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Feng Z, Wu X, Xu X, Cui Q, Wu F. Efficacy of inhaled nitric oxide in preterm infants ≤ 34 weeks: a systematic review and meta-analysis of randomized controlled trials. Front Pharmacol 2024; 14:1268795. [PMID: 38273818 PMCID: PMC10808707 DOI: 10.3389/fphar.2023.1268795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Background: The effect of inhaled nitric oxide (iNO) in neonates >34 weeks on improving respiration is well documented. However, the efficacy of iNO in preterm infants ≤34 weeks remains controversial. Objectives: The main purpose of this review is to assess the effectiveness and safety of iNO treatment in preterm infants ≤34 weeks. Search methods: We systematically searched PubMed, Embase and Cochrane Libraries from their inception to 1 June 2023. We also reviewed the reference lists of retrieved studies. Selection criteria: Our study involved randomized controlled trials on preterm infants ≤34 weeks, especially those receiving iNO treatment, and mainly assessed outcomes such as bronchopulmonary dysplasia (BPD) and mortality. Two authors independently reviewed these trials, extracted data, and evaluated study biases. Disagreements were resolved by consensus. We used the GRADE method to assess evidence quality. Results: Our research included a total of 17 studies involving 4,080 neonates and 7 follow-up studies. The synthesis of results showed that in neonates, iNO treatment reduced the incidence of BPD (RR: 0.92; 95% CI: 0.86-0.98). It also decreased the composite outcome of death or BPD (RR: 0.94; 95% CI: 0.90-0.98), without increasing the risk of short-term (such as intraventricular hemorrhage, periventricular leukomalacia) and long-term neurological outcomes (including Bayley mental developmental index <70, cerebral palsy and neurodevelopmental impairment). Furthermore, iNO did not significantly affect other neonatal complications like sepsis, pulmonary hemorrhage, necrotizing enterocolitis, and symptomatic patent ductus arteriosus. Subgroup analysis revealed that iNO significantly reduced BPD incidence in neonates at 36 weeks under specific intervention conditions, including age less than 3 days, birth weight over 1,000 g, iNO dose of 10 ppm or higher, or treatment duration exceeding 7 days (p < 0.05). Conclusion: Inhaled NO reduced the incidence of BPD in neonates at 36 weeks of gestation, and the effect of the treatment depended on neonatal age, birth weight, duration and dose of iNO. Therefore, iNO can be considered a promising treatment for the potential prevention of BPD in premature infants. More data, however, would be needed to support nitric oxide registration in this specific patient population, to minimize its off-label use.
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Affiliation(s)
- Zhoushan Feng
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Xiaohong Wu
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Xiaona Xu
- Department of Obstetrics and Gynecology, School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiliang Cui
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Fan Wu
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
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2
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Jin Z, Jiang MM, Lee B. Nitric oxide is required for lung alveolarization revealed by deficiency of argininosuccinate lyase. Hum Mol Genet 2023; 33:33-37. [PMID: 37738569 DOI: 10.1093/hmg/ddad158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023] Open
Abstract
Inhaled nitric oxide (NO) therapy has been reported to improve lung growth in premature newborns. However, the underlying mechanisms by which NO regulates lung development remain largely unclear. NO is enzymatically produced by three isoforms of nitric oxide synthase (NOS) enzymes. NOS knockout mice are useful tools to investigate NO function in the lung. Each single NOS knockout mouse does not show obvious lung alveolar phenotype, likely due to compensatory mechanisms. While mice lacking all three NOS isoforms display impaired lung alveolarization, implicating NO plays a pivotal role in lung alveolarization. Argininosuccinate lyase (ASL) is the only mammalian enzyme capable of synthesizing L-arginine, the sole precursor for NOS-dependent NO synthesis. ASL is also required for channeling extracellular L-arginine into a NO-synthetic complex. Thus, ASL deficiency (ASLD) is a non-redundant model for cell-autonomous, NOS-dependent NO deficiency. Here, we assessed lung alveolarization in ASL-deficient mice. Hypomorphic deletion of Asl (AslNeo/Neo) results in decreased lung alveolarization, accompanied with reduced level of S-nitrosylation in the lung. Genetic ablation of one copy of Caveolin-1, which is a negative regulator of NO production, restores total S-nitrosylation as well as lung alveolarization in AslNeo/Neo mice. Importantly, NO supplementation could partially rescue lung alveolarization in AslNeo/Neo mice. Furthermore, endothelial-specific knockout mice (VE-Cadherin Cre; Aslflox/flox) exhibit impaired lung alveolarization at 12 weeks old, supporting an essential role of endothelial-derived NO in the enhancement of lung alveolarization. Thus, we propose that ASLD is a model to study NO-mediated lung alveolarization.
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Affiliation(s)
- Zixue Jin
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States
| | - Ming-Ming Jiang
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States
| | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States
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3
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Zheng Y, Wu Q, Han S. Inhaled nitric oxide in premature infants for preventing bronchopulmonary dysplasia: a meta-analysis. BMC Pediatr 2023; 23:139. [PMID: 36991371 PMCID: PMC10053486 DOI: 10.1186/s12887-023-03923-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 02/20/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The effectiveness of nitric oxide (NO) in reducing the risk of bronchopulmonary dysplasia (BPD) remains debatable. In this study, we performed a meta-analysis to guide clinical decision-making regarding the significance of inhaled NO (iNO) on the potential occurrence and outcomes of BPD in premature infants. METHODS Data from clinical randomized controlled trials (RCTs) published in PubMed, Embase, Cochrane Library, Wanfang, China National Knowledge Infrastructure (CNKI) and Chinese Scientific Journal Database VIP databases for premature infants were searched from inception to March 2022. Review Manager 5.3 statistical software was used for heterogeneity analysis. RESULTS Of the 905 studies retrieved, 11 RCTs met the screening criteria of this study. Our analysis showed that the iNO group was associated with a significantly lower incidence of BPD than the control group (relative risk [RR] = 0.91, 95% confidence interval (CI) 0.85-0.97, P = 0.006). We also observed no significant difference in the incidence of BPD between the two groups at the initial dose of 5 ppm (ppm) (P = 0.09) but those treated with 10 ppm iNO had a significantly lower incidence of BPD (RR = 0.90, 95%CI 0.81-0.99, P = 0.03). However, it should be noted that although the iNO group had an increased risk for necrotizing enterocolitis (NEC) (RR = 1.33, 95%CI 1.04-1.71, P = 0.03), cases treated with an initial dose of 10 ppm revealed no significant difference in the incidence of NEC compared with the control group (P = 0.41), while those treated with an initial dosage of 5 ppm of iNO had a significantly greater NEC rates than the control group (RR = 1.41, 95%CI 1.03-1.91, P = 0.03). Further, we observed no statistically significant differences in the incidence of in-hospital mortality, intraventricular hemorrhage (IVH) (Grade 3/4) or periventricular leukomalacia (PVL) and pulmonary hemorrhage (PH) between the two treatment groups. CONCLUSIONS This meta-analysis of RCTs showed that iNO at an initial dosage of 10 ppm seemed more effective in reducing the risk of BPD than conventional treatment and iNO at an initial dosage of 5 ppm in preterm infants at a gestational age of ≤34 weeks who required respiratory support. However, the incidence of in-hospital mortality and adverse events between the overall iNO group and Control were similar.
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Affiliation(s)
- Yi Zheng
- Department of Pediatrics, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Qi Wu
- Department of Pediatrics, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Shuping Han
- Department of Pediatrics, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China.
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4
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Boly TJ, Dagle JM, Klein JM, Rios DR, McNamara PJ, Giesinger RE. Response categorization and outcomes in extremely premature infants born at 22-26 weeks gestation that received inhaled nitric oxide for hypoxic respiratory failure. J Perinatol 2023; 43:324-331. [PMID: 36509816 PMCID: PMC10173872 DOI: 10.1038/s41372-022-01582-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the outcomes of extremely premature infants who received inhaled nitric oxide(iNO) for hypoxic respiratory failure(HRF). STUDY DESIGN Retrospective analysis of 107 infants born 22-26 weeks gestation who received iNO for HRF at a single institution. Infants were categorized as positive, negative, or no responders based on change in FiO2 or OI. Underlying physiology was determined using Echocardiography/Radiography/Biochemistry. RESULTS 63% of infants had a positive response; they received iNO earlier and were more likely to have acute pulmonary hypertension(PH). Positive response correlated with decreased incidence of death or grade 3 BPD at 36 weeks postmenstrual age, as compared to a negative response. CONCLUSIONS Extremely premature infants have a positive response rate to iNO comparable to term infants when used for PH in the transitional period. Infants with a negative response to iNO had worse outcomes, necessitating the determination of the underlying physiology of HRF prior to iNO initiation.
