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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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Tang M, Ibrahim A, Laughon C, Moore K, Tejada A, Tran D, Kilpatrick R, Greenberg RG, Hornik CP, Zimmerman K, Laughon MM, Clark RH, Lang JE. Prescribing practices of inhaled corticosteroids for premature infants in the neonatal intensive care unit. J Perinatol 2024:10.1038/s41372-024-01891-w. [PMID: 38297180 DOI: 10.1038/s41372-024-01891-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/05/2024] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVE Despite limited safety and efficacy data, inhaled corticosteroids (ICS) are prescribed to premature infants in the neonatal intensive care unit (NICU). We examined contemporary use and risk factors for ICS use in the NICU. STUDY DESIGN Infants <33 weeks gestational age and <1500 gm birth weight discharged from Pediatrix Medical Group NICUs between 2010 and 2020 were included. We evaluated the association between ICS prescription and clinical characteristics using univariable and multivariable logistic regression. RESULTS Of 74,123 infants from 308 NICUs, 9253 (12.5%) were prescribed ICS: budesonide, fluticasone, or beclomethasone. Diagnosis of bronchopulmonary dysplasia (BPD), earlier gestational age, male sex, longer mechanical ventilation, oxygen support, and systemic steroids were independent risk factors for ICS prescription. CONCLUSIONS Use of ICS is common in many NICUs and is associated with a diagnosis of BPD and healthcare utilization. Prospective trials are needed to establish the safety, efficacy, and optimal indication in this vulnerable population.
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Affiliation(s)
- Monica Tang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Anna Ibrahim
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Kaila Moore
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Dean Tran
- Duke Clinical Research Institute, Durham, NC, USA
| | - Ryan Kilpatrick
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Kanecia Zimmerman
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Reese H Clark
- Pediatrix Center for Research and Education, Pediatrix Medical Group, Inc, Sunrise, FL, USA
| | - Jason E Lang
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
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3
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Slaughter JL, Klebanoff MA, Hade EM. Estimating the effect of diuretics and inhaled corticosteroids for evolving bronchopulmonary dysplasia in preterm infants. Paediatr Perinat Epidemiol 2024. [PMID: 38192005 DOI: 10.1111/ppe.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 12/15/2023] [Accepted: 12/17/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Off-label treatment of extremely preterm infants with diuretics and inhaled corticosteroids (ICS) for evolving bronchopulmonary dysplasia (BPD) is common. Their effectiveness in reducing mortality or BPD severity, and optimal treatment timing, are unclear. OBJECTIVES To determine whether diuretic treatment or ICS administration for infants with early evolving (between 10-27 days postnatal) and progressively evolving (28th-day-36th-week postnatal) BPD are independently associated with reduced mortality and moderate or severe BPD at 36-weeks postmenstrual age (PMA). METHODS We examined neonates born before 28 weeks' gestation and admitted to neonatal intensive care units on postnatal Day 0 between 2006 and 2016 using data collected during routine care recorded within the Paediatric Health Information System (PHIS). An early evolving BPD cohort consisted of infants treated with oxygen, positive pressure or mechanical ventilation at 10 days postnatal. The progressively evolving BPD cohort consisted of infants treated with these modalities at 28 days. In new users, we evaluated the effect of diuretic and ICS treatment on mortality or BPD severity at 36 weeks PMA, adjusting for time-dependent confounding by respiratory status using marginal structural models. RESULTS Early evolving BPD was present in 10,135 patients; progressively evolving BPD in 11,728. New diuretic exposure during early evolving BPD (adjusted risk ratio [aRR] 0.77, 95% confidence interval [CI] 0.65, 0.93) was associated with decreased mortality or moderate/severe BPD risk. New diuretics (aRR 0.86, 95% CI 0.75, 0.99) during progressively evolving BPD between 28-days-36-weeks PMA were less strongly associated with mortality or moderate/severe BPD reduction. There was no strong association for ICS in patients with early evolving (aRR: 1.40; 95% CI: 0.79, 2.51) or progressively evolving BPD (aRR 1.16, 95% CI 0.95, 1.49). CONCLUSION Diuretics, but not ICS, for evolving BPD were associated with mortality and BPD risk reduction.
