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Hascoët JM, Picaud JC, Ligi I, Blanc T, Daoud P, Zupan V, Moreau F, Guilhoto I, Rouabah M, Alexandre C, Saliba E, Storme L, Patkai J, Pomedio M, Hamon I. Review shows that using surfactant a number of times or as a vehicle for budesonide may reduce the risk of bronchopulmonary dysplasia. Acta Paediatr 2018; 107:1140-1144. [PMID: 29193276 DOI: 10.1111/apa.14171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/17/2017] [Accepted: 11/23/2017] [Indexed: 01/09/2023]
Abstract
AIM Bronchopulmonary dysplasia (BPD) remains the most common respiratory morbidity in immature infants. This review describes the diagnosis of BPD has evolved and summarises the therapeutic approaches that have made it possible to limit the incidence of BPD. METHOD We reviewed the literature from the first definition of BPD by Northway in 1967 to the surfactant treatment policies that are currently in use, drawing on more than 50 papers up to 2017. RESULTS Our review showed that improvements in neonatal survival have been associated with an increased risk of severe BPD, significant levels of long-term morbidity and the increased use of healthcare resources. These issues have encouraged researchers to explore potential new treatments that limit the incidence of BPD. Repeated surfactant instillation and the use of surfactant as a vehicle for budesonide are promising strategies for alleviating the burden of chronic lung disease. Ongoing research on surfactant or stem cell therapy may further improve the respiratory prognosis for prematurely born children. CONCLUSION Considerable research has been carried out into the increase in BPD, which has resulted from improvements in neonatal survival. Key areas of research include repeated surfactant administration, using surfactant as a vehicle for budesonide and stem cell therapy.
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Affiliation(s)
- JM Hascoët
- DevAH; University of Lorraine; Maternité Régionale; CHRU; Nancy France
| | - JC Picaud
- Neonatal Unit; Hôpital de la croix rousse; Hospices Civils; Lyon France
| | - I Ligi
- AP-HM Marseille; Marseille France
| | | | - P Daoud
- CH Montreuil; Montreuil France
| | - V Zupan
- AP-HP Clamart; Clamart France
| | | | | | - M Rouabah
- DevAH; University of Lorraine; Maternité Régionale; CHRU; Nancy France
| | | | | | | | - J Patkai
- AP-HP Paris Port Royal; Paris France
| | | | - I Hamon
- DevAH; University of Lorraine; Maternité Régionale; CHRU; Nancy France
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Inhaled nitric oxide prevents 3-nitrotyrosine formation in the lungs of neonatal mice exposed to >95% oxygen. Lung 2010; 188:217-27. [PMID: 20237791 DOI: 10.1007/s00408-010-9235-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 03/02/2010] [Indexed: 10/19/2022]
Abstract
Inhaled nitric oxide is being evaluated as a preventative therapy for patients at risk for bronchopulmonary dysplasia (BPD). Nitric oxide (NO), in the presence of superoxide, forms peroxynitrite, which reacts with tyrosine residues on proteins to form 3-nitrotyrosine (3-NT). However, NO can also act as an antioxidant and was recently found to improve the oxidative balance in preterm infants. Thus, we tested the hypothesis that the addition of a therapeutically relevant concentration (10 ppm) of NO to a hyperoxic exposure would lead to decreased 3-NT formation in the lung. FVB mouse pups were exposed to either room air (21% O(2)) or >95% O(2) with or without 10 ppm NO within 24 h of birth. In the first set of studies, body weights and survival were monitored for 7 days, and exposure to >95% O(2) resulted in impaired weight gain and near 100% mortality by 7 days. However, the mortality occurred earlier in pups exposed to >95% O(2) + NO than in pups exposed to >95% O(2) alone. In a second set of studies, lungs were harvested at 72 h. Immunohistochemistry of the lungs at 72 h revealed that the addition of NO decreased alveolar, bronchial, and vascular 3-NT staining in pups exposed to both room air and hyperoxia. The lung nitrite levels were higher in animals exposed to >95% oxygen + NO than in animals exposed to >95% oxygen alone. The protein levels of myeloperoxidase, monocyte chemotactic protein-1, and intracellular adhesion molecule-1 were assessed after 72 h of exposure and found to be greatest in the lungs of pups exposed to >95% O(2). This hyperoxia-induced protein expression was significantly attenuated by the addition of 10 ppm NO. We propose that in the presence of >95% O(2), peroxynitrite formation results in protein nitration; however, adding excess NO to the >95% O(2) exposure prevents 3-NT formation by NO reacting with peroxynitrite to produce nitrite and NO(2). We speculate that the decreased protein nitration observed with the addition of NO may be a potential mechanism limiting hyperoxic lung injury.
