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Bandiya P, Madappa R, Joshi AR. Etiology, Diagnosis and Management of Persistent Pulmonary Hypertension of the Newborn in Resource-limited Settings. Clin Perinatol 2024; 51:237-252. [PMID: 38325944 DOI: 10.1016/j.clp.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Persistent Pulmonary Hypertension of the Newborn (PPHN) is more common in Low and middle income countries (LMICs) due to high incidence of sepsis, perinatal asphyxia and meconium aspiration syndrome. Presence of hypoxic respiratory faillure and greater than 5% difference in preductal and post ductal saturation increases clinical sucipision for PPHN. The availability of Inhaled nitric oxide and extracorporaeal membrane oxygenation is limited but pulmonary vasodilators such as sildenafil are readily available in most LMICs.
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Affiliation(s)
- Prathik Bandiya
- Department of Neonatology, Neonatal Unit, 1st Floor, Indira Gandhi Institute of Child Health, South Hospital complex, Dharmaram college Post, Bangalore - 560029
| | - Rajeshwari Madappa
- Department of Pediatrics, SIGMA Hospital, P8/D, Thonachikoppal -Saraswathipuram Road, Mysore -570009 Karnataka, India.
| | - Ajay Raghav Joshi
- Department of Pediatrics, SIGMA Hospital, P8/D, Thonachikoppal -Saraswathipuram Road, Mysore -570009 Karnataka, India
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Coletti K, Wild KT, Foglia EE, Otter SCD, Kirpalani H. Randomized Controlled Trials of Pulmonary Vasodilator Therapy Adjunctive to Inhaled Nitric Oxide for Persistent Pulmonary Hypertension of the Newborn: A Systematic Review. Clin Perinatol 2024; 51:253-269. [PMID: 38325945 DOI: 10.1016/j.clp.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Inhaled nitric oxide (iNO) is a pulmonary vasodilator considered standard of care to treat persistent pulmonary hypertension of the newborn. However, not all infants respond to iNO. The authors performed a systematic review to examine methodology, outcomes, and challenges of randomized controlled trials testing pulmonary vasodilator medications adjunctive to iNO. The 5 trials identified showed heterogeneity in eligibility criteria and outcomes assessed. No trial achieved recruitment goals, limiting conclusions regarding efficacy, safety, and pharmacology. Trial design consensus and alternative methodologic strategies such as deferred consent, real-world controls, nonrandomized database assessments, and Bayesian statistical approaches are needed.
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Affiliation(s)
- Kristen Coletti
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - K Taylor Wild
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 8th Floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 8th Floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Suzan Cochius-den Otter
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC University Medical Center, Wytemaweg 80, Rotterdam 3015CN, The Netherlands
| | - Haresh Kirpalani
- Emeritus, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Emeritus, Pediatrics, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N3Z5, Canada
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Timberline S, Bhatt A, Sunderji S, Tancredi DJ, Lakshminrusimha S, Siefkes H. Novel scoring tool of hypoxemic respiratory failure and pulmonary hypertension for defining severity of persistent pulmonary hypertension of newborn. J Perinatol 2023; 43:1281-1287. [PMID: 37626160 PMCID: PMC10541330 DOI: 10.1038/s41372-023-01762-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE To obtain preliminary validity data for a hypoxemic respiratory failure/pulmonary hypertension (HRF/PH) score for classifying persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN Retrospective chart review of 100 consecutive neonates admitted to a Children's hospital from 2016-2021 with PPHN, gestational age ≥34 weeks, and echocardiograms in the first week. We assessed the correlation between HRF/PH score and short-term outcomes using linear and logistic regressions. RESULTS HRF/PH scores ranged 2-12 (mean 8.5), and were classified mild (0-5), moderate (6-10), and severe (11-15), with 6%, 77% and 17% infants in respective categories. HRF/PH score category correlated with invasive ventilation, nitric oxide, high frequency ventilation, vasoactive infusions, extracorporeal life support and death. HRF/PH score category did not correlate with duration of support or length of stay. CONCLUSION The HRF/PH score offers a promising representation of disease severity for PPHN. The tool requires further validation in prospective studies and evaluation for long-term outcomes.
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Affiliation(s)
- Sage Timberline
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Avni Bhatt
- School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Sherzana Sunderji
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | | | - Heather Siefkes
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA.