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Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
- Division of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Erinn M Hade
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
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Manley BJ, Kamlin COF, Donath S, Huang L, Birch P, Cheong JLY, Dargaville PA, Dawson JA, Doyle LW, Jacobs SE, Wilson R, Davis PG, McKinlay CJD. Intratracheal budesonide mixed with surfactant to increase survival free of bronchopulmonary dysplasia in extremely preterm infants: study protocol for the international, multicenter, randomized PLUSS trial. Trials 2023; 24:320. [PMID: 37161488 PMCID: PMC10169381 DOI: 10.1186/s13063-023-07257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/14/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), an inflammatory-mediated chronic lung disease, is common in extremely preterm infants born before 28 weeks' gestation and is associated with an increased risk of adverse neurodevelopmental and respiratory outcomes in childhood. Effective and safe prophylactic therapies for BPD are urgently required. Systemic corticosteroids reduce rates of BPD in the short-term but are associated with poorer neurodevelopmental outcomes if given to ventilated infants in the first week after birth. Intratracheal administration of corticosteroid admixed with exogenous surfactant could overcome these concerns by minimizing systemic sequelae. Several small, randomized trials have found intratracheal budesonide in a surfactant vehicle to be a promising therapy to increase survival free of BPD. METHODS An international, multicenter, double-blinded, randomized trial of intratracheal budesonide (a corticosteroid) mixed with surfactant for extremely preterm infants to increase survival free of BPD at 36 weeks' postmenstrual age (PMA; primary outcome). Extremely preterm infants aged < 48 h after birth are eligible if: (1) they are mechanically ventilated, or (2) they are receiving non-invasive respiratory support and there is a clinical decision to treat with surfactant. The intervention is budesonide (0.25 mg/kg) mixed with poractant alfa (200 mg/kg first intervention, 100 mg/kg if second intervention), administered intratracheally via an endotracheal tube or thin catheter. The comparator is poractant alfa alone (at the same doses). Secondary outcomes include the components of the primary outcome (death, BPD prior to or at 36 weeks' PMA), potential systemic side effects of corticosteroids, cost-effectiveness, early childhood health until 2 years of age, and neurodevelopmental outcomes at 2 years of age (corrected for prematurity). DISCUSSION Combining budesonide with surfactant for intratracheal administration is a simple intervention that may reduce BPD in extremely preterm infants and translate into health benefits in later childhood. The PLUSS trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants regardless of their initial mode of respiratory support. Should intratracheal budesonide mixed with surfactant increase survival free of BPD, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au ), ACTRN12617000322336. First registered on 28th February 2017.
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Affiliation(s)
- Brett J Manley
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia.
| | - C Omar F Kamlin
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Susan Donath
- Department of Paediatrics, Murdoch Children's Research Institute, the University of Melbourne, Melbourne, Australia
| | - Li Huang
- The University of Melbourne, Melbourne, Australia
| | - Pita Birch
- Department of Neonatology, Mater Mother's Hospitals South Brisbane, Brisbane, Australia
| | - Jeanie L Y Cheong
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter A Dargaville
- Royal Hobart Hospital, Hobart, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Jennifer A Dawson
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Lex W Doyle
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Susan E Jacobs
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Peter G Davis
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Christopher J D McKinlay
- Department of Paediatrics: Child and Youth Health, the University of Auckland, Kidz First Neonatal Care, TeWhatu Ora Counties Manukau, Auckland, New Zealand
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Md JNG, Ransom M, Kaspar A, Wilcox LJ, Whigham AS, Engelstad HJ. Neonatal Laryngotracheal Anomalies. Neoreviews 2022; 23:e613-e624. [PMID: 36047759 DOI: 10.1542/neo.23-9-e613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Respiratory distress in the neonate is one of the most common reasons for referral to a tertiary NICU, accounting for more than 20% of admissions. (1) The cause of respiratory distress can range from parenchymal lung disease to anomalies of any portion of the neonatal airway including the nose, pharynx, larynx, trachea, or bronchi. This review will focus on airway anomalies at or immediately below the level of the larynx. Although rare, those with such congenital or acquired laryngotracheal anomalies often require urgent evaluation and surgical intervention. This review describes 1) the pathophysiology associated with congenital and acquired laryngotracheal deformities in the neonate, 2) the clinical presentation and diagnostic evaluation of these anomalies, and 3) the current medical and surgical strategies available in the NICU and after discharge.
