765. [PMID: 33869113 PMCID: PMC8044816 DOI: 10.3389/fped.2021.631765] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/01/2021] [Indexed: 11/22/2022] Open
Abstract
Inhaled nitric oxide (iNO) use in premature newborns remains controversial among clinicians. In 2014, the American Academy of Pediatrics, Committee on Fetus and Newborn released a statement that the available data do not support routine iNO use in pre-term newborns. Despite the absence of significant benefits, 2016 California data showed that clinicians continue to utilize iNO in pre-term infants. With studies as recent as January 2017, the Cochrane review confirmed no major advantages of iNO in pre-term newborns. Still, it recognized that a subset of pre-term infants with pulmonary hypertension (PHTN) had not been separately investigated. Furthermore, recent non-randomized controlled trials have suggested that iNO may benefit specific subgroups of pre-term newborns, especially those with PHTN, prolonged rupture of membranes, and antenatal steroid exposure. Those pre-term infants who showed a clinical response to iNO had increased survival without disability. These findings underscore the need for future studies in pre-term newborns with hypoxemic respiratory failure and PHTN. This review will discuss the rationale for using iNO, controversies regarding the diagnosis of PHTN, and additional novel approaches of iNO treatment in perinatal asphyxia and neonatal resuscitation in the pre-term population < 34 weeks gestation.
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Affiliation(s)
- Frederico Vieira
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Marjorie Makoni
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Edgardo Szyld
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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11
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Zhao Y, Liang L, Liu G, Zheng H, Dai L, Wang Y, Wang L, Sheng W. Asphyxia and Neonatal Respiratory Distress Syndrome Are Independent Predictors of the Non-response to Inhaled Nitric Oxide in the Newborns With PPHN. Front Pediatr 2021; 9:665830. [PMID: 34095030 PMCID: PMC8172584 DOI: 10.3389/fped.2021.665830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: Not all the neonates respond with improvement in oxygenation following inhaled nitric oxide treatment (iNO) treatment. The aim of this study was to assess the independent risk factors associated with non-response to iNO during the 2 weeks of postnatal treatment in neonates diagnosed with persistent pulmonary hypertension (PPHN). Materials and Methods: This retrospective cohort study included all newborns with PPHN who received iNO treatment for more than 24 h. Demographic, obstetric, perinatal data and clinical complications were extracted from the hospitalization records. Subjects were divided into two groups according to their response to iNO inspiration during the first 24 h of iNO treatment. No response was defined as an increase in SpO2 < 5% or the inability to sustain saturation levels in the first 24 h of iNO treatment. For descriptive statistics, χ2 and t-test analysis were used to compare categorical and continuous variables between the two groups. To evaluate independent risk factors of non-responsiveness to iNO treatment, binary logistic regression analysis were performed. Results: A total of 75 newborns were included in the study. Sixty-two cases were in the responders group, and 13 cases were in the non-responders group. Univariate analysis showed that asphyxia, neonatal respiratory distress syndrome (NRDS), pulmonary surfactant administration, meconium aspiration syndrome (MAS), the severity of pulmonary hypertension (PH), and high-frequency oscillatory ventilation (HFOV) therapy were the high-risk factors affecting the response to iNO treatment in the newborns with PPHN. The binary logistic regression analysis indicated that asphyxia and NRDS incidence were independent predictors of non-responsiveness to iNO treatment [asphyxia: OR 4.193, 95% CI 1.104-15.927, P = 0.035; NRDS: OR 0.154, 95% CI 0.036-0.647, P = 0.011]. The patients in the non-responders group had shorter iNO inspiration followed by MV duration, supplemental oxygen and hospital stay, and higher mortality. There were no significant differences in IVH, PVL, and BPD between two groups. Conclusion: In the newborns with PPHN, asphyxia and NRDS resulted as the independent risk factors of non-responsiveness to iNO therapy. Asphyxia in the newborns with PPHN is detrimental to the response to iNO treatment, while NRDS is beneficial.