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Watterberg KL, Carlo WA, Brion LP, Cotten CM, Higgins RD. Overview of the neonatal research network: History, contributions, challenges, and future. Semin Perinatol 2022; 46:151634. [PMID: 35786518 PMCID: PMC10996928 DOI: 10.1016/j.semperi.2022.151634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) has been a leader in neonatal research since 1986. In this chapter we review its history and achievements in (1) continuing observation of populations, treatments, short and longer-term outcomes, and trends over time; (2) "negative studies" (trials with non-significant primary outcomes) and trials stopped for futility or adverse events, which have influenced practice and subsequent trial design; and, (3) landmark trials that have changed neonatal care. Its consistent framework has enabled the NRN to be a pioneer in conducting longer-term, school-age follow-up. Leveraging its established infrastructure, the NRN has also partnered with other NIH institutes, governmental agencies, and industry to more effectively advance neonatal care. As current examples of its evolution with changing times, the Network has instituted a process to open specific network trials to external institutions and is adding a parent and participant component to future endeavors.
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Affiliation(s)
- Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luc P Brion
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Raleigh, NC, USA
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Verma S, Lumba R, Kazmi SH, Vaz MJ, Prakash SS, Bailey SM, Mally PV, Randis TM. Effects of Inhaled Iloprost for the Management of Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2022; 39:1441-1448. [PMID: 33477175 DOI: 10.1055/s-0040-1722653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The study aimed to evaluate the effects of inhaled iloprost on oxygenation indices in neonates with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN We conducted a retrospective chart review of 30 patients with PPHN from January 2014 to November 2018, who did not respond to inhaled nitric oxide (iNO) alone and received inhaled iloprost. Twenty-two patients met the inclusion criteria and eight patients were excluded from the study (complex cardiac disease and extreme prematurity). Patients were categorized as responders or nonresponders (patients who required extracorporeal membrane oxygenation or died). Oxygenation index, mean airway pressure (MAP), and arterial partial pressure of oxygen (PaO2) were recorded. RESULTS Among a total of 22 patients who were included in the study, 10 were classified as nonresponders as they required either extracorporeal membrane oxygenation or died. Gestational age and gender did not differ between responders and nonresponders. The median PaO2 was lower (37 vs. 42 mm Hg; p < 0.05) and median MAP was higher (20 vs. 17 cm H2O; p < 0.02) in nonresponders compared with responders just prior to initiating iloprost. Iloprost responders had a significant increase in median PaO2 and decrease in median oxygenation index in the 24 hours after initiating treatment (p < 0.05), with no significant change in required mean airway pressure over that same period. There was no change in vasopressor use or clinically significant worsening of platelets count, liver, and kidney functions after initiating iloprost. CONCLUSION Inhaled iloprost is well tolerated and seems to have beneficial effects in improving oxygenation indices in neonates with PPHN who do not respond to iNO. There is a need of well-designed prospective trials to further ascertain the benefits of using inhaled iloprost as an adjunct treatment in neonates with PPHN who do not respond to iNO alone. KEY POINTS · Inhaled iloprost seems to have beneficial effects in improving oxygenation indices in PPHN.. · Inhaled iloprost is generally well tolerated in newborns with PPHN.. · There is a need for prospective randomized controlled trials to further ascertain the benefits of using inhaled iloprost..
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Affiliation(s)
- Sourabh Verma
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Rishi Lumba
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Sadaf H Kazmi
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Michelle J Vaz
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | | | - Sean M Bailey
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Tara M Randis
- Division of Neonatology, Departments of Pediatrics and Molecular Medicine, University of South Florida, Tampa, Florida
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Abstract
Inhaled nitric oxide (iNO) therapy had a transformational impact on the management of infants with persistent pulmonary hypertension of the newborn (PPHN). iNO remains the only approved pulmonary vasodilator for PPHN; yet 30% to 40% of patients do not respond or have incomplete response to iNO. Lung recruitment strategies with early surfactant administration and high-frequency ventilation can optimize the response to iNO in the presence of parenchymal lung diseases. Alternate pulmonary vasodilators are used commonly as rescue, life-saving measures, though there is a lack of high-quality evidence supporting their efficacy and safety. This article reviews the available evidence and future directions for research in PPHN.