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Affiliation(s)
- Jean-Nicolas Gallant Md
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Meaghan Ransom
- Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Ashley Kaspar
- Department of Therapy and Rehabilitation, Dell Children's Medical Center, Austin, TX
| | - Lyndy J Wilcox
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Amy S Whigham
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Holly J Engelstad
- Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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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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Sindelar R, Shepherd EG, Ågren J, Panitch HB, Abman SH, Nelin LD. Established severe BPD: is there a way out? Change of ventilatory paradigms. Pediatr Res 2021; 90:1139-1146. [PMID: 34012026 DOI: 10.1038/s41390-021-01558-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/04/2023]
Abstract
Improved survival of extremely preterm newborn infants has increased the number of infants at risk for developing bronchopulmonary dysplasia (BPD). Despite efforts to prevent BPD, many of these infants still develop severe BPD (sBPD) and require long-term invasive mechanical ventilation. The focus of research and clinical management has been on the prevention of BPD, which has had only modest success. On the other hand, research on the management of the established sBPD patient has received minimal attention even though this condition poses large economic and health problems with extensive morbidities and late mortality. Patients with sBPD, however, have been shown to respond to treatments focused not only on ventilatory strategies but also on multidisciplinary approaches where neurodevelopmental support, growth promoting strategies, and aggressive treatment of pulmonary hypertension improve their long-term outcomes. In this review we will try to present a physiology-based ventilatory strategy for established sBPD, emphasizing a possible paradigm shift from acute efforts to wean infants at all costs to a more chronic approach of stabilizing the infant. This chronic approach, herein referred to as chronic phase ventilation, aims at allowing active patient engagement, reducing air trapping, and improving ventilation-perfusion matching, while providing sufficient support to optimize late outcomes. IMPACT: Based on pathophysiological aspects of evolving and established severe BPD in premature infants, this review presents some lung mechanical properties of the most severe phenotype and proposes a chronic phase ventilatory strategy that aims at reducing air trapping, improving ventilation-perfusion matching and optimizing late outcomes.
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Affiliation(s)
- Richard Sindelar
- University Children's Hospital, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Edward G Shepherd
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Johan Ågren
- University Children's Hospital, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Howard B Panitch
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven H Abman
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Leif D Nelin
- University Children's Hospital, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
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Raffay TM, Brasher M, Place BC, Patwardhan A, Giannone PJ, Bada H, Westgate PM, Abu Jawdeh EG. Response to first dose of inhaled albuterol in mechanically ventilated preterm infants. J Perinatol 2021; 41:1704-1710. [PMID: 34035457 PMCID: PMC8147907 DOI: 10.1038/s41372-021-01071-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Bronchodilator responses among preterm infants are heterogeneous. Bedside measurements may identify responders. STUDY DESIGN Respiratory measurements (Resistance, Compliance, FiO2) and pulse oximetry (SpO2) patterns were downloaded from infants <30 weeks gestational age during the first 2 months of life. Mechanically ventilated infants who received albuterol were included (n = 33). Measurements were compared before and after first albuterol. Secondary analyses assessed subsequent doses. RESULTS Median gestation and birthweight were 25 3/7 weeks and 730 g, respectively. Mean Resistance decreased post-albuterol (p = 0.007). Sixty-eight percent of infants were responders based on decreased Resistance. Compliance and FiO2 did not significantly differ. Percent time in hypoxemia (SpO2 < 85%) decreased post albuterol (p < 0.02). In responders, Resistance changes diminished with subsequent administration (all p = 0.01). CONCLUSIONS Ventilator resistance decreased in two-thirds of preterm infants, consistent with studies that utilized formal pulmonary function testing. Albuterol had a variable effect on delivered FiO2; however, hypoxemia may be useful in evaluating albuterol response.
