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Ng G, Bruschettini M, Ibrahim J, da Silva O. Inhaled bronchodilators for the prevention and treatment of chronic lung disease in preterm infants. Cochrane Database Syst Rev 2024; 4:CD003214. [PMID: 38591664 PMCID: PMC11002972 DOI: 10.1002/14651858.cd003214.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Chronic lung disease (CLD) occurs frequently in preterm infants and is associated with respiratory morbidity. Bronchodilators have the potential effect of dilating small airways with muscle hypertrophy. Increased compliance and tidal volume, and decreased airway resistance, have been documented with the use of bronchodilators in infants with CLD. Therefore, bronchodilators are widely considered to have a role in the prevention and treatment of CLD, but there remains uncertainty as to whether they improve clinical outcomes. This is an update of the 2016 Cochrane review. OBJECTIVES To determine the effect of inhaled bronchodilators given as prophylaxis or as treatment for chronic lung disease (CLD) on mortality and other complications of preterm birth in infants at risk for or identified as having CLD. SEARCH METHODS An Information Specialist searched CENTRAL, MEDLINE, Embase, CINAHL and three trials registers from 2016 to May 2023. In addition, the review authors undertook reference checking, citation searching and contact with trial authors to identify additional studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials involving preterm infants less than 32 weeks old that compared bronchodilators to no intervention or placebo. CLD was defined as oxygen dependency at 28 days of life or at 36 weeks' postmenstrual age. Initiation of bronchodilator therapy for the prevention of CLD had to occur within two weeks of birth. Treatment of infants with CLD had to be initiated before discharge from the neonatal unit. The intervention had to include administration of a bronchodilator by nebulisation or metered dose inhaler. The comparator was no intervention or placebo. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Critical outcomes included: mortality within the trial period; CLD (defined as oxygen dependency at 28 days of life or at 36 weeks' postmenstrual age); adverse effects of bronchodilators, including hypokalaemia (low potassium levels in the blood), tachycardia, cardiac arrhythmia, tremor, hypertension and hyperglycaemia (high blood sugar); and pneumothorax. We used the GRADE approach to assess the certainty of the evidence for each outcome. MAIN RESULTS We included two randomised controlled trials in this review update. Only one trial provided useable outcome data. This trial was conducted in six neonatal intensive care units in France and Portugal, and involved 173 participants with a gestational age of less than 31 weeks. The infants in the intervention group received salbutamol for the prevention of CLD. The evidence suggests that salbutamol may result in little to no difference in mortality (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.50 to 2.31; risk difference (RD) 0.01, 95% CI -0.09 to 0.11; low-certainty evidence) or CLD at 28 days (RR 1.03, 95% CI 0.78 to 1.37; RD 0.02, 95% CI -0.13 to 0.17; low-certainty evidence), when compared to placebo. The evidence is very uncertain about the effect of salbutamol on pneumothorax. The one trial with usable data reported that there were no relevant differences between groups, without providing the number of events (very low-certainty evidence). Investigators in this study did not report if side effects occurred. We found no eligible trials that evaluated the use of bronchodilator therapy for the treatment of infants with CLD. We identified no ongoing studies. AUTHORS' CONCLUSIONS Low-certainty evidence from one trial showed that inhaled bronchodilator prophylaxis may result in little or no difference in the incidence of mortality or CLD in preterm infants, when compared to placebo. The evidence is very uncertain about the effect of salbutamol on pneumothorax, and neither included study reported on the incidence of serious adverse effects. We identified no trials that studied the use of bronchodilator therapy for the treatment of CLD. Additional clinical trials are necessary to assess the role of bronchodilator agents in the prophylaxis or treatment of CLD. Researchers studying the effects of inhaled bronchodilators in preterm infants should include relevant clinical outcomes in addition to pulmonary mechanical outcomes.
