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Sakaria RP, Dhanireddy R. Pharmacotherapy in Bronchopulmonary Dysplasia: What Is the Evidence? Front Pediatr 2022; 10:820259. [PMID: 35356441 PMCID: PMC8959440 DOI: 10.3389/fped.2022.820259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Bronchopulmonary Dysplasia (BPD) is a multifactorial disease affecting over 35% of extremely preterm infants born each year. Despite the advances made in understanding the pathogenesis of this disease over the last five decades, BPD remains one of the major causes of morbidity and mortality in this population, and the incidence of the disease increases with decreasing gestational age. As inflammation is one of the key drivers in the pathogenesis, it has been targeted by majority of pharmacological and non-pharmacological methods to prevent BPD. Most extremely premature infants receive a myriad of medications during their stay in the neonatal intensive care unit in an effort to prevent or manage BPD, with corticosteroids, caffeine, and diuretics being the most commonly used medications. However, there is no consensus regarding their use and benefits in this population. This review summarizes the available literature regarding these medications and aims to provide neonatologists and neonatal providers with evidence-based recommendations.
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Affiliation(s)
- Rishika P. Sakaria
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, United States
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2
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Shiraishi J, Kusuda S, Cho K, Nakao A, Hiroma T, Sugiura H, Suzuki S, Oshiro M, Yoshimoto S, Watabe S. Standardization of nitric oxide inhalation in extremely preterm infants in Japan. Pediatr Int 2019; 61:152-157. [PMID: 30523661 DOI: 10.1111/ped.13746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/31/2018] [Accepted: 11/13/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND In perinatal medicine, inhaled nitric oxide (iNO) has been an important tool for the treatment of full-term and late-preterm infants with persistent pulmonary hypertension of the newborn (PPHN) and hypoxemic respiratory failure (HRF). Its use in more premature infants, however, is controversial. To evaluate the current clinical practices regarding use of acute iNO in extremely preterm infants, a nationwide survey was conducted in Japan. METHODS A questionnaire survey was conducted from May to September, 2015. Questionnaires about PPHN and iNO treatment were sent to the doctor in charge of the neonatal care unit in 213 perinatal medical centers (PMC) that possessed iNO equipment in Japan. RESULTS A total of 143 of the 213 PMC provided responses (67.1%). A diagnosis of PPHN was made exclusively on echocardiography in all PMC. On definitive PPHN diagnosis, iNO was selected in the majority of the PMC (72%) and started from ≤10 p.p.m. in most PMC (49.7%) for extremely preterm infants. During iNO therapy, cardiac function was checked on echocardiography by a neonatologist every ≤8 h. iNO weaning was started when differential peripheral oxygen saturation (SpO2 ) disappeared, or when SpO2 reached 100% and so on. After iNO concentration reached 5 p.p.m., it was decreased gradually and carefully in five steps, taking 12-24 h to go from 5 to 0 p.p.m. CONCLUSIONS Inhaled nitric oxide was predominantly used in extremely preterm infants as early rescue therapy for PPHN based on echocardiography performed by a neonatologist.
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Affiliation(s)
- Jun Shiraishi
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Satoshi Kusuda
- Neonatal Research Network of Japan, Shinjuku, Tokyo, Japan
| | - Kazutoshi Cho
- Maternity and Perinatal Center, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Atsushi Nakao
- Neonatology, Japanese Red Cross Medical Center, Shibuya, Tokyo, Japan
| | - Takehiko Hiroma
- Neonatology, Nagano Children's Hospital, Azumino, Nagano, Japan
| | - Hiroshi Sugiura
- Neonatology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoshi Suzuki
- Pediatrics, Nagoya City West Medical Center, Nagoya, Aichi, Japan
| | - Makoto Oshiro
- Neonatology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Aichi, Japan
| | - Seiji Yoshimoto
- Neonatology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Shinichi Watabe
- Neonatal Intensive Care, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
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RHAMM induces progression of rheumatoid arthritis by enhancing the functions of fibroblast-like synoviocytes. BMC Musculoskelet Disord 2018; 19:455. [PMID: 30587175 PMCID: PMC6307322 DOI: 10.1186/s12891-018-2370-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/03/2018] [Indexed: 12/29/2022] Open
Abstract
Background Rheumatoid arthritis (RA) is a chronic and refractory autoimmune joint disease. Fibroblast-like synoviocytes (FLS) produce inflammatory cytokines and are involved in the migration and invasion of panuus tissue, which leads to the destruction of joints in RA. Receptor for hyaluronan mediated motility (RHAMM), is known to be one of the important receptors for hyaluronic acid. It has the ability to regulate migration of fibrocytes and infiltration of inflammatory cells. Here,we explored the mechanisms of RHAMM in RAFs. Methods Quantitative PCR and western blot were performed to test the expression of RHAMM in synoviocytes of RA patients and osteoarthritis (OA) controls. Collagen antibody-induced arthritis (CAIA) was used to investigate the RHAMM expression in mouse synovial issues. RHAMM siRNA was used to detect the function of RHAMM in FLS. Results RA-FLS has a significantly higher expression of RHAMM than OA-FLS. Expression of RHAMM in joint synovial tissue was markedly increased in the CAIA mice compared with the controls. RHAMM silencing using SiRNA was not only decreased the production of IL-6 and IL-8, but also inhibited the migration and invasion of RA-FLS. Conclusions RHAMM has an important role in the FLS induced modulation of inflammation and destruction of joints in RA.
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Askie LM, Davies LC, Schreiber MD, Hibbs AM, Ballard PL, Ballard RA. Race Effects of Inhaled Nitric Oxide in Preterm Infants: An Individual Participant Data Meta-Analysis. J Pediatr 2018; 193:34-39.e2. [PMID: 29241680 DOI: 10.1016/j.jpeds.2017.10.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/12/2017] [Accepted: 10/06/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess whether inhaled nitric oxide (iNO) improves survival without bronchopulmonary dysplasia (BPD) for preterm African American infants. STUDY DESIGN An individual participant data meta-analysis was conducted, including 3 randomized, placebo-controlled trials that enrolled infants born at <34 weeks of gestation receiving respiratory support, had at least 15% (or a minimum of 10 infants in each trial arm) of African American race, and used a starting iNO of >5 parts per million with the intention to treat for 7 days minimum. The primary outcome was a composite of death or BPD. Secondary outcomes included death before discharge, postnatal steroid use, gross pulmonary air leak, pulmonary hemorrhage, measures of respiratory support, and duration of hospital stay. RESULTS Compared with other races, African American infants had a significant reduction in the composite outcome of death or BPD with iNO treatment: 49% treated vs 63% controls (relative risk, 0.77; 95% CI, 0.65-0.91; P = .003; interaction P = .016). There were no differences between racial groups for death. There was also a significant difference between races (interaction P = .023) of iNO treatment for BPD in survivors, with the greatest effect in African American infants (P = .005). There was no difference between racial groups in the use of postnatal steroids, pulmonary air leak, pulmonary hemorrhage, or other measures of respiratory support. CONCLUSION iNO therapy should be considered for preterm African American infants at high risk for BPD. iNO to prevent BPD in African Americans may represent an example of a racially customized therapy for infants.