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Li P, Gu L, Tan J, Song Z, Bian Q, Jiao D, Xu Z, Wang L. A randomised controlled trial on roles of prostaglandin E1 nebulization among patients undergoing one lung ventilation. BMC Pulm Med 2022; 22:37. [PMID: 35027012 PMCID: PMC8759228 DOI: 10.1186/s12890-022-01831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/06/2022] [Indexed: 12/24/2022] Open
Abstract
Background Prostaglandin E1 (PGE1) has been reported to maintain adequate oxygenation among patients under 60% FiO2 one-lung ventilation (OLV). This research aimed to explore whether PGE1 is safe in pulmonary shunt and oxygenation under 40% FiO2 OLV and provide a reference concentration of PGE1. Methods Totally 90 esophageal cancer patients treated with thoracotomy were enrolled in this study, randomly divided into three groups (n = 30/group): Group A (60% FiO2 and 0.1 µg/kg PGE1), Group B (40% FiO2 and 0.1 µg/kg PGE1), and Group C (40% FiO2, 0.2 µg/kg PGE1). Primary outcomes were oxygenation and pulmonary shunt during OLV. Secondary outcomes included oxidative stress after OLV. Results During OLV, patients in Group C and B had lower levels of PaO2, SaO2, SpO2, MAP, and Qs/Qt than those in Group A (P < 0.05). At T2 (OLV 10 min), patients in Group C and B exhibited a lower level of PaO2/FiO2 than those in Group A, without any statistical difference at other time points. The IL-6 levels of patients in different groups were different at T8 (F = 3.431, P = 0.038), with IL-6 in Group C being lower than that in Group B and A. MDA levels among the three groups differed at T5 (F = 4.692, P = 0.012) and T7 (F = 5.906, P = 0.004), with the MDA level of Group C being lower than that of Group B and A at T5, and the MDA level of Group C and B being lower than that of Group A at T7. In terms of TNF-α level, patients in Group C had a lower level than those in Group B and A at T8 (F = 3.598, P = 0.033). Compared with patients who did not use PGE1, patients in Group C had comparable complications and lung infection scores. Conclusion The concentration of FiO2 could be reduced from 60 to 40% to maintain oxygenation. 40% FiO2 + 0.2 µg/kg PGE1 is recommended as a better combination on account of its effects on the inflammatory factors. Trial registration: Chictr.org.cn identifier: ChiCTR1800018288, 09/09/2018.
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Martinho S, Adão R, Leite-Moreira AF, Brás-Silva C. Persistent Pulmonary Hypertension of the Newborn: Pathophysiological Mechanisms and Novel Therapeutic Approaches. Front Pediatr 2020; 8:342. [PMID: 32850518 PMCID: PMC7396717 DOI: 10.3389/fped.2020.00342] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is one of the main causes of neonatal morbidity and mortality. It is characterized by sustained elevation of pulmonary vascular resistance (PVR), preventing an increase in pulmonary blood flow after birth. The affected neonates fail to establish blood oxygenation, precipitating severe respiratory distress, hypoxemia, and eventually death. Inhaled nitric oxide (iNO), the only approved pulmonary vasodilator for PPHN, constitutes, alongside supportive therapy, the basis of its treatment. However, nearly 40% of infants are iNO resistant. The cornerstones of increased PVR in PPHN are pulmonary vasoconstriction and vascular remodeling. A better understanding of PPHN pathophysiology may enlighten targeted and more effective therapies. Sildenafil, prostaglandins, milrinone, and bosentan, acting as vasodilators, besides glucocorticoids, playing a role on reducing inflammation, have all shown potential beneficial effects on newborns with PPHN. Furthermore, experimental evidence in PPHN animal models supports prospective use of emergent therapies, such as soluble guanylyl cyclase (sGC) activators/stimulators, l-citrulline, Rho-kinase inhibitors, peroxisome proliferator-activated receptor-γ (PPAR-γ) agonists, recombinant superoxide dismutase (rhSOD), tetrahydrobiopterin (BH4) analogs, ω-3 long-chain polyunsaturated fatty acids (LC-PUFAs), 5-HT2A receptor antagonists, and recombinant human vascular endothelial growth factor (rhVEGF). This review focuses on current knowledge on alternative and novel pathways involved in PPHN pathogenesis, as well as recent progress regarding experimental and clinical evidence on potential therapeutic approaches for PPHN.