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Affiliation(s)
- Thomas M Raffay
- Pediatrics/Neonatology, UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Mandy Brasher
- Pediatrics/Neonatology, University of Kentucky, Lexington, KY, USA
| | - Brooke C Place
- Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | | | - Peter J Giannone
- Pediatrics/Neonatology, University of Kentucky, Lexington, KY, USA
| | - Henrietta Bada
- Pediatrics/Neonatology, University of Kentucky, Lexington, KY, USA
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9
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN-BASEL 2021; 8:children8040298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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10
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Abstract
Few medications are available and well tested to treat infants who already have developed or inevitably will develop severe bronchopulmonary dysplasia (sBPD). Infants who develop sBPD clearly have not benefited from decades of research efforts to identify clinically meaningful preventive therapies for very preterm infants in the first days and weeks of their postnatal lives. This review addresses challenges to individualized approaches to medication use for sBPD. Specific challenges include understanding the combination of an individual infant's postmenstrual and postnatal age and the developmental status of drug-metabolizing enzymes and receptor expression. This review will also explore the reasons for the variable responsiveness of infants to specific therapies, based on current understanding of developmental pharmacology and pharmacogenetics. Data demonstrating the remarkable variability in the use of commonly prescribed drugs for sBPD are presented, and a discussion about the current use of some of these medications is provided. Finally, the potential use of antifibrotic medications in late-stage sBPD, which is characterized by a profibrotic state, is addressed.
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Affiliation(s)
- William E Truog
- Division of Neonatology, Children's Mercy-Kansas City and the Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Tamorah R Lewis
- Divisions of Neonatology and Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy-Kansas City and the Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Nicolas A Bamat
- Division of Neonatology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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11
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Tiong NP, Peng CC, Hsin-Ju Ko M, Tseng KT, Chang JH, Hsu CH, Sung YH, Chang HY. Impact of inhaled corticosteroids on the neurodevelopmental outcomes in chronically ventilated extremely low birth weight preterm infants. J Formos Med Assoc 2020; 120:275-280. [PMID: 32507344 DOI: 10.1016/j.jfma.2020.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Few studies have assessed the long-term impact of inhaled corticosteroids (ICS) in preterm infants. This study evaluated the neurodevelopmental outcomes of chronically ventilated extremely low birth weight (ELBW) preterm infants exposed to ICS. METHODS The medical records of ELBW preterm infants admitted to two tertiary-level neonatal intensive care units from 2008 to 2014 were reviewed. Infants intubated for more than 28 days were included. The neurodevelopmental outcomes were compared at 24 months corrected age, between those with ICS exposure (inhaled group, IH) and those without it (non-inhaled group, NIH), by using the Bayley-Scale-of-Infant-and-Toddler Development-III (BSID-III). RESULTS Out of the 115 infants included, 64 had an ICS exposure. The incidence of the morbidities at the time of discharge, was comparable between the two groups, except for the duration of oxygen and mechanical ventilation dependence (IH 124.8 ± 40.3 days vs. NIH: 101.0 ± 28.6 days, p < 0.001 and IH 60.0 ± 25.8 days vs. NIH: 42.3 ± 14.2 days, p < 0.001, respectively). Multiple logistic regression analysis at 24 months corrected age revealed no significant differences in the BSID-III scores and in the incidence of cerebral palsy and neurodevelopmental impairment. CONCLUSION The late ICS exposure was not associated with neurodevelopmental impairment at 24 months corrected age in chronically ventilated ELBW infants; however, it did not reduce the duration of their dependence on oxygen and mechanical ventilation.
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Affiliation(s)
- Ngiik-Ping Tiong
- Department of Neonatology, MacKay Children's Hospital, Taipei City, Taiwan
| | - Chun-Chih Peng
- Department of Neonatology, MacKay Children's Hospital, Taipei City, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Mary Hsin-Ju Ko
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan
| | - Kai-Ti Tseng
- Department of Neonatology, MacKay Children's Hospital, Taipei City, Taiwan
| | - Jui-Hsing Chang
- Department of Neonatology, MacKay Children's Hospital, Taipei City, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Chyong-Hsin Hsu
- Department of Neonatology, MacKay Children's Hospital, Taipei City, Taiwan
| | - Yi-Hsiang Sung
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan
| | - Hung-Yang Chang
- Department of Neonatology, MacKay Children's Hospital, Taipei City, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan.
