1
|
Sevilmis YD, Olutoye OO, Peiffer S, Mehl SC, Belfort MA, Rhee CJ, Garcia-Prats JA, Vogel AM, Lee TC, Keswani SG, King A. Surfactant Therapy in Congenital Diaphragmatic Hernia and Fetoscopic Endoluminal Tracheal Occlusion. J Surg Res 2024; 296:239-248. [PMID: 38295711 DOI: 10.1016/j.jss.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) is a complex pathology with severe pulmonary morbidity. Administration of surfactant in CDH is controversial, and the advent of fetoscopic endoluminal tracheal occlusion (FETO) has added further complexity. While FETO has been shown to improve survival outcomes, there are risks of prematurity and potential surfactant deficiency. We aim to evaluate the characteristics and outcomes of surfactant administration for CDH infants and elucidate potential benefits or risks in this unique population. METHODS A single-center retrospective cohort review of patients with unilateral CDH from September 2015 to July 2022 was performed. Demographics, prognostic perinatal imaging features, and outcomes were collected. Patients were stratified by surfactant administration and history of FETO. Data were analyzed with descriptive statistics, two-sample t-tests, chi-squared analyses, and logistic regression. RESULTS Of 105 included patients, 19 (18%) underwent FETO and 25 (24%) received surfactant. Overall, surfactant recipients were born at earlier gestational ages and lower birthweights regardless of FETO history. Surfactant recipients possessed significantly worse prenatal prognostic features such as observed to expected total fetal lung volume, observed to expected lung to head ratio, and percent liver herniation. In CDH patients without FETO history, surfactant recipients demonstrated worse outcomes than nonrecipients. This association is notably absent in the FETO population, where surfactant recipients have more favorable survival and comparable outcomes. When controlling for defect severity or surfactant usage, as a proxy for respiratory status, surfactant recipients that underwent FETO trended toward improved survival and decreased ECMO use. CONCLUSIONS Surfactant administration is not associated with increased morbidity and mortality and may be beneficial in CDH patients that have undergone FETO.
Collapse
Affiliation(s)
- Y Deniz Sevilmis
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sarah Peiffer
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas
| | - Christopher J Rhee
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Joseph A Garcia-Prats
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas.
| |
Collapse
|
2
|
Dargaville PA, Herting E, Soll RF. Neonatal surfactant therapy beyond respiratory distress syndrome. Semin Fetal Neonatal Med 2023; 28:101501. [PMID: 38040584 DOI: 10.1016/j.siny.2023.101501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Whilst exogenous surfactant therapy is central to the management of newborn infants with respiratory distress syndrome, its use in other neonatal lung diseases remains inconsistent and controversial. Here we discuss the evidence and experience in relation to surfactant therapy in newborns with other lung conditions in which surfactant may be deficient or dysfunctional, including meconium aspiration syndrome, pneumonia, congenital diaphragmatic hernia and pulmonary haemorrhage. We find that, for all of these diseases, administration of exogenous surfactant as bolus therapy is frequently associated with transient improvement in oxygenation, likely related to temporary mitigation of surfactant inhibition in the airspaces. However, for none of them is there a lasting clinical benefit of surfactant therapy. By virtue of interrupting disease pathogenesis, lavage therapy with dilute surfactant in MAS offers the greatest possibility of a more pronounced therapeutic effect, but this has yet to be definitively proven. Lavage therapy also involves a greater degree of procedural risk.
Collapse
Affiliation(s)
- Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Egbert Herting
- Department of Paediatrics, University of Luebeck, Luebeck, Germany
| | - Roger F Soll
- Division of Neonatal-Perinatal Medicine, Larner College of Medicine, The University of Vermont, Burlington, USA
| |
Collapse
|
3
|
Olutoye Ii OO, Short WD, Gilley J, Hammond Ii JD, Belfort MA, Lee TC, King A, Espinoza J, Joyeux L, Lingappan K, Gleghorn JP, Keswani SG. The Cellular and Molecular Effects of Fetoscopic Endoluminal Tracheal Occlusion in Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:925106. [PMID: 35865706 PMCID: PMC9294219 DOI: 10.3389/fped.2022.925106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a complex disease associated with pulmonary hypoplasia and pulmonary hypertension. Great strides have been made in our ability to care for CDH patients, specifically in the prenatal improvement of lung volume and morphology with fetoscopic endoluminal tracheal occlusion (FETO). While the anatomic effects of FETO have been described in-depth, the changes it induces at the cellular and molecular level remain a budding area of CDH research. This review will delve into the cellular and molecular effects of FETO in the developing lung, emphasize areas in which further research may improve our understanding of CDH, and highlight opportunities to optimize the FETO procedure for improved postnatal outcomes.
Collapse
Affiliation(s)
- Oluyinka O Olutoye Ii
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Walker D Short
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jamie Gilley
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - J D Hammond Ii
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Jimmy Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Luc Joyeux
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Krithika Lingappan
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jason P Gleghorn
- Department of Biomedical Engineering, University of Delaware, Newark, DE, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
4
|
Assessment of the nitrofen model of congenital diaphragmatic hernia and of the dysregulated factors involved in pulmonary hypoplasia. Pediatr Surg Int 2019; 35:41-61. [PMID: 30386897 DOI: 10.1007/s00383-018-4375-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To study pulmonary hypoplasia (PH) associated with congenital diaphragmatic hernia (CDH), investigators have been employing a fetal rat model based on nitrofen administration to dams. Herein, we aimed to: (1) investigate the validity of the model, and (2) synthesize the main biological pathways implicated in the development of PH associated with CDH. METHODS Using a defined strategy, we conducted a systematic review of the literature searching for studies reporting the incidence of CDH or factors involved in PH development. We also searched for PH factor interactions, relevance to lung development and to human PH. RESULTS Of 335 full-text articles, 116 reported the incidence of CDH after nitrofen exposure or dysregulated factors in the lungs of nitrofen-exposed rat fetuses. CDH incidence: 54% (27-85%) fetuses developed a diaphragmatic defect, whereas the whole litter had PH in varying degrees. Downregulated signaling pathways included FGF/FGFR, BMP/BMPR, Sonic Hedgehog and retinoid acid signaling pathway, resulting in a delay in early epithelial differentiation, immature distal epithelium and dysfunctional mesenchyme. CONCLUSIONS The nitrofen model effectively reproduces PH as it disrupts pathways that are critical for lung branching morphogenesis and alveolar differentiation. The low CDH rate confirms that PH is an associated phenomenon rather than the result of mechanical compression alone.
Collapse
|
5
|
Moya FR, Lally KP, Moyer VA, Blakely ML. Surfactant for newborn infants with congenital diaphragmatic hernia. Hippokratia 2017. [DOI: 10.1002/14651858.cd004209.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Fernando R Moya
- New Hanover Regional Medical Center; PLLC Director of Neonatology; Wilmington NC USA 28401
| | - Kevin P Lally
- University of Texas Health Science Center at Houston; Department of Pediatric Surgery; PO Box 20708 Houston Texas USA TX 77225-0708
| | - Virginia A Moyer
- The American Board of Pediatrics; 111 Silver Cedar Court Chapel Hill North Carolina USA 27514
| | - Martin L Blakely
- University of Texas, Houston; Pediatric Surgery; 6431 Fannin MSB 5.254 Houston TX USA 77584
| |
Collapse
|
6
|
Morini F, Lally KP, Lally PA, Crisafulli RM, Capolupo I, Bagolan P. Treatment Strategies for Congenital Diaphragmatic Hernia: Change Sometimes Comes Bearing Gifts. Front Pediatr 2017; 5:195. [PMID: 28959686 PMCID: PMC5603669 DOI: 10.3389/fped.2017.00195] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/23/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report treatment strategies' evolution and its impact on congenital diaphragmatic hernia (CDH) outcome. DESIGN Registry-based cohort study using the CDH Study Group database, 1995-2013. SETTING International multicenter database. PATIENTS CDH patients entered into the registry. Late presenters or patients with very incomplete data were excluded. Patients were divided into three Eras (1995-2000; 2001-2006; 2007-2013). MAIN OUTCOME MEASURES Treatment strategies and outcomes. One-way ANOVA, X2 test, and X2 test for trend were used. A Sydak-adjusted p < 0.0027 was considered significant. Prevalence or mean (SE) are reported. RESULTS Patients: 8,603; included: 7,716; Era I: 2,146; Era II: 2,572; Era III: 2,998. From Era I to Era III, significant changes happened. Some severity indicators such as gestational age, prevalence of prenatal diagnosis, and inborn patients significantly worsened. Also, treatment strategies such as the use of prenatal steroids and inhaled nitric oxide, age at operation, prevalence of minimal access surgery, and the use of surfactant significantly changed. Finally, length of hospital stay became significantly longer and survival to discharge slightly but significantly improved, from 67.7 to 71.4% (p for trend 0.0019). CONCLUSION Treatment strategies for patients registered since 1995 in the CDH Study Group significantly changed. Survival to discharge slightly but significantly improved.
Collapse
Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Rosa Maria Crisafulli
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| |
Collapse
|
7
|
Abstract
BACKGROUND Surfactant replacement therapy is an established modality of treatment in preterm neonates with respiratory distress syndrome. In addition, there are various neonatal respiratory disorders which are characterized by surfactant deficiency in which surfactant therapy can be a feasible and safe option. OBJECTIVE To collate the literature on the use of surfactant replacement therapy in neonates beyond respiratory distress syndrome and examine the evidence and newer developments. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, and EMBASE up to June 2015; and previous reviews, including cross-references, abstracts, and conference proceedings. RESULTS Evidence supports surfactant administration via bolus route in neonates with meconium aspiration syndrome, but additional robust evidence is required before its adoption in clinical practice. There is limited evidence to support surfactant therapy in neonates with pneumonia, pulmonary hemorrhage and bronchopulmonary dysplasia. Large multicenter randomized trials are needed to cement or refute the role of surfactant therapy in these disorders.