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Richir MC, van Leeuwen PAM, van den Berg A, Wessels R, Twisk JWR, Rauwerda JA, Teerlink T, de Vries TPGM, van Elburg RM. Plasma ADMA concentrations at birth and mechanical ventilation in preterm infants: a prospective pilot study. Pediatr Pulmonol 2008; 43:1161-6. [PMID: 18991340 DOI: 10.1002/ppul.20886] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
RATIONALE Nitric oxide (NO) produced in the lung is an important mediator of normal lung development, vascular smooth muscle relaxation, and ventilation perfusion matching. NO is synthesized from arginine by the action of NO-synthase (NOS). Asymmetric dimethylarginine (ADMA), an endogenous derivate of arginine, inhibits NOS and is thereby a determinant of NO synthesis. We compared ADMA and arginine levels in preterm infants requiring mechanical ventilation with preterm infants who did not require mechanical ventilation and determined the relation between ADMA and the length of mechanical ventilation in these infants. METHODS Thirty preterm infants, mean (SD) gestational age 29.3 (1.7) weeks and birth weight 1,340 (350) gram, of the Neonatal Intensive Care Unit of the VU University Medical Center were included. ADMA and arginine were measured in umbilical cord blood and the length of mechanical ventilation (days) was registered. RESULTS Gestational age and birth weight were significantly smaller in infants requiring mechanical ventilation, but were not significantly correlated with plasma ADMA concentration after birth. Plasma ADMA concentrations were significantly higher in infants who required mechanical ventilation than in infants who did not require mechanical ventilation (1.53 +/- 0.23 and 1.37 +/- 0.14 micromol/L, respectively; P = 0.036). ADMA concentration was significantly related to length of mechanical ventilation (B = 3.4; 95% CI: 1.1-5.6; P = 0.006), also after adjustment for gestational age (B = 2.3; 95% CI: 0.4-4.2; P = 0.024). CONCLUSIONS Preterm infants who require mechanical ventilation have increased ADMA levels compared to non-ventilated preterm infants. ADMA levels at birth are related to the length of mechanical ventilation. An increased ADMA concentration could reduce NO synthesis, which could lead to insufficient gas exchange and, consequently, a longer period of mechanical ventilation.
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Affiliation(s)
- Milan C Richir
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
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4
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Abstract
Inhaled nitric oxide (iNO) has quickly become a standard therapy for term and near-term infants with hypoxic respiratory failure and persistent pulmonary hypertension. Its effect on the lung is believed to be through the stimulation of soluble guanylyl cyclase and the increased production of cyclic guanosine 3',5'-monophosphate (cGMP). However, in addition to pulmonary vasodilation and a decrease in pulmonary vascular resistance, nitric oxide (NO) shows several additional potential beneficial effects on the lung. This article reviews NO mechanisms of action, early clinical trial of iNO and clinical aspects for the use of iNO in acute respiratory failure of the term and near-tem neonates.