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12
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Therapeutic effect of inhaled budesonide in transient tachypnea of newborn: A placebo-controlled study. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY 2020; 27:e78-e86. [DOI: 10.15586/jptcp.v27i2.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/18/2020] [Indexed: 11/18/2022]
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13
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White H, Berenson A, Mannan J, Feldman HA, Rhein L. Utilization trends of respiratory medication in premature infants discharged on home oxygen therapy. Pediatr Pulmonol 2020; 55:1359-1365. [PMID: 32348638 DOI: 10.1002/ppul.24735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/09/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Roughly half of all extremely preterm infants will be diagnosed with bronchopulmonary dysplasia (BPD), and a third will be discharged on home oxygen therapy (HOT). To date, there have been no studies that have examined the relationship between respiratory medication utilization in infants with BPD on HOT. METHODS The recorded home oximetry trial was a multicenter, randomized trial comparing two home oxygen management strategies in premature infants. Infants were enrolled at first outpatient pulmonary or neonatal intensive care unit (NICU) follow-up visit with a pulmonary component. Respiratory medication prescriptions and dosage were collected from time of enrollment through 6 months after HOT discontinuation. Patients were seen monthly while on HOT and at 1, 3, and 6 months after successful discontinuation. RESULTS During protocol visits, 174 (89%) infants had respiratory medications documented. Respiratory medication use was higher at initial follow-up visit compared with NICU discharge and decreased at the final 6-month follow-up visit. Infants who received inhaled steroids (IS) before weaning had mean HOT duration of 138 days (range: 24-562 days); infants who received IS after weaning had shorter mean HOT duration (55 days, range: 21-264). In time-to-event analysis the no IS group and the postwean group differed significantly (χ21 = 8.1; P = .004). NICU clinics gave a total of 35 prescriptions to 43 patients, an average of 0.8 per patient, while the pulmonary clinics gave 837 prescriptions to 153 patients, or 5.5 per patient (P < .0001). CONCLUSION Respiratory prescribing patterns for infants on HOT are highly variable. Utilization of IS was not associated with shorter duration of HOT.
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Affiliation(s)
- Heather White
- Division of Neonatology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Alice Berenson
- School of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Javed Mannan
- Division of Neonatology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Henry A Feldman
- Division of Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts
| | - Lawrence Rhein
- Division of Neonatology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts.,Division of Pediatric Pulmonology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
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14
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Kim YH, Kim KW, Eun HS, Shin JE, Sol IS, Kim SY, Kim YS, Sohn MH, Namgung R. Small for gestational age birth may increase airflow limitation in bronchopulmonary dysplasia. Pediatr Pulmonol 2020; 55:346-353. [PMID: 31794162 DOI: 10.1002/ppul.24580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 11/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To determine significant indices for assessing the pulmonary function of infants according to bronchopulmonary dysplasia (BPD) severity and to evaluate whether small for gestational age (SGA) could affect pulmonary function in BPD. METHODS We evaluated 117 preterm infants who had undergone tidal breathing flow-volume loop and multiple-breath washout analyses within 7 months after birth. We categorized preterm infants according to BPD severity into mild/moderate BPD (n = 86), severe BPD (n = 21), and without BPD (n = 10) and the presence of SGA or appropriate gestational age (AGA) using the Fenton growth chart. We evaluated nine healthy term infants as controls. RESULTS The tidal breathing ratio (time to peak expiratory flow/expiratory time [tPEF /tE ]) was significantly lower in infants with severe BPD than in those with mild/moderate BPD. Lung clearance index (LCI) was not different based on BPD severity. In the correlation analysis after adjusting for gestational age and sex, tPEF /tE was correlated with the duration of mechanical ventilation (r = -0.347, P < .001) and the duration of oxygen supply (r = -0.248, P = .013) in infants with BPD. The proportion of "lower tPEF /tE ," defined as below the cut-off value, was greater in SGA infants (P = .017), while no significant difference was seen in the percentage of "higher LCI," defined as above the cut-off value between SGA and AGA infants. CONCLUSIONS In infants with BPD, tPEF /tE could be a useful pulmonary index which shows lower values in severe BPD. The finding of SGA in infants with BPD could be associated with poor pulmonary function related to the tPEF /tE values.