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Affiliation(s)
- Sofia Martinho
- Department of Surgery and Physiology, Cardiovascular Research and Development Center-UnIC, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui Adão
- Department of Surgery and Physiology, Cardiovascular Research and Development Center-UnIC, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Adelino F Leite-Moreira
- Department of Surgery and Physiology, Cardiovascular Research and Development Center-UnIC, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Carmen Brás-Silva
- Department of Surgery and Physiology, Cardiovascular Research and Development Center-UnIC, Faculty of Medicine, University of Porto, Porto, Portugal.,Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
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Shivanna B, Gowda S, Welty SE, Barrington KJ, Pammi M. Prostanoids and their analogues for the treatment of pulmonary hypertension in neonates. Cochrane Database Syst Rev 2019; 10:CD012963. [PMID: 31573068 PMCID: PMC6771085 DOI: 10.1002/14651858.cd012963.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Persistent pulmonary hypertension of the newborn (PPHN) is a disease entity that describes a physiology in which there is persistence of increased pulmonary arterial pressure. PPHN is characterised by failure to adapt to a functional postnatal circulation with a fall in pulmonary vascular resistance. PPHN is responsible for impairment in oxygenation and significant neonatal mortality and morbidity. Prostanoids and their analogues may be useful therapeutic interventions due to their pulmonary vasodilatory and immunomodulatory effects. OBJECTIVES Primary objective• To determine the efficacy and safety of prostanoids and their analogues (iloprost, treprostinil, and beraprost) in decreasing mortality and the need for extracorporeal membrane oxygenation (ECMO) among neonates with PHSecondary objective• To determine the efficacy and safety of prostanoids and their analogues (iloprost, treprostinil, and beraprost) in decreasing neonatal morbidity (necrotizing enterocolitis (NEC), chronic lung disease (CLD), retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), length of hospital stay, and duration of mechanical ventilation) and improving neurodevelopmental outcomes among neonates with PHComparisons• Prostanoids and their analogues at any dosage or duration used to treat PPHN versus 'standard treatment without these agents', placebo, or inhaled nitric oxide (iNO) therapy• Prostanoids and their analogues at any dosage or duration used to treat refractory PPHN as an 'add-on' therapy to iNO versus iNO alone SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9), MEDLINE via PubMed (1966 to 16 September 2018), Embase (1980 to 16 September 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 16 September 2018). We also searched clinical trials databases, conference proceedings of the Pediatric Academic Societies (1990 to 16 September 2018), and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. We contacted authors who have published in this field as discerned from the reference lists of identified clinical trials and review authors' personal files. SELECTION CRITERIA Randomized and quasi-randomized controlled trials evaluating prostanoids or their analogues (at any dose, route of administration, or duration) used in neonates at any gestational age less than 28 days' postnatal age for confirmed or suspected PPHN. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal to conduct a systematic review and to assess the methodological quality of included studies (neonatal.cochrane.org/en/index.html). Three review authors independently assessed the titles and abstracts of studies identified by the search strategy and obtained full-text versions for assessment if necessary. We designed forms for trial inclusion or exclusion and for data extraction. We planned to use the GRADE approach to assess the quality of evidence. MAIN RESULTS We did not identify any eligible neonatal trials evaluating prostanoids or their analogues as sole agents in the treatment of PPHN. AUTHORS' CONCLUSIONS Implications for practiceCurrently, no evidence shows the use of prostanoids or their analogues as pulmonary vasodilators and sole therapeutic agents for the treatment of PPHN in neonates (age 28 days or less).Implications for researchThe safety and efficacy of different preparations and doses and routes of administration of prostacyclins and their analogues in neonates must be established. Well-designed, adequately powered, randomized, multi-center trials are needed to address the efficacy and safety of prostanoids and their analogues in the treatment of PPHN. These trials should evaluate long-term neurodevelopmental and pulmonary outcomes, in addition to short-term outcomes.