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Affiliation(s)
- Yuwei Zhao
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
| | - Lei Liang
- Pulmonary Department, Anhui Provincial Children Hospital, Hefei, China
| | - Guanghui Liu
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
| | - Hong Zheng
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
| | - Liying Dai
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
| | - Yan Wang
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
| | - Lei Wang
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
| | - Weiting Sheng
- Neonatology Department, Anhui Provincial Children Hospital, Hefei, China
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12
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Abman SH. Pulmonary Hypertension: The Hidden Danger for Newborns. Neonatology 2021; 118:211-217. [PMID: 33951650 PMCID: PMC8177056 DOI: 10.1159/000516107] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 11/19/2022]
Abstract
Despite growing awareness of the clinical importance of pulmonary hypertension (PH) in preterm infants, uncertainty persists regarding the different clinical settings in which abnormalities of pulmonary vascular growth, function, and structure contribute to high morbidity and mortality, and potential interventions to improve outcomes are uncertain. A major gap for improving outcomes of preterm infants with PH has been the limited characterization of the distinct settings of PH and related disease-specific mechanisms in preterm infants that represent diverse pulmonary vascular phenotypes of prematurity. In comparison with term newborns, preterm infants have a higher risk for developing hypoxemia due to suprasystemic levels of PH in preterm infants shortly after birth or persistent pulmonary hypertension of the newborn (PPHN). Variable and milder levels of PH have also been demonstrated in preterm infants without evidence of severe hypoxemic respiratory failure, suggesting delayed vascular transition of the lung which is associated with higher risks of mortality and developing bronchopulmonary dysplasia (BPD). In addition, early echocardiographic signs of PH at day 7 are strongly associated with the subsequent diagnosis of BPD, late PH, and respiratory disease throughout early childhood. In infants with evolving or established BPD, PH that persists beyond the first few months of life in preterm infants is associated with high mortality. Recent data further show that PVD can persist and cause PH in prematurely born adults. Overall, more precise characterization and studies of diverse pulmonary vascular phenotypes in preterm infants will be likely to improve the development of therapeutic strategies to optimize care of preterm infants with PH.
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Affiliation(s)
- Steven H Abman
- Pediatric Pulmonary Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
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13
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Chandrasekharan P, Lakshminrusimha S, Chowdhury D, Van Meurs K, Keszler M, Kirpalani H, Das A, Walsh MC, McGowan EC, Higgins RD. Early Hypoxic Respiratory Failure in Extreme Prematurity: Mortality and Neurodevelopmental Outcomes. Pediatrics 2020; 146:e20193318. [PMID: 32943536 PMCID: PMC7546092 DOI: 10.1542/peds.2019-3318] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the survival and neurodevelopmental impairment (NDI) in extremely low birth weight (ELBW) infants at 18 to 26 months with early hypoxemic respiratory failure (HRF). We also assessed whether African American infants with early HRF had improved outcomes after exposure to inhaled nitric oxide (iNO). METHODS ELBW infants ≤1000 g and gestational age ≤26 weeks with maximal oxygen ≥60% on either day 1 or day 3 were labeled as "early HRF" and born between 2007 and 2015 in the Neonatal Research Network were included. Using a propensity score regression model, we analyzed outcomes and effects of exposure to iNO overall and separately by race. RESULTS Among 7639 ELBW infants born ≤26 weeks, 22.7% had early HRF. Early HRF was associated with a mortality of 51.3%. The incidence of moderate-severe NDI among survivors was 41.2% at 18 to 26 months. Mortality among infants treated with iNO was 59.4%. Female sex (adjusted odds ratio [aOR]: 2.4, 95% confidence interval [CI]: 1.8-3.3), birth weight ≥720 g (aOR: 2.3, 95% CI: 1.7-3.1) and complete course of antenatal steroids (aOR: 1.6, 95% CI: 1.1-2.2) were associated with intact survival. African American infants had a similar incidence of early HRF (21.7% vs 23.3%) but lower exposure to iNO (16.4% vs 21.6%). Among infants with HRF exposed to iNO, intact survival (no death or NDI) was not significantly different between African American and other races (aOR: 1.5, 95% CI: 0.6-3.6). CONCLUSIONS Early HRF in infants ≤26 weeks' gestation is associated with high mortality and NDI at 18 to 26 months. Use of iNO did not decrease mortality or NDI. Outcomes following iNO exposure were not different in African American infants.