Collapse
|
8
|
Carnielli VP, Giorgetti C, Simonato M, Vedovelli L, Cogo P. Neonatal Respiratory Diseases in the Newborn Infant: Novel Insights from Stable Isotope Tracer Studies. Neonatology 2016; 109:325-33. [PMID: 27251153 DOI: 10.1159/000444891] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Respiratory distress syndrome is a common problem in preterm infants and the etiology is multifactorial. Lung underdevelopment, lung hypoplasia, abnormal lung water metabolism, inflammation, and pulmonary surfactant deficiency or disfunction play a variable role in the pathogenesis of respiratory distress syndrome. High-quality exogenous surfactant replacement studies and studies on surfactant metabolism are available; however, the contribution of surfactant deficiency, alteration or dysfunction in selected neonatal lung conditions is not fully understood. In this article, we describe a series of studies made by applying stable isotope tracers to the study of surfactant metabolism and lung water. In a first set of studies, which we call 'endogenous studies', using stable isotope-labelled intravenous surfactant precursors, we showed the feasibility of measuring surfactant synthesis and kinetics in infants using several metabolic precursors including plasma glucose, plasma fatty acids and body water. In a second set of studies, named 'exogenous studies', using stable isotope-labelled phosphatidylcholine tracer given endotracheally, we could estimate surfactant disaturated phosphatidylcholine pool size and half-life. Very recent studies are focusing on lung water and on the endogenous biosynthesis of the surfactant-specific proteins. Information obtained from these studies in infants will help to better tailor exogenous surfactant treatment in neonatal lung diseases.
Collapse
Affiliation(s)
- Virgilio P Carnielli
- Division of Neonatology, Salesi Hospital and Polytechnic University of Marche, Ancona, Italy
| | | | | | | | | |
Collapse
|
9
|
Simonato M, Baritussio A, Vedovelli L, Lamonica G, Carnielli VP, Cogo PE. Surfactant protein B amount and kinetics in newborn infants: an optimized procedure. JOURNAL OF MASS SPECTROMETRY : JMS 2012; 47:1415-1419. [PMID: 23147816 DOI: 10.1002/jms.3065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Surfactant protein B (SP-B) plays a key role in surfactant homeostasis affecting its biophysical properties and physiological function. Recently, a method to measure SP-B amount and kinetics from tracheal aspirates (TAs) became available. The main objective of this study was to improve the critical steps of the procedure to obtain a better SP-B sensitivity. We administered a 24 h continuous infusion of 1 mg/kg/h of 1(13)C-leucine to ten newborn infants. SP-B was isolated from serial TAs and its fractional synthesis rate, secretion time, peak time and half life were derived from (13)C enrichment curves obtained by gas chromatography mass spectrometry. SP-B amount in TAs was also assessed. During the extraction step, acidification and organic solvent ratio optimization doubled the recovery of SP-B from TAs, so did the elongation of the propylation time (from 20 min to 1 h) with enhanced leucine derivatization yield. Measurement of (13)C leucine enrichments, and therefore all SP-B kinetics parameters, were successfully calculated in all TAs samples due to the increase of SP-B yield. SP-B amount was 0.29 (0.16-0.41) % of total phospholipids with a minimum value of 0.08% belonging to one of the respiratory distress syndrome (RDS) patients. In conclusion, this new procedure enables accurate determination of SP-B kinetics even in the presence of low protein amount like in preterm RDS patients.
Collapse
Affiliation(s)
- Manuela Simonato
- Department of Medicine, Anaesthesia and Critical Care, University of Padova, Padova, Italy.
| | | | | | | | | | | |
Collapse
|
10
|
Roussel A, Hascoet JM, Desandes R, Claris O, Vieux R. [Does the regional health care organization impact the outcome of infants born with congenital diaphragmatic hernia?]. Arch Pediatr 2011; 18:1062-8. [PMID: 21873038 DOI: 10.1016/j.arcped.2011.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 04/06/2011] [Accepted: 07/22/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) is a serious pathology that requires optimal management in very specialized health centers. French medical care organization is regionally based. Hence, evaluating local practices may help deliver clear information to parents before delivery. The aim of this study was to analyze the neonatal characteristics and the postnatal outcome of infants affected with CDH, treated within two different French perinatal health care networks. PATIENTS AND METHODS Retrospective cohort study of infants with CDH, cared for in the Lorraine perinatal health care network (Réseau Périnatal Lorrain [RPL]) or at Édouard-Herriot Hospital (HEH) in Lyon, between 1997 and 2007. RESULTS One hundred and twenty-seven newborns were included, 44 in the RPL and 83 in Lyon. Prenatal diagnosis of CDH was similar in RPL and at HEH; 47.7% of infants with CDH died in RPL vs 36.1% in HEH (P=0.2). Surgery delayed for more than 24h was more frequent in RPL (68.6% vs 31.7%; P<0.001), with a postoperative mortality rate of 31.4% vs 15.9%; P=0.08. In RPL, specialized medical follow-up was rare (33.3% vs 100%; P<0.001), while psychomotor retardation was more frequent (33.3% vs 5.7%; P=0.002). CONCLUSION This study brings to light the diversity of care and outcome for infants affected with CDH in two French perinatal health care networks. These results may help improve both centers' practices. In Lorraine for instance, the follow-up of these vulnerable children can be improved.
Collapse
MESH Headings
- Algorithms
- Cohort Studies
- France/epidemiology
- Health Services
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/diagnosis
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/surgery
- Intensive Care, Neonatal
- Perinatal Care
- Postoperative Period
- Psychomotor Disorders/epidemiology
- Psychomotor Disorders/etiology
- Retrospective Studies
- Survival Rate
- Treatment Outcome
- Ultrasonography, Prenatal
Collapse
Affiliation(s)
- A Roussel
- Service de néonatalogie, soins intensifs et réanimation néonatale, maternité régionale universitaire de Nancy, 10, rue du Docteur-Heydenreich, 54042 Nancy cedex, France
| | | | | | | | | |
Collapse
|
11
|
Porto ACR, Mirandola RM, Mori CS, Fernandes WR. Ureia como marcador de diluição em amostras de lavado traqueobrônquico de potros com rodococose. PESQUISA VETERINÁRIA BRASILEIRA 2010. [DOI: 10.1590/s0100-736x2010000900007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
No estudo das infecções e dos mecanismos inflamatórios do trato respiratório posterior, a diluição desconhecida de amostras de lavados traqueobrônquicos leva a um grave problema na interpretação das concentrações de várias substâncias. Foi investigada a amplitude da diluição em uma situação clínica verdadeira, com o objetivo de determinar a validez do uso da dosagem da ureia em lavados traqueobrônquicos para correção da diluição. As amostras do estudo consistiram em lavados traqueobrônquicos obtidos de sete potros com infecção por Rhodococcus equi. Foi realizada a contagem celular total e diferencial e comprado com o quadro clínico e a recuperação bacteriana de todas as amostras. Os fatores de diluição dos lavados variaram entre 14,3 e 130 (média 59,7). O uso da ureia como marcador de diluição melhorou a exatidão na determinação da concentração total de células nos lavados. Estes resultados sugerem que a prática de mensurar substâncias em lavado traqueobrônquico sem correção da diluição possa induzir a falsas conclusões.
Collapse
|
12
|
Ruttenstock E, Doi T, Dingemann J, Puri P. Insulin receptor is downregulated in the nitrofen-induced hypoplastic lung. J Pediatr Surg 2010; 45:948-52. [PMID: 20438933 DOI: 10.1016/j.jpedsurg.2010.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/03/2010] [Indexed: 11/16/2022]
Abstract
PURPOSE The pathogenesis of pulmonary hypoplasia in congenital diaphragmatic hernia (CDH) is still poorly understood. During fetal lung development, the insulin receptor (IR) plays an important role by mediating the cellular uptake of glucose, which is a major substrate for the biosynthesis of surfactant phospholipids. In fetal rat lung, IR gene expression has been revealed on type II pneumocytes. Recent studies have demonstrated that downregulation of pulmonary IR in late gestation causes pulmonary hypoplasia by inhibition of surfactant synthesis. We hypothesized that pulmonary gene expression of IR is downregulated during the late stages of lung development in the nitrofen-induced CDH model. METHODS Timed pregnant Sprague-Dawley rats were exposed to either olive oil or nitrofen on day 9 of gestation (D9). Cesarean deliveries were performed on D15, D18, and D21. Fetal lungs were divided into 3 groups: control, nitrofen without CDH (CDH[-]), and nitrofen with CDH (CDH[+]) (n = 8 at each time-point, respectively). Relative messenger RNA (mRNA) levels of IR were determined by using real time reverse transcription polymerase chain reaction. Immunohistochemistry was performed to evaluate protein expression of IR. RESULTS Relative expression levels of IR mRNA on D21 were significantly decreased in CDH(-) and CDH(+) group (3.99 +/- 1.50 and 5.14 +/- 0.99, respectively) compared to control (7.45 +/- 3.95; P < .05). Immunohistochemistry showed decreased IR expression in the proximal alveolar epithelium on D21 in hypoplastic lungs compared to control lungs. CONCLUSION Downregulation of IR gene and protein expression in hypoplastic lung during late stages of lung development may interfere with normal surfactant synthesis, causing pulmonary hypoplasia in the nitrofen-induced CDH model.