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Affiliation(s)
- Binoy Shivanna
- Baylor College of MedicineSection of Neonatology, Department of PediatricsOne Baylor PlazaHoustonTexasUSA77030
| | - Sharada Gowda
- Baylor College of MedicineSection of Neonatology, Department of PediatricsOne Baylor PlazaHoustonTexasUSA77030
| | - Stephen E Welty
- Baylor College of MedicineSection of Neonatology, Department of PediatricsOne Baylor PlazaHoustonTexasUSA77030
| | - Keith J Barrington
- CHU Ste‐JustineDepartment of Pediatrics3175 Cote Ste CatherineMontrealQCCanadaH3T 1C5
| | - Mohan Pammi
- Baylor College of MedicineSection of Neonatology, Department of PediatricsOne Baylor PlazaHoustonTexasUSA77030
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Pedersen J, Hedegaard ER, Simonsen U, Krüger M, Infanger M, Grimm D. Current and Future Treatments for Persistent Pulmonary Hypertension in the Newborn. Basic Clin Pharmacol Toxicol 2018; 123:392-406. [PMID: 29855164 DOI: 10.1111/bcpt.13051] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/27/2018] [Indexed: 01/18/2023]
Abstract
Persistent pulmonary hypertension in newborn (PPHN) is a serious and possibly fatal syndrome characterized by sustained foetal elevation of pulmonary vascular resistance at birth. PPHN may manifest secondary to other conditions as meconium aspiration syndrome, infection and congenital diaphragmatic hernia. This MiniReview provides the reader with an overview of current and future treatment options for patients with PPHN without congenital diaphragmatic hernia. The study is based on systematic searches in the databases PubMed and Cochrane Library and registered studies on Clinicaltrials.gov investigating PPHN. Inhaled nitric oxide (iNO) is well documented for treatment of PPHN, but 30% fail to respond to iNO. Other current treatment options could be sildenafil, milrinone, prostaglandin analogues and bosentan. There are several ongoing trials with sildenafil, but evidence is lacking for the other treatments and/or for the combination with iNO. Currently, there is no evidence for effect in PPHN of other treatments, for example tadalafil, macitentan, ambrisentan, riociguat and selexipag used for pulmonary arterial hypertension in adults. Experimental studies in animal models for PPHN suggest effect of a series of approaches including recombinant human superoxide dismutase, L-citrulline, Rho-kinase inhibitors and peroxisome proliferator-activated receptor-γ agonists. We conclude that iNO is the most investigated and the only approved pulmonary vasodilator for infants with PPHN. In the iNO non-responders, sildenafil currently seems to be the best alternative either alone or in combination with iNO. Systematic and larger clinical studies are required for testing the other potential treatments of PPHN.
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Affiliation(s)
- Jonas Pedersen
- Department of Biomedicine, Pharmacology, Aarhus University, Aarhus, Denmark
| | - Elise R Hedegaard
- Department of Biomedicine, Pharmacology, Aarhus University, Aarhus, Denmark
| | - Ulf Simonsen
- Department of Biomedicine, Pharmacology, Aarhus University, Aarhus, Denmark
| | - Marcus Krüger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Manfred Infanger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Daniela Grimm
- Department of Biomedicine, Pharmacology, Aarhus University, Aarhus, Denmark.,Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
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Barriers to enrollment in a randomized controlled trial of hydrocortisone for cardiovascular insufficiency in term and late preterm newborn infants. J Perinatol 2017; 37:1220-1223. [PMID: 28880260 PMCID: PMC5688018 DOI: 10.1038/jp.2017.131] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/08/2017] [Accepted: 07/05/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To analyze reasons for low enrollment in a randomized controlled trial (RCT) of the effect of hydrocortisone for cardiovascular insufficiency on survival without neurodevelopmental impairment (NDI) in term/late preterm newborns. STUDY DESIGN The original study was a multicenter RCT. Eligibility: ⩾34 weeks' gestation, <72 h old, mechanically ventilated, receiving inotrope. Primary outcome was NDI at 2 years; infants with diagnoses at high risk for NDI were excluded. This paper presents an analysis of reasons for low patient enrollment. RESULTS Two hundred and fifty-seven of the 932 otherwise eligible infants received inotropes; however, 207 (81%) had exclusionary diagnoses. Only 12 infants were randomized over 10 months; therefore, the study was terminated. Contributing factors included few eligible infants after exclusions, open-label steroid therapy and a narrow enrollment window. CONCLUSION Despite an observational study to estimate the population, very few infants were enrolled. Successful RCTs of emergent therapy may require fewer exclusions, a short-term primary outcome, waiver of consent and/or other alternatives.