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Tin W, Wiswell TE. Adjunctive therapies in chronic lung disease: examining the evidence. Semin Fetal Neonatal Med 2008; 13:44-52. [PMID: 17983879 DOI: 10.1016/j.siny.2007.09.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) is one of the most common long-term complications in very premature infants. The incidence of CLD has been increasing over the past two decades in parallel with an improvement in the survival of this population. We have witnessed a revolution in the therapies that are used, either to manage these infants' respiratory distress syndrome (RDS) with an aim to prevent CLD or to manage the established condition. Several devices and strategies have been developed to provide respiratory support with minimal risk of lung injuries. Multiple adjunctive agents have also been used either to reduce the risk of CLD or to mitigate its course. There is considerable evidence supporting the use of exogenous surfactant, but unfortunately many other therapies currently used for CLD, either preventative or as a treatment, are based on very little or no evidence. The gold standard to assess a given therapy is the randomised controlled trial (RCT), designed to look at clinically meaningful outcomes and long-term safety. In this context, we discuss the support - or lack thereof - for the adjunctive therapies used in relation to CLD. Many of the therapies have been examined as systematic reviews by the Cochrane Neonatal Review Group. These reviews are noted in the references and can be easily accessed at the following website sponsored by the National Institute of Child Health and Human Development: www.nichd.nih.gov/cochrane/default.cfm.
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Affiliation(s)
- Win Tin
- The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK.
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Abstract
This review provides the readers with background information on the state of the art and science of inhaled nitric oxide (iNO) as therapy for prevention or amelioration of bronchopulmonary dysplasia (BPD) in preterm infants. The goal is to review and critique relevant published information. A total of six clinical trials, all placebo-controlled, four out of six blinded, four out of six multi-centered with a predetermined outcome of reduction in death or BPD, have been reported in full text. These definitive studies have included a total of > 2100 preterm, mostly very preterm, infants. Their designs were informed by results of earlier non-definitive studies which cumulatively enrolled > 350 preterm patients. This very substantial experience provides a firm framework for asserting that iNO will be useful in this population of patients. The use of iNO can reduce the occurrence of BPD and possibly the severity of the disorder. Optimal time of initiation, dosing (both initial dose, duration of treatment and possibly the route of administration) and most importantly, optimal patient subset selection, are not determined. Any clear adverse neurological finding in iNO-treated infants will of course limit or halt the use of this promising therapy.
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Affiliation(s)
- William E Truog
- University of Missouri-Kansas City School of Medicine, Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri 64108, USA.
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Rosati E, Butera G, Bossone E, De Felice C, Latini G. Inhaled nitric oxide and oral nifedipine in a preterm infant with bronchopulmonary dysplasia and pulmonary hypertension. Eur J Pediatr 2007; 166:737-8. [PMID: 17103192 DOI: 10.1007/s00431-006-0292-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Revised: 07/14/2006] [Accepted: 08/22/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Enrico Rosati
- Division of Neonatology, Perrino Hospital, S.S. 7 per Mesagne, 72100 Brindisi, Italy
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Truog WE, Ballard PL, Norberg M, Golombek S, Savani RC, Merrill JD, Parton LA, Cnaan A, Luan X, Ballard RA. Inflammatory markers and mediators in tracheal fluid of premature infants treated with inhaled nitric oxide. Pediatrics 2007; 119:670-8. [PMID: 17403837 DOI: 10.1542/peds.2006-2683] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We compared serial measurements of inflammatory mediators and markers in infants treated with inhaled nitric oxide or placebo to assess the effects of inhaled nitric oxide therapy on lung inflammation during bronchopulmonary dysplasia. We investigated relationships between respiratory severity scores and airway concentrations of inflammatory markers/mediators. METHODS As part of the Nitric Oxide (to Prevent) Chronic Lung Disease trial, a subset of 99 infants (52 placebo-treated infants and 47 inhaled nitric oxide-treated infants; well matched at baseline) had tracheal aspirate fluid collected at baseline, at 2 to 4 days, and then weekly while still intubated during study gas treatment (minimum of 24 days). Fluid was assessed for interleukin-1beta, interleukin-8, transforming growth factor-beta, N-acetylglucosaminidase, 8-epi-prostaglandin F2alpha, and hyaluronan. Results were normalized to total protein and secretory component of immunoglobulin A. RESULTS At baseline, there was substantial variability of each measured substance and no correlation between tracheal aspirate fluid levels of any substance and respiratory severity scores. Inhaled nitric oxide administration did not result in any time-matched significant change for any of the analytes, compared with the placebo-treated group. There was no correlation between any of the measured markers/mediators and respiratory severity scores throughout the 24 days of study gas administration. In the posthoc analysis of data for inhaled nitric oxide-treated infants, there was a difference at baseline in 8-epi-prostaglandin F2alpha levels for infants who did (n = 21) and did not (n = 26) develop bronchopulmonary dysplasia at postmenstrual age of 36 weeks. CONCLUSIONS Inhaled nitric oxide, as administered in this study, seemed to be safe. Its use was not associated with any increase in airway inflammatory substances.