Collapse
Affiliation(s)
- Elke Ruttenstock
- Children's Research Center, Our Lady's Children's Hospital, Dublin 12, Ireland
| | | | | | | |
Collapse
|
13
|
Balassy C, Kasprian G, Brugger PC, Weber M, Csapo B, Herold C, Prayer D. Assessment of lung development in isolated congenital diaphragmatic hernia using signal intensity ratios on fetal MR imaging. Eur Radiol 2009; 20:829-37. [DOI: 10.1007/s00330-009-1633-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 08/07/2009] [Accepted: 08/26/2009] [Indexed: 11/29/2022]
|
14
|
Janssen DJ, Zimmermann LJ, Cogo P, Hamvas A, Bohlin K, Luijendijk IH, Wattimena D, Carnielli VP, Tibboel D. Decreased surfactant phosphatidylcholine synthesis in neonates with congenital diaphragmatic hernia during extracorporeal membrane oxygenation. Intensive Care Med 2009; 35:1754-60. [PMID: 19582395 PMCID: PMC2749174 DOI: 10.1007/s00134-009-1564-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 06/10/2009] [Indexed: 11/09/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) may result in severe respiratory insufficiency with a high morbidity. The role of a disturbed surfactant metabolism in the pathogenesis of CDH is unclear. We therefore studied endogenous surfactant metabolism in the most severe CDH patients who required extracorporeal membrane oxygenation (ECMO). METHODS Eleven neonates with CDH who required ECMO and ten ventilated neonates without significant lung disease received a 24-h infusion of the stable isotope [U-(13)C] glucose. The (13)C-incorporation into palmitic acid in surfactant phosphatidylcholine (PC) isolated from serial tracheal aspirates was measured. Mean PC concentration in epithelial lining fluid (ELF) was measured during the first 4 days of the study. RESULTS Fractional surfactant PC synthesis was decreased in CDH-ECMO patients compared to controls (2.4 +/- 0.33 vs. 8.0 +/- 2.4%/day, p = 0.04). The control group had a higher maximal enrichment (0.18 +/- 0.03 vs. 0.09 +/- 0.02 APE, p = 0.04) and reached this maximal enrichment earlier (46.7 +/- 3.0 vs. 69.4 +/- 6.6 h, p = 0.004) compared to the CDH-ECMO group, which reflects higher and faster precursor incorporation in the control group. Surfactant PC concentration in ELF was similar in both groups. CONCLUSION These results show that CDH patients who require ECMO have a decreased surfactant PC synthesis, which may be part of the pathogenesis of severe pulmonary insufficiency and has a negative impact on weaning from ECMO.
Collapse
Affiliation(s)
- Daphne J. Janssen
- Department of Pediatrics and Pediatric Surgery, Intensive Care Erasmus MC-Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Luc J. Zimmermann
- Division of Neonatology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Paola Cogo
- Department of Pediatrics, University of Padova, Padua, Italy
| | - Aaron Hamvas
- Department of Pediatrics, Washington University/St. Louis Children’s Hospital, St. Louis, USA
| | - Kajsa Bohlin
- Department of Pediatrics, Washington University/St. Louis Children’s Hospital, St. Louis, USA
- Division of Pediatrics, Karolinska University Hospital Huddinge and the Karolinska Institute, Stockholm, Sweden
| | - Ingrid H. Luijendijk
- Department of Pediatrics and Pediatric Surgery, Intensive Care Erasmus MC-Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Darcos Wattimena
- Internal Medicine, Erasmus MC-Dijkzigt, Rotterdam, The Netherlands
| | | | - Dick Tibboel
- Department of Pediatrics and Pediatric Surgery, Intensive Care Erasmus MC-Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| |
Collapse
|
15
|
Verlato G, Cogo PE, Benetti E, Gomirato S, Gucciardi A, Carnielli VP. Kinetics of surfactant in respiratory diseases of the newborn infant. J Matern Fetal Neonatal Med 2009. [DOI: 10.1080/jmf.16.2.21.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- G Verlato
- Department of Pediatrics University of Padova Padova Italy
| | - PE Cogo
- Department of Pediatrics University of Padova Padova Italy
| | - E Benetti
- Department of Pediatrics University of Padova Padova Italy
| | - S Gomirato
- Department of Pediatrics University of Padova Padova Italy
| | - A Gucciardi
- Department of Pediatrics University of Padova Padova Italy
| | - VP Carnielli
- Division of Neonatology Salesi Children Hospital Ancona Italy
| |
Collapse
|
16
|
Pulmonary surfactant kinetics of the newborn infant: novel insights from studies with stable isotopes. J Perinatol 2009; 29 Suppl 2:S29-37. [PMID: 19399007 DOI: 10.1038/jp.2009.32] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Deficiency or dysfunction of the pulmonary surfactant plays a critical role in the pathogenesis of respiratory diseases of the newborn. After a short review of the pulmonary surfactant, including its role in selected neonatal respiratory conditions, we describe a series of studies conducted by applying two recently developed methods to measure surfactant kinetics. In the first set of studies, namely 'endogenous studies', which used stable isotope-labeled intravenous surfactant precursors, we have shown the feasibility of measuring surfactant synthesis and kinetics in infants using several metabolic precursors, including plasma glucose, plasma fatty acids and body water. In the second set of studies, namely 'exogenous studies', which used a stable isotope-labeled phosphatidylcholine (PC) tracer given endotracheally, we estimated the surfactant disaturated phosphatidylcholine (DSPC) pool size and half-life. The major findings of our studies are presented here and can be summarized as follows: (a) the de novo synthesis and turnover rates of the surfactant (DSPC) in preterm infants with respiratory distress syndrome (RDS) are very low with either precursor; (b) in preterm infants with RDS, pool size is very small and half-life much longer than what has been reported in animal studies; (c) patients recovering from RDS who required higher continuous positive airway pressure pressure after extubation or reintubation have a lower level of intrapulmonary surfactant than those who did well after extubation; (d) term newborn infants with pneumonia have greatly accelerated surfactant catabolism; and (e) infants with uncomplicated congenital diaphragmatic hernia (CDH) and on conventional mechanical ventilation have normal surfactant synthesis, but those requiring extracorporeal membrane oxygenated (ECMO) do not. Information obtained from these studies in infants will help to better tailor exogenous surfactant treatment in neonatal lung diseases.
Collapse
|
17
|
Fredly S, Aksnes G, Viddal KO, Lindemann R, Fugelseth D. The outcome in newborns with congenital diaphragmatic hernia in a Norwegian region. Acta Paediatr 2009; 98:107-11. [PMID: 18795908 DOI: 10.1111/j.1651-2227.2008.01024.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the therapeutic strategies used in neonates with congenital diaphragmatic hernia (CDH) during the last 15 years in our department. METHOD A retrospective study of 27 neonates with CDH treated at the Neonatal Intensive Care Unit at Ullevaal University Hospital between 1992 and 2006. Since 1992 we have used delayed operative repair and high-frequency ventilation (HFV). Because surfactant replacement and inhaled nitric oxide (iNO) therapy have been used since 1997, we divided the patients into two groups; group 1 from 1992 to 1996 (9 patients) and group 2 from 1997 to 2006 (18 patients). RESULTS The overall survival was 70%. Group 1 had an exceptionally good outcome, 100% survival versus 56% in the last group. CONCLUSION Pulmonary hypoplasia and pulmonary hypertension are still the most challenging factors in treatment of neonates with CDH, despite novel therapeutic modalities, such as HFV, surfactant and iNO. Delayed surgery in CDH allows pre-operative stabilization. Extracorporeal membrane oxygenation must be considered in the most severe cases.
Collapse
Affiliation(s)
- S Fredly
- Department of Paediatrics, Ullevaal University Hospital, Oslo, Norway.
| | | | | | | | | |
Collapse
|
18
|
Volpe MV, Wang KTW, Nielsen HC, Chinoy MR. Unique spatial and cellular expression patterns of Hoxa5, Hoxb4, and Hoxb6 proteins in normal developing murine lung are modified in pulmonary hypoplasia. ACTA ACUST UNITED AC 2008; 82:571-84. [PMID: 18553509 DOI: 10.1002/bdra.20481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Hox transcription factors modulate signaling pathways controlling organ morphogenesis and maintain cell fate and differentiation in adults. Retinoid signaling, key in regulating Hox expression, is altered in pulmonary hypoplasia. Information on pattern-specific expression of Hox proteins in normal lung development and in pulmonary hypoplasia is minimal. Our objective was to determine how pulmonary hypoplasia alters temporal, spatial, and cellular expression of Hoxa5, Hoxb4, and Hoxb6 proteins compared to normal lung development. METHODS Temporal, spatial, and cellular Hoxa5, Hoxb4, and Hoxb6 expression was studied in normal (untreated) and nitrofen-induced hypoplastic (NT-PH) lungs from gestational day 13.5, 16, and 19 fetuses and neonates using Western blot and immunohistochemistry. RESULTS Modification of protein levels and spatial and cellular Hox expression patterns in NT-PH lungs was consistent with delayed lung development. Distinct protein isoforms were detected for each Hox protein. Expression levels of the Hoxa5 and Hoxb6 protein isoforms changed with development and were altered further in NT-PH lungs. Compared to normal lungs, GD19 and neonatal NT-PH lungs had decreased Hoxb6 and increased Hoxa5 and Hoxb4. Hoxa5 cellular localization changed from mesenchyme to epithelia earlier in normal lungs. Hoxb4 was expressed in mesenchyme and epithelial cells throughout development. Hoxb6 remained mainly in mesenchymal cells around distal airways. CONCLUSIONS Unique spatial and cellular expression of Hoxa5, Hoxb4, and Hoxb6 participates in branching morphogenesis and terminal sac formation. Altered Hox protein temporal and cellular balance of expression either contributes to pulmonary hypoplasia or functions as a compensatory mechanism attempting to correct abnormal lung development and maturation in this condition.
Collapse
Affiliation(s)
- MaryAnn Vitoria Volpe
- Div. of Newborn Medicine, Department of Pediatrics, Tufts Medical Center, Boston, Massachusetts 02111, USA.
| | | | | | | |
Collapse
|
19
|
Gallot D, Coste K, Jani J, Roubliova X, Marceau G, Velemir L, Verheyen A, Lemery D, Sapin V, Deprest J. Effects of maternal retinoic acid administration in a congenital diaphragmatic hernia rabbit model. Pediatr Pulmonol 2008; 43:594-603. [PMID: 18435480 DOI: 10.1002/ppul.20829] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Maternal retinoid administration has beneficial effects on lung development in the nitrofen rodent toxic model of congenital diaphragmatic hernia (DH). We wanted to investigate the effects in a surgical model, where the retinoid signaling pathway is not primarily disrupted by the toxic agent. We created DH in fetal rabbits at day 23 of gestation, administrated to the does all trans-retinoic acid (ATRA) or vehicle (VHC) intramuscularly for 8 consecutive days and harvested normal and operated (DH) fetuses at 31 d (n = 7 in each group). Normal lungs exposed to ATRA had increased surfactant protein mRNA levels without change in type II pneumocyte density. There was no measurable effect on lung-to-body weight ratio and airway morphometry by ATRA. In DH lungs (DH/VHC) surfactant protein mRNA levels were increased, as well as the density of type II pneumocytes. When supplemented with ATRA (DH/ATRA) these parameters returned to normal (VHC). Cell proliferation or apoptosis were not influenced by ATRA supplementation. In conclusion, maternal ATRA supplementation does not affect gross anatomic, morphologic or proliferation indices in hypoplastic lungs related to surgically induced DH in rabbit. However, ATRA lowers surfactant protein expression and normalizes type I/II pneumocyte ratio to what is observed in normal lungs.