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12
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Afshari A, Bastholm Bille A, Allingstrup M. Aerosolized prostacyclins for acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev 2017; 7:CD007733. [PMID: 28806480 PMCID: PMC6483148 DOI: 10.1002/14651858.cd007733.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a critical condition that is associated with high mortality and morbidity. Aerosolized prostacyclin has been used to improve oxygenation despite the limited evidence available so far.This review was originally published in 2010 and updated in 2017. OBJECTIVES To assess the benefits and harms of aerosolized prostacyclin in adults and children with ARDS. SEARCH METHODS In this update, we searched CENTRAL (2017, Issue 4); MEDLINE (OvidSP), Embase (OvidSP), ISI BIOSIS Previews, ISI Web of Science, LILACS, CINAHL (EBSCOhost), and three trials registers. We handsearched the reference lists of the latest reviews, randomized and non-randomized trials, and editorials, and cross-checked them with our search of MEDLINE. We contacted the main authors of included studies to request any missed, unreported or ongoing studies. The search was run from inception to 5 May 2017. SELECTION CRITERIA We included all randomized controlled trials (RCTs), irrespective of publication status, date of publication, blinding status, outcomes published or language. We contacted trial investigators and study authors to retrieve relevant and missing data. DATA COLLECTION AND ANALYSIS Three authors independently abstracted data and resolved any disagreements by discussion. Our primary outcome measure was all-cause mortality. We planned to perform subgroup and sensitivity analyses to assess the effect of aerosolized prostacyclin in adults and children, and on various clinical and physiological outcomes. We assessed the risk of bias through assessment of methodological trial components and the risk of random error through trial sequential analysis. MAIN RESULTS We included two RCTs with 81 participants.One RCT involved 14 critically ill children with ARDS (very low quality of evidence), and one RCT involved 67 critically ill adults (very low quality evidence).Only one RCT (paediatric trial) provided data on mortality and found no difference between intervention and control. However, this trial was eligible for meta-analysis due to a cross-over design.We assessed the benefits and harms of aerosolized prostacyclin. One RCT found no difference in improvement of partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) ratio (mean difference (MD) -25.35, 95% confidence interval (CI) -60.48 to 9.78; P = 0.16; 67 participants, very low quality evidence).There were no adverse events such as bleeding or organ dysfunction in any of the included trials. Due to the limited number of RCTs, we were unable to perform the prespecified subgroup and sensitivity analyses or trial sequential analysis. AUTHORS' CONCLUSIONS We are unable to tell from our results whether the intervention has an important effect on mortality because the results were too imprecise to rule out a small or no effect. Therefore, no current evidence supports or refutes the routine use of aerosolized prostacyclin for people with ARDS. There is an urgent need for more RCTs.
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Affiliation(s)
- Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and
Surgical Clinic Department 4013CopenhagenDenmark
| | - Anders Bastholm Bille
- Juliane Marie Centret, RigshospitaletDepartment of AnaesthesiaBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Mikkel Allingstrup
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and
Surgical Clinic Department 4013CopenhagenDenmark
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13
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Steinhorn RH, Fineman J, Kusic-Pajic A, Cornelisse P, Gehin M, Nowbakht P, Pierce CM, Beghetti M. Bosentan as Adjunctive Therapy for Persistent Pulmonary Hypertension of the Newborn: Results of the Randomized Multicenter Placebo-Controlled Exploratory Trial. J Pediatr 2016; 177:90-96.e3. [PMID: 27502103 DOI: 10.1016/j.jpeds.2016.06.078] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/28/2016] [Accepted: 06/27/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy, safety, and pharmacokinetics of the endothelin receptor antagonist bosentan as adjunctive therapy for neonates with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN This was a phase 3, multicenter, randomized, placebo-controlled exploratory trial (FUTURE-4). Eligible patients were >34 weeks gestation, <7 days old, receiving inhaled nitric oxide (iNO) treatment (≥4 hours), and had persistent respiratory failure (oxygenation index [OI] ≥12). After 2:1 randomization, bosentan 2 mg/kg or placebo was given by nasogastric tube twice daily for ≥48 hours and up to 1 day after iNO weaning. RESULTS Twenty-one neonates received a study drug (13 bosentan, 8 placebo). Compared with the placebo group, the group treated with bosentan had a higher median baseline OI and greater need for vasoactive agents. One treatment failure (need for extracorporeal membrane oxygenation) occurred in the group treated with bosentan. The time to weaning from iNO or mechanical ventilation was not different between the groups. Bosentan was well tolerated and did not adversely affect systemic blood pressure or hepatic transaminase levels. Anemia and edema were more frequent in patients receiving bosentan. Blood concentrations of bosentan were low and variable on day 1, and achieved steady state on day 5. CONCLUSION Adjunctive bosentan was well tolerated, but did not improve oxygenation or other outcomes in our patients with PPHN. This effect may be related to delayed absorption of bosentan on treatment initiation in critically ill neonates or to more severe illness of the neonates who received bosentan. TRIAL REGISTRATION ClinicalTrials.gov:NCT01389856.