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Affiliation(s)
- Timothy J Boly
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- Department of Biochemistry, University of Iowa, Iowa City, IA, USA
| | - Jonathan M Klein
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Danielle R Rios
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
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5
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Oka S, Nishimura E, Ozawa J, Haga M, Miyahara N, Sakatani S, Minamitani Y, Namba F. Therapeutic response of iNO in preterm infants with hypoxemic respiratory failure. Pediatr Int 2023; 65:e15423. [PMID: 36412230 DOI: 10.1111/ped.15423] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) has been used as a rescue treatment for preterm infants with hypoxemic respiratory failure (HRF). However, its effectiveness remains debatable. Thus, in this study, we aimed to examine the impact of iNO therapy on HRF in extremely preterm infants. METHODS A retrospective observational study was performed. Extremely preterm infants admitted to our neonatal intensive care unit who received iNO therapy later in their postnatal life were included. The oxygen saturation index (OSI) was used as an index of the severity of respiratory failure. RESULTS In total, 30 extremely preterm infants were included in this study. Oxygenation was enhanced after the administration of iNO in infants with HRF. The OSI decreased by more than 20% in 12 patients (40%, positive responder) and did not decrease in 17 patients (57%, negative responder) within the first 6 h of treatment. The iNO initiation day was the significant independent factor associated with a positive response to iNO therapy in extremely preterm infants with HRF. CONCLUSIONS iNO therapy was effective in enhancing oxygenation in extremely preterm infants with HRF. Earlier use of iNO was the significant factor associated with a positive therapeutic response to iNO, implying that iNO may be more effective in pulmonary vessels which are less damaged by shorter-term mechanical ventilation.
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Affiliation(s)
- Shuntaro Oka
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Eri Nishimura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Junichi Ozawa
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Mitsuhiro Haga
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Naoyuki Miyahara
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shun Sakatani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan.,Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yohei Minamitani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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6
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Redaelli S, Magliocca A, Malhotra R, Ristagno G, Citerio G, Bellani G, Berra L, Rezoagli E. Nitric oxide: Clinical applications in critically ill patients. Nitric Oxide 2022; 121:20-33. [PMID: 35123061 PMCID: PMC10189363 DOI: 10.1016/j.niox.2022.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/19/2022]
Abstract
Inhaled nitric oxide (iNO) acts as a selective pulmonary vasodilator and it is currently approved by the FDA for the treatment of persistent pulmonary hypertension of the newborn. iNO has been demonstrated to effectively decrease pulmonary artery pressure and improve oxygenation, while decreasing extracorporeal life support use in hypoxic newborns affected by persistent pulmonary hypertension. Also, iNO seems a safe treatment with limited side effects. Despite the promising beneficial effects of NO in the preclinical literature, there is still a lack of high quality evidence for the use of iNO in clinical settings. A variety of clinical applications have been suggested in and out of the critical care environment, aiming to use iNO in respiratory failure and pulmonary hypertension of adults or as a preventative measure of hemolysis-induced vasoconstriction, ischemia/reperfusion injury and as a potential treatment of renal failure associated with cardiopulmonary bypass. In this narrative review we aim to present a comprehensive summary of the potential use of iNO in several clinical conditions with its suggested benefits, including its recent application in the scenario of the COVID-19 pandemic. Randomized controlled trials, meta-analyses, guidelines, observational studies and case-series were reported and the main findings summarized. Furthermore, we will describe the toxicity profile of NO and discuss an innovative proposed strategy to produce iNO. Overall, iNO exhibits a wide range of potential clinical benefits, that certainly warrants further efforts with randomized clinical trials to determine specific therapeutic roles of iNO.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy.
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7
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Nelin L, Kinsella JP, Courtney SE, Pallotto EK, Tarau E, Potenziano JL. Use of inhaled nitric oxide in preterm vs term/near-term neonates with pulmonary hypertension: results of the PaTTerN registry study. J Perinatol 2022; 42:14-18. [PMID: 34711938 DOI: 10.1038/s41372-021-01252-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate inhaled nitric oxide (iNO) in preterm (PT) vs term/near-term (TNT) neonates with hypoxic respiratory failure (HRF) and pulmonary hypertension (PH) in an observational registry (PaTTerN). STUDY DESIGN Non-inferiority study comparing PT neonates of GA ≥ 27 to <34 weeks vs TNT neonates of GA ≥ 34 to ≤40 weeks with HRF associated with PH, who received iNO for 24-96 h during the first 0-7 days after birth. Primary endpoint: Achieving ≥25% decrease in oxygenation index/surrogate oxygenation index during iNO treatment. RESULTS Of 140 neonates (PT, n = 55; TNT, n = 85), the primary endpoint was achieved in 50 (90.9%) PT vs 75 (88.2%) TNT neonates (difference [95% CI]: 0.027 [-0.033, 0.087]); PT neonates achieved non-inferiority interval, and the study was stopped early based on prespecified criteria. CONCLUSIONS Use of iNO for improving oxygenation in PT neonates with HRF associated with PH is at least as effective as in TNT neonates. CLINICAL TRIAL REGISTRATION #NCT03132428, registered April 27, 2017.
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Affiliation(s)
- Leif Nelin
- The Research Institute at Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA.
| | - John P Kinsella
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Sherry E Courtney
- Arkansas Children's Hospital Research Institute, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR, USA
| | | | - Eva Tarau
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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8
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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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9
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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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10
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Hoyle ES, Slee SL, Subhedar NV. Variation in the definition of pulmonary hypertension and clinical indications for the use of nitric oxide in neonatal clinical trials. Acta Paediatr 2020; 109:930-934. [PMID: 31614025 DOI: 10.1111/apa.15058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/07/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
AIM Pulmonary hypertension (PH) frequently complicates neonatal hypoxaemic respiratory failure, but is inconsistently defined. We aimed to describe the variation among randomised controlled trials (RCTs) of inhaled nitric oxide (iNO), in relation to the definition of PH and/or hypoxaemic respiratory failure used to select patients for trial inclusion. METHODS PubMed, Cochrane Library and ClinicalTrials.gov were systematically searched for RCTs of iNO in neonates. Included studies were assessed for clinical and/or echocardiography criteria used to define PH/hypoxaemic respiratory failure. RESULTS Thirty-two trials were included in this review, of which 23 enrolled infants ≥34 weeks' gestation. Echocardiographic diagnosis was used in 21 studies, but there was considerable variation in the echocardiographic parameters used to diagnose PH. The most commonly used indices included markers of tricuspid regurgitation and extrapulmonary shunt. CONCLUSION There is wide variation in the definition of PH used to select infants for inclusion into RCTs of iNO therapy in neonates. We recommend that an international consensus be reached on which parameters should be used and the thresholds defining severity of disease.
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Affiliation(s)
- Emily S. Hoyle
- Neonatal Intensive Care Unit Liverpool Women’s Hospital Liverpool UK
| | - Samantha L. Slee
- Neonatal Intensive Care Unit Liverpool Women’s Hospital Liverpool UK
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11
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Lakshminrusimha S, Kinsella JP, Krishnan US, Van Meurs K, Edwards EM, Bhatt DR, Chandrasekharan P, Oei JL, Manja V, Ramanathan R, Abman SH. Just Say No to iNO in Preterms-Really? J Pediatr 2020; 218:243-252. [PMID: 31810629 DOI: 10.1016/j.jpeds.2019.10.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/08/2019] [Accepted: 10/24/2019] [Indexed: 12/28/2022]
Affiliation(s)
| | - John P Kinsella
- Department of Pediatrics, University of Colorado, Aurora, CO
| | | | - Krisa Van Meurs
- Department of Pediatrics, Stanford University, Palo Alto, CA
| | | | | | | | - Ju-Lee Oei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Veena Manja
- Department of Pediatrics, University of California at Davis, Sacramento, CA
| | - Rangasamy Ramanathan
- Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado, Aurora, CO
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12
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Ahmed MS, Giesinger RE, Ibrahim M, Baczynski M, Louis D, McNamara KP, Jain A, Weisz DE, McNamara PJ. Clinical and echocardiography predictors of response to inhaled nitric oxide in hypoxic preterm neonates. J Paediatr Child Health 2019; 55:753-761. [PMID: 30537276 DOI: 10.1111/jpc.14286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/04/2018] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the clinical and echocardiography modulators of treatment response in hypoxemic preterm infants exposed to inhaled nitric oxide (iNO). METHODS In this multicentre retrospective study, clinical parameters, including oxygenation, ventilation and haemodynamics, were collected for preterm infants <36 weeks gestation before and 2 h after initiation of iNO for acute hypoxemia. Comprehensive echocardiography, performed near the time iNO initiation, was analysed by experts blind to the clinical course. Multiple logistic regression analysis was used to identify factors associated with iNO response as defined by a reduction in the fraction of inspired oxygen by >0.20. RESULTS A total of 213 infants met eligibility criteria, of which 73 had echocardiography data available and formed the study cohort. Response to iNO was demonstrated in 56% of patients. Younger post-natal age (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.89, 0.99) and the presence of pulmonary hypertension (PH) (OR 4.47; 95% CI 1.23-11.9) were independently predictive of iNO response regardless of gestational age. Among neonates <72 h old with documented PH, iNO response was seen in 82%. The onset of a new diagnosis of severe (grade III/IV) intraventricular haemorrhage (IVH) after iNO treatment was seen in 6 of 40 patients <28 weeks' gestational age, with a greater frequency in responders (32 vs. 0%, P = 0.02). CONCLUSIONS Positive response to iNO is greatest in the first 3 days of life and in patients with echo-confirmed PH, independent of gestational age. The association between critical illness, iNO administration and IVH in extremely premature infants may merit prospective delineation.