Collapse
Affiliation(s)
- Denis Gallot
- Université d'Auvergne, JE2447 ARDEMO, F-63000, Clermont-Ferrand, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
The incidence of congenital diaphragmatic hernia (CDH) may be as high as 1 in 2000. Over the past two decades, antenatal diagnosis rates have increased, the pathophysiology of CDH has become better understood, and advances in clinical care, including foetal surgery, have occurred. However, there remains a paucity of randomised controlled trials to provide evidence-based management guidelines. Reports of improved survival rates appear to be confined to a select subset of CDH infants, surviving to surgical repair, while the overall mortality, at over 60%, appears to be unchanged, largely due to the often forgotten 'hidden mortality' of CDH. The significant long-term morbidity in surviving infants has become apparent, and the need for long-term multidisciplinary follow up established. A total of 10% of cases may present later in life, and misdiagnosis on initial chest X-ray may lead to significant morbidity.
Collapse
Affiliation(s)
- Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, University of Sydney, New South Wales, Westmead, Australia.
| | | |
Collapse
|
21
|
Boucherat O, Benachi A, Chailley-Heu B, Franco-Montoya ML, Elie C, Martinovic J, Bourbon JR. Surfactant maturation is not delayed in human fetuses with diaphragmatic hernia. PLoS Med 2007; 4:e237. [PMID: 17676984 PMCID: PMC1950205 DOI: 10.1371/journal.pmed.0040237] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 06/07/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary hypoplasia and persistent pulmonary hypertension account for significant mortality and morbidity in neonates with congenital diaphragmatic hernia (CDH). Global lung immaturity and studies in animal models suggest the presence of surfactant deficiency that may further complicate the pathophysiology of CDH. However, data about surfactant status in human fetuses with CDH at birth are contradictory. The lack of a chronological study of surfactant content in late pregnancy has been a significant limitation. The appropriateness of administering surfactant supplements to neonates with CDH is therefore a debated question. METHODS AND FINDINGS We investigated surfactant content in human fetuses with CDH compared to age-matched fetuses with nonpulmonary diseases used as controls. Concentrations of disaturated phosphatidylcholine and surfactant proteins were found to be similar at a given stage of pregnancy, with both components showing a similar pattern of increase with progressing pregnancy in fetuses with CDH and in control fetuses. Thyroid transcription factor 1, a critical regulator of surfactant protein transcription, similarly displayed no difference in abundance. Finally, we examined the expression of three glucocorticoid-regulated diffusible mediators involved in lung epithelial maturation, namely: keratinocyte growth factor (KGF), leptin, and neuregulin 1 beta 1 (NRG1-beta1). KGF expression decreased slightly with time in control fetuses, but remained unchanged in fetuses with CDH. Leptin and NRG1-beta1 similarly increased in late pregnancy in control and CDH lungs. These maturation factors were also determined in the sheep fetus with surgical diaphragmatic hernia, in which surfactant deficiency has been reported previously. In contrast to the findings in humans, surgical diaphragmatic hernia in the sheep fetus was associated with decreased KGF and neuregulin expression. Fetoscopic endoluminal tracheal occlusion performed in the sheep model to correct lung hypoplasia increased leptin expression, partially restored KGF expression, and fully restored neuregulin expression. CONCLUSIONS Our results indicate that CDH does not impair surfactant storage in human fetuses. CDH lungs exhibited no trend toward a decrease in contents, or a delay in developmental changes for any of the studied surfactant components and surfactant maturation factors. Surfactant amounts are likely to be appropriate to lung size. These findings therefore do not support the use of surfactant therapy for infants with CDH. Moreover, they raise the question of the relevance of CDH animal models to explore lung biochemical maturity.
Collapse
Affiliation(s)
- Olivier Boucherat
- Institut national de la santé et de la recherche médicale (INSERM), Unité 841—Institut Mondor de Recherche Biomédicale, Créteil, France
- Université Paris 12, Faculté de Médecine, Créteil, France
| | - Alexandra Benachi
- Institut national de la santé et de la recherche médicale (INSERM), Unité 841—Institut Mondor de Recherche Biomédicale, Créteil, France
- Université Paris 12, Faculté de Médecine, Créteil, France
- Université Paris-Descartes, Paris, France
- Maternité, Assistance Publique-Hôpitaux de Paris et Hôpital Necker-Enfants Malades, Paris, France
| | - Bernadette Chailley-Heu
- Institut national de la santé et de la recherche médicale (INSERM), Unité 841—Institut Mondor de Recherche Biomédicale, Créteil, France
- Université Paris 12, Faculté de Médecine, Créteil, France
| | - Marie-Laure Franco-Montoya
- Institut national de la santé et de la recherche médicale (INSERM), Unité 841—Institut Mondor de Recherche Biomédicale, Créteil, France
- Université Paris 12, Faculté de Médecine, Créteil, France
| | - Caroline Elie
- Maternité, Assistance Publique-Hôpitaux de Paris et Hôpital Necker-Enfants Malades, Paris, France
- Service de Biostatistique et Informatique Médicale, Assistance Publique-Hôpitaux de Paris et Hôpital Necker-Enfants Malades, Paris, France
| | - Jelena Martinovic
- Maternité, Assistance Publique-Hôpitaux de Paris et Hôpital Necker-Enfants Malades, Paris, France
- Service de Fœtopathologie, Assistance Publique-Hôpitaux de Paris et Hôpital Necker-Enfants Malades, Paris, France
| | - Jacques R Bourbon
- Institut national de la santé et de la recherche médicale (INSERM), Unité 841—Institut Mondor de Recherche Biomédicale, Créteil, France
- Université Paris 12, Faculté de Médecine, Créteil, France
- * To whom correspondence should be addressed. E-mail:
| |
Collapse
|
22
|
Abstract
Marcus Davey discusses a new autopsy study that found that pulmonary surfactant content is not decreased in congenital diaphragmatic hernia.
Collapse
Affiliation(s)
- Marcus Davey
- Department of Surgery, The University of Pennsylvania, Pennsylvania, USA.
| |
Collapse
|
23
|
Laberge JM, Flageole H. Fetal Tracheal Occlusion for the Treatment of Congenital Diaphragmatic Hernia. World J Surg 2007; 31:1577-86. [PMID: 17510770 DOI: 10.1007/s00268-007-9074-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Accepted: 03/12/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) continues to be associated with significant mortality and morbidity rates despite advances in neonatal care. Fetal intervention for CDH has been studied for 25 years. After initial difficulties encountered with open fetal repair, attention has turned to tracheal occlusion (TO) as a method to correct pulmonary hypoplasia before birth. This article reviews our contribution to this field of research and outlines the current status of this treatment modality. MATERIALS AND METHODS Using the fetal lamb model, we have studied the effects of fetal TO on tracheal fluid pressure, lung growth and type II pneumocyte maturation, and surfactant production. We developed a minimally invasive and reversible technique of TO, using a detachable balloon placed using single-port tracheoscopy. We examined differential lung growth, structural maturation, pulmonary artery remodeling, and lung function during an 8-h resuscitation period in lambs, comparing normal controls, lambs with a surgically created CDH, those with CDH+TO, and those with CDH+TO and release of TO 1 week before delivery. We also studied the potential benefits of maternal betamethasone administration and the administration of surfactant at birth. Using a neonatal piglet model, we examined the effect of postnatal pulmonary distension with perfluorocarbon on lung growth. More recently, we turned to the rat nitrofen-induced CDH model to study the effects of TO on bronchial branching and some molecular markers of lung growth (Shh and LGL1). CONCLUSIONS Fetal TO is being used to treat human CDH, but its application remains limited by the absence of reliable and widely reproducible prenatal prognostic criteria. A better understanding of the molecular events guiding the lung growth seen with TO may help to refine its use in humans.
Collapse
Affiliation(s)
- Jean-Martin Laberge
- Department of Surgery, The Montreal Children's Hospital of the McGill University Health Center, 2300 rue Tupper, H3H 1P3, Montreal, QC, Canada.
| | | |
Collapse
|
24
|
Abstract
Although there is no doubt that administration of exogenous surfactant to very preterm babies who have respiratory distress syndrome is safe and efficacious, surfactant inactivation or deficiency plays a role in the pathophysiology of other pulmonary disorders affecting newborn infants. Preliminary data suggest that there may be a role for surfactant administration to babies who have meconium aspiration syndrome, pneumonia, and possibly bronchopulmonary dysplasia. Further investigation is necessary but seems warranted.
Collapse
Affiliation(s)
- Thierry Lacaze-Masmonteil
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
25
|
|
26
|
Janssen DJ, Carnielli VP, Cogo P, Bohlin K, Hamvas A, Luijendijk IH, Bunt JEH, Tibboel D, Zimmermann LJ. Surfactant phosphatidylcholine metabolism in neonates with meconium aspiration syndrome. J Pediatr 2006; 149:634-9. [PMID: 17095334 DOI: 10.1016/j.jpeds.2006.07.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Revised: 05/25/2006] [Accepted: 07/12/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Because meconium directly inhibits surfactant function, we sought to determine the effect of meconium on endogenous surfactant synthesis and clearance. STUDY DESIGN We studied surfactant phosphatidylcholine kinetics with the use of stable isotopes in 11 newborn infants with meconium aspiration syndrome (MAS) who required extracorporeal membrane oxygenation (ECMO). For comparison we studied 6 neonates with persistent pulmonary hypertension (PPHN) on ECMO and 10 term neonates ventilated for non-pulmonary indications and not on ECMO. All patients received a 24-hour [U- 13C]glucose infusion as precursor for the palmitic acid in surfactant phosphatidylcholine. RESULTS In the meconium group, the maximal 13C-incorporation in phosphatidylcholine (PC) was half of that in controls (0.09 +/- 0.01 vs 0.18 +/- 0.03 atom percent excess [APE], P = .027). There was a trend toward lower surfactant synthesis in the MAS group (3.3 +/- 0.7%/day) and PPHN group (2.6 +/- 0.3%/day) compared with controls 8.0 +/- 2.4%/day, P = .058). Significantly lower PC concentrations in tracheal aspirates were found in the MAS group (4.4 +/- 2.6 mg/mL) and PPHN group (3.6 +/- 2.0 mg/mL) compared with controls (12.8 +/- 2.6 mg/mL, P = .01). Endogenously synthesized surfactant had a similar half-life in all groups, ranging from 63 to 98 hours. CONCLUSION We conclude that surfactant synthesis is disturbed and that surfactant PC concentrations are low in infants with MAS on ECMO.