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Affiliation(s)
- Yoon Hee Kim
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Sun Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Division of Neonatology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Eun Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Division of Neonatology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - In Suk Sol
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Suh Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.,Division of Neonatology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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15
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Duijts L, van Meel ER, Moschino L, Baraldi E, Barnhoorn M, Bramer WM, Bolton CE, Boyd J, Buchvald F, Del Cerro MJ, Colin AA, Ersu R, Greenough A, Gremmen C, Halvorsen T, Kamphuis J, Kotecha S, Rooney-Otero K, Schulzke S, Wilson A, Rigau D, Morgan RL, Tonia T, Roehr CC, Pijnenburg MW. European Respiratory Society guideline on long-term management of children with bronchopulmonary dysplasia. Eur Respir J 2020; 55:13993003.00788-2019. [PMID: 31558663 DOI: 10.1183/13993003.00788-2019] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/30/2019] [Indexed: 12/22/2022]
Abstract
This document provides recommendations for monitoring and treatment of children in whom bronchopulmonary dysplasia (BPD) has been established and who have been discharged from the hospital, or who were >36 weeks of postmenstrual age. The guideline was based on predefined Population, Intervention, Comparison and Outcomes (PICO) questions relevant for clinical care, a systematic review of the literature and assessment of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. After considering the balance of desirable (benefits) and undesirable (burden, adverse effects) consequences of the intervention, the certainty of the evidence, and values, the task force made conditional recommendations for monitoring and treatment of BPD based on very low to low quality of evidence. We suggest monitoring with lung imaging using ionising radiation in a subgroup only, for example severe BPD or recurrent hospitalisations, and monitoring with lung function in all children. We suggest to give individual advice to parents regarding daycare attendance. With regards to treatment, we suggest the use of bronchodilators in a subgroup only, for example asthma-like symptoms, or reversibility in lung function; no treatment with inhaled or systemic corticosteroids; natural weaning of diuretics by the relative decrease in dose with increasing weight gain if diuretics are started in the neonatal period; and treatment with supplemental oxygen with a saturation target range of 90-95%. A multidisciplinary approach for children with established severe BPD after the neonatal period into adulthood is preferable. These recommendations should be considered until new and urgently needed evidence becomes available.
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Affiliation(s)
- Liesbeth Duijts
- Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands .,Dept of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Evelien R van Meel
- Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laura Moschino
- Dept of Women's and Children's Health, University of Padua, Padua, Italy
| | - Eugenio Baraldi
- Dept of Women's and Children's Health, University of Padua, Padua, Italy
| | | | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme and Division of Respiratory Medicine, University of Nottingham, Nottingham, UK
| | | | - Frederik Buchvald
- Pediatric Pulmonary Service, DBLC, Rigshospitalet, Copenhagen, Denmark
| | | | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Refika Ersu
- Division of Respirology, Marmara University Istanbul, Istanbul, Turkey.,Division of Respirology, University of Ottowa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Thomas Halvorsen
- Dept of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Sailesh Kotecha
- Dept of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Sven Schulzke
- Dept of Neonatology, University Children's Hospital Basel UKBB, Basel, Switzerland
| | - Andrew Wilson
- Dept of Respiratory and Sleep Medicine, Princess Margaret Hospital for Children, Perth, Australia
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Rebecca L Morgan
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Thomy Tonia
- Insitute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Charles C Roehr
- Dept of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK.,Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Marielle W Pijnenburg
- Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Einisman HJ, Gaston B, Wijers C, Smith LA, Lewis TH, Lewis SJ, Raffay TM. Tracheomalacia in bronchopulmonary dysplasia: Trachealis hyper-relaxant responses to S-nitrosoglutathione in a hyperoxic murine model. Pediatr Pulmonol 2019; 54:1989-1996. [PMID: 31486289 PMCID: PMC7329187 DOI: 10.1002/ppul.24513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/26/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) with airway hyperreactivity is a long-term pulmonary complication of prematurity. The endogenous nonadrenergic, noncholinergic signaling molecule, S-nitrosoglutathione (GSNO) and its catabolism by GSNO reductase (GSNOR) modulate airway reactivity. Tracheomalacia is a major, underinvestigated complication of BPD. We studied trachealis, left main bronchus (LB), and intrapulmonary bronchiolar (IPB) relaxant responses to GSNO in a murine hyperoxic BPD model. METHODS Wild-type (WT) or GSNOR knockout (KO) newborn mice were raised in 60% (BPD) or 21% (control) oxygen during the first 3 weeks of life. After room air recovery, adult trachealis, LB, and IPB smooth muscle relaxant responses to GSNO (after methacholine preconstriction) were studied using wire myographs. Studies were repeated after GSNOR inhibitor (GSNORi) pretreatment and in KO mice. RESULTS GSNO relaxed all airway preparations. GSNO relaxed WT BPD trachealis substantially more than WT controls (P < .05). Pharmacologic or genetic ablation of GSNOR abolished the exaggerated BPD tracheal relaxation to GSNO and also augmented BPD IPB relaxation to GSNO. LB ring contractility was not significantly different between groups or conditions. Additionally, GSNORi treatment induced relaxation of WT IPBs but not trachealis or LB. CONCLUSION GSNO dramatically relaxed the trachealis in our BPD model, an effect paradoxically reversed by loss of GSNOR. Conversely, GSNOR inhibition augmented IBP relaxation. These data suggest that GSNOR inhibition could benefit both the BPD trachealis and distal airways, restoring relaxant responses to those of room air controls. Because therapeutic options are limited in this high-risk population, future studies of GSNOR inhibition are needed.