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Affiliation(s)
- Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, UBMD, University at Buffalo, Buffalo, New York;
| | | | - Dhuly Chowdhury
- Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland
| | - Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Martin Keszler
- Department of Neonatology, Brown University, Providence, Rhode Island
| | | | - Abhik Das
- Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and
- Department of Global and Community Health, George Mason University, Fairfax, Virginia
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14
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Greenough A, Decobert F, Field D, Hallman M, Hummler HD, Jonsson B, Sánchez Luna M, Van Overmeire B, Carnielli VP, Potenziano JL, Mercier JC. Inhaled nitric oxide (iNO) for preventing prematurity-related bronchopulmonary dysplasia (BPD): 7-year follow-up of the European Union Nitric Oxide (EUNO) trial. J Perinat Med 2020; 49:104-110. [PMID: 32892178 DOI: 10.1515/jpm-2020-0164] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/08/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Most studies of inhaled nitric oxide (iNO) for prevention of bronchopulmonary dysplasia (BPD) in premature infants have focused on short-term mortality and morbidity. Our aim was to determine the long-term effects of iNO. METHODS A 7-year follow-up was undertaken of infants entered into a multicenter, double-blind, randomized, placebo-controlled trial of iNO for prevention of BPD in premature infants born between 24 and 28 weeks plus six days of gestation. At 7 years, survival and hospital admissions since the 2-year follow-up, home oxygen therapy in the past year, therapies used in the previous month and growth assessments were determined. Questionnaires were used to compare general health, well-being, and quality of life. RESULTS A total of 305 children were assessed. No deaths were reported. Rates of hospitalization for respiratory problems (6.6 vs. 10.5%, iNO and placebo group, respectively) and use of respiratory medications (6.6 vs. 9.2%) were similar. Two patients who received iNO and one who received placebo had received home oxygen therapy. There were no significant differences in any questionnaire-documented health outcomes. CONCLUSIONS iNO for prevention of BPD in very premature infants with respiratory distress did not result in long-term benefits or adverse long-term sequelae. In the light of current evidence, routine use of iNO cannot be recommended for prevention of BPD in preterm infants.
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Affiliation(s)
| | | | - David Field
- University of Leicester Centre for Medicine, Leicester, UK
| | - Mikko Hallman
- University of Oulu and Oulu University Hospital, Oulu, Finland
| | | | - Baldvin Jonsson
- Karolinska University Hospital and Institute, Stockholm, Sweden
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15
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Wang SH, Tsao PN. Phenotypes of Bronchopulmonary Dysplasia. Int J Mol Sci 2020; 21:ijms21176112. [PMID: 32854293 PMCID: PMC7503264 DOI: 10.3390/ijms21176112] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/18/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic morbidity in preterm infants. In the absence of effective interventions, BPD is currently a major therapeutic challenge. Several risk factors are known for this multifactorial disease that results in disrupted lung development. Inflammation plays an important role and leads to persistent airway and pulmonary vascular disease. Since corticosteroids are potent anti-inflammatory agents, postnatal corticosteroids have been used widely for BPD prevention and treatment. However, the clinical responses vary to a great degree across individuals, and steroid-related complications remain major concerns. Emerging studies on the molecular mechanism of lung alveolarization during inflammatory stress will elucidate the complicated pathway and help discover novel therapeutic targets. Moreover, with the advances in metabolomics, there are new opportunities to identify biomarkers for early diagnosis and prognosis prediction of BPD. Pharmacometabolomics is another novel field aiming to identify the metabolomic changes before and after a specific drug treatment. Through this "metabolic signature," a more precise treatment may be developed, thereby avoiding unnecessary drug exposure in non-responders. In the future, more clinical, genetic, and translational studies would be required to improve the classification of BPD phenotypes and achieve individualized care to enhance the respiratory outcomes in preterm infants.