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Affiliation(s)
- Mohamed Shalabi Ahmed
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Regan E Giesinger
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mohamed Ibrahim
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle Baczynski
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Deepak Louis
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Karl P McNamara
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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13
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Rhine WD, Suzuki S, Potenziano JL, Escalante S, Togari H. An Analysis of Time to Improvement in Oxygenation in Japanese Preterm and Late Preterm or Term Neonates With Hypoxic Respiratory Failure and Pulmonary Hypertension. Clin Ther 2019; 41:910-919. [PMID: 30987776 DOI: 10.1016/j.clinthera.2019.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/07/2019] [Accepted: 03/17/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE We analyzed data from an ongoing registry to determine time to improvement in oxygenation in preterm and late preterm or term neonates with hypoxic respiratory failure and pulmonary hypertension receiving inhaled nitric oxide (iNO) in Japan. METHODS Registry neonates received iNO ≤7 days after birth (February 26, 2010, to October 9, 2012). Efficacy and safety profile data were collected up to 96 h after iNO initiation and, if necessary, every 24 h thereafter and before iNO discontinuation. Patients were stratified by gestational age (GA), oxygenation index (OI), and shunt direction at baseline. FINDINGS Data were evaluated for 1106 neonates (431 with a GA <34 weeks and 675 with a GA of ≥34 weeks). Sixty percent of patients had improved OI; rates were similar for those with GAs of <34 versus ≥34 weeks (61% vs 59%). Overall, mean time to improvement was 11.4 h and tended to be shorter in the groups with a GA <34 weeks versus ≥34 weeks (9.2 vs 12.9 h). Thirty percent of responding neonates required >1 h to achieve improvement in oxygenation. Neonates with higher baseline OI had the greatest decrease in OI during the first hour of treatment. The mortality rate was higher among iNO-treated patients with a baseline OI ≥25 versus those with OI ≥15 to <25 (25% vs 12%; P = 0.0073). IMPLICATIONS iNO treatment provided acute, sustained improvement in oxygenation in neonates with GAs <34 and ≥34 weeks; 70% of patients had improvement within 1 h, but the remaining 30% took >1 h to respond. Initiation of iNO at lower OIs was associated with reduced mortality compared with higher OI.
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Affiliation(s)
- William D Rhine
- Department of Pediatrics-Neonatology, Stanford University School of Medicine, Palo Alto, CA, USA.
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14
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Collura CA, Mara KC, Weaver AL, Clark RH, Carey WA. Outcomes of early inhaled nitric oxide use in premature African American neonates. J Perinatol 2018; 38:1657-1665. [PMID: 30275545 DOI: 10.1038/s41372-018-0232-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/02/2018] [Accepted: 08/15/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Meta-analysis of individual-patient clinical trial data suggests that inhaled nitric oxide (iNO) improves respiratory outcomes in premature African American neonates. We hypothesized that early iNO therapy would be associated with lower mortality and less chronic lung disease (CLD) in extremely premature African American neonates. STUDY DESIGN We conducted a retrospective cohort study of propensity score- and race-matched neonates 22-29 weeks gestation who were mechanically ventilated for treatment of respiratory distress and associated pulmonary hypertension (RDS + PPHN). We evaluated the association of iNO within 7 days of life with in-hospital mortality and CLD, using Cox proportional hazards regression and logistic regression, respectively. RESULT Among 178 matched pairs of African American patients, iNO was not associated with lower mortality (HR = 0.94, 95% CI 0.69-1.30) or less CLD (OR = 0.94, 95% CI 0.47-1.87). CONCLUSIONS Early, off-label iNO use is not associated with improved outcomes in premature African American neonates with RDS + PPHN.
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Affiliation(s)
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Reese H Clark
- Center for Research, Education & Quality, Pediatrix Medical Group, Sunrise, FL, USA
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, MN, USA.
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15
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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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16
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Carey WA, Weaver AL, Mara KC, Clark RH. Inhaled Nitric Oxide in Extremely Premature Neonates With Respiratory Distress Syndrome. Pediatrics 2018; 141:peds.2017-3108. [PMID: 29439205 DOI: 10.1542/peds.2017-3108] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is increasingly prescribed to extremely premature neonates with respiratory distress syndrome (RDS). Most of this off-label use occurs during the first week of life. We studied this practice, hypothesizing that it would not be associated with improved survival. METHODS We queried the Pediatrix Medical Group Clinical Data Warehouse to identify all neonates born at 22 to 29 weeks' gestation from 2004 to 2014. In our study sample, we included singletons who required mechanical ventilation for treatment of RDS and excluded those with anomalies. The primary outcome was death before discharge. Through a sequential risk set approach, each patient who received iNO during the first 7 days of life ("case patient") was matched by using propensity scores to a patient who had not received iNO at a chronological age before the case patient's iNO initiation age (defined as the index age for the matched pair). The association between iNO status and in-hospital mortality was evaluated in a Cox proportional hazards regression model by using age as the time scale with patients entering the risk set at their respective index age. RESULTS Among 37 909 neonates in our study sample, we identified 993 (2.6%) who received iNO. The 2 matched cohorts each contained 971 patients. We did not observe a significant association between iNO exposure and mortality (hazard ratio, 1.08; 95% confidence interval, 0.94-1.25; P = .29). CONCLUSIONS Off-label prescription of iNO is not associated with reduced in-hospital mortality among extremely premature neonates with RDS.
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Affiliation(s)
| | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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17
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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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18
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Dani C, Corsini I, Cangemi J, Vangi V, Pratesi S. Nitric oxide for the treatment of preterm infants with severe RDS and pulmonary hypertension. Pediatr Pulmonol 2017; 52:1461-1468. [PMID: 29058384 DOI: 10.1002/ppul.23843] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) cannot be recommended for the routine treatment of respiratory failure in premature neonates, but it has been suggested that the effectiveness of iNO therapy should be further studied in more select preterm infants, such as those with persistent pulmonary hypertension of the newborn (PPHN). OBJECTIVE To evaluate the frequency of PPHN in very preterm infants with severe respiratory distress syndrome (RDS), to assess the effectiveness of iNO in these patients, and to individuate possible predictive factors for the response to iNO in preterm infants with RDS. STUDY DESIGN We retrospectively studied infants <30 weeks of gestational age or birth weight <1250 g, who were affected by severe RDS and treated with iNO during the first week of life. Clinical characteristics of infants with or without echocardiographic diagnosis of PPHN were compared, as well as those of responder or no responder to iNO therapy. Effectiveness of iNO was evaluated by recording changes of MAP, FiO2 , SpO2 /FiO2 ratio, and oxygenation index (OI) before, and 3 ± 1, 6 ± 1, 12 ± 3, 24 ± 6, 48 ± 6, and 72 ± 12 h after beginning therapy. RESULTS We studied 42 (4.6%) infants, of whom 28 (67%) had PPHN and 14 (33%) did not. iNO therapy was associated with improved oxygenation in both the groups but it was quicker in the PPHN than in the no PPHN group. Multivariate analysis showed that FiO2 >0.65, diagnosis of PPHN, and birth weight >750 g independently predicts effectiveness of iNO in very preterm infants with RDS. CONCLUSION We found that PPHN is a frequent complication of severe RDS in very preterm infants and iNO therapy can improve their oxygenation earlier than in infants without PPHN. iNO therapy is not recommended for the routinely treatment of RDS in premature neonates but in cases of concurrent diagnosis of PPHN it should be considered carefully.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Jessica Cangemi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Venturella Vangi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
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19
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Chandrasekharan P, Kozielski R, Kumar VH, Rawat M, Manja V, Ma C, Lakshminrusimha S. Early Use of Inhaled Nitric Oxide in Preterm Infants: Is there a Rationale for Selective Approach? Am J Perinatol 2017; 34:428-440. [PMID: 27627792 PMCID: PMC5572579 DOI: 10.1055/s-0036-1592346] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background Inhaled nitric oxide (iNO) is being increasingly used in preterm infants < 34 weeks with hypoxemic respiratory failure (HRF) and/or pulmonary hypertension (PH). Objective To evaluate the risk factors, survival characteristics, and lung histopathology in preterm infants with PH/HRF. Methods Retrospective chart review was conducted to determine characteristics of 93 preterm infants treated with iNO in the first 28 days and compared with 930 matched controls. Factors associated with survival with preterm HRF and smooth muscle actin from nine autopsies were evaluated. Results Preterm neonates treated with iNO had a higher incidence of preterm prolonged rupture of membrane (pPROM ≥ 18 hours), oligohydramnios and delivered by C-section. In infants treated with iNO, antenatal steroids (odds ratio [OR],3.7; confidence interval [CI], 1.2-11.3; p = 0.02), pPROM (OR, 1.001; CI, 1.0-1.004; p = 0.3), and oxygenation response to iNO (OR, 3.7; CI, 1.08-13.1; p = 0.037) were associated with survival. Thirteen infants with all three characteristics had 100% (13/13) survival without severe intraventricular hemorrhage (IVH)/periventricular leukomalacia (PVL) compared with 48% survival (12/25, p = 0.004) and 16% severe IVH/PVL without any of these factors. Severity of HRF correlated with increased smooth muscle in pulmonary vasculature. Conclusion Preterm infants with HRF exposed to antenatal steroids and pPROM had improved oxygenation with iNO and survival without severe IVH/PVL. Precisely targeting this subset may be beneficial in future trials of iNO.