Collapse
Affiliation(s)
- Daphne J Janssen
- Erasmus MC-Sophia, Division of Neonatology and Pediatric Surgery, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Gonzalez-Reyes S, Martinez L, Martinez-Calonge W, Fernandez-Dumont V, Tovar JA. Effects of antioxidant vitamins on molecular regulators involved in lung hypoplasia induced by nitrofen. J Pediatr Surg 2006; 41:1446-52. [PMID: 16863852 DOI: 10.1016/j.jpedsurg.2006.04.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Oxidant herbicide nitrofen (2,4-dichloro-4'-nitrodiphenyl ether) induces in rat embryos congenital diaphragmatic hernia (CDH) with lung hypoplasia. The present study aims at examining whether antioxidant vitamins A, E, and C reverse the effects of the teratogen in the lungs of exposed rats and how they modify the expression of molecular regulators known to be involved in their pathogenesis. MATERIALS AND METHODS Wet lung weight-body weight ratio, total DNA, and total protein were determined. Thyroid transcription factor 1 (TTF-1), hepatocyte nuclear factor 3beta (HNF-3beta), and surfactant protein B (SP-B) proteins were measured by immunoblot assay in lung homogenates from rat fetuses exposed in utero to either nitrofen 100 mg intragastrically or vehicle. The coexpression of these factors in the alveolar epithelium was demonstrated by immunohistochemistry. The effects of the addition of vitamins A, C, and E were assessed by comparison with analysis of variance. RESULTS Nitrofen decreased lung weight, total DNA, and total protein. The addition of antioxidant vitamins had no effect on lung weight, but increased DNA and protein contents. TTF-1, HNF-3beta, and SP-B proteins were decreased in lung homogenates of exposed rats with CDH. The addition of antioxidant vitamins nearly normalized these values. CONCLUSIONS The effects of nitrofen in fetal rat lungs are reversed in part by antioxidant vitamins by upregulating the expression of TTF-1, HNF-3beta, and SP-B. This approach could help to develop transplacental prenatal interventions for CDH.
Collapse
Affiliation(s)
- Salome Gonzalez-Reyes
- Department of Pediatric Surgery, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | | | | | | | | |
Collapse
|
28
|
Affiliation(s)
- David W Kays
- Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA.
| |
Collapse
|
29
|
Bütter A, Bratu I, Flageole H, Laberge JM, Kovacs L, Faucher D, Piedoboeuf B. Fetal tracheal occlusion in lambs with congenital diaphragmatic hernia: role of exogenous surfactant at birth. Pediatr Res 2005; 58:689-94. [PMID: 16189194 DOI: 10.1203/01.pdr.0000180534.42731.95] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fetal tracheal occlusion (TO) has been used to reverse the lung hypoplasia associated with congenital diaphragmatic hernia (CDH). However, TO has a detrimental effect on type II pneumocyte function and surfactant production. Previously, we have shown that in surgically created CDH lambs, TO improved markedly the response to resuscitation even though the lungs remain surfactant deficient. The goal of this investigation was to assess the effects of exogenous surfactant administered at birth to CDH lambs with or without fetal TO during 8 h of resuscitation. Lambs were divided into five groups: CDH, CDH+surfactant (SURF), CDH+TO, CDH+TO+SURF, and nonoperated controls. A left-sided CDH was created in fetal lambs at 80 d gestation. TO was performed at 108 d, and the lambs were delivered by hysterotomy at 136 d. Bovine lipid extract surfactant was administered before the first breath and again at 4 h of life. All CDH+SURF lambs, but only three of five CDH lambs, survived up to 8 h. When compared with the corresponding nonsurfactant-treated group, surfactant-treated CDH and CDH+TO lambs did not demonstrate improved alveolar-arterial oxygen gradients, pH, or Pco(2). In fact, in the CDH+TO group, surfactant treatment significantly worsened ventilation efficiency as measured by the ventilation efficiency index. The observed improvement in pulmonary compliance secondary to surfactant treatment was not significant. This investigation demonstrates that prophylactic surfactant treatment at birth does not improve gas exchange or ventilation efficiency in CDH lambs with or without TO.
Collapse
Affiliation(s)
- Andreana Bütter
- Division of Pediatric Surgery, Montréal Children's Hospital, McGill University Health Centre, Canada
| | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
With the use of stable isotope-labeled intravenous precursors for surfactant phosphatidylcholine (PC) synthesis, it has been shown that the de novo synthesis rates in preterm infants with respiratory distress syndrome (RDS) are very low as are turnover rates. This is consistent with animal data. Surfactant therapy does not inhibit endogenous surfactant synthesis, and prenatal corticosteroids stimulate it. With the use of stable isotope-labeled PC given endotracheally, surfactant pool size was estimated. It turned out to be low in RDS, as expected. Similar studies were performed in term neonates with severe lung diseases. In general, patients with lung injury show a lower surfactant synthesis. The controversy around surfactant in congenital diaphragmatic hernia (CDH) persists: studies on CDH with and without extracorporeal membrane oxygenation yielded different results. In severe meconium aspiration syndrome surfactant synthesis was found to be decreased but surfactant pool size was maintained. It is possible and safe to study surfactant metabolism in human neonates with the use of stable isotopes. This can help in answering clinical questions and has the potential to bring new in vitro and animal findings about surfactant metabolism to the patient.
Collapse
Affiliation(s)
- L J I Zimmermann
- Division of Neonatology, University Hospital Maastricht, Maastricht, The Netherlands.
| | | | | | | | | |
Collapse
|
31
|
Davey MG, Biard JM, Robinson L, Tsai J, Schwarz U, Danzer E, Adzick NS, Flake AW, Hedrick HL. Surfactant protein expression is increased in the ipsilateral but not contralateral lungs of fetal sheep with left-sided diaphragmatic hernia. Pediatr Pulmonol 2005; 39:359-67. [PMID: 15704191 DOI: 10.1002/ppul.20175] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Congenital diaphragmatic hernia (CDH) impairs fetal lung growth and increases the density of alveolar epithelial type 2 (AE2) cells. There is controversy whether surfactant protein (SP) expression is altered in CDH. The primary aim of this study was to assess SP expression (mRNA and protein) in the left and right lungs of fetal sheep with and without a diaphragmatic hernia (DH). Left-sided DH was created in four fetal sheep at 65 days of gestational age (g.a.). Sham-operated animals were used as controls. At 138 days g.a., lungs were harvested and the following parameters were measured: SP-A, -B, and -C mRNA expression (Northern blot), SP-A and -B expression (Western blot), and AE2 cell density (immunohistochemistry). The lung weight-to-body weight ratio was reduced by 42% in DH animals. The left-to-right lung weight ratio was lower in DH animals (0.47 +/- 0.03 vs. 0.69 +/- 0.03), indicative of asymmetric lung growth. SP-A, -B, and -C mRNA expression were increased by 61.7%, 32.9%, and 75.5%, respectively, in the left lungs of DH animals. SP-A and SP-B were also increased in DH. In the right lung, SP expression (mRNA and protein) was not different between groups. AE2 cell density was higher (by 67%) in the left but not right lungs of DH animals. Although DH in fetal sheep results in significant lung hypoplasia, SP expression is not reduced. On the contrary, SP expression was increased in the ipsilateral lung of fetuses with left-sided DH. Furthermore, AE2 cell density is increased in DH, suggesting that the increase in SP mRNA and protein levels is due to increases AE2 cell number. Our data further support the premise that fetal lung hypoplasia favors an AE2 phenotype.
Collapse
Affiliation(s)
- Marcus G Davey
- Children's Institute for Surgical Science and Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Abramson 1112 D, 3615 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Congenital Diaphragmatic Hernia (CDH) is a congenital disorder with an incidence of 1 in 2500 live births. Respiratory distress of newborns with CDH is the result of pulmonary hypoplasia and pulmonary hypertension. Hypoplastic lungs are characterized by a decreased number of airways with smaller airspaces, whereas the combination of a decreased number of vascular branches and an increased adventitia and medial thickness of the pulmonary arterial walls result in pulmonary hypertension. The appearance of the CDH lungs suggests that its complete formation is stalled during development. Understanding the basic mechanisms of lung development is mandatory to unravel the origin of CDH. Although the histological abnormalities in CDH lungs have been well described, less is known about the underlying molecular mechanisms. In this review we will discuss the current molecular and genetic background of lung formation, as well as a reflection of this knowledge towards CDH.
Collapse
Affiliation(s)
- Robbert Rottier
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | |
Collapse
|
33
|
Harrington KP, Goldman AP. The role of extracorporeal membrane oxygenation in congenital diaphragmatic hernia. Semin Pediatr Surg 2005; 14:72-6. [PMID: 15770591 DOI: 10.1053/j.sempedsurg.2004.10.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this paper is to review the role of extracorporeal membrane oxygenation (ECMO) in neonates with severe acute hypoxemic respiratory failure secondary to congenital diaphragmatic hernia (CDH). The difficulties in identifying patients with fatal lung hypoplasia are highlighted and the role of adjunctive therapies on ECMO (surfactant, inhaled nitric oxide, high-frequency ventilation and liquid lung distension) as well as the timing of surgical repair is discussed. Survivors of severe CDH who have been supported on ECMO have significant late mortality and morbidity. There remains a need for a randomized controlled trial of the role of ECMO in neonates with severe CDH.