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Affiliation(s)
- Lisa M Askie
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Lucy C Davies
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, and Rainbow Babies and Children's Hospital, Cleveland, OH
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Laube M, Amann E, Uhlig U, Yang Y, Fuchs HW, Zemlin M, Mercier JC, Maier RF, Hummler HD, Uhlig S, Thome UH. Inflammatory Mediators in Tracheal Aspirates of Preterm Infants Participating in a Randomized Trial of Inhaled Nitric Oxide. PLoS One 2017; 12:e0169352. [PMID: 28046032 PMCID: PMC5207654 DOI: 10.1371/journal.pone.0169352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 12/15/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ventilated preterm infants frequently develop bronchopulmonary dysplasia (BPD) which is associated with elevated inflammatory mediators in their tracheal aspirates (TA). In animal models of BPD, inhaled nitric oxide (iNO) has been shown to reduce lung inflammation, but data for human preterm infants is missing. METHODS Within a European multicenter trial of NO inhalation for preterm infants to prevent BPD (EUNO), TA was collected to determine the effects of iNO on pulmonary inflammation. TA was collected from 43 premature infants randomly assigned to receive either iNO or placebo gas (birth weight 530-1230 g, median 800 g, gestational age 24 to 28 2/7 weeks, median 26 weeks). Interleukin (IL)-1β, IL-6, IL-8, transforming growth factor (TGF)-β1, interferon γ-induced protein 10 (IP-10), macrophage inflammatory protein (MIP)-1α, acid sphingomyelinase (ASM), neuropeptide Y and leukotriene B4 were measured in serial TA samples from postnatal day 2 to 14. Furthermore, TA levels of nitrotyrosine and nitrite were determined under iNO therapy. RESULTS The TA levels of IP-10, IL-6, IL-8, MIP-1α, IL-1β, ASM and albumin increased with advancing postnatal age in critically ill preterm infants, whereas nitrotyrosine TA levels declined in both, iNO-treated and placebo-treated infants. The iNO treatment generally increased nitrite TA levels, whereas nitrotyrosine TA levels were not affected by iNO treatment. Furthermore, iNO treatment transiently reduced early inflammatory and fibrotic markers associated with BPD development including TGF-β1, IP-10 and IL-8, but induced a delayed increase of ASM TA levels. CONCLUSION Treatment with iNO may have played a role in reducing several inflammatory and fibrotic mediators in TA of preterm infants compared to placebo-treated infants. However, survival without BPD was not affected in the main EUNO trial. TRIAL REGISTRATION NCT00551642.
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Affiliation(s)
- Mandy Laube
- Center for Pediatric Research Leipzig, Hospital for Children & Adolescents, Division of Neonatology, University of Leipzig, Leipzig, Germany
- * E-mail:
| | - Elena Amann
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Ulrike Uhlig
- Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Yang Yang
- Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Hans W. Fuchs
- Department of Pediatrics, University Medical Center Freiburg, Freiburg, Germany
| | - Michael Zemlin
- Department of Pediatrics, University of Marburg, Marburg, Germany
- Department of Pediatrics, University of Saarland, Homburg, Germany
| | | | - Rolf F. Maier
- Department of Pediatrics, University of Marburg, Marburg, Germany
| | - Helmut D. Hummler
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Stefan Uhlig
- Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Ulrich H. Thome
- Center for Pediatric Research Leipzig, Hospital for Children & Adolescents, Division of Neonatology, University of Leipzig, Leipzig, Germany
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Abstract
Hyperoxic acute lung injury (HALI) refers to the damage to the lungs secondary to exposure to elevated oxygen partial pressure. HALI has been a concern in clinical practice with the development of deep diving and the use of normobaric as well as hyperbaric oxygen in clinical practice. Although the pathogenesis of HALI has been extensively studied, the findings are still controversial. Nitric oxide (NO) is an intercellular messenger and has been considered as a signaling molecule involved in many physiological and pathological processes. Although the role of NO in the occurrence and development of pulmonary diseases including HALI has been extensively studied, the findings on the role of NO in HALI are conflicting. Moreover, inhalation of NO has been approved as a therapeutic strategy for several diseases. In this paper, we briefly summarize the role of NO in the pathogenesis of HALI and the therapeutic potential of inhaled NO in HALI.
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Affiliation(s)
- Wen-Wu Liu
- Department of Diving and Hyperbaric Medicine, Secondary Military Medical University, Shanghai, China
| | - Cui-Hong Han
- Department of Pathology, the First Hospital of Jining City, Jining, Shandong Province, China
| | - Pei-Xi Zhang
- Department of Cardiothoracic Surgery, the First Hospital of Jining City, Jining, Shandong Province, China
| | - Juan Zheng
- Department of Diving and Hyperbaric Medicine, Secondary Military Medical University, Shanghai, China
| | - Kan Liu
- Department of Diving and Hyperbaric Medicine, Secondary Military Medical University, Shanghai, China
| | - Xue-Jun Sun
- Department of Diving and Hyperbaric Medicine, Secondary Military Medical University, Shanghai, China
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Jensen EA, Kirpalani H. Inhaled nitric oxide to prevent bronchopulmonary dysplasia in preterm infants--less than a silver bullet. J Pediatr 2014; 165:1079-81. [PMID: 25266344 DOI: 10.1016/j.jpeds.2014.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 08/20/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Erik A Jensen
- Division of Neonatology Department of Pediatrics, The Children's Hospital of Philadelphia The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haresh Kirpalani
- Division of Neonatology Department of Pediatrics, The Children's Hospital of Philadelphia The University of Pennsylvania, Philadelphia, Pennsylvania.
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Symonette CJ, Kaur Mann A, Tan XC, Tolg C, Ma J, Perera F, Yazdani A, Turley EA. Hyaluronan-phosphatidylethanolamine polymers form pericellular coats on keratinocytes and promote basal keratinocyte proliferation. BIOMED RESEARCH INTERNATIONAL 2014; 2014:727459. [PMID: 25276814 PMCID: PMC4172883 DOI: 10.1155/2014/727459] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/28/2014] [Indexed: 12/26/2022]
Abstract
Aged keratinocytes have diminished proliferative capacity and hyaluronan (HA) cell coats, which are losses that contribute to atrophic skin characterized by reduced barrier and repair functions. We formulated HA-phospholipid (phosphatidylethanolamine, HA-PE) polymers that form pericellular coats around cultured dermal fibroblasts independently of CD44 or RHAMM display. We investigated the ability of these HA-PE polymers to penetrate into aged mouse skin and restore epidermal function in vivo. Topically applied Alexa(647)-HA-PE penetrated into the epidermis and dermis, where it associated with both keratinocytes and fibroblasts. In contrast, Alexa(647)-HA was largely retained in the outer cornified layer of the epidermis and quantification of fluorescence confirmed that significantly more Alexa(647)-HA-PE penetrated into and was retained within the epidermis than Alexa(647)-HA. Multiple topical applications of HA-PE to shaved mouse skin significantly stimulated basal keratinocyte proliferation and epidermal thickness compared to HA or vehicle cream alone. HA-PE had no detectable effect on keratinocyte differentiation and did not promote local or systemic inflammation. These effects of HA-PE polymers are similar to those reported for endogenous epidermal HA in youthful skin and show that topical application of HA-PE polymers can restore some of the impaired functions of aged epidermis.