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Affiliation(s)
- Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, Women and Children’s Hospital of Buffalo, Buffalo, New York
| | - Rafal Kozielski
- Department of Pathology, Women and Children’s Hospital of Buffalo, Buffalo, New York
| | - Vasantha H.S. Kumar
- Division of Neonatology, Department of Pediatrics, Women and Children’s Hospital of Buffalo, Buffalo, New York
| | - Munmun Rawat
- Division of Neonatology, Department of Pediatrics, Women and Children’s Hospital of Buffalo, Buffalo, New York
| | - Veena Manja
- Department of Internal Medicine (Cardiology), University at Buffalo, Buffalo, New York,Department of Epidemiology, McMasters University, Hamilton, Ontario, Canada
| | - Changxing Ma
- Department of Biostatistics, School of Public Health, University at Buffalo, Buffalo, New York
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, Women and Children’s Hospital of Buffalo, Buffalo, New York
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20
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Abstract
BACKGROUND Inhaled nitric oxide (iNO) is effective in term infants with hypoxic respiratory failure. The pathophysiology of respiratory failure and the potential risks of iNO differ substantially in preterm infants, necessitating specific study in this population. OBJECTIVES To determine effects of treatment with inhaled nitric oxide (iNO) on death, bronchopulmonary dysplasia (BPD), intraventricular haemorrhage (IVH) or other serious brain injury and on adverse long-term neurodevelopmental outcomes in preterm newborn infants with hypoxic respiratory failure.Owing to substantial variation in study eligibility criteria, which decreases the utility of an overall analysis, we divided participants post hoc into three groups: (1) infants treated over the first three days of life because of defects in oxygenation, (2) preterm infants with evidence of pulmonary disease treated routinely with iNO and (3) infants treated later (after three days of age) because of elevated risk of BPD. SEARCH METHODS We used standard methods of the Cochrane Neonatal Review Group. We searched MEDLINE, Embase, Healthstar and the Cochrane Central Register of Controlled Trials in the Cochrane Library through January 2016. We also searched the abstracts of the Pediatric Academic Societies. SELECTION CRITERIA Eligible for inclusion were randomised and quasi-randomised studies in preterm infants with respiratory disease that compared effects of iNO gas versus control, with or without placebo. DATA COLLECTION AND ANALYSIS We used standard methods of the Cochrane Neonatal Review Group and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence. MAIN RESULTS We found 17 randomised controlled trials of iNO therapy in preterm infants. We grouped these trials post hoc into three categories on the basis of entry criteria: treatment during the first three days of life for impaired oxygenation, routine use in preterm babies along with respiratory support and later treatment for infants at increased risk for bronchopulmonary dysplasia (BPD). We performed no overall analyses.Eight trials providing early rescue treatment for infants on the basis of oxygenation criteria demonstrated no significant effect of iNO on mortality or BPD (typical risk ratio (RR) 0.94, 95% confidence interval (CI) 0.87 to 1.01; 958 infants). Four studies examining routine use of iNO in infants with pulmonary disease reported no significant reduction in death or BPD (typical RR 0.94, 95% CI 0.87 to 1.02; 1924 infants), although this small effect approached significance. Later treatment with iNO based on risk of BPD (three trials) revealed no significant benefit for this outcome in analyses of summary data (typical RR 0.92, 95% CI 0.85 to 1.01; 1075 infants).Investigators found no clear effect of iNO on the frequency of all grades of IVH nor severe IVH. Early rescue treatment was associated with a non-significant 20% increase in severe IVH.We found no effect on the incidence of neurodevelopmental impairment. AUTHORS' CONCLUSIONS iNO does not appear to be effective as rescue therapy for the very ill preterm infant. Early routine use of iNO in preterm infants with respiratory disease does not prevent serious brain injury or improve survival without BPD. Later use of iNO to prevent BPD could be effective, but current 95% confidence intervals include no effect; the effect size is likely small (RR 0.92) and requires further study.
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Affiliation(s)
- Keith J Barrington
- CHU Ste‐JustineDepartment of Pediatrics3175 Cote Ste CatherineMontrealQCCanadaH3T 1C5
| | - Neil Finer
- University of California San DiegoDepartment of Pediatrics200 W Arbor DrSan DiegoCaliforniaUSA92103‐8774
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21
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Yang Y, Feng Y, Zhou XG, Pan JJ, Zhou XY. Inhaled nitric oxide in preterm infants: An updated meta-analysis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:41. [PMID: 27904587 PMCID: PMC5122073 DOI: 10.4103/1735-1995.183990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 02/24/2016] [Accepted: 04/07/2016] [Indexed: 11/08/2022]
Abstract
Background: In the past several years, randomized controlled trials (RCTs) have indicated that inhaled nitric oxide (iNO) can potentially lower for both the incidence of bronchopulmonary dysplasia (BPD) and mortality in affected infants. Other research has, however, disagreed with these findings. Materials and Methods: We performed an updated meta analysis of all relevant RCTs to assess the benefits of iNO in preterm infants by searching PubMed, EMBASE, Cochrane databases, Wanfang, VIP, and CNKI databases for English and Chinese references. Results: Ultimately, 22 RCTs were incorporated. (1) Risk of BPD was significantly lower in preterm infants supplemented with iNO (relative risk [RR] = 0.88; P = 0.0007). There are no differences concerning pulmonary hemorrhage (PH) (RR = 0.94; P = 0.72). (2) Incidences of necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and severe intracranial hemorrhage (ICH) were compared. No significant difference was discovered concerning these risks (RR = 1.21, P = 0.08; RR = 1.01, P = 0.89; and RR = 0.99, P = 0.86). (3) In addition, no significant differences were found between experimental and control groups with respect to morality. (RR = 1.00, P = 0.98). Conclusion: Our meta analysis has shown a beneficial effect in BPD and morality. In addition, our meta analysis suggests that iNO therapy does not increase the risk of common complications, such as NEC and ROP, and that it may also have no adverse effect on bleeding tendency diseases (severe ICH and PH).
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Affiliation(s)
- Yang Yang
- Department of Neonates, Nanjing Children's Hospital of Nanjing Medical University, Nanjing 210008, P. R. China
| | - Yun Feng
- Department of Neonates, Nanjing Children's Hospital of Nanjing Medical University, Nanjing 210008, P. R. China
| | - Xiao-Guang Zhou
- Department of Neonates, Nanjing Children's Hospital of Nanjing Medical University, Nanjing 210008, P. R. China
| | - Jing-Jing Pan
- Department of Pediatrics, Jiangsu Provincial Hospital of Nanjing Medical University, Nanjing 210029, P. R. China
| | - Xiao-Yu Zhou
- Department of Neonates, Nanjing Children's Hospital of Nanjing Medical University, Nanjing 210008, P. R. China
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22
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Kim SB, Lee JH, Lee J, Shin SH, Eun HS, Lee SM, Sohn JA, Kim HS, Choi BM, Park MS, Park KI, Namgung R, Park MS. The efficacy and safety of Montelukast sodium in the prevention of bronchopulmonary dysplasia. KOREAN JOURNAL OF PEDIATRICS 2015; 58:347-53. [PMID: 26512261 PMCID: PMC4623454 DOI: 10.3345/kjp.2015.58.9.347] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/21/2014] [Accepted: 11/04/2014] [Indexed: 11/27/2022]
Abstract
Purpose The purpose of this study was to evaluate the efficacy and safety of Montelukast sodium in the prevention of bronchopulmonarydysplasia (BPD). Methods The Interventional study was designed as a multicenter, prospective, and randomized trial, with open labeled and parallel-experimental groups, 66 infants were enrolled and allocated to either the case group (n=30) or the control group (n=36) based on gestational age (GA). Infants in the case group were given Montelukast sodium (Singulair) based on their body weight (BW). Zero week was defined as the start time of the study. Results The incidence of moderate to severe BPD was not different between the groups (case group: 13 of 30 [43.3%] vs. control group: 19 of 36 [52.8%], P=0.912). Additionally, secondary outcomes such as ventilation index, mean airway pressure and resort to systemic steroids were not significantly different. There were no serious adverse drug reactions in either group, and furthermore the rate of occurrence of mild drug related-events were not significantly different (case group: 10 of 42 [23.8%] vs. control group: 6 of 48 (15.8%), P=0.414). Conclusion Montelukast was not effective in reducing moderate or severe BPD. There were no significant adverse drug events associated with Montelukast treatment.
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Affiliation(s)
- Sang Bum Kim
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Jang Hoon Lee
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Juyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Sun Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Jin A Sohn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University Ansan Hospital, Ansan, Korea
| | - Min Soo Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kook In Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Sung Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
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Ellsworth MA, Harris MN, Carey WA, Spitzer AR, Clark RH. Off-label use of inhaled nitric oxide after release of NIH consensus statement. Pediatrics 2015; 135:643-8. [PMID: 25755237 DOI: 10.1542/peds.2014-3290] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) therapy is an off-label medication in infants <34 weeks' gestational age. In 2011, the National Institutes of Health released a statement discouraging routine iNO use in premature infants. The objective of this study was to describe utilization patterns of iNO in American NICUs in the years surrounding the release of the National Institutes of Health statement. We hypothesized that iNO prescription rates in premature infants have remained unchanged since 2011. METHODS The Pediatrix Medical Group Clinical Data Warehouse was queried for the years 2009-2013 to describe first exposure iNO use among all admitted neonates stratified by gestational age. RESULTS Between 2009 and 2013, the rate of iNO utilization in 23- to 29-week neonates increased from 5.03% to 6.19%, a relative increase of 23% (confidence interval: 8%-40%; P = .003). Of all neonates who received iNO therapy in 2013, nearly half were <34 weeks' gestation, with these infants accounting for more than half of all first exposure iNO days each year of the study period. CONCLUSIONS The rates of off-label iNO use in preterm infants continue to rise despite evidence revealing no clear benefit in this population. This pattern of iNO prescription is not benign and comes with economic consequences.