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Affiliation(s)
- Shih-Hsin Wang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan;
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100225, Taiwan
- Center for Developmental Biology & Regenerative Medicine, National Taiwan University, Taipei 100226, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71013)
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16
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Yang MC, Hsu JF, Hsiao HF, Yang LY, Pan YB, Lai MY, Chu SM, Huang HR, Chiang MC, Fu RH, Tsai MH. Use of high frequency oscillatory ventilator in neonates with respiratory failure: the clinical practice in Taiwan and early multimodal outcome prediction. Sci Rep 2020; 10:6603. [PMID: 32313052 PMCID: PMC7171122 DOI: 10.1038/s41598-020-63655-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/20/2020] [Indexed: 12/02/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) can be a rescue for neonates with refractory respiratory failure or an early elective therapy for preterm infants with severe respiratory distress syndrome (RDS). However, little is known about the current evolution and therapeutic limitations of HFOV. We therefore aimed to describe its use in clinical practice and predict the risk of mortality for neonates receiving HFOV. A retrospective observational study of all neonates treated with HFOV in a quaternary referral NICU between January 2007 and December 2016 was conducted. We classified these patients into five subgroups based on primary respiratory diagnoses. We performed the logistic regression and decision tree regression analyses to identify independent factors of 30-day mortality following HFOV. A total of 1125 patients who were ever supported on HFOV were enrolled, of whom 64.1% received HFOV as a rescue therapy, 27.2% received it as an elective therapy, and 8.7% received it for air leak. An average oxygenation index (OI) greater than 25 in the first 24 hours after the initiation of HFOV and patients with secondary pulmonary hypertension were found to have the greatest risk of in-hospital mortality (p < 0.0001). The overall in-hospital mortality rate was 25.8% (290/1125). Decision tree regression analysis revealed that neonates with refractory respiratory failure who had a pre-HFOV OI value higher than 20.5 and OI values higher than 21.5, 23.5 and 34 at 2 hours, 6 hours, and 12 hours after the use of HFOV, respectively, had a significantly increased risk of 30-day mortality. We identified the predictors and cutoff points of OI before and after the initiation of HFOV in neonates with respiratory failure, which can be clinically used as a reference for 30-day mortality. Further efforts are still needed to optimize the outcomes.
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Affiliation(s)
- Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan.,School of Business, Executive MBA program in Health Care Management, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan.,School of Business, Executive MBA program in Health Care Management, Chang Gung University, Taoyuan, Taiwan
| | - Lan-Yan Yang
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Bin Pan
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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17
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Sherlock LG, Wright CJ, Kinsella JP, Delaney C. Inhaled nitric oxide use in neonates: Balancing what is evidence-based and what is physiologically sound. Nitric Oxide 2019; 95:12-16. [PMID: 31866361 DOI: 10.1016/j.niox.2019.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 12/22/2022]
Abstract
Inhaled nitric oxide is a powerful therapeutic used in neonatology. Its use is evidenced-based for term and near-term infants with persistent pulmonary hypertension; however, it is frequently used off-label both in term and preterm babies. This article reviews the off-label uses of iNO in infants. Rationale is discussed for a selective application of iNO based on physiologically guided principles, and new research avenues are considered.
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Affiliation(s)
- Laurie G Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Cassidy Delaney
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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18
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Abstract
In the absence of effective interventions to prevent preterm births, improved survival of infants who are born at the biological limits of viability has relied on advances in perinatal care over the past 50 years. Except for extremely preterm infants with suboptimal perinatal care or major antenatal events that cause severe respiratory failure at birth, most extremely preterm infants now survive, but they often develop chronic lung dysfunction termed bronchopulmonary dysplasia (BPD; also known as chronic lung disease). Despite major efforts to minimize injurious but often life-saving postnatal interventions (such as oxygen, mechanical ventilation and corticosteroids), BPD remains the most frequent complication of extreme preterm birth. BPD is now recognized as the result of an aberrant reparative response to both antenatal injury and repetitive postnatal injury to the developing lungs. Consequently, lung development is markedly impaired, which leads to persistent airway and pulmonary vascular disease that can affect adult lung function. Greater insights into the pathobiology of BPD will provide a better understanding of disease mechanisms and lung repair and regeneration, which will enable the discovery of novel therapeutic targets. In parallel, clinical and translational studies that improve the classification of disease phenotypes and enable early identification of at-risk preterm infants should improve trial design and individualized care to enhance outcomes in preterm infants.