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Affiliation(s)
- Caitlin J. Symonette
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, 1151 Richmond Street, London, ON, Canada N6A 3K7
| | - Aman Kaur Mann
- London Regional Cancer Program, London Health Sciences Centre, Room A4-931A, 790 Commissioners Road East, London, ON, Canada N6A 4L6
| | - Xiao Cherie Tan
- London Regional Cancer Program, London Health Sciences Centre, Room A4-931A, 790 Commissioners Road East, London, ON, Canada N6A 4L6
| | - Cornelia Tolg
- London Regional Cancer Program, London Health Sciences Centre, Room A4-931A, 790 Commissioners Road East, London, ON, Canada N6A 4L6
| | - Jenny Ma
- London Regional Cancer Program, London Health Sciences Centre, Room A4-931A, 790 Commissioners Road East, London, ON, Canada N6A 4L6
| | - Francisco Perera
- London Regional Cancer Program, London Health Sciences Centre, Room A4-931A, 790 Commissioners Road East, London, ON, Canada N6A 4L6
| | - Arjang Yazdani
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, 1151 Richmond Street, London, ON, Canada N6A 3K7
- London Health Science Center, Victoria Hospital, Room E2-647, 800 Commissioners Road East, London, ON, Canada N6A 4G5
| | - Eva A. Turley
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, 1151 Richmond Street, London, ON, Canada N6A 3K7
- London Regional Cancer Program, London Health Sciences Centre, Room A4-931A, 790 Commissioners Road East, London, ON, Canada N6A 4L6
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Hyaluronan and RHAMM in wound repair and the "cancerization" of stromal tissues. BIOMED RESEARCH INTERNATIONAL 2014; 2014:103923. [PMID: 25157350 PMCID: PMC4137499 DOI: 10.1155/2014/103923] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/04/2014] [Indexed: 12/12/2022]
Abstract
Tumors and wounds share many similarities including loss of tissue architecture, cell polarity and cell differentiation, aberrant extracellular matrix (ECM) remodeling (Ballard et al., 2006) increased inflammation, angiogenesis, and elevated cell migration and proliferation. Whereas these changes are transient in repairing wounds, tumors do not regain tissue architecture but rather their continued progression is fueled in part by loss of normal tissue structure. As a result tumors are often described as wounds that do not heal. The ECM component hyaluronan (HA) and its receptor RHAMM have both been implicated in wound repair and tumor progression. This review highlights the similarities and differences in their roles during these processes and proposes that RHAMM-regulated wound repair functions may contribute to “cancerization” of the tumor microenvironment.
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Abstract
Nitric oxide, an important signaling molecule with multiple regulatory effects throughout the body, is an important tool for the treatment of full-term and late-preterm infants with persistent pulmonary hypertension of the newborn and hypoxemic respiratory failure. Several randomized controlled trials have evaluated its role in the management of preterm infants ≤ 34 weeks' gestational age with varying results. The purpose of this clinical report is to summarize the existing evidence for the use of inhaled nitric oxide in preterm infants and provide guidance regarding its use in this population.
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Cytidine 5'-diphosphocholine ameliorates hyperoxic lung injury in a neonatal rat model. Pediatr Res 2013; 74:26-33. [PMID: 23598810 DOI: 10.1038/pr.2013.68] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/26/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is an important cause of morbidity. The aim of this study was to evaluate the preventive effect of cytidine 5'-diphosphocholine (CDP-choline) treatment on hyperoxic lung injury in a neonatal rat model. METHODS A total of 30 newborn pups were divided into control, hyperoxia, and hyperoxia + CDP-choline groups. After birth, pups in the control group were kept in room air and received saline injections, whereas those in hyperoxia and hyperoxia + CDP-choline groups were exposed to 95% O₂ and received daily injections of saline and CDP-choline throughout postnatal day 10, respectively. Histopathological scoring, radial alveolar count, lamellar body membrane protein expression, fibrosis, proinflammatory cytokine levels, lung tissue and bronchoalveolar lavage (BAL) fluid phospholipid content, and apoptosis were evaluated. RESULTS Hyperoxia-induced severe lung damage was reduced significantly by CDP-choline treatment. Radial alveolar count and lamellar body membrane protein expression were significantly recovered, and the number of terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling-positive cells, active caspase-3 expression, and tissue proinflammatory cytokine levels were decreased by CDP-choline administration. Lung tissue and BAL phospholipid contents showed significant increases after CDP-choline administration. CONCLUSION These data show that CDP-choline ameliorates hyperoxic lung injury in a neonatal rat model. It may therefore be suggested that CDP-choline may be a novel therapeutic option for the prevention of BPD.
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Abstract
Bronchopulmonary dysplasia (BPD) is the most prevalent long-term morbidity in surviving extremely preterm infants and is linked to increased risk of reactive airways disease, pulmonary hypertension, post-neonatal mortality, and adverse neurodevelopmental outcomes. BPD affects approximately 20% of premature newborns, and up to 60% of premature infants born before completing 26 weeks of gestation. It is characterized by the need for assisted ventilation and/or supplemental oxygen at 36 weeks postmenstrual age. Approaches to prevention and treatment of BPD have evolved with improved understanding of its pathogenesis. This review will focus on recent advancements and detail current research in pharmacotherapy for BPD. The evidence for both current and potential future experimental therapies will be reviewed in detail. As our understanding of the complex and multifactorial pathophysiology of BPD changes, research into these current and future approaches must continue to evolve.
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Affiliation(s)
- Sailaja Ghanta
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA 02115, , Tel: (774) 249 8137, Fax: (617) 730-0260
| | - Kristen Tropea Leeman
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA 02115, , Tel: (919) 475 9260, Fax: (617) 730 0222
| | - Helen Christou
- Division of Newborn Medicine, Brigham and Women’s Hospital, Boston Children’s Hospital, Harvard Medical School, 75 Francis Street, Thorn 1005, Boston, MA 02115, , Tel: (617) 515 8129, Fax: (617) 582 6026
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13
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Askie LM, Ballard RA, Cutter GR, Dani C, Elbourne D, Field D, Hascoet JM, Hibbs AM, Kinsella JP, Mercier JC, Rich W, Schreiber MD, Wongsiridej P(S, Subhedar NV, Van Meurs KP, Voysey M, Barrington K, Ehrenkranz RA, Finer NN. Inhaled nitric oxide in preterm infants: an individual-patient data meta-analysis of randomized trials. Pediatrics 2011; 128:729-39. [PMID: 21930540 PMCID: PMC3387905 DOI: 10.1542/peds.2010-2725] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is an effective therapy for pulmonary hypertension and hypoxic respiratory failure in term infants. Fourteen randomized controlled trials (n = 3430 infants) have been conducted on preterm infants at risk for chronic lung disease (CLD). The study results seem contradictory. DESIGN/METHODS Individual-patient data meta-analysis included randomized controlled trials of preterm infants (<37 weeks' gestation). Outcomes were adjusted for trial differences and correlation between siblings. RESULTS Data from 3298 infants in 12 trials (96%) were analyzed. There was no statistically significant effect of iNO on death or CLD (59% vs 61%: relative risk [RR]: 0.96 [95% confidence interval (CI): 0.92-1.01]; P = .11) or severe neurologic events on imaging (25% vs 23%: RR: 1.12 [95% CI: 0.98-1.28]; P = .09). There were no statistically significant differences in iNO effect according to any of the patient-level characteristics tested. In trials that used a starting iNO dose of >5 vs ≤ 5 ppm there was evidence of improved outcome (interaction P = .02); however, these differences were not observed at other levels of exposure to iNO. This result was driven primarily by 1 trial, which also differed according to overall dose, duration, timing, and indication for treatment; a significant reduction in death or CLD (RR: 0.85 [95% CI: 0.74-0.98]) was found. CONCLUSIONS Routine use of iNO for treatment of respiratory failure in preterm infants cannot be recommended. The use of a higher starting dose might be associated with improved outcome, but because there were differences in the designs of these trials, it requires further examination.