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Affiliation(s)
- Marc A Ellsworth
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Malinda N Harris
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Alan R Spitzer
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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Our paper 20 years later: Inhaled nitric oxide for the acute respiratory distress syndrome—discovery, current understanding, and focussed targets of future applications. Intensive Care Med 2014; 40:1649-58. [DOI: 10.1007/s00134-014-3458-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/18/2014] [Indexed: 11/26/2022]
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Abstract
Nitric oxide, an important signaling molecule with multiple regulatory effects throughout the body, is an important tool for the treatment of full-term and late-preterm infants with persistent pulmonary hypertension of the newborn and hypoxemic respiratory failure. Several randomized controlled trials have evaluated its role in the management of preterm infants ≤ 34 weeks' gestational age with varying results. The purpose of this clinical report is to summarize the existing evidence for the use of inhaled nitric oxide in preterm infants and provide guidance regarding its use in this population.
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Qi Y, Jiang Q, Chen C, Cao Y, Qian L. Circulating endothelial progenitor cells decrease in infants with bronchopulmonary dysplasia and increase after inhaled nitric oxide. PLoS One 2013; 8:e79060. [PMID: 24244420 PMCID: PMC3823930 DOI: 10.1371/journal.pone.0079060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 09/24/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Impairment of endothelial progenitor cells (EPCs) has been shown to contribute to the development of bronchopulmonary dysplasia (BPD). In the current study, the relationship between EPC changes of after birth and the development of BPD was investigated, and the effects of inhaled nitric oxide (iNO) on EPCs were evaluated. METHODS Sixty infants with a gestational age of less than 32 weeks and a birth weight of less than 1500 g were studied. NO was administered to infants who were receiving mechanical ventilation or CPAP for at least 2 days between the ages of 7 and 21 days. EPC level was determined by flow cytometry at birth, 7, 21 and 28 days of age and 36 weeks' postmenstrual age (PMA), before and after the iNO treatment. Plasma concentrations of vascular endothelial growth factor (VEGF), stromal cell-derived factor-1 and granulocyte-macrophage colony-stimulating factor were determined via immunochemical assay. RESULTS Twenty-five neonates developed BPD, 35 neonates survived and did not develop BPD. EPC level was decreased on day 7 and 21 in infants who later developed BPD compared with infants that did not develop BPD. From birth to 21 days of age, BPD infants had a persistently lower VEGF concentration compared with non-BPD infants. No difference was found between the two groups at day 28 or 36 weeks PMA. In infants that later developed BPD, iNO raised the KDR(+)CD133(+) and CD34(+)KDR(+)CD133(+) EPC numbers along with increasing the level of plasma VEGF. CONCLUSION EPC level was reduced at 7 days of age in infants with BPD, and iNO increased the EPC number along with increasing the level of VEGF. Further studies are needed to elucidate the mechanism leading to the decrease of EPCs in infants with BPD and to investigate the role of iNO treatment in the prevention of BPD.
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Affiliation(s)
- Yuanyuan Qi
- Departments of Pediatrics, Children’s Hospital of Fudan University, Shanghai, P. R. China
| | - Qian Jiang
- Departments of Pediatrics, Children’s Hospital of Fudan University, Shanghai, P. R. China
| | - Chao Chen
- Departments of Pediatrics, Children’s Hospital of Fudan University, Shanghai, P. R. China
| | - Yun Cao
- Departments of Pediatrics, Children’s Hospital of Fudan University, Shanghai, P. R. China
| | - Liling Qian
- Departments of Pediatrics, Children’s Hospital of Fudan University, Shanghai, P. R. China
- * E-mail:
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Dani C, Pratesi S. Nitric oxide for the treatment of preterm infants with respiratory distress syndrome. Expert Opin Pharmacother 2012. [PMID: 23194109 DOI: 10.1517/14656566.2013.746662] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Inhaled Nitric oxide (iNO) has been proposed as effective treatment for improving oxygenation in preterm infants with respiratory distress syndrome (RDS), and for preventing the development of bronchopulmonary dysplasia (BPD). AREAS COVERED This drug evaluation mainly reviews the results of clinical studies on the effects of iNO in preterm infants with RDS which have provided contradictory results probably due to their different designs. Three recent meta-analyses of these studies have concluded that iNO therapy is not effective in decreasing the risk of death and BPD and cannot be recommended as routine treatment. The same meta-analyses suggest that some strategy of iNO treatment and some subgroups of patients, such as infants with persistent pulmonary hypertension of the newborn (PPHN), should be further studied. EXPERT OPINION At present, the available evidence does not support the use of iNO in preterm infants with RDS, and iNO therapy cannot be recommended for the routine treatment of respiratory failure in premature neonates. In the future, further studies in selected populations using adequate doses and investigating the effectiveness of other drugs, such as sildenafil, might affect the use and diffusion of iNO.
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Affiliation(s)
- Carlo Dani
- Careggi University Hospital of Florence, Department of Surgical and Medical Critical Care, Section of Neonatology, Viale Morgagni, 85, 50134 Florence, Italy.
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Raffay TM, Martin RJ, Reynolds JD. Can nitric oxide-based therapy prevent bronchopulmonary dysplasia? Clin Perinatol 2012; 39:613-38. [PMID: 22954273 PMCID: PMC3437658 DOI: 10.1016/j.clp.2012.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A growing understanding of endogenous nitric oxide (NO) biology is helping to explain how and when exogenous NO may confer benefit or harm; this knowledge is also helping to identify new better-targeted NO-based therapies. In this review, results of the bronchopulmonary dysplasia clinical trials that used inhaled NO in the preterm population are placed in context, the biologic basis for novel NO therapeutics is considered, and possible future directions for NO-focused clinical and basic research in developmental lung disease are identified.
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Affiliation(s)
- Thomas M. Raffay
- Division of Neonatology, Department of Pediatrics Rainbow Babies & Children’s Hospital, Case Medical Center/University Hospitals, Cleveland, Ohio
| | - Richard J. Martin
- Division of Neonatology, Department of Pediatrics Rainbow Babies & Children’s Hospital, Case Medical Center/University Hospitals, Cleveland, Ohio
| | - James D. Reynolds
- Department of Anesthesia and Perioperative Medicine, Case Medical Center/University Hospitals, Cleveland, Ohio
,Institute for Transformative Molecular Medicine, Case Medical Center/University Hospitals, Cleveland, Ohio
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Askie LM, Ballard RA, Cutter GR, Dani C, Elbourne D, Field D, Hascoet JM, Hibbs AM, Kinsella JP, Mercier JC, Rich W, Schreiber MD, Wongsiridej P(S, Subhedar NV, Van Meurs KP, Voysey M, Barrington K, Ehrenkranz RA, Finer NN. Inhaled nitric oxide in preterm infants: an individual-patient data meta-analysis of randomized trials. Pediatrics 2011; 128:729-39. [PMID: 21930540 PMCID: PMC3387905 DOI: 10.1542/peds.2010-2725] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is an effective therapy for pulmonary hypertension and hypoxic respiratory failure in term infants. Fourteen randomized controlled trials (n = 3430 infants) have been conducted on preterm infants at risk for chronic lung disease (CLD). The study results seem contradictory. DESIGN/METHODS Individual-patient data meta-analysis included randomized controlled trials of preterm infants (<37 weeks' gestation). Outcomes were adjusted for trial differences and correlation between siblings. RESULTS Data from 3298 infants in 12 trials (96%) were analyzed. There was no statistically significant effect of iNO on death or CLD (59% vs 61%: relative risk [RR]: 0.96 [95% confidence interval (CI): 0.92-1.01]; P = .11) or severe neurologic events on imaging (25% vs 23%: RR: 1.12 [95% CI: 0.98-1.28]; P = .09). There were no statistically significant differences in iNO effect according to any of the patient-level characteristics tested. In trials that used a starting iNO dose of >5 vs ≤ 5 ppm there was evidence of improved outcome (interaction P = .02); however, these differences were not observed at other levels of exposure to iNO. This result was driven primarily by 1 trial, which also differed according to overall dose, duration, timing, and indication for treatment; a significant reduction in death or CLD (RR: 0.85 [95% CI: 0.74-0.98]) was found. CONCLUSIONS Routine use of iNO for treatment of respiratory failure in preterm infants cannot be recommended. The use of a higher starting dose might be associated with improved outcome, but because there were differences in the designs of these trials, it requires further examination.