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19
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Wedgwood S, Steinhorn RH, Lakshminrusimha S. Optimal oxygenation and role of free radicals in PPHN. Free Radic Biol Med 2019; 142:97-106. [PMID: 30995536 PMCID: PMC6761018 DOI: 10.1016/j.freeradbiomed.2019.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023]
Abstract
Effective ventilation of the lungs is essential in mediating pulmonary vasodilation at birth to allow effective gas exchange and an increase in systemic oxygenation. Unsuccessful transition prevents the increase in pulmonary blood flow after birth resulting in hypoxemia and persistent pulmonary hypertension of the newborn (PPHN). Management of neonates with PPHN includes ventilation of the lungs with supplemental oxygen to correct hypoxemia. Optimal oxygenation should meet oxygen demand to the tissues and avoid hypoxic pulmonary vasoconstriction (HPV) while preventing oxidative stress. The optimal target for oxygenation in PPHN is not known. Animal models have demonstrated that PaO2<45 mmHg exacerbates HPV. However, there are no practical methods of assessing oxygen levels associated with oxidant stress. Oxidant stress can be due to free radical generation from underlying lung disease or from free radicals generated by supplemental oxygen. Free radicals act on the nitric oxide pathway reducing cGMP and promoting pulmonary vasoconstriction. Antioxidant therapy improves systemic oxygenation in an animal model of PPHN but there are no clinical trials to support such therapy. Targeting preductal SpO2 between 90 and 97% and PaO2 at 50-80 mmHg appears prudent in PPHN but clinical trials to support this practice are lacking. Preterm infants with PPHN present unique challenges due to lack of antioxidant defenses and functional and structural immaturity of the lungs. This review highlights the need for additional studies to mitigate the impact of oxidative stress in the lung and pulmonary vasculature in PPHN.
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Affiliation(s)
- Stephen Wedgwood
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA
| | - Robin H Steinhorn
- Department of Hospitalist Medicine, Children's National Health System, Washington DC, USA
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20
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Hsiao HF, Yang MC, Lai MY, Chu SM, Huang HR, Chiang MC, Fu RH, Hsu JF, Tsai MH. The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality. J Clin Med 2019; 8:jcm8081113. [PMID: 31357613 PMCID: PMC6722605 DOI: 10.3390/jcm8081113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/18/2019] [Accepted: 07/24/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The indication of inhaled nitric oxide (iNO) used in preterm infants has not been well defined. Neonates with refractory hypoxemia may benefit from the pulmonary vasodilatory effects of iNO. The aim of this study was to investigate the off-label use of iNO as a rescue therapy. METHODS Between January 2010 and December 2017, all neonates who received iNO as a rescue therapy from a tertiary-level medical center were enrolled, and those who were not diagnosed with persistent pulmonary hypertension of newborn (PPHN) were defined as having received off-label use of iNO. The controls were 636 neonates with severe respiratory failure requiring high-frequency oscillatory ventilation but no iNO. RESULTS A total of 206 neonates who received iNO as a rescue therapy were identified, and 84 (40.8%) had off-label use. The median (interquartile) gestational age was 30.5 (26.3-37.0) weeks. Neonates receiving iNO had significantly more severe respiratory failure and a higher oxygenation index than the controls (p < 0.001). Respiratory distress syndrome and secondary pulmonary hypertension after severe bronchopulmonary dysplasia (BPD) were the most common causes of the off-label iNO prescription. Of the 84 neonates with off-label use of iNO, 53 (63.1%) had initial improvement in oxygenation, but 44 (52.4%) eventually died. The overall mortality rate was 41.7% (86/206). After multivariate logistic regression, extremely preterm (odds ratio [OR] 5.51; p < 0.001), presence of pulmonary hemorrhage (OR 2.51; p = 0.036) and severe hypotension (OR 2.78; p = 0.008) were the independent risk factors for final mortality. CONCLUSIONS iNO is applicable to be an off-label rescue therapy for premature neonates with refractory hypoxemia due to severe pulmonary hypertension and bronchopulmonary dysplasia.