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Affiliation(s)
- Lisa M. Askie
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Roberta A. Ballard
- Department of Pediatrics, University of California at San Francisco, School of Medicine, San Francisco, California
| | - Gary R. Cutter
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlo Dani
- Section of Neonatology, Department of Surgical and Medical Critical Care, Careggi University Hospital of Florence, Florence, Italy
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Field
- Department of Health Science, University of Leicester, Leicester, United Kingdom
| | | | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - John P. Kinsella
- Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Jean-Christophe Mercier
- Department of Pediatric Emergency Medicine, Hôpital Robert Debré, Université Paris-7 Denis Diderot, Paris, France
| | - Wade Rich
- Division of Neonatology, University of California, San Diego, California
| | | | - Pimol (Srisuparp) Wongsiridej
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nim V. Subhedar
- Neonatal Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Merryn Voysey
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Keith Barrington
- Division of Neonatology, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada; and
| | - Richard A. Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Neil N. Finer
- Division of Neonatology, University of California, San Diego, California
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Boggaram V, Chandru H, Gottipati KR, Thakur V, Das A, Berhane K. Transcriptional regulation of SP-B gene expression by nitric oxide in H441 lung epithelial cells. Am J Physiol Lung Cell Mol Physiol 2010; 299:L252-62. [PMID: 20418387 PMCID: PMC2928609 DOI: 10.1152/ajplung.00062.2010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 04/20/2010] [Indexed: 11/22/2022] Open
Abstract
Surfactant protein B (SP-B) is essential for the surface tension-lowering function of pulmonary surfactant. Surfactant dysfunction and reduced SP-B levels are associated with elevated nitric oxide (NO) in inflammatory lung diseases, such as acute respiratory distress syndrome. We previously found that NO donors decreased SP-B expression in H441 and MLE-12 lung epithelial cells by reducing SP-B promoter activity. In this study, we determined the roles of DNA elements and interacting transcription factors necessary for NO inhibition of SP-B promoter activity in H441 cells. We found that the NO donor diethylenetriamine-nitric oxide adduct (DETA-NO) decreased SP-B promoter thyroid transcription factor 1 (TTF-1), hepatocyte nuclear factor 3 (HNF-3), and Sp1 binding activities but increased activator protein 1 (AP-1) binding activity. DETA-NO decreased TTF-1, but not Sp1, levels, suggesting that reduced TTF-1 expression contributes to reduced TTF-1 binding activity. Lack of effect on Sp1 levels suggested that DETA-NO inhibits Sp1 binding activity per se. Overexpression of Sp1, but not TTF-1, blocked DETA-NO inhibition of SP-B promoter activity. DETA-NO inhibited SP-B promoter induction by exogenous TTF-1 without altering TTF-1 levels. DETA-NO decreased TTF-1 mRNA levels and gene transcription rate, indicating that DETA-NO inhibits TTF-1 expression at the transcriptional level. We conclude that NO inhibits SP-B promoter by decreasing TTF-1, Sp1, and HNF-3 binding activities and increasing AP-1 binding activity. NO inhibits TTF-1 levels and activity to decrease SP-B expression. NO inhibition of SP-B expression could be a mechanism by which surfactant dysfunction occurs in inflammatory lung diseases.
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Affiliation(s)
- Vijay Boggaram
- Center for Biomedical Research, Univ. of Texas Health Science Center at Tyler, TX 75708-3154, USA.
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15
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Johnston LC, Gonzales LW, Lightfoot RT, Guttentag SH, Ischiropoulos H. Opposing regulation of human alveolar type II cell differentiation by nitric oxide and hyperoxia. Pediatr Res 2010; 67:521-5. [PMID: 20098340 PMCID: PMC3066065 DOI: 10.1203/pdr.0b013e3181d4f20f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Clinical trials demonstrated decreasing rates of bronchopulmonary dysplasia in preterm infants with hypoxic respiratory failure treated with inhaled nitric oxide (iNO). However, the molecular and biochemical effects of iNO on developing human fetal lungs remain vastly unknown. By using a well-characterized model of human fetal alveolar type II cells, we assessed the effects of iNO and hyperoxia, independently and concurrently, on NO-cGMP signaling pathway and differentiation. Exposure to iNO increased cGMP levels by 40-fold after 3 d and by 8-fold after 5 d despite constant expression of phosphodiesterase-5 (PDE5). The levels of cGMP declined significantly on exposure to iNO and hyperoxia at 3 and 5 d, although expression of soluble guanylyl cyclase (sGC) was sustained. Surfactant proteins B and C (SP-B, SP-C) and thyroid transcription factor (TTF)-1 mRNA levels increased in cells exposed to iNO in normoxia but not on exposure to iNO plus hyperoxia. Collectively, these data indicate an increase in type II cell markers when undifferentiated lung epithelial cells are exposed to iNO in room air. However, hyperoxia overrides these potentially beneficial effects of iNO despite sustained expression of sGC.
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Affiliation(s)
- Lindsay C Johnston
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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16
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MacCarrick MJ, Torbati D, Kimura D, Raszynski A, Zeng W, Totapally BR. Does hypercapnia ameliorate hyperoxia-induced lung injury in neonatal rats? Lung 2009; 188:235-40. [PMID: 20033196 DOI: 10.1007/s00408-009-9211-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 11/29/2009] [Indexed: 12/28/2022]
Abstract
Therapeutic hypercapnia (TH), an intentional inhalation of CO(2), has been shown to improve pulmonary function in certain models of lung injury. We tested the null hypothesis that TH does not improve hyperoxic lung injury in neonatal rats. The prospective, randomized study was set at Research laboratory in Children's Hospital. Forty-five newborn rats were randomly assigned to three groups (n = 15/group), and exposed to 96 h of normoxia (FiO(2) = 0.21), hyperoxia (FiO(2) > 0.98), and TH (FiO(2) = 0.95, FiCO(2) = 0.05). Lung histology, wet-weight to dry-weight ratio, and concentrations of pro- and anti-inflammatory cytokines (IL-1beta, IL-6, TNF-alpha, and IL-10) were used to evaluate pulmonary damage. Using a scale of 0-4, the total scores for lungs hypercellularity, inflammation, and hemorrhage was significantly increased from a median value of 1.5 in normoxia to 2.5 in hyperoxia (P < 0.05) and 3.0 with TH (P < 0.001, nonparametric ANOVA). The interstitial space relative to the alveolar space, as a measure of hypercellularity, was increased by 18% during hyperoxia and by 44% with TH compared with normoxia. TH significantly increased the size of the interstitial space by 22% compared with hyperoxia (P < 0.001). The lung wet-weight to dry-weight ratio was increased by 10% in both hyperoxic groups (P < 0.001). Both hyperoxic groups showed significant reductions in the concentration of IL-1beta compared with normoxia (P < 0.001), whereas the ratio of IL-1beta to IL-10 was significantly decreased, indicating an anti-inflammatory trend. TH does not prevent histological manifestations of hyperoxic lung injury in spontaneously breathing neonatal rats and may worsen the outcome.