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Affiliation(s)
- Lisa M. Askie
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Roberta A. Ballard
- Department of Pediatrics, University of California at San Francisco, School of Medicine, San Francisco, California
| | - Gary R. Cutter
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlo Dani
- Section of Neonatology, Department of Surgical and Medical Critical Care, Careggi University Hospital of Florence, Florence, Italy
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Field
- Department of Health Science, University of Leicester, Leicester, United Kingdom
| | | | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - John P. Kinsella
- Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Jean-Christophe Mercier
- Department of Pediatric Emergency Medicine, Hôpital Robert Debré, Université Paris-7 Denis Diderot, Paris, France
| | - Wade Rich
- Division of Neonatology, University of California, San Diego, California
| | | | - Pimol (Srisuparp) Wongsiridej
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nim V. Subhedar
- Neonatal Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Merryn Voysey
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Keith Barrington
- Division of Neonatology, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada; and
| | - Richard A. Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Neil N. Finer
- Division of Neonatology, University of California, San Diego, California
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Donohue PK, Gilmore MM, Cristofalo E, Wilson RF, Weiner JZ, Lau BD, Robinson KA, Allen MC. Inhaled nitric oxide in preterm infants: a systematic review. Pediatrics 2011; 127:e414-22. [PMID: 21220391 DOI: 10.1542/peds.2010-3428] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Studies of the efficacy of inhaled nitric oxide (iNO) to prevent or treat respiratory failure in preterm infants have had variable and contradictory findings. OBJECTIVES To systematically review the evidence on the use of iNO in infants born at ≤ 34 weeks' gestation who receive respiratory support. METHODS Medline, Embase, the Cochrane Central Register of Controlled Studies, PsycInfo, ClinicalTrials.gov, and proceedings of the 2009 and 2010 Pediatric Academic Societies meetings were searched in June 2010. Additional studies from reference lists of eligible articles, relevant reviews, and technical experts were considered. Two investigators independently screened search results and abstracted data from eligible articles. We focus here on mortality, bronchopulmonary dysplasia (BPD), the composite outcome of death or BPD, and neurodevelopmental impairment. RESULTS Fourteen randomized controlled trials, 7 follow-up studies, and 1 observational study were eligible for inclusion. Mortality rates in the NICU did not differ for infants treated with iNO compared with controls (risk ratio [RR]: 0.97 [95% confidence interval (CI): 0.82-1.15]). BPD at 36 weeks for iNO and control groups also did not differ for survivors (RR: 0.93 [95% CI: 0.86-1.003]). A small difference was found in favor of iNO in the composite outcome of death or BPD (RR: 0.93 [95% CI: 0.87-0.99]). There was no evidence to suggest a difference in the incidence of cerebral palsy (RR: 1.36 [95% CI: 0.88-2.10]), neurodevelopmental impairment (RR: 0.91 [95% CI: 0.77-1.12]), or cognitive impairment (RR: 0.72 [95% CI: 0.35-1.45]). CONCLUSIONS There was a 7% reduction in the risk of the composite outcome of death or BPD at 36 weeks for infants treated with iNO compared with controls but no reduction in death alone or BPD. There is currently no evidence to support the use of iNO in preterm infants with respiratory failure outside the context of rigorously conducted randomized clinical trials.
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Affiliation(s)
- Pamela K Donohue
- Department of Pediatrics, Johns Hopkins School of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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Abstract
BACKGROUND Inhaled nitric oxide (iNO) is effective in term infants with hypoxic respiratory failure. The pathophysiology of respiratory failure and the potential risks of iNO differ substantially in preterm infants, necessitating study in this population. OBJECTIVES To determine the effect of treatment with iNO on death, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and neurodevelopmental disability in preterm newborn infants with respiratory disease. SEARCH STRATEGY Standard methods of the Cochrane Neonatal Review Group were used. MEDLINE, EMBASE, Healthstar and the Cochrane Central Register of Controlled Trials (The Cochrane Library) were searched covering the years from 1985 to 2010. In addition, the abstracts of the Pediatric Academic Societies were also searched. SELECTION CRITERIA Randomized and quasi-randomized studies in preterm infants with respiratory disease that compared the effects of iNO gas to control, with or without placebo were eligible. DATA COLLECTION AND ANALYSIS Standard methods of the Cochrane Neonatal Review Group were used. MAIN RESULTS Fourteen randomized controlled trials of inhaled nitric oxide therapy in preterm infants were found. The trials have been grouped post hoc into three categories depending on entry criteria; entry in the first three days of life based on oxygenation criteria, routine use in preterm babies with pulmonary disease, and later enrolment based on an increased risk of BPD. No overall analyses were performed.Nine trials of early rescue treatment of infants based on oxygenation criteria demonstrated no significant effect of iNO on mortality or BPD. Three studies with routine use of iNO in infants with pulmonary disease also demonstrated no significant reduction in death or BPD [typical RR 0.93 (95% CI 0.86 to 1.01)] although this small effect approached significance. Later treatment with iNO based on the risk of BPD (two trials) demonstrated no significant benefit for this outcome in analyses which are possible using summary data.There is no clear effect of iNO on the frequency of all grades of IVH or of severe IVH. Early rescue treatment was associated with a non-significant 20% increase in severe IVH.No effect on the incidence of neurodevelopmental impairment was found. AUTHORS' CONCLUSIONS iNO as rescue therapy for the very ill preterm infant does not appear to be effective. Early routine use of iNO in preterm infants with respiratory disease does not affect serious brain injury or improve survival without BPD. Later use of iNO to prevent BPD might be effective, but requires further study.
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Affiliation(s)
- Keith J Barrington
- Department of Pediatrics, CHU Ste-Justine, 3175 Cote Ste Catherine, Montreal, Quebec, Canada, H3T 1C5
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Dewhurst C, Ibrahim H, Göthberg S, Jónsson B, Subhedar N. Use of inhaled nitric oxide in the new born period: results from the European Inhaled Nitric Oxide Registry. Acta Paediatr 2010; 99:854-60. [PMID: 20219040 DOI: 10.1111/j.1651-2227.2010.01722.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this study was to present data relating to the use of inhaled nitric oxide (iNO) in newborn infants included in the European Inhaled Nitric Oxide Registry. METHODS Demographic, clinical and therapeutic data from seven European centres are reported. Univariate analyses were performed to identify factors associated with acute response to iNO and survival without extra corporeal membrane oxygenation (ECMO). RESULTS A total of 112 newborn infants received iNO, with 40% being less than 34 weeks gestational age. The commonest indication for iNO was secondary pulmonary hypertension. Acute response to iNO was more common in infants with a higher oxygenation index (median OI 32.7 vs 22.6, p = 0.040), although acute response did not predict survival without ECMO. Infants who survived without ECMO had a lower OI prior to therapy (median OI 24 vs 43, p = 0.009), were commenced on a higher starting dose (median dose 20 ppm vs 10 ppm p = 0.013) and received a lower maintenance dose (median dose 10 vs 17 ppm, p = 0.027) than those who died or received ECMO. CONCLUSION Collating and reporting data about iNO therapy in neonates across a number of European centres using a web-based system is feasible. These data may be used to monitor the clinical use of iNO, identify adverse effects, generate research hypotheses and promote high standards in the clinical use of iNO.
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Joriot-Chekaf S, Sfeir R, Riou Y, Gressens P, Vallée L, Bordet R, Vamecq J. Evaluation of inhaled .NO in a model of rat neonate brain injury caused by hypoxia-ischaemia. Injury 2010; 41:517-21. [PMID: 19539281 DOI: 10.1016/j.injury.2009.03.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Revised: 03/11/2009] [Accepted: 03/30/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Inhaled NO (INO), at 5-40 parts per million (ppm) in the air, is indicated for treating neonatal hypoxic respiratory failure. Whether these doses of INO are protective or toxic towards brain was here evaluated in laboratory animals. METHODS In rat neonates (postnatal day 7), a brain injury based on permanent right carotid artery occlusion plus transient (90 min) respiratory hypoxia (8% O(2)) was challenged by two NO dosages (10 and 40 ppm) given either before, during or after transient hypoxia. Three weeks later, animal brains were studied for the loss of cerebral matter (infarct or atrophy). RESULTS In right hemispheres, significant increases (26-39%) in lesion sizes were induced by 40 and not 10 ppm INO, whatever the inhalation period. The two doses reduced significantly the left hemisphere volume only when NO was inhaled at the re-oxygenation period. DISCUSSION Our results suggest that high doses of INO, brain damaging events and inhalation at re-oxygenation might affect brain integrity when these conditions are cumulated. However, the clinical relevance of this (infarct or atrophy) and previously described (haematomas) brain toxicity associated with INO remains to be clarified in the human neonates, for instance through non-invasive cerebral imagery follow-up of patients given INO.