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Affiliation(s)
- Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.
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21
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Lautner G, Stringer B, Brisbois EJ, Meyerhoff ME, Schwendeman SP. Controlled light-induced gas phase nitric oxide release from S-nitrosothiol-doped silicone rubber films. Nitric Oxide 2019; 86:31-37. [DOI: 10.1016/j.niox.2019.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/12/2018] [Accepted: 01/31/2019] [Indexed: 11/29/2022]
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22
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Manja V, Guyatt G, Lakshminrusimha S, Jack S, Kirpalani H, Zupancic JAF, Dukhovny D, You JJ, Monteiro S. Factors influencing decision making in neonatology: inhaled nitric oxide in preterm infants. J Perinatol 2019; 39:86-94. [PMID: 30353082 PMCID: PMC6298829 DOI: 10.1038/s41372-018-0258-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We studied decision making regarding inhaled nitric oxide (iNO) in preterm infants with Pulmonary Hypertension (PH). STUDY DESIGN We asked members of the AAP-Society of Neonatal-Perinatal Medicine and Division-Chiefs to select from three management options- initiate iNO, engage parents in shared decision making or not consider iNO in an extremely preterm with PH followed by rating of factors influencing their decision. RESULTS Three hundred and four respondents (9%) completed the survey; 36.5% chose to initiate iNO, 42% to engage parents, and 21.5% did not consider iNO. Provider's prior experience, safety, and patient-centered care were rated higher by those who initiated or offered iNO; lack of effectiveness and cost considerations by participants who did not chose iNO. CONCLUSIONS Most neonatologists offer or initiate iNO therapy based on their individual experience. The minority who chose not to consider iNO placed higher value on lack of effectiveness and cost. These results demonstrate a tension between evidence and pathophysiology-based-therapy/personal experience.
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Affiliation(s)
- Veena Manja
- Departments of Surgery and Pediatrics, University of California at Davis, Sacramento, CA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Satyan Lakshminrusimha
- Departments of Surgery and Pediatrics, University of California at Davis, Sacramento, CA, USA.
- Department of Pediatrics, UC Davis Medical Center, 2516 Stockton Blvd, Sacramento, CA, USA.
| | - Susan Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Haresh Kirpalani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine,, Philadelphia, PA, USA
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - John J You
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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23
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Pandya S, Baser O, Wan GJ, Lovelace B, Potenziano J, Pham AT, Huang X, Wang L. The Burden of Hypoxic Respiratory Failure in Preterm and Term/Near-term Infants in the United States 2011-2015. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:130-141. [PMID: 32685586 PMCID: PMC7299458 DOI: 10.36469/9682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This study quantified the burden of hypoxic respiratory failure (HRF)/persistent pulmonary hypertension of newborn (PPHN) in preterm and term/near-term infants (T/NTs) by examining health care resource utilization (HRU) and charges in the United States. METHODS Preterms and T/NTs (≤34 and >34 weeks of gestation, respectively) having HRF/PPHN, with/without meconium aspiration in inpatient setting from January 1, 2011-October 31, 2015 were identified from the Vizient database (first hospitalization=index hospitalization). Comorbidities, treatments, HRU, and charges during index hospitalization were evaluated among preterms and T/NTs with HRF/PPHN. Logistic regression was performed to evaluate mortality-related factors. RESULTS This retrospective study included 504 preterms and 414 T/NTs with HRF/PPHN. Preterms were more likely to have respiratory distress syndrome, neonatal jaundice, and anemia of prematurity than T/NTs. Preterms had significantly longer inpatient stays (54.1 vs 29.0 days), time in a neonatal intensive care unit (34.1 vs 17.5 days), time on ventilation (4.7 vs 2.2 days), and higher total hospitalization charges ($613 350 vs $422 558) (all P<0.001). Similar rates were observed for use of antibiotics (96.2% vs 95.4%), sildenafil (9.5% vs 8.2%), or inhaled nitric oxide (93.8% vs 94.2%). Preterms had a significantly higher likelihood of mortality than T/NTs (odds ratio: 3.6, 95% confidence interval: 2.3-5.0). CONCLUSIONS The findings of more severe comorbidities, higher HRU, hospitalization charges, and mortality in preterms than in T/NTs underscore the significant clinical and economic burden of HRF/PPHN among infants. The results show significant unmet medical need; further research is warranted to determine new treatments and real-world evidence for improved patient outcomes.