Collapse
|
34
|
Escande B, Kuhn P, Rivera S, Messer J. Les déficits secondaires en surfactant. Arch Pediatr 2004; 11:1351-9. [PMID: 15519836 DOI: 10.1016/j.arcped.2004.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2003] [Accepted: 05/19/2004] [Indexed: 11/21/2022]
Abstract
Preterm babies born before the 33rd week of gestation often exhibit primary surfactant deficiency responsible for the respiratory distress syndrome or hyaline membrane disease. In that situation, there is a limited and insufficient production of surfactant by type II alveolar cells of the lung due to immaturity. Secondary surfactant deficiencies occur in patients with prior normal surfactant synthesis and can be related to sepsis, hypoxia, ventilator induced lung injury or surfactant inhibition by a variety of substances reaching the alveolar spaces. They occur in full-term newborns with meconium aspiration syndrome, acute respiratory distress syndrome and congenital diaphragmatic hernia. In children and adults, acute respiratory distress syndrome and respiratory syncytial virus bronchiolitis can be responsible. In prematures they occur after the initial primary deficiency during pulmonary hemorrhage, pneumonia and bronchopulmonary dysplasia. Treatment with exogenous surfactant may be beneficial. There is a need for randomized controlled studies for evaluation of this treatment. Next generation of surfactants containing recombinant surfactant protein or synthetic peptides appear as promising agents in these situations of secondary surfactant deficiencies.
Collapse
Affiliation(s)
- B Escande
- Service de pédiatrie-II, médecine néonatale et réanimation pédiatrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, avenue Molière, 67098 Strasbourg cedex, France
| | | | | | | |
Collapse
|
35
|
Colby CE, Lally KP, Hintz SR, Lally PA, Tibboel D, Moya FR, VanMeurs KP. Surfactant replacement therapy on ECMO does not improve outcome in neonates with congenital diaphragmatic hernia. J Pediatr Surg 2004; 39:1632-7. [PMID: 15547824 DOI: 10.1016/j.jpedsurg.2004.07.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND PURPOSE Respiratory failure in neonates with congenital diaphragmatic hernia (CDH) may in part be caused by a primary or secondary surfactant deficiency. Knowledge of the optimal approach to surfactant replacement in neonates with CDH and respiratory failure is limited. The aim of this study was to determine if surfactant replacement on extracorporeal membrane oxygenation (ECMO) results in improved outcomes in neonates > or =35 weeks' gestation with unrepaired CDH. METHODS Using the CDH Study Group Registry, the authors identified 448 neonates with CDH who were > or =35 weeks' gestation, had no major anomalies, were treated with ECMO within the first 7 days of life, and underwent repair on or after ECMO therapy. Patients in 2 groups were compared: group 1 (- Surf, n = 334) consisted of patients who received no surfactant and group 2 (+ Surf, n = 114) consisted of patients who received at least 1 dose of surfactant while on ECMO. An analysis of all patients in both groups was performed. Additionally, subgroup analyses stratified by gestational age were performed for patients 351/7 to 366/7 weeks' gestation and for patients > or =37 weeks' gestation. Primary end-points for the study were survival and length of ECMO run. Secondary end-points were length of intubation, need for supplemental oxygen at 30 days of life, and at discharge to home. Demographic, clinical, and outcome variables were examined using Fisher's Exact tests for categorical variables and using unpaired t tests for continuous variables. Odds ratios were calculated for categorical end-point variables. RESULTS Demographic and clinical variables were similar between groups. Analyses of aggregate data showed no significant differences between groups in length of ECMO run, survival, number of days intubated, and percent of patients requiring supplemental oxygen at 30 days or discharge. Subgroup stratification by gestational age did not show significant differences between groups in any of the outcome variables. CONCLUSIONS The data from this study suggest that surfactant replacement on ECMO for neonates with congenital diaphragmatic hernia does not provide significant benefit in the infant's clinical course with respect to survival, length of ECMO course, length of intubation, or subsequent need for supplemental oxygen.
Collapse
Affiliation(s)
- Christopher E Colby
- Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA 94304, USA
| | | | | | | | | | | | | |
Collapse
|
36
|
Van Meurs K. Is surfactant therapy beneficial in the treatment of the term newborn infant with congenital diaphragmatic hernia? J Pediatr 2004; 145:312-6. [PMID: 15343181 DOI: 10.1016/j.jpeds.2004.04.056] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine the impact of surfactant replacement on survival, need for extracorporeal membrane oxygenation (ECMO), and chronic lung disease in term infants with prenatally diagnosed congenital diaphragmatic hernia (CDH). STUDY DESIGN Prenatally diagnosed infants born at > or =37 weeks' gestation with immediate distress at delivery and no other major congenital anomalies, who were enrolled in the CDH Registry, were analyzed. For univariate analysis, chi 2 tests were used for categoric variables and unpaired t tests for nominal variables. Multiple logistic regression was used to calculate adjusted odds ratios. RESULTS Eligible infants (n = 522) were identified. Demographic variables were similar between the surfactant-treated (n = 192) and nonsurfactant-treated (n = 330) groups, with the exception of race (white, 88.0% vs 71.2%; P =.0007). The use of ECMO and incidence of chronic lung disease were higher (59.8 vs 50.6, P =.04; 59.9 vs 47.6, P =.0066) and survival lower in the surfactant-treated cohort (57.3 vs 70.0, P =.0033). Adjusted logistic regression for use of ECMO, survival, and chronic lung disease resulted in odds ratios inconsistent with an improved outcome associated with surfactant use. CONCLUSIONS This analysis shows no benefit associated with surfactant therapy for term infants with a prenatal diagnosis of isolated CDH.
Collapse
Affiliation(s)
- Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, 750 Welch Road, Palo Alto, CA 94304, USA.
| |
Collapse
|
37
|
Cogo PE, Zimmermann LJI, Verlato G, Midrio P, Gucciardi A, Ori C, Carnielli VP. A dual stable isotope tracer method for the measurement of surfactant disaturated-phosphatidylcholine net synthesis in infants with congenital diaphragmatic hernia. Pediatr Res 2004; 56:184-90. [PMID: 15181183 DOI: 10.1203/01.pdr.0000132665.73234.f6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim of the study was to measure for the first time in humans surfactant disaturated-phosphatidylcholine (DSPC) net synthesis and kinetics by using a novel, dual stable isotope tracer approach. Ten infants with congenital diaphragmatic hernia [CDH; birth weight, 3.4 +/- 0.2; gestational age, 39.8 +/- 0.4 wk] and 6 age-matched control subjects with no lung disease (birth weight, 3.2 +/- 0.3 kg; gestational age, 39.1 +/- 1.1 wk), all of whom were admitted to the neonatal intensive care unit (Padua, Italy), were studied. All infants received simultaneously an intratracheal (carbon-13 di-palmitoyl-phosphatidylcholine) and an i.v. (deuterated palmitic acid) stable isotope tracer. Isotopic enrichment curves of DSPC from sequential tracheal aspirates were analyzed by mass spectrometry. DSPC kinetic data were expressed as mean +/- SEM and compared by the Mann-Whitney test. DSPC net synthesis from plasma palmitate was nearly identical in infants with CDH and control subjects (8.6 +/- 2.2 and 8.1 +/- 1.5 mg. kg(-1). d(-1); P = 0.7). DSPC apparent pool size was 36.7 +/- 7.5 and 58.5 +/- 9.1 mg/kg (P = 0.07) and half-life was 26.7 +/- 4.5 and 50.3 +/- 9.7 h (P = 0.03) in infants with CDH and control subjects, respectively. Both DSPC turnover and percentage of catabolism/recycling significantly correlated with duration of mechanical ventilation. In conclusion, the measurements of net DSPC synthesis and catabolism/recycling were reported for the first time in humans. Mean net DSPC synthesis was approximately 8 mg. kg(-1). d(-1). No significant differences were found between control subjects and infants with CDH. DSPC turnover was faster in infants with CDH, presumably reflecting an increased DSPC catabolism/recycling. Whether this may ultimately lead to a secondary surfactant deficiency in infants with CDH is still to be ascertained.
Collapse
Affiliation(s)
- Paola E Cogo
- Department of Pediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy.
| | | | | | | | | | | | | |
Collapse
|
38
|
Lally KP, Lally PA, Langham MR, Hirschl R, Moya FR, Tibboel D, Van Meurs K. Surfactant does not improve survival rate in preterm infants with congenital diaphragmatic hernia. J Pediatr Surg 2004; 39:829-33. [PMID: 15185206 DOI: 10.1016/j.jpedsurg.2004.02.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Use of exogenous surfactant in congenital diaphragmatic hernia (CDH) patients is routine in many centers. The authors sought to determine the impact of surfactant use in the premature infant with CDH. METHODS Data on liveborn infants with CDH from participating institutions were collected prospectively. Surfactant use and timing and outcome data were analyzed retrospectively. The authors evaluated the prenatal diagnosis patients as well. The outcome variable was survival to discharge. Odds ratios with confidence intervals were calculated. RESULTS Five hundred ten infants less than 37 weeks' gestation were entered in the CDH registry. Infants with severe anomalies (n = 80) were excluded. Information on surfactant use was available for 424 patients. Infants receiving surfactant (n = 209) had a greater odds of death than infants not receiving surfactant (n = 215, odds ratio, 2.17, 95% CI: 1.5 to 3.2; P <.01). In prenatally diagnosed infants with immediate distress, there was a trend toward worse survival rates among those receiving surfactant at 1 hour (52 patients) versus those that did not (93 patients; odds ratio, 1.93, 95% CI: 0.96 to 3.9; P <.07). CONCLUSIONS Surfactant, as currently used, is associated with a lower survival rate in preterm infants with CDH. The use of surfactant replacement in premature infants with CDH can be recommended only within the context of a randomized clinical trial.