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Affiliation(s)
- Matthew J MacCarrick
- Division of Critical Care Medicine, Miami Children's Hospital, 3100 SW 62nd Avenue, Miami, FL 33155, USA
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17
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Abstract
Lung development is orchestrated by highly integrated morphogenic programs of interrelated patterns of gene and protein expression. Injury to the developing lung in the canalicular and saccular phases of lung development alters subsequent alveolar and vascular development resulting in simplified alveolar structures, dysmorphic capillary configuration, variable interstitial cellularity and fibroproliferation that are characteristic of the 'new' bronchopulmonary dysplasia (BPD). Fetal and neonatal infection, abnormal stretch of the developing airways and alveoli, altered expression of surfactant proteins (or genetically altered proteins), polymorphisms of genes encoding for vascular endothelial growth factors, and reactive oxygen species result in imparied gas exchange in the developing lung. However, the 'new' BPD represents only one form of neonatal chronic lung disease and the consistent use of both the physiologic definition and severity scale would provide greater accuracy in determining the impact of the disease currently defined by its treatment. Our present labelling of the clinical state of oxygen supplementation and/or ventilatory support at 36 weeks' postmenstrual age and the histopathologic severity of alveolar arrest and vascular 'simplification' may not always be predictive of the degree of altered lung development and thus longer-term pulmonary function evaluations are needed to determine the impact of this disorder in specific infants. The proposed role of novel molecular therapies, and the combined effects of currently established therapies, as well as exogenous surfactant and inhaled nitric oxide or repetitive surfactant dosing, on the severity and incidence of new BPD hold considerable promise for reducing the long-term pulmonary morbidity among infants delivered prematurely.
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18
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Abstract
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease (CLD), is one of the most challenging complications in premature infants. The incidence of BPD has been increasing over the past two decades in parallel with an improvement in the survival of this population. Furthermore, the clinical characteristics and the natural history of infants affected by BPD have changed considerably, and newer definitions to clarify the term 'BPD' have also evolved since its first description more than four decades ago. Several drug therapies have also evolved, either to manage these infants' respiratory distress syndrome with an aim to prevent BPD or to manage the established condition. Although there is good evidence to support the 'routine' use of some therapies, many other therapies currently used in relation to BPD remain individual- or institution-specific, depending on beliefs and myths that we have adopted. In this article, we discuss the importance of defining BPD more objectively and the support--or lack thereof--for the drug therapies used in relation to BPD.
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Affiliation(s)
- Win Tin
- James Cook University Hospital, Marton Road, Middlesbrough, UK
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19
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Watson RS, Clermont G, Kinsella JP, Kong L, Arendt RE, Cutter G, Linde-Zwirble WT, Abman SH, Angus DC. Clinical and economic effects of iNO in premature newborns with respiratory failure at 1 year. Pediatrics 2009; 124:1333-43. [PMID: 19841128 DOI: 10.1542/peds.2009-0114] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The long-term consequences of inhaled nitric oxide (iNO) use in premature newborns with respiratory failure are unknown. We therefore studied the clinical and economic outcomes to 1 year of corrected age after a randomized controlled trial of prophylactic iNO. METHODS Premature newborns (gestational age <or=34 w, birth weight 500-1250 g) with respiratory failure randomly received 5 ppm iNO or placebo within 48 h of birth until 21 d or extubation. We assessed clinical outcomes via in-person neurodevelopmental evaluation at 1 y corrected age and telephone interviews every 3 m. We estimated costs from detailed hospital bills and interviews, converting all costs to 2008 US$. Of 793 trial subjects, 631 (79.6%) contributed economic data, and 455 (77.1% of survivors) underwent neurodevelopmental evaluation. RESULTS At 1 y corrected age, survival was not different by treatment arm (79.2% iNO vs. 74.5% placebo, P = .12), nor were other post-discharge outcomes. For subjects weighing 750-999 g, those receiving iNO had greater survival free from neurodevelopmental impairment (67.9% vs. 55.6%, P = .04). However, in subjects weighing 500-749 g, iNO led to greater oxygen dependency (11.7% vs. 4.0%, P = .04). Median total costs were similar ($235,800 iNO vs. $198,300 placebo, P = .19). Quality-adjusted survival was marginally better with iNO (by 0.011 quality-adjusted life-years/subject). The incremental cost-effectiveness ratio was $2.25 million/quality-adjusted life-year. CONCLUSIONS Subjects in both arms commonly experienced neurodevelopmental and pulmonary morbidity, consuming substantial health care resources. Prophylactic iNO beginning in the first days of life did not lower costs and had a poor cost-effectiveness profile.
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Affiliation(s)
- R Scott Watson
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
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20
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Abstract
The evidence for the benefits of inhaled nitric oxide (iNO) on gas exchange, cytokine-induced lung inflammation, and vascular dysfunction has been demonstrated by several animal and human studies. The use of iNO in extremely low birth weight neonates for the prevention of adverse outcomes like chronic lung disease and neurologic injury has been investigated, but the findings remain inconclusive. This review briefly outlines the biologic rationale for the use of iNO in preterm neonates and the results on the outcome measures of bronchopulmonary dysplasia and brain injury from the recent clinical trials. This article focuses on the potential toxicities, persistent controversies, and unanswered questions regarding the use of this treatment modality in this patient population at high risk for adverse outcomes.
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Affiliation(s)
- Nandini Arul
- Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI, USA.
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21
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Rieger-Fackeldey E, Hentschel R. Bronchopulmonary dysplasia and early prophylactic inhaled nitric oxide in preterm infants: current concepts and future research strategies in animal models. J Perinat Med 2009; 36:442-7. [PMID: 18605970 DOI: 10.1515/jpm.2008.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We reviewed the literature on the use of inhaled nitric oxide and the influence of supplemental oxygen on bronchopulmonary dysplasia (BPD), and the role of endogenous nitric oxide-synthase, vascular endothelial growth factor, the interplay of nitric oxide and superoxide, protein nitration and the nuclear factor kappa B-pathway. BPD is a major cause of neonatal mortality and morbidity leading to arrested lung development in newborns. Several studies indicate that inhaled nitric oxide (iNO) improves pulmonary angiogenesis, lung alveolarization, distal lung growth and pulmonary function in preterm infants. Given the inconclusive results of clinical studies, however, it is unclear which subpopulations of infants might benefit. Moreover, data on iNO are conflicting whether exogenous nitric oxide is protective or damaging in the presence of hyperoxia. The toxicology of iNO is poorly understood and its potential interaction with oxygen has to be considered given that infants treated with iNO are also supplemented with oxygen. The underlying mechanisms of the effects of iNO in the newborn lung need further analysis. New data clarifying the role of endogenous nitric oxide-synthases, vascular endothelial growth factor (VEGF), the interplay of nitric oxide and superoxide, and protein nitration with concurrent iNO-therapy might answer some of these questions.