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Affiliation(s)
- Robin H Steinhorn
- Children's National Health System, Department of Pediatrics, Washington, DC.
| | - Jeffrey Fineman
- Benioff Children's Hospital, Department of Pediatrics, University of California, San Francisco, CA
| | - Andjela Kusic-Pajic
- Department of Clinical Development, Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Peter Cornelisse
- Department of Biostatistics, Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Martine Gehin
- Department of Clinical Pharmacology, Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Pegah Nowbakht
- Department of Clinical Development, Actelion Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Christine M Pierce
- Pediatric and Neonatal Intensive Care Units, Great Ormond Street Hospital for Children, London, UK
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Children's Hospital, University of Geneva, Geneva, Switzerland
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Cosa N, Costa E. Inhaled pulmonary vasodilators for persistent pulmonary hypertension of the newborn: safety issues relating to drug administration and delivery devices. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:45-51. [PMID: 27110141 PMCID: PMC4835137 DOI: 10.2147/mder.s99601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Treatment for persistent pulmonary hypertension of the newborn (PPHN) aims to reduce pulmonary vascular resistance while maintaining systemic vascular resistance. Selective pulmonary vasodilation may be achieved by targeting pulmonary-specific pathways or by delivering vasodilators directly to the lungs. Abrupt withdrawal of a pulmonary vasodilator can cause rebound pulmonary hypertension. Therefore, use of consistent delivery systems that allow for careful monitoring of drug delivery is important. This manuscript reviews published studies of inhaled vasodilators used for treatment of PPHN and provides an overview of safety issues associated with drug delivery and delivery devices as they relate to the risk of rebound pulmonary hypertension. Off-label use of aerosolized prostacyclins and an aerosolized prostaglandin in neonates with PPHN has been reported; however, evidence from large randomized clinical trials is lacking. The amount of a given dose of aerosolized drug that is actually delivered to the lungs is often unknown, and the actual amount of drug deposited in the lungs can be affected by several factors, including patient size, nebulizer used, and placement of the nebulizer within the breathing circuit. Inhaled nitric oxide (iNO) is the only pulmonary vasodilator approved by the US Food and Drug Administration for the treatment of PPHN. The iNO delivery device, INOmax DSIR®IR, is designed to constantly monitor NO, NO2, and O2 deliveries and is equipped with audible and visual alarms to alert providers of abrupt discontinuation and incorrect drug concentration. Other safety features of this device include two independent backup delivery systems, a backup drug cylinder, a battery that provides up to 6 hours of uninterrupted medication delivery, and 27 alarms that monitor delivery, dosage, and system functions. The ability of the drug delivery device to provide safe, consistent dosing is important to consider when selecting a pulmonary vasodilator.
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Affiliation(s)
- Nathan Cosa
- Department of Respiratory Care, Banner Desert Medical Center, Cardon Children's Medical Center, Mesa, AZ, USA
| | - Edward Costa
- Department of Medical Affairs, Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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15
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Abstract
Inhaled nitric oxide (iNO) is approved for use in persistent pulmonary hypertension of the newborn (PPHN) but does not lead to sustained improvement in oxygenation in one-third of patients with PPHN. Inhaled NO is less effective in the management of PPHN secondary to congenital diaphragmatic hernia (CDH), extreme prematurity, and bronchopulmonary dysplasia (BPD). Intravenous pulmonary vasodilators such as prostacyclin, alprostadil, sildenafil, and milrinone have been successfully used in PPHN resistant to iNO. Oral pulmonary vasodilators such as endothelin receptor antagonist bosentan and phosphodiesterase-5 inhibitors such as sildenafil and tadalafil are used both during acute and chronic phases of PPHN. In the absence of infection, glucocorticoids may also be effective in PPHN. Many of these pharmacologic agents are not approved for use in PPHN and our knowledge is based on case reports and small trials. Large multicenter randomized controlled trials with long-term follow-up are required to evaluate alternate pharmacologic strategies in PPHN.