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Affiliation(s)
- Sylvie Joriot-Chekaf
- Inserm Univ 045131 & EA 1046, IMPRT-IFR114, Pharmacology, Faculty of Medicine, University of Lille North of France, 59045 Lille, France
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Askie LM, Ballard RA, Cutter G, Dani C, Elbourne D, Field D, Hascoet JM, Hibbs AM, Kinsella JP, Mercier JC, Rich W, Schreiber MD, Srisuparp P, Subhedar NV, Van Meurs KP, Voysey M, Barrington K, Ehrenkranz RA, Finer N. Inhaled nitric oxide in preterm infants: a systematic review and individual patient data meta-analysis. BMC Pediatr 2010; 10:15. [PMID: 20331899 PMCID: PMC2860486 DOI: 10.1186/1471-2431-10-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 03/23/2010] [Indexed: 11/23/2022] Open
Abstract
Background Preterm infants requiring assisted ventilation are at significant risk of both pulmonary and cerebral injury. Inhaled Nitric Oxide, an effective therapy for pulmonary hypertension and hypoxic respiratory failure in the full term infant, has also been studied in preterm infants. The most recent Cochrane review of preterm infants includes 11 studies and 3,370 participants. The results show a statistically significant reduction in the combined outcome of death or chronic lung disease (CLD) in two studies with routine use of iNO in intubated preterm infants. However, uncertainty remains as a larger study (Kinsella 2006) showed no significant benefit for iNO for this combined outcome. Also, trials that included very ill infants do not demonstrate significant benefit. One trial of iNO treatment at a later postnatal age reported a decrease in the incidence of CLD. The aim of this individual patient meta-analysis is to confirm or refute these potentially conflicting results and to determine the extent to which patient or treatment characteristics may explain the results and/or may predict benefit from inhaled Nitric Oxide in preterm infants. Methods/Design The Meta-Analysis of Preterm Patients on inhaled Nitric Oxide (MAPPiNO) Collaboration will perform an individual patient data meta-analysis to answer these important clinical questions. Studies will be included if preterm infants receiving assisted ventilation are randomized to receive inhaled Nitric Oxide or to a control group. The individual patient data provided by the Collaborators will be analyzed on an intention-to-treat basis where possible. Binary outcomes will be analyzed using log-binomial regression models and continuous outcomes will be analyzed using linear fixed effects models. Adjustments for trial differences will be made by including the trial variable in the model specification. Discussion Thirteen (13) trials, with a total of 3567 infants are eligible for inclusion in the MAPPiNO systematic review. To date 11 trials (n = 3298, 92% of available patients) have agreed to participate. Funding was successfully granted from Ikaria Inc as an unrestricted grant. A collaborative group was formed in 2006 with data collection commencing in 2007. It is anticipated that data analysis will commence in late 2009 with results being publicly available in 2010.
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Affiliation(s)
- Lisa M Askie
- NHMRC Clinical Trials Centre, University of Sydney, Australia.
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35
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Abstract
Inhaled nitric oxide (iNO) has been used to treat both term and preterm infants with respiratory failure. Term infants with persistent pulmonary hypertension, either as a primary cause or secondary to other disease processes, respond to iNO with improvement in oxygenation indices and a decreased need for extracorporeal membrane oxygenation. Infants with congenital diaphragmatic hernia are the exception to this finding, with little clinical benefit observed with iNO treatment. Although respiratory disease in preterm infants has a component of increased pulmonary vascular resistance, little benefit of iNO administration has been observed in premature infants either early in their course or later as a treatment to prevent the evolution of chronic lung disease.
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Affiliation(s)
- R F Soll
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA.
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36
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Abstract
The evidence for the benefits of inhaled nitric oxide (iNO) on gas exchange, cytokine-induced lung inflammation, and vascular dysfunction has been demonstrated by several animal and human studies. The use of iNO in extremely low birth weight neonates for the prevention of adverse outcomes like chronic lung disease and neurologic injury has been investigated, but the findings remain inconclusive. This review briefly outlines the biologic rationale for the use of iNO in preterm neonates and the results on the outcome measures of bronchopulmonary dysplasia and brain injury from the recent clinical trials. This article focuses on the potential toxicities, persistent controversies, and unanswered questions regarding the use of this treatment modality in this patient population at high risk for adverse outcomes.
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Affiliation(s)
- Nandini Arul
- Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI, USA.
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37
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Inhaled nitric oxide to prevent bronchopulmonary dysplasia in preterm neonates. Semin Fetal Neonatal Med 2009; 14:28-34. [PMID: 18986855 DOI: 10.1016/j.siny.2008.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Bronchopulmonary dysplasia is a chronic lung disease that affects premature infants and contributes to their morbidity and mortality. With the advent of prenatal steroids and postnatal exogenous surfactant and less aggressive respiratory support, premature infants can develop chronic oxygen dependency without even acute respiratory distress. This 'new bronchopulmonary dysplasia' could be the result of impaired postnatal growth. Several experimental studies have suggested a possible role of the vascular endothelial growth factor/nitric oxide (VEGF/NO) pathway in restoring pulmonary angiogenesis and enhancing distal lung growth. The results of the clinical studies are, however, inconclusive, and it is currently unclear which subsets of premature infants might benefit from inhaled nitric oxide. Besides, severe intracranial haemorrhage and/or cystic periventricular leucomalacia may affect the most immature babies, many of whom are spared from severe initial respiratory disease. Recently, inhaled nitric oxide was shown to significantly decrease the incidence of these neurological events, and to improve the long-term outcome in a few clinical trials. At times neuroprotective, at times neurotoxic, nitric oxide is capable of divergent effects depending upon the extent of cerebral damage, the redox state of the cell, and the experimental model used. Recently, our group found that inhaled nitric oxide had remote effects including angiogenesis and maturation on the developing brain in rodent pups. Thus, we await the results of the recently completed randomised clinical trial of inhaled nitric oxide to prevent bronchopulmonary dysplasia (the European Nitric Oxide or 'EUNO' trial) where, besides the primary endpoint of chronic oxygen dependency reduction at 36 weeks' postconceptional age, long-term lung and brain will be followed-up until 7 years of age.
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38
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Hoo AF, Beardsmore CS, Castle RA, Ranganathan SC, Tomlin K, Field D, Elbourne D, Stocks J. Respiratory function during infancy in survivors of the INNOVO trial. Pediatr Pulmonol 2009; 44:155-61. [PMID: 19148936 DOI: 10.1002/ppul.20967] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
RATIONALE Despite encouraging reports suggesting that inhaled nitric oxide (iNO) appear to improve outcome in hypoxemic term and near term infants by improving oxygenation and reducing need for ECMO, the long-term benefits of iNO remain unclear. This study aimed to compare lung function at approximately 1 year in infants who were and were not randomly allocated to iNO as part of their neonatal management for severe respiratory failure at birth. Furthermore, results were compared to lung function of healthy infants. METHODS Maximal expiratory flow at functional residual capacity (V'maxFRC) was measured at approximately 1 year of age (corrected for any prematurity) in survivors of the INNOVO trial. Results were expressed as Z-scores, adjusted for sex and body size, based on data from healthy controls using identical techniques. RESULTS Technically satisfactory results were obtained in 30 infants (53% < 34 weeks gestation), 19 of whom were randomized to receive iNO V'maxFRC. Z-score was significantly reduced in infants with prior respiratory failure, whether or not they had been allocated to iNO (mean (SD) Z-score: -2.0 (1.2) and -2.6 (1.1), respectively, 95% CI difference; iNO vs. no iNO: -0.3; 1.6, P = 0.2). There was significant respiratory morbidity in both groups during the first year of life. CONCLUSIONS These results suggest that airway function remains reduced at 1 year of age following severe respiratory failure at birth, whether or not iNO is administered.
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Affiliation(s)
- Ah-Fong Hoo
- Portex Anaesthesia, Intensive Therapy and Respiratory Medicine Unit, UCL Institute of Child Health, London, UK.
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Miller SS, Rhine WD. Inhaled nitric oxide in the treatment of preterm infants. Early Hum Dev 2008; 84:703-7. [PMID: 18930359 DOI: 10.1016/j.earlhumdev.2008.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 08/25/2008] [Indexed: 10/21/2022]
Abstract
Inhaled nitric oxide (iNO) has been used successfully in select term and near-term infants with respiratory failure. The use of iNO in the premature infant population, however, remains controversial. This article will review some of the current literature regarding the use of iNO in premature infants and discuss current recommendations and future research directions.
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Affiliation(s)
- Stephanie S Miller
- Department of Pediatrics, Lucile Packard Children's Hospital at Stanford University, Stanford, CA, United States.
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Hoskote AU, Castle RA, Hoo AF, Lum S, Ranganathan SC, Mok QQ, Stocks J. Airway function in infants treated with inhaled nitric oxide for persistent pulmonary hypertension. Pediatr Pulmonol 2008; 43:224-35. [PMID: 18203182 DOI: 10.1002/ppul.20733] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
RATIONALE Inhaled nitric oxide (iNO), used for treatment of persistent pulmonary hypertension of newborn (PPHN), is an oxygen free radical with potential for lung injury. Deferring ECMO with iNO in these neonates could potentially have long-term detrimental effects on lung function. We studied respiratory morbidity (defined as occurrence of respiratory infections requiring treatment, episodes of wheezing, and/or need for ongoing medications following discharge) and airway function at 1 year postnatal age in term neonates treated with iNO but not ECMO for PPHN, and compared data from similar infants recruited to the UK ECMO Trial randomized to receive ECMO or conventional management (CM). METHODS Maximal expiratory flow at FRC (V(') (maxFRC)) was measured in infants treated with iNO for PPHN (oxygenation index >or=25) at birth. RESULTS V(') (maxFRC) was measured in 23 infants and expressed as z-scores, to adjust for sex and body size and compared to data from 71 (46 ECMO, 25 CM) infants studied at a similar age in the ECMO Trial. Respiratory morbidity was low in iNO group. V(') (maxFRC) z-score was lower than predicted in all groups (P < 0.001), with no significant difference between those treated with iNO [mean (SD) z-score: -1.65 (1.2)] and those treated with ECMO [-1.59 (1.2)] or CM [-2.1(1.0)]. Within iNO, ECMO and CM groups; 26%, 37% and 56%, respectively, had V(') (maxFRC) z-scores below normal. CONCLUSIONS Respiratory outcome at 1 year in iNO treated neonates with moderately severe PPHN is encouraging, with no apparent increase in respiratory morbidity when compared to the general population. Sub-clinical reductions in airway function are evident at 1 year, suggesting that continuing efforts to minimize lung injury in the neonatal period are warranted to maximize lung health in later life.