Collapse
Affiliation(s)
- Kevin P Lally
- Department of Surgery, University of Texas-Houston, 6431 Fannin St, MSB 5.258, Houston, TX 77030, USA
| | | | | | | | | | | | | |
Collapse
|
39
|
Affiliation(s)
- M Hösgor
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
40
|
Van Tuyl M, Blommaart PJE, Keijzer R, Wert SE, Ruijter JM, Lamers WH, Tibboel D. Pulmonary surfactant protein A, B, and C mRNA and protein expression in the nitrofen-induced congenital diaphragmatic hernia rat model. Pediatr Res 2003; 54:641-52. [PMID: 12904592 DOI: 10.1203/01.pdr.0000086906.19683.42] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neonates with congenital diaphragmatic hernia (CDH) suffer from a diaphragmatic defect, lung hypoplasia, and pulmonary hypertension, with poor lung function forming the major clinical challenge. Despite prenatal diagnosis and advanced postnatal treatment strategies, the mortality rate of CDH is still high. CDH has been subject of extensive research over the past decades, but its etiology remains unknown. A major problem with CDH is the failure to predict the individual response to treatment modalities like high-frequency ventilation, inhaled nitric oxide, and extracorporeal membrane oxygenation. In this study, we tested the possibility that CDH lungs are surfactant protein deficient, which could explain the respiratory failure and difficulties in treating CDH infants. We investigated this hypothesis in the nitrofen-induced CDH rat model and assessed the cellular concentrations of surfactant protein (SP)-A, -B, and -C mRNA with a quantitative radioactive in situ hybridization technique. No differences were observed between control and CDH lungs for SP mRNA expression patterns. The cellular concentration (mean OD) of SP-A and SP-B mRNA was similar at all stages whereas the mean OD of SP-C mRNA and the volume fraction of cells (% Area) expressing SP mRNA was higher in CDH lungs at term. Immunohistochemical analysis revealed no differences between control and CDH lungs for SP protein expression. No differences in the mean OD or % Area for the SP mRNAs were found between the ipsi- and contralateral side of CDH lungs. We conclude that there is no primary deficiency of surfactant proteins in the nitrofen-induced CDH rat model.
Collapse
Affiliation(s)
- Minke Van Tuyl
- Department of Surgery, Sophia Children's Hospital, Erasmus Medical Center Rotterdam, 3015 GJ Rotterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
41
|
Cogo PE, Zimmermann LJI, Meneghini L, Mainini N, Bordignon L, Suma V, Buffo M, Carnielli VP. Pulmonary surfactant disaturated-phosphatidylcholine (DSPC) turnover and pool size in newborn infants with congenital diaphragmatic hernia (CDH). Pediatr Res 2003; 54:653-8. [PMID: 12904604 DOI: 10.1203/01.pdr.0000084344.42409.c6] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In animal CDH models, surfactant deficiency contributes to the pathophysiology of the condition but information on human disease is very limited. The aim of our study was to investigate surfactant kinetics in CDH newborns. We studied surfactant disaturated-phosphatidylcholine (DSPC) half-life, turnover and apparent pool size by stable isotope methodology in CDH newborns with no ExtraCorporeal Membrane Oxygenation (ECMO) support (n = 13, birth weight (BW) 3.2 +/- 2.2 kg, gestational age (GA) 39 +/- 0.4 wks, postnatal age 43 +/- 11 h) and in 8 term infants with no lung disease (CONTROLS, BW 2.7 +/- 0 kg, GA 38 +/- 0.8 wks, postnatal age 96 +/- 26 h). We administered a trace dose of 13C-palmitic acid dipalmitoyl-phosphatidylcholine (DPPC) through the endotracheal (ET) tube and we measured DSPC kinetics by gas chromatography-mass spectrometry from DSPC13C-enrichment decay curves obtained from sequential tracheal aspirates. DSPC amount from tracheal aspirates (TA-DSPC) was measured by gas chromatography. In CDH infants DSPC half-life was shorter (24 +/- 4 and 53 +/- 11 h, p = 0.01), turnover faster (0.6 +/- 0.1 and 1.5 +/- 0.3 d-1 p = 0.01), apparent pool size smaller (34 +/- 6 and 57 +/- 7 mg/kg body weight, p = 0.02) and tracheal aspirates DSPC amount lower (2.4 +/- 0.4 and 4.6 +/- 0.5 mg/mL Epithelial Lining Fluid (ELF), p = 0.007) than in CONTROLS. In conclusion surfactant kinetics is grossly abnormal in mechanically ventilated CDH. Whether alterations of DSPC kinetics in CDH infants are caused by a primary surfactant deficiency or are secondary to oxygen therapy and ventilator support has still to be determined.
Collapse
Affiliation(s)
- Paola E Cogo
- Department of Pediatrics, University of Padova, Padova, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Janssen DJMT, Tibboel D, Carnielli VP, van Emmen E, Luijendijk IHT, Darcos Wattimena JL, Zimmermann LJI. Surfactant phosphatidylcholine pool size in human neonates with congenital diaphragmatic hernia requiring ECMO. J Pediatr 2003; 142:247-52. [PMID: 12640370 DOI: 10.1067/mpd.2003.94] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We measured surfactant phosphatidylcholine (PC) pool size and half-life in human congenital diaphragmatic hernia (CDH) patients who required extracorporeal membrane oxygenation (ECMO). Study design Surfactant PC pool size and half-life were measured by endotracheal administration of deuterium-labeled dipalmitoylphosphatidylcholine in 8 neonates with CDH on ECMO (CDH-ECMO), in 7 neonates with meconium aspiration syndrome on ECMO (MAS-ECMO), and in 6 ventilated infants (NON-ECMO). RESULTS Lung PC pool size in the CDH-ECMO group was 73 +/- 17 mg/kg (mean +/- SEM), which was not significantly different from the MAS-ECMO (50 +/- 18 mg/kg) and the NON-ECMO group (69 +/- 38 mg/kg). Surfactant PC concentration in tracheal aspirates was not different between groups (~6 mg/mL). However, the percentage of palmitic acid in surfactant PC was significantly lower in the MAS-ECMO (56.3%) and the NON-ECMO (55.8%) group compared with the CDH-ECMO (67.6%) group. Surfactant PC half-life (~24 hours) was not different between the groups. A correlation was found between the surfactant PC half-life and the duration of ECMO. CONCLUSIONS These data show no decreased surfactant PC pool size in high risk CDH patients who require ECMO. A shorter half-life of surfactant PC, indicating a faster turnover, may result in a faster improvement of the pulmonary condition during ECMO.
Collapse
Affiliation(s)
- Daphne J M T Janssen
- Department of Pediatrics/Neonatology, Sophia Children's Hospital/Erasmus University Rotterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
43
|
Janssen DJMT, Carnielli VP, Cogo PE, Seidner SR, Luijendijk IHI, Wattimena JLD, Jobe AH, Zimmermann LJI. Surfactant phosphatidylcholine half-life and pool size measurements in premature baboons developing bronchopulmonary dysplasia. Pediatr Res 2002; 52:724-9. [PMID: 12409520 DOI: 10.1203/00006450-200211000-00019] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Because minimal information is available about surfactant metabolism in bronchopulmonary dysplasia, we measured half-lives and pool sizes of surfactant phosphatidylcholine in very preterm baboons recovering from respiratory distress syndrome and developing bronchopulmonary dysplasia, using stable isotopes, radioactive isotopes, and direct pool size measurements. Eight ventilated premature baboons received (2)H-DPPC (dipalmitoyl phosphatidylcholine) on d 5 of life, and radioactive (14)C-DPPC with a treatment dose of surfactant on d 8. After 14 d, lung pool sizes of saturated phosphatidylcholine were measured. Half-life of (2)H-DPPC (d 5) in tracheal aspirates was 28 +/- 4 h (mean +/- SEM). Half-life of radioactive DPPC (d 8) was 35 +/- 4 h. Saturated phosphatidylcholine pool size measured with stable isotopes on d 5 was 129 +/- 14 micro mol/kg, and 123 +/- 11 micro mol/kg on d 14 at autopsy. Half-lives were comparable to those obtained at d 0 and d 6 in our previous baboon studies. We conclude that surfactant metabolism does not change during the early development of bronchopulmonary dysplasia, more specifically, the metabolism of exogenous surfactant on d 8 is similar to that on the day of birth. Surfactant pool size is low at birth, increases after surfactant therapy, and is kept constant during the first 2 wk of life by endogenous surfactant synthesis. Measurements with stable isotopes are comparable to measurements with radioactive tracers and measurements at autopsy.
Collapse
Affiliation(s)
- Daphne J M T Janssen
- Department of Pediatrics/Neonatology, Sophia's Children's Hospital/Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Benachi A, Chailley-Heu B, Barlier-Mur AM, Dumez Y, Bourbon J. Expression of surfactant proteins and thyroid transcription factor 1 in an ovine model of congenital diaphragmatic hernia. J Pediatr Surg 2002; 37:1393-8. [PMID: 12378441 DOI: 10.1053/jpsu.2002.35375] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The question of delayed lung maturation in congenital diaphragmatic hernia (CDH) is pending. Data about surfactant proteins (SPs) are sparse in human fetuses and discrepant in the ovine CDH model. The purpose of this study was to investigate, in the ovine surgically created CDH model, the expression of SPs and of thyroid transcription factor 1 (TTF-1), a key regulator of lung development that also controls the expression of surfactant proteins. METHODS Diaphragmatic hernia (DH) was created surgically in lamb fetuses on day 85 of gestation. On day 139, 5 DH and 6 control fetuses were retrieved by cesarean section. The mRNA levels for SPs and TTF-1 were determined by Northern blot analysis; SP-A and SP-B protein levels were assessed by Western blot analysis. RESULTS In DH lungs, SP-A, SP-B, and SP-C messenger RNAs were diminished by 82%, 67%, and 32%, respectively, compared with control level. SP-A and SP-B protein amounts were decreased consistently. TTF-1 expression was not altered in the surgical model. CONCLUSIONS SP's deficiency appears to be a common feature of the various CDH models. By contrast with the nitrofen model, TTF-1 expression was not altered in the surgical model indicating different underlying molecular mechanisms in both models.