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Affiliation(s)
- William E Truog
- Department of Pediatrics, Section of Neonatology, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108, USA.
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Greenough A, Donn SM. Matching ventilatory support strategies to respiratory pathophysiology. Clin Perinatol 2007; 34:35-53, v-vi. [PMID: 17394929 DOI: 10.1016/j.clp.2006.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Neonates can suffer from various diseases that impact differently on lung function according to the specific pulmonary pathophysiology. As a consequence, the optimal respiratory support will vary according to disorder. Most randomized trials have only included prematurely born infants who have respiratory distress syndrome (RDS) or infants who have severe respiratory failure. Meta-analysis of the results has demonstrated that for the prematurely born infant who has RDS, prophylactic high-frequency oscillatory ventilation only results in a modest reduction in bronchopulmonary dysplasia, and patient-triggered ventilation (assist/control or synchronized intermittent mandatory ventilation) reduces the duration of ventilation if started in the recovery phase. Whether the newer triggered modes are more efficacious remains to be appropriately tested. In term infants who have severe respiratory failure, extracorporeal membrane oxygenation increases survival, but inhaled nitric oxide only reduces the need for extracorporeal membrane oxygenation. Research is required to identify the optimum respiratory strategy for infants who have other respiratory disorders, particularly bronchopulmonary dysplasia.
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Affiliation(s)
- Anne Greenough
- Division of Asthma, Allergy and Lung Biology, King's College London, Children Nationwide Regional Neonatal Intensive Care Centre, 4th Floor, Golden Jubilee Wing, King's College Hospital, London SE5 9PJ, UK.
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Ballard RA, Truog WE, Cnaan A, Martin RJ, Ballard PL, Merrill JD, Walsh MC, Durand DJ, Mayock DE, Eichenwald EC, Null DR, Hudak ML, Puri AR, Golombek SG, Courtney SE, Stewart DL, Welty SE, Phibbs RH, Hibbs AM, Luan X, Wadlinger SR, Asselin JM, Coburn CE. Inhaled nitric oxide in preterm infants undergoing mechanical ventilation. N Engl J Med 2006; 355:343-53. [PMID: 16870913 DOI: 10.1056/nejmoa061088] [Citation(s) in RCA: 318] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia in premature infants is associated with prolonged hospitalization, as well as abnormal pulmonary and neurodevelopmental outcome. In animal models, inhaled nitric oxide improves both gas exchange and lung structural development, but the use of this therapy in infants at risk for bronchopulmonary dysplasia is controversial. METHODS We conducted a randomized, stratified, double-blind, placebo-controlled trial of inhaled nitric oxide at 21 centers involving infants with a birth weight of 1250 g or less who required ventilatory support between 7 and 21 days of age. Treated infants received decreasing concentrations of nitric oxide, beginning at 20 ppm, for a minimum of 24 days. The primary outcome was survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age. RESULTS Among 294 infants receiving nitric oxide and 288 receiving placebo birth weight (766 g and 759 g, respectively), gestational age (26 weeks in both groups), and other characteristics were similar. The rate of survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age was 43.9 percent in the group receiving nitric oxide and 36.8 percent in the placebo group (P=0.042). The infants who received inhaled nitric oxide were discharged sooner (P=0.04) and received supplemental oxygen therapy for a shorter time (P=0.006). There were no short-term safety concerns. CONCLUSIONS Inhaled nitric oxide therapy improves the pulmonary outcome for premature infants who are at risk for bronchopulmonary dysplasia when it is started between 7 and 21 days of age and has no apparent short-term adverse effects. (ClinicalTrials.gov number, NCT00000548 [ClinicalTrials.gov] .).