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Affiliation(s)
- Geraldine Ng
- Department of Neonatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - John Ibrahim
- Department of Pediatrics, Division of Newborn Medicine, University of PIttsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Orlando da Silva
- Department of Pediatrics, University of Western Ontario, London, Canada
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Kittiarpornpon V, Siripattanapipong P, Bowornkitiwong W, Kitsommart R, Ngerncham S, Wongsiridach P, Yangthara B. Association of Antenatal Terbutaline and Respiratory Support Requirements in Preterm Neonates. Am J Perinatol 2024; 41:478-487. [PMID: 34768291 DOI: 10.1055/a-1695-8220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Before the advent of antenatal steroids, early non-invasive respiratory support (NIV), and intratracheal surfactant, antenatal terbutaline was also used to improve lung compliance and reduce the incidence of respiratory distress syndrome (RDS). OBJECTIVES The objective of this paper was to study the association between antenatal terbutaline and endotracheal intubation (ET) within the first 24 hours of life, RDS, bronchopulmonary dysplasia (BPD), and intraventricular hemorrhage (IVH) in infants with the gestational age (GA) of <32 weeks, and to study the association between antenatal terbutaline, and ET or NIV within the first 24 hours of life, and RDS in infants with the GA of 32 to 36 weeks. METHOD This was a retrospective medical record review of preterm infants delivered at a single tertiary care center from October 2016 to December 2020. Multivariable logistic regression was used to explore the association between antenatal terbutaline and neonatal respiratory support. RESULT 1,794 infants were included, 234 (13.0%) had the GA of <32 weeks and 1,560 (86.9%) had the GA of 32 to 36 weeks. Antenatal terbutaline, corticosteroid, or both agents were administered in 561 (31.3%), 1,461 (81.4%), and 555 (30.9%), respectively. Antenatal terbutaline was significantly associated with a reduction in ET (adjusted odds ratio [aOR] = 0.40, 95% confident interval [CI] 0.19-0.82, p = 0.012) in infants with the GA of <32 weeks, but not in infants with the GA of 32-36 weeks. Antenatal terbutaline was not associated with RDS or BPD but was significantly associated with a reduction in grade III-IV IVH (aOR 0.11, CI 0.01-0.98; p = 0.048), in infants with the GA of <32 weeks. CONCLUSION In a state-of-the-art neonatal care setting, antenatal terbutaline was associated with a reduction in ET during the first 24 hours in infants with the GA of <32 weeks. The use of antenatal terbutaline to improve acute neonatal respiratory outcomes merits reconsideration. KEY POINTS · The neonatal respiratory benefits of antenatal terbutaline in the era of antenatal corticosteroids were uncertain.. · Terbutaline is associated with a reduction in endotracheal intubation in a modern care setting.. · The role of terbutaline, and potentially other betamimetics, to improve neonatal respiratory outcomes merits reconsideration..
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Affiliation(s)
- Visanu Kittiarpornpon
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pitiporn Siripattanapipong
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Walaiporn Bowornkitiwong
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ratchada Kitsommart
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sopapan Ngerncham
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pimol Wongsiridach
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Buranee Yangthara
- Department of Pediatrics, Division of Neonatology and Perinatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Goudarzi RM, Badiee Z, Sadeghnia A, Barekatain B. Evaluation of intratracheal salbutamol effects in addition to surfactant in the clinical course of premature neonates with respiratory distress syndrome. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:53. [PMID: 37496643 PMCID: PMC10366974 DOI: 10.4103/jrms.jrms_548_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 01/25/2023] [Accepted: 03/01/2023] [Indexed: 07/28/2023]
Abstract
Background In addition to surfactant deficiency, secretion of fluid from blood to the lungs and increase in the fluid content of the lung play significant roles in the pathogenesis of respiratory distress syndrome (RDS). Thus, we aimed to evaluate the effect of salbutamol (a beta-agonist) on fluid clearance from the lungs in neonates with RDS. Materials and Methods This randomized controlled clinical trial included 82 neonates with RDS admitted to the neonatal intensive care units of Alzahra and Shahid Beheshti Hospitals of Isfahan University of Medical Science from 2017 to 2018. Patients were recruited through convenience sampling. They were randomized into two groups, using simple randomization: 42 were only treated with intra-tracheal surfactant (control group) and 40 with intra-tracheal surfactant plus salbutamol (intervention group). The two groups were compared regarding intubation surfactant administration and extubation (INSURE) failure, duration of nasal continuous positive airway pressure, intubation, oxygen therapy, morbidity, and mortality. Results INSURE failure leading to mechanical ventilation occurred in 3 neonates in the control group and 2 in the intervention group (P = 0.680). Mean hospital length of stay did not differ significantly between groups (P = 0.230). Comparison of controls with the intervention group regarding complications and the incidence of morbidities revealed no statistically significant difference (P > 0.05). Conclusion Findings of this study were not in favor of the routine use of salbutamol in neonates with RDS as it did not improve the course of the disease among newborns.