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Affiliation(s)
| | - Onur Baser
- Department of Internal Medicine, the University of Michigan, Ann Arbor, MI
| | | | | | | | - An T Pham
- School of Pharmacy, University of California San Francisco, San Francisco, CA
| | | | - Li Wang
- STATinMED Research, Plano, TX
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24
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Ellsworth KR, Ellsworth MA, Weaver AL, Mara KC, Clark RH, Carey WA. Association of Early Inhaled Nitric Oxide With the Survival of Preterm Neonates With Pulmonary Hypoplasia. JAMA Pediatr 2018; 172:e180761. [PMID: 29800952 PMCID: PMC6137510 DOI: 10.1001/jamapediatrics.2018.0761] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Pulmonary hypoplasia affects a very small percentage of preterm neonates, but its presence is associated with high rates of mortality. OBJECTIVE To determine whether treatment with inhaled nitric oxide during the first week of life was associated with improved in-hospital survival in a cohort of extremely preterm neonates with pulmonary hypoplasia. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Pediatrix Medical Group's Clinical Data Warehouse, a data set containing information from more than 350 neonatal intensive care units in 35 US states and Puerto Rico. Since inhaled nitric oxide was not randomly prescribed, we used 1-to-1 propensity score matching to reduce the imbalance of measured covariates between the 2 treatment groups. The initial, unmatched cohort included singleton neonates who were born between 22 and 29 weeks' gestation, had a birth weight of 400 g or more, were diagnosed with pulmonary hypoplasia as a cause of their respiratory distress, remained free of major anomalies, and were discharged between January 1, 2000, and December 31, 2014. We defined exposure as the initiation of inhaled nitric oxide on day t in days 0 to 7 of the life of a neonate. Each exposed neonate was matched 1-to-1 to a neonate who had not initiated inhaled nitric oxide on a given day. MAIN OUTCOMES AND MEASURES The primary outcome was mortality defined as death prior to transfer or discharge home. Secondary outcomes were any-stage necrotizing enterocolitis, retinopathy of prematurity requiring treatment, chronic lung disease, and periventricular leukomalacia. RESULTS Among 92 635 neonates in our study sample, we identified 767 (0.8%) with pulmonary hypoplasia who met all study inclusion criteria, of whom 185 (0.2%) were exposed to inhaled nitric oxide. Among 151 matched pairs of exposed and unexposed neonates, we did not identify a significant association between inhaled nitric oxide use and mortality (hazard ratio [HR], 0.79; 95% CI, 0.57-1.11). Subgroup analyses of neonates with and without persistent pulmonary hypertension (PPHN) likewise revealed no significant association between inhaled nitric oxide use and mortality (pulmonary hypoplasia with PPHN: HR, 0.67; 95% CI, 0.45-1.01; pulmonary hypoplasia without PPHN: HR, 1.11; 95% CI, 0.61-2.02), but these findings may have been influenced by ascertainment bias. CONCLUSIONS AND RELEVANCE Early treatment with inhaled nitric oxide is not associated with improved survival among extremely preterm neonates with pulmonary hypoplasia. Clinical trials are warranted to clarify the matter.