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Hascoet JM, Fresson J, Claris O, Hamon I, Lombet J, Liska A, Cantagrel S, Al Hosri J, Thiriez G, Valdes V, Vittu G, Egreteau L, Henrot A, Buchweiller MC, Onody P. The safety and efficacy of nitric oxide therapy in premature infants. J Pediatr 2005; 146:318-23. [PMID: 15756211 DOI: 10.1016/j.jpeds.2004.10.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the safety-efficacy balance of low-dose inhaled nitric oxide (iNO) in hypoxemic premature infants because no sustained beneficial effect has been demonstrated clearly and there are concerns about side effects. STUDY DESIGN Eight hundred and sixty infants <32 weeks were randomized at birth to receive 5 ppm iNO or placebo when they presented with hypoxemic respiratory failure (HRF) defined by a requirement for mechanical ventilation, fraction of inspired oxygen (FIO 2 ) >40%, and arterio-alveolar ratio in oxygen (aAO 2 ) <0.22. The primary end point was intact survival at 28 days of age. RESULTS Sixty-one of 415 infants presented with HRF and were compared with 84 of 445 controls who presented with HRF. There was no difference in the primary end point (61.4% in infants [23% with HRF who were treated with iNO] vs 61.1% in controls [21.4% in controls with HRF]; P = .943). For the infants with HRF who were treated with iNO, there was no significant difference from controls for intraventricular hemorrhage (IVH) (6% vs 7%), necrotizing enterocolitis (8% vs 6 %), or patent ductus arteriosus (PDA) (34% vs 37%). Compared with nonhypoxemic infants, the risk of bronchopulmonary displasia (BPD) increased significantly in HRF controls (OR = 3.264 [CI 1.461-7.292]) but not in infants with HRF who were treated with iNO (OR = 1.626 [CI 0.633-4.178]). CONCLUSIONS iNO appears to be safe in premature infants but did not lead to a significant improvement in intact survival on day 28.
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Affiliation(s)
- J M Hascoet
- Neonatology Department, Maternite Regionale Universitaire, Nancy, France.
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Ichinose F, Roberts JD, Zapol WM. Inhaled nitric oxide: a selective pulmonary vasodilator: current uses and therapeutic potential. Circulation 2005; 109:3106-11. [PMID: 15226227 DOI: 10.1161/01.cir.0000134595.80170.62] [Citation(s) in RCA: 210] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Fumito Ichinose
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, and Harvard Medical School, 55 Fruit St, Boston, Mass 02114, USA.
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Athavale K, Claure N, D'Ugard C, Everett R, Swaminathan S, Bancalari E. Acute effects of inhaled nitric oxide on pulmonary and cardiac function in preterm infants with evolving bronchopulmonary dysplasia. J Perinatol 2004; 24:769-74. [PMID: 15496967 DOI: 10.1038/sj.jp.7211216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) reduces pulmonary vascular resistance by preferential vasodilation in ventilated lung units. In experimental animals, iNO also reduces airway resistance by smooth muscle relaxation. Hence, there may be a therapeutic role for iNO in evolving bronchopulmonary dysplasia (BPD). OBJECTIVE To evaluate the acute effects of low-dose iNO on lung mechanics, ventilation distribution, oxygenation, and cardiac function in preterm infants with evolving BPD. METHODS Measurements of lung compliance (C(L)), airway resistance (R(L)), ventilation-distribution (N(2) clearance in multiple-breath washout), oxygenation (SpO(2)), left ventricular ejection fraction (LVEF) and right ventricular shortening fraction were obtained before and during 2 hours of iNO (10 ppm) in a group of ventilated preterm infants with evolving BPD. RESULTS A total of 13 preterm infants with (mean+/-SD) BW: 663.8+/-116 g, GA: 24.9+/-1.2 weeks, age: 32+/-14 days, mean airway pressure: 6.7+/-0.9 cmH(2)O and fraction of inspired oxygen: 0.35+/-0.06 were studied. iNO did not affect C(L), R(L) or N(2) clearance. There was a small increase in LVEF. Mean SpO(2) remained unchanged, but the duration of spontaneous hypoxemic episodes increased during iNO. CONCLUSION Low-dose iNO had no acute effects on lung function, cardiac function and oxygenation in evolving BPD.