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Affiliation(s)
- Esther Rieger-Fackeldey
- Center for Pediatrics and Adolescent Medicine, Neonatology and Pediatric Critical Care, University Hospital Freiburg, Germany.
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22
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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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23
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Hibbs AM, Walsh MC, Martin RJ, Truog WE, Lorch SA, Alessandrini E, Cnaan A, Palermo L, Wadlinger SR, Coburn CE, Ballard PL, Ballard RA. One-year respiratory outcomes of preterm infants enrolled in the Nitric Oxide (to prevent) Chronic Lung Disease trial. J Pediatr 2008; 153:525-9. [PMID: 18534620 PMCID: PMC2745607 DOI: 10.1016/j.jpeds.2008.04.033] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 03/21/2008] [Accepted: 04/09/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify whether inhaled nitric oxide treatment decreased indicators of long-term pulmonary morbidities after discharge from the neonatal intensive care unit. STUDY DESIGN The Nitric Oxide (to Prevent) Chronic Lung Disease trial enrolled preterm infants (<1250 g) between 7 to 21 days of age who were ventilated and at high risk for bronchopulmonary dysplasia. Follow-up occurred at 12 +/- 3 months of age adjusted for prematurity; long-term pulmonary morbidity and other outcomes were reported by parents during structured blinded interviews. RESULTS A total of 456 infants (85%) were seen at 1 year. Compared with control infants, infants randomized to inhaled nitric oxide received significantly less bronchodilators (odds ratio [OR] 0.53 [95% confidence interval 0.36-0.78]), inhaled steroids (OR 0.50 [0.32-0.77]), systemic steroids (OR 0.56 [0.32-0.97]), diuretics (OR 0.54 [0.34-0.85]), and supplemental oxygen (OR 0.65 [0.44-0.95]) after discharge from the neonatal intensive care unit. There were no significant differences between parental report of rehospitalizations (OR 0.83 [0.57-1.21]) or wheezing or whistling in the chest (OR 0.70 [0.48-1.03]). CONCLUSIONS Infants treated with inhaled nitric oxide received fewer outpatient respiratory medications than the control group. However, any decision to institute routine use of this dosing regimen should also take into account the results of the 24-month neurodevelopmental assessment.
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Affiliation(s)
- Anna Maria Hibbs
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH 44106-6010, USA.
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Richard J. Martin
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City, MO
| | - Scott A. Lorch
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Avital Cnaan
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lisa Palermo
- Department of Biostatistics, University of California San Francisco, San Francisco, CA
| | - Sandra R. Wadlinger
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christine E. Coburn
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Philip L. Ballard
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Roberta A. Ballard
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
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Qian L, Liu H, Yu W, Wang X, Sun Z, Wang W, Zhu L, Sun B. Effects of positive end-expiratory pressure, inhaled nitric oxide and surfactant on expression of proinflammatory cytokines and growth factors in preterm piglet lungs. Pediatr Res 2008; 64:17-23. [PMID: 18360309 DOI: 10.1203/pdr.0b013e31817330a6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We hypothesized that imbalance of proinflammatory cytokines and growth factors (GFs) in immature lungs of early postnatal life may be affected by protective ventilation strategy, and evaluated correlations of these aspects. Preterm neonate piglets were mechanically ventilated with low tidal volume and 5-6 or 10-12 cm H2O positive end-expiratory pressure (PEEP) with or without surfactant and inhaled nitric oxide (iNO) for 6 h, followed by biochemical, biophysical, and histopathological assessment of lung injury severity. Compared with surfactant and the control, iNO combined with lower PEEP exerted better oxygenation, lower activity of myeloperoxidase, lower expression of mRNA of interleukin (IL)-1beta, IL-6, IL-8, and platelet derived growth factor-B (PDGF-B), but higher expression of insulin-like growth factor-I (IGF-I), whereas that of tumor necrosis factor-alpha, keratinocyte GF, hepatocyte GF, vascular endothelial growth factor, and TGF-beta1 had no or modest changes. IL-1beta, IL-6 mRNA were closely correlated to PDGF-B mRNA and myeloperoxidase, but inversely to IGF-I mRNA, Pao2/FiO2 and dynamic lung compliance at 6 h. These results indicate that the association of lower PEEP and iNO may be more protective than surfactant on preventing lung injury and facilitating reparation by affecting the expression of proinflammatory cytokines and GFs.
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Affiliation(s)
- Liling Qian
- Laboratory of Pediatric Respiratory and Critical Care Medicine, Fudan University, Shanghai 200032, P.R. China
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MESH Headings
- Brain Diseases/etiology
- Bronchopulmonary Dysplasia/etiology
- Bronchopulmonary Dysplasia/prevention & control
- Developmental Disabilities/etiology
- Ductus Arteriosus, Patent/epidemiology
- Enterocolitis, Necrotizing/etiology
- Humans
- Infant Care
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/prevention & control
- Infant, Very Low Birth Weight
- Neonatology
- Prognosis
- Respiration, Artificial
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Affiliation(s)
- Eric C Eichenwald
- Department of Pediatrics and the Section of Neonatology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX 77030, USA.
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26
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Affiliation(s)
- Andrew Bush
- F.R.C.P., Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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27
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Cogo PE, Simonato M, Mariatoffolo G, Stefanutti G, Chierici M, Cobelli C, Ori C, Carnielli VP. Dexamethasone therapy in preterm infants developing bronchopulmonary dysplasia: effect on pulmonary surfactant disaturated-phosphatidylcholine kinetics. Pediatr Res 2008; 63:433-7. [PMID: 18356753 DOI: 10.1203/pdr.0b013e3181659759] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The role of corticosteroid in severe bronchopulmonary dyplasia (BPD) is still debated. Scanty data are available on the corticosteroids effect on surfactant metabolism. Our objective was to compare surfactant kinetics in preterm infants with developing BPD, before and after dexamethasone (DEXA) treatment. Twenty-eight studies were performed in 14 preterm infants (birth weight 786 +/- 192 g, gestational age 26 +/- 1 wk) on high ventilatory setting, before (age 22 +/- 11 d) and after (age 33 +/- 11 d) DEXA. C-labeled dipalmitoyl-phosphatidylcholine (DPPC) was administered endotrachelly to trace pulmonary surfactant. Surfactant disaturated-phosphatidylcholine (DSPC) kinetics and pools were calculated from DSPC C-enrichment curves of serial tracheal aspirates and bi-compartmental analysis. Total protein and myeloperoxidase (MPO) activity in tracheal aspirates were also measured and expressed per ml of Epithelial Lining Fluid (ELF). After DEXA, DSPC alveolar pool increased significantly from 8.2 +/- 7.6 to 10.6 +/- 11.3 mg/kg (p = 0.039), total proteins and MPO were reduced from 8.8 +/- 8.6 to 3.1 +/- 2.1 mg/ml ELF (p = 0.046) and from 1822 +/- 1224 to 1261 +/- 987 mU/mlELF (p = 0.028) respectively. In conclusion, DEXA treatment in mechanically ventilated preterm infants with severe respiratory failure and at high risk of developing BPD, significantly reduced inflammatory markers and increased alveolar surfactant DSPC pool.