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Affiliation(s)
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Corinne L Leach
- Department of Pediatrics, University at Buffalo, Buffalo, NY
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Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is often secondary to parenchymal lung disease (such as meconium aspiration syndrome) or lung hypoplasia (with congenital diaphragmatic hernia) but can also be idiopathic. PPHN is characterized by elevated pulmonary vascular resistance, resulting in right-to-left shunting of blood and hypoxemia. The diagnosis of PPHN is based on clinical evidence of labile hypoxemia often associated with differential cyanosis and confirmed by echocardiography. Lung volume recruitment with optimal use of positive end-expiratory pressure or mean airway pressure and/or surfactant is very important in secondary PPHN due to parenchymal lung disease. Other management strategies include optimal oxygenation, avoiding respiratory and metabolic acidosis, blood pressure stabilization, sedation, and pulmonary vasodilator therapy. Failure of these measures leads to consideration of extracorporeal membrane oxygenation, although this rescue therapy is needed less frequently with advances in medical management. Randomized clinical trials with long-term follow-up are required to evaluate various therapeutic strategies in PPHN.
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Affiliation(s)
| | - Martin Keszler
- Department of Pediatrics, Brown University, Providence, RI
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17
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Kraemer U, Cochius-den Otter S, Snoek KG, Tibboel D. Pharmacodynamic considerations in the treatment of pulmonary hypertension in infants: challenges and future perspectives. Expert Opin Drug Metab Toxicol 2015; 12:1-19. [DOI: 10.1517/17425255.2016.1116520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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18
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Sharma V, Berkelhamer S, Lakshminrusimha S. Persistent pulmonary hypertension of the newborn. Matern Health Neonatol Perinatol 2015; 1:14. [PMID: 27057331 PMCID: PMC4823682 DOI: 10.1186/s40748-015-0015-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/27/2015] [Indexed: 01/18/2023] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is characterized by elevated pulmonary vascular resistance resulting in right-to-left shunting of blood and hypoxemia. PPHN is often secondary to parenchymal lung disease (such as meconium aspiration syndrome, pneumonia or respiratory distress syndrome) or lung hypoplasia (with congenital diaphragmatic hernia or oligohydramnios) but can also be idiopathic. The diagnosis of PPHN is based on clinical evidence of labile hypoxemia often associated with differential cyanosis. The diagnosis is confirmed by the echocardiographic demonstration of - (a) right-to-left or bidirectional shunt at the ductus or foramen ovale and/or, (b) flattening or leftward deviation of the interventricular septum and/or, (c) tricuspid regurgitation, and finally (d) absence of structural heart disease. Management strategies include optimal oxygenation, avoiding respiratory and metabolic acidosis, blood pressure stabilization, sedation and pulmonary vasodilator therapy. Failure of these measures would lead to consideration of extracorporeal membrane oxygenation (ECMO); however decreased need for this rescue therapy has been documented with advances in medical management. While trends also note improved survival, long-term neurodevelopmental disabilities such as deafness and learning disabilities remain a concern in many infants with severe PPHN. Funded by: 1R01HD072929-0 (SL).
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Affiliation(s)
- Vinay Sharma
- Department of Pediatrics (Neonatology), Hennepin County Medical Center, 701 Park Avenue, Shapiro Building, Minneapolis, MN 55415 USA
| | - Sara Berkelhamer
- Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222 USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222 USA
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Sharma M, Callan E, Konduri GG. Pulmonary vasodilator therapy in persistent pulmonary hypertension of the newborn. Clin Perinatol 1984; 11:693-701. [PMID: 6488673 PMCID: PMC8885147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A review of the physiology of persistent pulmonary hypertension of the newborn is provided, followed by a critical review of many of the agents that have been employed to treat this condition. In addition, the authors speculate on what type of pharmacologic therapy may prove useful in the future.
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Affiliation(s)
- Megha Sharma
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Emily Callan
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI
| | - G. Ganesh Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI
- Corresponding author: G. Ganesh Konduri, MD., 999 N 92 St, CCC Ste C410, Wauwatosa, WI, 53226.
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