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Affiliation(s)
- Kamlesh Athavale
- Department of Pediatrics, University of Miami School of Medicine, Miami, FL 33101, USA
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Ekekezie II, Thibeault DW, Simon SD, Norberg M, Merrill JD, Ballard RA, Ballard PL, Truog WE. Low levels of tissue inhibitors of metalloproteinases with a high matrix metalloproteinase-9/tissue inhibitor of metalloproteinase-1 ratio are present in tracheal aspirate fluids of infants who develop chronic lung disease. Pediatrics 2004; 113:1709-14. [PMID: 15173495 DOI: 10.1542/peds.113.6.1709] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The pathogenesis of chronic lung disease (CLD) involves inflammation with proteolytic damage to lung extracellular matrix. Matrix metalloproteinases (MMPs) are zinc-dependent endopeptidases that, acting in concert with their tissue inhibitors, tightly orchestrate extracellular matrix morphogenesis and repair after injury. Imbalances in their levels relative to that of their inhibitors have been implicated in diseases characterized by matrix disruption and remodeling. We investigated the possibility that imbalances in MMP-9 and MMP-2 relative to their tissue inhibitor of metalloproteinase-1 (TIMP-1) and TIMP-2, respectively, in tracheal aspirates of preterm infants may be involved in the development of CLD. METHODS Serial tracheal aspirates collected from birth until extubation in 49 ventilated preterm infants (24-32 weeks' gestations) were analyzed for MMP-2, MMP-9, TIMP-1, and TIMP-2. Data normalized by TA values of free secretory component of immunoglobulin A were compared for CLD (n = 22) versus no CLD (n = 27). Also, known clinical predictors of CLD (gestational age, birth weight, and sex) were assessed for both groups. Association of predictors with the outcome CLD was assessed by logistic regression. RESULTS Mean gestational age was lower in CLD infants, but birth weight and gender were comparable for both groups. CLD infants had significantly lower TIMP-1 level with higher MMP-9/TIMP-1 ratio during the first 2 weeks of life and low TIMP-2 and MMP-2 levels during the first 3 days of life compared with no-CLD infants. Logistic regression analysis indicated that the findings are predictive of CLD. CONCLUSIONS We conclude that low tracheal aspirate levels of TIMPs, with a high MMP-9/TIMP-1 ratio early in life, are associated with subsequent development of CLD.
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Affiliation(s)
- Ikechukwu I Ekekezie
- Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City, School of Medicine, Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Kansas City, Missouri, USA.
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Abstract
Pulmonary hypertension with elevated pulmonary vascular resistance is a common cardiovascular complication associated with increased morbidity and mortality in preterm infants with chronic lung disease. Injury to the developing pulmonary circulation results in structural and functional abnormalities of the pulmonary vasculature. Animal studies have demonstrated that disruption of angiogenesis may contribute to the failure of normal alveolarisation in chronic lung disease. Levels of vascular endothelial growth factor in bronchoalveolar lavage fluid are lower in infants with chronic lung disease compared to preterm controls. Supplemental oxygen is commonly used to prevent and treat pulmonary hypertension, although optimal arterial oxygen saturation levels remain uncertain. Other vasodilators such as inhaled nitric oxide appear promising, but as yet have not been evaluated in the form of randomised controlled trials. Further studies are required to investigate the long-term effectiveness of pulmonary vasodilator therapy.
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Affiliation(s)
- N V Subhedar
- Neonatal Intensive Care Unit, Liverpool Women's Hospital, Liverpool, UK.
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17
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:421-36. [PMID: 12271887 DOI: 10.1002/pds.661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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