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Affiliation(s)
- Paola E Cogo
- Departments of Pediatrics, University of Padova, 35128 Padova, Italy.
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28
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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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29
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Dani C, Bertini G. Inhaled nitric oxide for the treatment of preterm infants with respiratory distress syndrome. Neonatology 2008; 94:87-95. [PMID: 18332638 DOI: 10.1159/000119719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Many authors have hypothesized that inhaled nitric oxide (iNO) might acutely improve oxygenation in preterm neonates with infant respiratory distress syndrome (iRDS) and decrease the risk of bronchopulmonary dysplasia. The studies on the effects of iNO in preterm infants with iRDS have given contradictory results. We report their main methodological characteristics and the observed effects of iNO in preterm infants. Moreover, we discuss the infants' age at the beginning of the study, the dose and duration of iNO therapy, its potential effect on neurodevelopment, its relationship with surfactant properties, and the need to identify patients who are likely to respond to this therapy. We advise caution against the widespread use of iNO in preterm infants with iRDS. At present, it appears to be premature to have specific recommendations regarding the indications for iNO therapy in this group of patients. The conclusion of current trials and the follow-up studies of recently completed trials will give further data to guide neonatologists' decisions, and until then it is likely that clinicians will continue to make case-by-case decisions for the treatment of iNO in preterm infants with hypoxia that is unresponsive to other therapies. However, this decision should always be discussed with the parents.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Department of Surgical and Medical Critical Care, Careggi University Hospital, University of Florence School of Medicine, Florence, Italy.
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30
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Dani C, Pavoni V, Corsini I, Longini M, Gori G, Giannesello L, Perna A, Gritti G, Paternostro F, Forestieri A, Buonocore G, Rubaltelli FF. Inhaled nitric oxide combined with prostacyclin and adrenomedullin in acute respiratory failure with pulmonary hypertension in piglets. Pediatr Pulmonol 2007; 42:1048-56. [PMID: 17902148 DOI: 10.1002/ppul.20695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Our aim was to evaluate if the combined inhalation of both nitric oxide (iNO) and aerosolized prostacyclin or iNO and adrenomedullin (ADM) is more effective in lowering pulmonary arterial pressure (PAP) and improving oxygenation than nitric oxide alone in an animal model with pulmonary hypertension (PH). Moreover, we studied the effect on pulmonary mechanics, surfactant activity, and pulmonary oxidative stress of the different treatments. Twenty-eight piglets with acute lung injury induced by lung lavages with saline were randomized to receive nitric oxide, nitric oxide plus prostacyclin, nitric oxide plus ADM or saline, after. Dynamic compliance, tidal volume, and airway resistance were measured. Lung tissue oxidation was evaluated by measuring total hydroperoxide and advanced oxidation protein products in bronchial aspirate samples. Surface surfactant activity was studied using Capillary Surfactometer. Inhaled nitric oxide combined with prostacyclin or ADM was more effective than nitric oxide alone in lowering PAP and improving oxygenation. Nitric oxide alone or combined increased lung compliance and tidal volume, and decreased airway resistance. No effects on surfactant surface activity and lung tissue oxidation were observed. The treatment with nitric oxide alone or combined with prostacyclin or ADM were effective in decreasing mean PAP and improving oxygenation in a piglet model of PH. However, nitric oxide plus prostacyclin and nitric oxide plus ADM were more effective than nitric oxide alone. The combination of aerosolized prostacyclin and ADM with nitric oxide might have a role in the treatment of infants with PH refractory to nitric oxide alone.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Florence, Italy.
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Olmsted K, Oluola O, Parthiban A, Raghuveer T. Can inhaled prostacyclin stimulate surfactant in ELBW infants? J Perinatol 2007; 27:724-6. [PMID: 17960144 DOI: 10.1038/sj.jp.7211811] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Respiratory distress syndrome (RDS) causes significant hypoxia in extremely low birth weight (ELBW) infants. We report an ELBW infant with RDS and pulmonary hypertension whose hypoxia did not respond to inhaled nitric oxide but improved with inhaled prostacyclin. We propose that inhaled prostacyclin alleviated the hypoxia by stimulating surfactant secretion.
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Affiliation(s)
- K Olmsted
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA
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Ballard PL, Merrill JD, Truog WE, Godinez RI, Godinez MH, McDevitt TM, Ning Y, Golombek SG, Parton LA, Luan X, Cnaan A, Ballard RA. Surfactant function and composition in premature infants treated with inhaled nitric oxide. Pediatrics 2007; 120:346-53. [PMID: 17671061 DOI: 10.1542/peds.2007-0095] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We hypothesized that inhaled nitric oxide treatment of premature infants at risk for bronchopulmonary dysplasia would not adversely affect endogenous surfactant function or composition. METHODS As part of the Nitric Oxide Chronic Lung Disease Trial of inhaled nitric oxide, we examined surfactant in a subpopulation of enrolled infants. Tracheal aspirate fluid was collected at specified intervals from 99 infants with birth weights <1250 g who received inhaled nitric oxide (20 ppm, weaned to 2 ppm) or placebo gas for 24 days. Large-aggregate surfactant was analyzed for surface activity with a pulsating bubble surfactometer and for surfactant protein contents with an immunoassay. RESULTS At baseline, before administration of study gas, surfactant function and composition were comparable in the 2 groups, and there was a positive correlation between minimum surface tension and severity of lung disease for all infants. Over the first 4 days of treatment, minimum surface tension increased in placebo-treated infants and decreased in inhaled nitric oxide-treated infants. There were no significant differences between groups in recovery of large-aggregate surfactant or contents of surfactant protein A, surfactant protein B, surfactant protein C, or total protein, normalized to phospholipid. CONCLUSIONS We conclude that inhaled nitric oxide treatment for premature infants at risk of bronchopulmonary dysplasia does not alter surfactant recovery or protein composition and may improve surfactant function transiently.
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Affiliation(s)
- Philip L Ballard
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94118, USA.
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Grover TR. The diverse role of inhaled nitric oxide in experimental BPD: reduced fibrin deposition and improved lung growth. Am J Physiol Lung Cell Mol Physiol 2007; 293:L33-4. [PMID: 17483195 DOI: 10.1152/ajplung.00167.2007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Theresa R Grover
- University of Colorado Health Sciences Center, Pediatric Heart Lung Center and Department of Pediatrics, Denver, Colorado, USA.
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Auten RL, Mason SN, Whorton MH, Lampe WR, Foster WM, Goldberg RN, Li B, Stamler JS, Auten KM. Inhaled ethyl nitrite prevents hyperoxia-impaired postnatal alveolar development in newborn rats. Am J Respir Crit Care Med 2007; 176:291-9. [PMID: 17478622 PMCID: PMC1994219 DOI: 10.1164/rccm.200605-662oc] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE Inhaled nitric oxide (NO) has been used to prevent bronchopulmonary dysplasia, but with variable results. Ethyl nitrite (ENO) forms S-nitrosothiols more readily than does NO, and resists higher-order nitrogen oxide formation. Because S-nitrosylation is a key pathway mediating many NO biological effects, treatment with inhaled ENO may better protect postnatal lung development from oxidative stress than NO. OBJECTIVES To compare inhaled NO and ENO on hyperoxia-impaired postnatal lung development. METHODS We treated newborn rats beginning at birth to air or 95% O(2) +/- 0.2-20.0 ppm ENO for 8 days, or to 10 ppm NO for 8 days. Pups treated with the optimum ENO dose, 10 ppm, and pups treated with 10 ppm NO were recovered in room air for 6 more days. MEASUREMENTS AND MAIN RESULTS ENO and NO partly prevented 95% O(2)-induced airway neutrophil influx in lavage, but ENO had a greater effect than did NO in prevention of lung myeloperoxidase accumulation, and in expression of cytokine-induced neutrophil chemoattractant-1. Treatment with 10 ppm ENO, but not NO, for 8 days followed by recovery in air for 6 days prevented 95% O(2)-induced impairments of body weight, lung compliance, and alveolar development. CONCLUSIONS Inhaled ENO conferred protection superior to inhaled NO against hyperoxia-induced inflammation. ENO prevented hyperoxia impairments of lung compliance and postnatal alveolar development in newborn rats.