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Affiliation(s)
- Aparna U Hoskote
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Dani C, Bertini G. Inhaled nitric oxide for the treatment of preterm infants with respiratory distress syndrome. Neonatology 2008; 94:87-95. [PMID: 18332638 DOI: 10.1159/000119719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Many authors have hypothesized that inhaled nitric oxide (iNO) might acutely improve oxygenation in preterm neonates with infant respiratory distress syndrome (iRDS) and decrease the risk of bronchopulmonary dysplasia. The studies on the effects of iNO in preterm infants with iRDS have given contradictory results. We report their main methodological characteristics and the observed effects of iNO in preterm infants. Moreover, we discuss the infants' age at the beginning of the study, the dose and duration of iNO therapy, its potential effect on neurodevelopment, its relationship with surfactant properties, and the need to identify patients who are likely to respond to this therapy. We advise caution against the widespread use of iNO in preterm infants with iRDS. At present, it appears to be premature to have specific recommendations regarding the indications for iNO therapy in this group of patients. The conclusion of current trials and the follow-up studies of recently completed trials will give further data to guide neonatologists' decisions, and until then it is likely that clinicians will continue to make case-by-case decisions for the treatment of iNO in preterm infants with hypoxia that is unresponsive to other therapies. However, this decision should always be discussed with the parents.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Department of Surgical and Medical Critical Care, Careggi University Hospital, University of Florence School of Medicine, Florence, Italy.
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Abstract
OBJECTIVE Our goal was to determine whether, for preterm newborn infants with respiratory disease, inhaled nitric oxide reduced the rates of death, bronchopulmonary dysplasia, intracranial hemorrhage, or neurodevelopmental disability. METHODS We searched Medline, Embase, Healthstar, and the Cochrane Central Register of Controlled Trials using the search terms "nitric oxide," "clinical trial," and "newborn" and covering 1985-2006. We also searched abstracts of the Pediatric Academic Societies. RESULTS Eleven randomized, controlled trials of inhaled nitric oxide therapy for preterm infants were found. The trials were grouped into 3 categories according to the entry criteria, that is, entry in the first 3 days of life on the basis of oxygenation criteria (early rescue), enrollment after 3 days on the basis of elevated risk of bronchopulmonary dysplasia, and routine use for intubated preterm infants. Early rescue treatment based on oxygenation criteria did not seem to affect mortality or bronchopulmonary dysplasia rates. Routine use for intubated preterm infants showed a barely significant reduction in the incidence of the combined outcome of death or bronchopulmonary dysplasia (relative risk [RR]: 0.91 [95% confidence limits (CLs): 0.84, 0.99]). Later treatment based on the risk of bronchopulmonary dysplasia showed no significant effect on this outcome. Early rescue treatment showed a trend toward increased incidence of severe intracranial hemorrhage, whereas routine use for intubated preterm infants seemed to show a reduction in the incidence of either severe intracranial hemorrhage or periventricular leukomalacia (RR: 0.70 [95% CLs: 0.53, 0.91]). CONCLUSIONS Inhaled nitric oxide as rescue therapy for very ill preterm infants undergoing ventilation does not seem to be effective and may increase severe intracranial hemorrhage. Later use of inhaled nitric oxide to prevent bronchopulmonary dysplasia does not seem to be effective. Early routine use of inhaled nitric oxide for mildly sick, preterm infants seems to decrease the risk of serious brain injury and may improve rates of survival without bronchopulmonary dysplasia.
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Affiliation(s)
- Keith J Barrington
- Department of Pediatrics, McGill University, Royal Victoria Hospital, 687 Pine Ave W, Montreal, Quebec, Canada H3A 1A1.
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Abstract
There is insufficient evidence to support the routine use of inhaled nitric oxide in preterms with respiratory failure
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Affiliation(s)
- Nimish Subhedar
- Nimish Subhedar, Neonatal Unit, Liverpool Women's NHS Foundation Trust, Liverpool L8 7SS, UK
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Abstract
This review provides the readers with background information on the state of the art and science of inhaled nitric oxide (iNO) as therapy for prevention or amelioration of bronchopulmonary dysplasia (BPD) in preterm infants. The goal is to review and critique relevant published information. A total of six clinical trials, all placebo-controlled, four out of six blinded, four out of six multi-centered with a predetermined outcome of reduction in death or BPD, have been reported in full text. These definitive studies have included a total of > 2100 preterm, mostly very preterm, infants. Their designs were informed by results of earlier non-definitive studies which cumulatively enrolled > 350 preterm patients. This very substantial experience provides a firm framework for asserting that iNO will be useful in this population of patients. The use of iNO can reduce the occurrence of BPD and possibly the severity of the disorder. Optimal time of initiation, dosing (both initial dose, duration of treatment and possibly the route of administration) and most importantly, optimal patient subset selection, are not determined. Any clear adverse neurological finding in iNO-treated infants will of course limit or halt the use of this promising therapy.
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Affiliation(s)
- William E Truog
- University of Missouri-Kansas City School of Medicine, Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri 64108, USA.
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Abstract
BACKGROUND Inhaled nitric oxide (iNO) has been proven to be effective in term infants with hypoxic respiratory failure. The pathophysiology of respiratory failure, and the potential risks, differ substantially in preterm infants. Therefore, analysis of the efficacy and toxicities of iNO in infants born before 35 weeks is necessary. OBJECTIVES To determine the effect of treatment with iNO on the rates of death, bronchopulmonary dysplasia (BPD), intraventricular haemorrhage (IVH), or neurodevelopmental disability in preterm newborn infants (< 35 weeks gestation) with respiratory disease. SEARCH STRATEGY Standard methods of the Cochrane Neonatal Review Group were used. MEDLINE, EMBASE, Healthstar and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) were searched, using the following keywords: nitric oxide, clinical trial, and newborn covering the years from 1985 to 2006. In addition, the abstracts of the Pediatric Academic Societies were also searched. SELECTION CRITERIA Randomised and quasi-randomised studies in preterm infants with respiratory disease that compared the effects of administration of iNO gas compared to control, with or without placebo are included in this review. DATA COLLECTION AND ANALYSIS Data regarding clinical outcomes including death, BPD (defined as oxygen dependence at 36 weeks postmenstrual age), IVH, periventricular leukomalacia (PVL), long term neurodevelopmental outcome and short term effects on oxygenation were excerpted from the trial reports by the investigators. Standard methods of the Cochrane Neonatal Review Group were used. Two investigators extracted, assessed and coded separately all data for each study. Any disagreement was resolved by discussion. MAIN RESULTS Eleven randomised controlled trials of inhaled nitric oxide therapy in preterm infants were found. The trials have been grouped post hoc into three categories depending on the entry criteria; entry in the first three days of life based on oxygenation criteria (Kinsella 1999; Hascoet 2004; INNOVO 2005; Van Meurs 2004; Mercier 1999; Dani 2006), routine use in intubated preterm babies (Schreiber 2003; Kinsella 2006) and later enrolment based on an increased risk of BPD (Subhedar 1997; Ballard 2006). The usefulness of the overall analyses was considered limited by the differing characteristics of the studies, and only subgroup analyses were performed. Trials of early rescue treatment of infants based on oxygenation criteria demonstrated no significant effect of iNO on mortality or BPD. The subgroup of studies with routine use of iNO in intubated preterm infants demonstrated a marginally significant reduction in the combined outcome of death or BPD [typical RR 0.91 (95% CI 0.84, 0.99); typical RD -0.06 (95% CI -0.12, -0.01)]. Later treatment with iNO based on the risk of BPD demonstrated no significant benefit for this outcome in our analysis. Studies of early rescue treatment with iNO demonstrated a trend toward increased risk of severe IVH, whereas the subgroup of studies with routine use in intubated preterm infants seems to show a reduction in the risk of having either a severe IVH or PVL [typical RR 0.70 (95% CI 0.53, 0.91); typical RD -0.07 (95% CI -0.12, -0.02)]. Later iNO treatment of infants at risk of BPD is given after the major risk period for IVH, and does not appear to lead to progression of old lesions. Two studies (Schreiber 2003; INNOVO 2005) presented data on long term neurodevelopmental outcome. The early routine treatment study (Schreiber 2003) showed an improved outcome at two years corrected age, while the rescue treatment study (INNOVO 2005) showed no effect of iNO. AUTHORS' CONCLUSIONS iNO as rescue therapy for the very ill ventilated preterm infant does not appear to be effective and may increase the risk of severe IVH. Later use of iNO to prevent BPD also does not appear to be effective. Early routine use of iNO in mildly sick preterm infants may decrease serious brain injury and may improve survival without BPD. Further studies are needed to confirm these findings, to define groups most likely to benefit, and to describe long term outcomes.
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Affiliation(s)
- K J Barrington
- Royal Victoria Hospital, Pediatrics, 687 av des Pins O, Montreal, P. Quebec, Canada, H3A 1A1.
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