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Affiliation(s)
| | | | - Amy L. Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Reese H. Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - William A. Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
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25
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Controversies in the identification and management of acute pulmonary hypertension in preterm neonates. Pediatr Res 2017; 82:901-914. [PMID: 28820870 DOI: 10.1038/pr.2017.200] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 08/05/2017] [Indexed: 12/22/2022]
Abstract
It is increasingly recognized that the abnormal physiologic consequences of pulmonary hypertension (PH) may contribute to poor cardiopulmonary health in premature babies. Conflicting literature has led to clinical uncertainty, pathological misinterpretation, and variability in treatment approaches among practitioners. There are several disorders with overlapping and interrelated presentations, and other disorders with a similar clinical phenotype but diverse pathophysiological contributors. In this review, we provide a diagnostic approach for acute hypoxemic respiratory failure in the preterm neonate, outline the pathophysiological conditions that may present as acute PH, and discuss the implications of high pulmonary vascular resistance (PVR) on the cardiovascular system. Although PVR and respiratory management are highly interrelated, there may be a population of preterm neonates in whom inhaled nitric oxide may improve illness severity and may relate to outcomes. A management approach based on physiology that considers common clinical conundrums is provided. A more comprehensive understanding of the physiology may help in informed decision-making in clinical situations where conclusive scientific evidence is lacking. Regardless, high-quality research is required, and appropriate definition of the target population is paramount. A thoughtful approach to cardiovascular therapy may also provide an avenue to improve neurodevelopmental outcomes while awaiting more clear answers.
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26
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Diagnostic Approach to Pulmonary Hypertension in Premature Neonates. CHILDREN-BASEL 2017; 4:children4090075. [PMID: 28837121 PMCID: PMC5615265 DOI: 10.3390/children4090075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/01/2017] [Accepted: 08/09/2017] [Indexed: 02/01/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease in premature infants following respiratory distress at birth. With increasing survival of extremely low birth weight infants, alveolar simplification is the defining lung characteristic of infants with BPD, and along with pulmonary hypertension, increasingly contributes to both respiratory morbidity and mortality in these infants. Growth restricted infants, infants born to mothers with oligohydramnios or following prolonged preterm rupture of membranes are at particular risk for early onset pulmonary hypertension. Altered vascular and alveolar growth particularly in canalicular and early saccular stages of lung development following mechanical ventilation and oxygen therapy, results in developmental lung arrest leading to BPD with pulmonary hypertension (PH). Early recognition of PH in infants with risk factors is important for optimal management of these infants. Screening tools for early diagnosis of PH are evolving; however, echocardiography is the mainstay for non-invasive diagnosis of PH in infants. Cardiac computed tomography (CT) and magnetic resonance are being used as imaging modalities, however their role in improving outcomes in these patients is uncertain. Follow-up of infants at risk for PH will help not only in early diagnosis, but also in appropriate management of these infants. Aggressive management of lung disease, avoidance of hypoxemic episodes, and optimal nutrition determine the progression of PH, as epigenetic factors may have significant effects, particularly in growth-restricted infants. Infants with diagnosis of PH are managed with pulmonary vasodilators and those resistant to therapy need to be worked up for the presence of cardio-vascular anomalies. The management of infants and toddlers with PH, especially following premature birth is an emerging field. Nonetheless, combination therapies in a multi-disciplinary setting improves outcomes for these infants.
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27
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Mathew B, Lakshminrusimha S. Persistent Pulmonary Hypertension in the Newborn. CHILDREN-BASEL 2017; 4:children4080063. [PMID: 28788074 PMCID: PMC5575585 DOI: 10.3390/children4080063] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/18/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a syndrome of failed circulatory adaptation at birth due to delay or impairment in the normal fall in pulmonary vascular resistance (PVR) that occurs following birth. The fetus is in a state of physiological pulmonary hypertension. In utero, the fetus receives oxygenated blood from the placenta through the umbilical vein. At birth, following initiation of respiration, there is a sudden precipitous fall in the PVR and an increase of systemic vascular resistance (SVR) due to the removal of the placenta from circulation. There is dramatic increase in pulmonary blood flow with a decrease in, and later reversal of shunts at the foramen ovale and ductus arteriosus. The failure of this normal physiological pulmonary transition leads to the syndrome of PPHN. PPHN presents with varying degrees of hypoxemic respiratory failure. Survival of infants with PPHN has significantly improved with the use of gentle ventilation, surfactant and inhaled nitric oxide (iNO). PPHN is associated with significant mortality and morbidity among survivors. Newer agents that target different enzymatic pathways in the vascular smooth muscle are in different stages of development and testing. Further research using these agents is likely to further reduce morbidity and mortality associated with PPHN.
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Affiliation(s)
- Bobby Mathew
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14222, USA.
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