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Affiliation(s)
- Razieh Moazami Goudarzi
- Department of Pediatrics, School of Medicine, Hormozgan University of Medical Sciences, Hormozgan, Iran
| | - Zohreh Badiee
- Department of Pediatrics, School of Medicine, Isfahan University of Medical Sciences and Child Growth and Development Center, Isfahan, Iran
| | - Alireza Sadeghnia
- Department of Pediatrics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behzad Barekatain
- Department of Pediatrics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Sriram K, Insel MB, Insel PA. Inhaled β2 Adrenergic Agonists and Other cAMP-Elevating Agents: Therapeutics for Alveolar Injury and Acute Respiratory Disease Syndrome? Pharmacol Rev 2021; 73:488-526. [PMID: 34795026 DOI: 10.1124/pharmrev.121.000356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/15/2021] [Indexed: 12/15/2022] Open
Abstract
Inhaled long-acting β-adrenergic agonists (LABAs) and short-acting β-adrenergic agonists are approved for the treatment of obstructive lung disease via actions mediated by β2 adrenergic receptors (β2-ARs) that increase cellular cAMP synthesis. This review discusses the potential of β2-AR agonists, in particular LABAs, for the treatment of acute respiratory distress syndrome (ARDS). We emphasize ARDS induced by pneumonia and focus on the pathobiology of ARDS and actions of LABAs and cAMP on pulmonary and immune cell types. β2-AR agonists/cAMP have beneficial actions that include protection of epithelial and endothelial cells from injury, restoration of alveolar fluid clearance, and reduction of fibrotic remodeling. β2-AR agonists/cAMP also exert anti-inflammatory effects on the immune system by actions on several types of immune cells. Early administration is likely critical for optimizing efficacy of LABAs or other cAMP-elevating agents, such as agonists of other Gs-coupled G protein-coupled receptors or cyclic nucleotide phosphodiesterase inhibitors. Clinical studies that target lung injury early, prior to development of ARDS, are thus needed to further assess the use of inhaled LABAs, perhaps combined with inhaled corticosteroids and/or long-acting muscarinic cholinergic antagonists. Such agents may provide a multipronged, repurposing, and efficacious therapeutic approach while minimizing systemic toxicity. SIGNIFICANCE STATEMENT: Acute respiratory distress syndrome (ARDS) after pulmonary alveolar injury (e.g., certain viral infections) is associated with ∼40% mortality and in need of new therapeutic approaches. This review summarizes the pathobiology of ARDS, focusing on contributions of pulmonary and immune cell types and potentially beneficial actions of β2 adrenergic receptors and cAMP. Early administration of inhaled β2 adrenergic agonists and perhaps other cAMP-elevating agents after alveolar injury may be a prophylactic approach to prevent development of ARDS.
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Affiliation(s)
- Krishna Sriram
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
| | - Michael B Insel
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
| | - Paul A Insel
- Departments of Pharmacology (K.S., P.A.I.) and Medicine (P.A.I.), University of California San Diego, La Jolla, California; Department of Medicine (M.B.I.) University of Arizona, Tucson, Arizona
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Dassios T, Ambulkar H, Greenough A. Treatment and respiratory support modes for neonates with respiratory distress syndrome. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1769598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Theodore Dassios
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
| | - Hemant Ambulkar
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Anne Greenough
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
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Caffarelli C, Santamaria F, Di Mauro D, Mastrorilli C, Montella S, Bernasconi S. Advances in paediatrics in 2016: current practices and challenges in allergy, autoimmune diseases, cardiology, endocrinology, gastroenterology, infectious diseases, neonatology, nephrology, neurology, nutrition, pulmonology. Ital J Pediatr 2017; 43:80. [PMID: 28915908 PMCID: PMC5602868 DOI: 10.1186/s13052-017-0401-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 09/10/2017] [Indexed: 12/20/2022] Open
Abstract
This review reports main progresses in various pediatric issues published in Italian Journal of Pediatrics and in international journals in 2016. New insights in clinical features or complications of several disorders may be useful for our better understanding. They comprise severe asthma, changing features of lupus erythematosus from birth to adolescence, celiac disease, functional gastrointestinal disorders, Moebius syndrome, recurrent pneumonia. Risk factors for congenital heart defects, Kawasaki disease have been widely investigated. New diagnostic tools are available for ascertaining brucellosis, celiac disease and viral infections. The usefulness of aCGH as first-tier test is confirmed in patients with neurodevelopmental disorders. Novel information have been provided on the safety of milk for infants. Recent advances in the treatment of common disorders, including neonatal respiratory distress syndrome, hypo-glycemia in newborns, atopic dermatitis, constipation, cyclic vomiting syndrome, nephrotic syndrome, diabetes mellitus, regurgitation, short stature, secretions in children with cerebral palsy have been reported. Antipyretics treatment has been updated by national guidelines and studies have excluded side effects (e.g. asthma risk during acetaminophen therapy). Vaccinations are a painful event and several options are reported to prevent this pain. Adverse effects due to metabolic abnormalities are reported for second generation antipsychotic drugs.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci, 14 Parma, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Dora Di Mauro
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci, 14 Parma, Italy
| | - Carla Mastrorilli
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci, 14 Parma, Italy
| | - Silvia Montella
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Sergio Bernasconi
- Pediatrics Honorary Member University Faculty, G D’Annunzio University of Chieti-Pescara, Chieti, Italy
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Greenough A, Papalexopoulou N. The roles of drug therapy given via the endotracheal tube to neonates. Arch Dis Child Fetal Neonatal Ed 2017; 102:F277-F281. [PMID: 28270430 DOI: 10.1136/archdischild-2016-311711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 11/04/2022]
Abstract
Many drugs are given to intubated neonates by the inhalation route. The optimum aerosol delivery system, however, has not been identified and there are many challenges in delivering drugs effectively to the lower airways of intubated neonates. The effectiveness of surfactant in prematurely born infants and nitric oxide has been robustly investigated. Other drugs are being used on very limited evidence.
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Affiliation(s)
- Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Niovi Papalexopoulou
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
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