Collapse
Affiliation(s)
- Alexandra Benachi
- Maternité Hospitalo-Universitaire Necker-Enfants Malades, Paris, France
| | | | | | | | | |
Collapse
|
45
|
Cogo PE, Zimmermann LJI, Rosso F, Tormena F, Gamba P, Verlato G, Baritussio A, Carnielli VP. Surfactant synthesis and kinetics in infants with congenital diaphragmatic hernia. Am J Respir Crit Care Med 2002; 166:154-8. [PMID: 12119226 DOI: 10.1164/rccm.2108028] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In animal models of congenital diaphragmatic hernia (CDH), surfactant deficiency contributes to the pathophysiology of the disease; however, information on CDH in humans is limited. We compared surfactant disaturated phosphatidylcholine (DSPC) synthesis and metabolism, by stable isotope technology, in newborn infants with CDH and in control subjects. DSPC amount, total proteins, and surfactant protein-A (SP-A) from tracheal aspirates were also measured. DSPC and SP-A were significantly lower in 14 infants with CDH than in the eight control subjects. Mean DSPC was 2.3 +/- 1.3 mg/ml of epithelial lining fluid (ELF) in infants with CDH and 4.6 +/- 1.5 mg/ml of ELF in control subjects (p = 0.001). Mean SP-A in infants with CDH and in control subjects was 16.2 +/- 9.3 and 61.2 +/- 30.6 microg/ml of ELF, respectively (p = 0.03). DSPC kinetics was measured in 12 of 14 infants with CDH and in 5 of 8 control subjects. Secretion time was 8.3 +/- 5.5 and 8.5 +/- 2.5 hours and peak time 51.9 +/- 15.2 and 51 +/- 13 hours in infants with CDH and in control subjects, respectively. Fractional synthesis rate was not different for infants with CDH and control subjects (p = 0.4). In conclusion, surfactant DSPC synthesis and kinetics were not significantly deranged in infants with CDH compared with control subjects. Other factors, such as lower surface area or increased DSPC catabolism, may contribute to surfactant pool alteration in CDH.
Collapse
Affiliation(s)
- Paola E Cogo
- Department of Pediatrics, Division of Pediatric Surgery, and Institute of Internal Medicine, University of Padova, Padova, Italy
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Van Tuyl M, Hösgor M, Tibboel D. Tracheal ligation and corticosteroids in congenital diaphragmatic hernia: for better for worse? Pediatr Res 2001; 50:441-4. [PMID: 11568285 DOI: 10.1203/00006450-200110000-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- M Van Tuyl
- Department of Pediatric Surgery, Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
| | | | | |
Collapse
|
47
|
Thébaud B, Barlier-Mur AM, Chailley-Heu B, Henrion-Caude A, Tibboel D, Dinh-Xuan AT, Bourbon JR. Restoring effects of vitamin A on surfactant synthesis in nitrofen-induced congenital diaphragmatic hernia in rats. Am J Respir Crit Care Med 2001; 164:1083-9. [PMID: 11588001 DOI: 10.1164/ajrccm.164.6.2010115] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a major cause of refractory respiratory failure in the newborn. Besides pulmonary hypoplasia, the pathophysiology of CDH also includes surfactant deficiency. Vitamin A (vit A) is important for various aspects of lung development. We hypothesized that antenatal treatment with vit A would stimulate lung surfactant synthesis in experimental CDH induced in rats by maternal ingestion of the herbicide nitrofen (2,4-dichloro-phenyl-p-nitrophenyl-ether) on Day 12. Fetuses were assigned to six experimental groups: (1) controls from rats that received olive oil, the vehicle; (2) fetuses from rats that received olive oil on Day 12 and vit A orally (15,000 IU) on Day 14; (3) nitrofen (N)-exposed fetuses without diaphragmatic hernia (N/no DH); (4) N/no DH from rats given vit A on Day 14; (5 ) nitrofen-exposed fetuses with DH (N/+DH); (6) N/+DH from rats given vit A on Day 14. Fetuses were delivered by C-section at Day 21. Lung DNA content was lowered in the nitrofen group as compared with the controls group, but increased by subsequent vit A treatment. Lung surfactant disaturated phosphatidylcholine was reduced in the N/+DH group and restored to control level by vit A. The expression level of surfactant proteins (SP) -A and -C was decreased in vit A-treated control rats and in nitrofen-exposed fetuses with or without DH. Vit A restored SP-A and -C mRNA expression to control levels in N/+DH. SP-B expression was lowered in N/no DH and increased by vit A in this group. The proportion of type II cells assessed by SP-B immunolabeling was lowered in N/+DH and restored by vit A treatment. We conclude that antenatal treatment with vit A restores lung maturation in nitrofen-induced hypoplastic lungs with CDH. These findings point out vit A as a potential therapeutical agent for correcting surfactant deficiency in CDH.
Collapse
Affiliation(s)
- B Thébaud
- Réanimation Néonatale-UPRES 2704, Hôpital Antoine Béclère, Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, France.
| | | | | | | | | | | | | |
Collapse
|
48
|
Bunt JE, Carnielli VP, Darcos Wattimena JL, Hop WC, Sauer PJ, Zimmermann LJ. The effect in premature infants of prenatal corticosteroids on endogenous surfactant synthesis as measured with stable isotopes. Am J Respir Crit Care Med 2000; 162:844-9. [PMID: 10988093 DOI: 10.1164/ajrccm.162.3.9906139] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Most in vitro studies show that prenatal administration of corticosteroids stimulates the synthesis of surfactant phosphatidylcholine (PC), but studies in animals are controversial. Whether prenatal corticosteroids stimulate surfactant PC synthesis in humans has not been studied. We studied endogenous surfactant PC synthesis in relation to prenatal corticosteroid treatment in 27 preterm infants with respiratory distress syndrome. Infants received a 24-h infusion of the stable isotope [U-(13)C]glucose, starting approximately 5 h after birth. We measured (13)C-incorporation into palmitic acid in surfactant PC from serial tracheal aspirates and in plasma triglycerides and phospholipids by isotope-ratio mass spectrometry. Premature infants had received either zero (n = 11), one (n = 4), or two doses (n = 12) of prenatal betamethasone (12 mg intramuscularly). The fractional synthesis rate (FSR) of surfactant PC from glucose was 1.7 +/- 0.3%/d without corticosteroid treatment, 2.9 +/- 1.4%/d with one dose of prenatal corticosteroid, and 5.8 +/- 1.3%/d after two doses of prenatal corticosteroid. Using multiple regression analysis, we found that the FSR of surfactant PC increased by 40% (confidence interval: 7 to 82%/d, p < 0.02) per dose of corticosteroid and doubled after two doses of corticosteroid. The (13)C-enrichment of plasma triglycerides and phospholipids was not increased by corticosteroid. These data show for the first time that prenatal corticosteroid treatment stimulates surfactant synthesis in the preterm infant.
Collapse
Affiliation(s)
- J E Bunt
- Department of Pediatrics, Sophia Children's Hospital, Department of Internal Medicine II, University Hospital Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
49
|
Keijzer R, van Tuyl M, Tibboel D. Hormonal modulation of fetal pulmonary development: relevance for the fetus with diaphragmatic hernia. Eur J Obstet Gynecol Reprod Biol 2000; 92:127-33. [PMID: 10986446 DOI: 10.1016/s0301-2115(00)00436-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Antenatal hormonal modulation of pulmonary growth has been successfully introduced in clinical practice to reduce the incidence of respiratory distress syndrome (RDS) of preterm born infants. However, a certain amount of reserve to repeat courses should be taken into account because of possible adverse effects of antenatal administration of glucocorticoids. Although in experimental animals thyroid hormones given alone were not shown to have stimulatory effects on pulmonary development, there was an apparent synergistic effect with corticosteroids. Yet, such effects have not been substantiated in clinical trials. Whereas in cases of congenital diaphragmatic hernia (CDH) in utero tracheal occlusion could stimulate fetal lung growth and modulation, the enhancement of type II cell differentiation is more likely to be achieved with antenatal exposure to hormonal therapies. However, there is still no firm scientific basis for either of these two treatment modalities in CDH. Yet, antenatal hormonal modulation is now soon to be tested in an extensive multi-center clinical trial. In this review, the current status of antenatal hormonal modulation of pulmonary growth will be described and its potential role in the treatment of CDH will be discussed.
Collapse
Affiliation(s)
- R Keijzer
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus Medical Centre Rotterdam, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | | | | |
Collapse
|
50
|
Rüdiger M, von Baehr A, Haupt R, Wauer RR, Rüstow B. Preterm infants with high polyunsaturated fatty acid and plasmalogen content in tracheal aspirates develop bronchopulmonary dysplasia less often. Crit Care Med 2000; 28:1572-7. [PMID: 10834714 DOI: 10.1097/00003246-200005000-00052] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Oxygen toxicity causes chronic bronchopulmonary dysplasia (BPD) in extremely preterm infants. Polyunsaturated fatty acids (PUFA) and plasmalogens are the two main substrates for lipid peroxidation in the pulmonary surfactant. In the present study, we tested whether low concentrations of both were associated with development of BPD and whether both were further reduced during mechanical ventilation with oxygen. DESIGN Prospective, noninterventional, descriptive study. SETTING Level III neonatal intensive care unit in a university hospital. PATIENTS In 25 extremely low birth weight infants with respiratory distress syndrome, tracheal aspirates were collected immediately after birth and in the following 4 days. As control, tracheal and pharyngeal aspirates were collected from healthy infants immediately after birth. The amount of PUFA and dimethylacetals (DMA, representing plasmalogens) was determined gas-chromatographically. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The relative percentages of PUFA and DMA on all fatty acids in non-BPD infants (PUFA% 26+/-8.9, DMA% 3.5+/-1.2) were higher compared with infants who developed BPD (PUFA% 14.5+/-3.8, DMA% 1.8+/-0.9). In term healthy infants, DMA% and PUFA% were in the same range as in the BPD group. The higher levels found for non-BPD infants decreased after day 1 to values equal to the BPD group and remained low. CONCLUSIONS The results suggest that initially higher levels of PUFA and plasmalogens in the tracheal effluent are associated with a reduced risk of developing BPD and are reduced during the first day of ventilation.
Collapse
Affiliation(s)
- M Rüdiger
- Department of Neonatology, Charité, Hospital of Humboldt University, Berlin, Germany
| | | | | | | | | |
Collapse
|