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Affiliation(s)
- Richard L Auten
- Division of Neonatal Medicine, Department of Pediatrics, Neonatal-Perinatal Research Institute, University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
PURPOSE OF REVIEW Inhaled nitric oxide is established therapy for term infants with hypoxemic respiratory failure. Laboratory studies demonstrate that inhaled nitric oxide improves lung function and morphology in animal models of bronchopulmonary dysplasia, creating a rationale for clinical studies in premature infants. Four large multicenter randomized trials have now completed enrollment, and one trial has reported neurodevelopmental outcomes at 18-22 months. The purpose of this review is to summarize the results of the most recent preclinical studies and clinical trials. RECENT FINDINGS In 2006, short-term outcomes from two large multicenter randomized trials were published. These studies differed in their target population and study design. Early use of inhaled nitric oxide was associated with a decrease in brain injury, and decreased chronic lung disease in infants over 1000 g. Inhaled nitric oxide use in older infants (7-21 days) was associated with decreased chronic lung disease, particularly if started early. SUMMARY Neurodevelopmental outcomes after discharge are still needed from three large multicenter randomized trials. These results will help confirm the long-term implications of the benefits reported in the two most recent trials.
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Affiliation(s)
- Robin H Steinhorn
- Children's Memorial Hospital and Northwestern University, Chicago, Illinois 60614, USA.
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Abstract
Although there is no doubt that administration of exogenous surfactant to very preterm babies who have respiratory distress syndrome is safe and efficacious, surfactant inactivation or deficiency plays a role in the pathophysiology of other pulmonary disorders affecting newborn infants. Preliminary data suggest that there may be a role for surfactant administration to babies who have meconium aspiration syndrome, pneumonia, and possibly bronchopulmonary dysplasia. Further investigation is necessary but seems warranted.
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Affiliation(s)
- Thierry Lacaze-Masmonteil
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
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Lindwall R, Svensson ME, Frostell CG, Eksborg S, Gustafsson LE. Workplace NO and NO2 during combined treatment of infants with nasal CPAP and NO. Intensive Care Med 2006; 32:2034-41. [PMID: 17043849 DOI: 10.1007/s00134-006-0393-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2006] [Accepted: 09/08/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the workplace concentrations of NO and NO(2) in and around a paediatric incubator during inhaled NO (iNO) treatment and during an accidental emptying of NO cylinders into room air. DESIGN We simulated iNO-nasal CPAP treatment in order to assess the impact on the occupational environment. Furthermore, two full NO cylinders for therapy, 1,000 ppm, 20 litres, 150 bar and 400 ppm, 10 litres, 150 bar, were emptied as rapidly as possible into an intensive care unit (ICU) room. SETTING University hospital ICU. MEASUREMENTS AND RESULTS To correctly gauge the contribution from iNO-CPAP we constructed a system measuring breathing zone and room ventilation inlet-outlet values during a 10-ppm iNO treatment of a simulated infant. Maximal breathing zone values were 17.9 +/- 7.0 (mean +/- 95% CI) ppb for NO and 25.2 +/- 4.8 ppb for NO(2). If room inlet values were subtracted, the contributions to breathing zone values emanating from iNO-CPAP were 14.8 +/- 4.6 ppb for NO and 14.6 +/- 4.6 ppb for NO(2). At the ventilation outlet the maximal contributions were 4.2 +/- 2.9 ppb NO and 9.6 +/- 4.3 ppb NO(2). During rapid total release of a gas cylinder in the ICU room, simulating an accident, we found transient NO levels comparable to the high therapeutic dosing range, but only low NO(2) levels. CONCLUSIONS Neither 8-h time-weighted average (TWA) nor 15 min short-term exposure limits (STEL) were exceeded during normal operation or during a simulated accident. The contribution of nitrogen oxides from treatment to workplace air were minor compared to those from ambient air.
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Affiliation(s)
- Robert Lindwall
- Karolinska Institutet, Department of Clinical Sciences, Division of Anaesthesia and Intensive Care, Danderyd University Hospital, Stockholm, Sweden.
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Abstract
Bronchopulmonary dysplasia (BPD), initially described 40 years ago, is a dynamic clinical entity that continues to affect tens of thousands of premature infants each year. BPD was first characterized as a fibrotic pulmonary endpoint following severe Respiratory Distress Syndrome (RDS). It was the result of pulmonary healing after RDS, high oxygen exposure, positive pressure ventilation, and poor bronchial drainage secondary to endotracheal intubation in premature infants. With improved treatment for RDS, including surfactant replacement, oxygen saturation monitoring, improved modes of mechanical ventilation, antibiotic therapies, nutritional support, and infants surviving at younger gestations, the clinical picture of BPD has changed. In the following pages, we will summarize the multifaceted pathophysiologic factors leading to the pulmonary changes in "new" BPD, which is primarily characterized by disordered or delayed development. The contribution of hyperoxia and hypoxia, mechanical forces, vascular maldevelopment, inflammation, fluid management, patent ductus arteriosus (PDA), nutrition, and genetics will be discussed.
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Affiliation(s)
- Patricia R Chess
- Department of Pediatrics, University of Rochester, Rochester, NY 14642, USA.
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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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Abstract
BACKGROUND Recent improvements in the survival of extremely preterm infants have been accompanied by evolution in the pathogenesis and histopathology of bronchopulmonary dysplasia (BPD). Although oxygen and barotrauma-induced injury remain important contributing factors, pulmonary developmental arrest appears to play an equally important causal role in prolonged respiratory illness, especially among the most immature surviving preterm newborns. To date, clinical trials have failed to demonstrate a substantial benefit of a single treatment or preventive strategy for BPD. OBJECTIVES To evaluate the current evidence in favor of treatments that might prevent BPD. METHODS Review of clinical studies of preventive treatment strategies for BPD. RESULTS High frequency oscillatory ventilation, permissive hypercapnea, and inhaled nitric oxide might offer benefit to infants at risk of BPD. These and other potential preventive therapies for BPD, such as superoxide dismutase, inositol, and alpha(1)-proteinase inhibitor, deserve further study. CONCLUSIONS Although some current treatments offer promise, no preventive therapy for BPD has proven safe and effective, except for intramuscular vitamin A. Additional studies of respiratory technologies, management strategies, and protective molecules are needed.
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Affiliation(s)
- Linda J Van Marter
- Children's Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass., USA.
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