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Affiliation(s)
- Helly J Einisman
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.,Division of Pediatric Pulmonology, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Benjamin Gaston
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.,Division of Pediatric Pulmonology, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Christiaan Wijers
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Laura A Smith
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Tristan H Lewis
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Stephen J Lewis
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.,Division of Pediatric Pulmonology, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Thomas M Raffay
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.,Division of Neonatology, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio
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17
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Yang MC, Hsiao HF, Tseng HL, Chiu YW, Weng YH. Aerosol therapy in relation to retinopathy of prematurity in mechanically ventilated preterm infants. BMC Pulm Med 2019; 19:145. [PMID: 31409326 PMCID: PMC6693186 DOI: 10.1186/s12890-019-0912-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 08/02/2019] [Indexed: 11/28/2022] Open
Abstract
Background Aerosol administration is increasingly being used as a therapeutic intervention for mechanically ventilated preterm infants. However, the effects of inhalation therapy on retinopathy of prematurity (ROP) have not yet been explored. Methods A retrospective cohort study was conducted in a tertiary level neonatal intensive care unit (NICU) from 2011 to 2013. All preterm infants with a gestational age (GA) of 24~29 weeks receiving invasive intubation for more than 1 week in the NICU were included. Infants with severe congenital anomalies were excluded. ROP was defined as stage II or greater according to medical records by ophthalmologists. A multivariate logistic regression model was used to estimate the risk of ROP in relation to inhalation therapy after adjusting for confounders. Results In total, 205 infants were enrolled in this study, including 154 with inhalation therapy and 51 without inhalation therapy. Univariate analyses showed an association of inhalation with the following characteristics: sex (p = 0.047), GA (p = 0.029), sepsis (p = 0.047), bronchopulmonary dysplasia (BPD) (p < 0.001), and ROP (p = 0.001). Furthermore, logistic regression analysis indicated that inhalation therapy was an independent risk factor for ROP (odds ratio (OR) = 2.639; 95% confidence interval (CI) = 1.050~6.615). In addition, infants with a GA of 24~25 weeks (OR = 6.063; 95% CI = 2.482~14.81) and 26~27 weeks (OR = 3.825; 95% CI = 1.694~8.638) were at higher risk of ROP than those with a GA of 28~29 weeks. Other factors – including sex, sepsis, BPD, and delivery mode – did not carry significant risk. Conclusion Aerosol therapy with pure oxygen delivery is associated with ROP. Clinicians should exercise great caution when conducting aerosol therapy with excess oxygen in mechanically ventilated preterm infants.
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Affiliation(s)
- Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hsiu-Li Tseng
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Wen Chiu
- Master Program in Global Health and Development, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Yi-Hao Weng
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan. .,Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 199 Dunhua North Road, Taipei, 105, Taiwan.
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18
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Abstract
Introduction: Bronchopulmonary dysplasia (BPD) is a common long-term adverse complication of very premature delivery. Affected infants can suffer chronic respiratory morbidities including lung function abnormalities and reduced exercise capacity even as young adults. Many studies have investigated possible preventative strategies; however, it is equally important to identify optimum management strategies for infants with evolving or established BPD. Areas covered: Respiratory support modalities and established and novel pharmacological treatments. Expert opinion: Respiratory support modalities including proportional assist ventilation and neurally adjusted ventilatory assist are associated with short term improvements in oxygenation indices. Such modalities need to be investigated in appropriate RCTs. Many pharmacological treatments are routinely used with a limited evidence base, for example diuretics. Stem cell therapies in small case series are associated with promising results. More research is required before it is possible to determine if such therapies should be investigated in large RCTs with long-term outcomes.
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Affiliation(s)
- Emma Williams
- a Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , UK.,b The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London , UK
| | - Anne Greenough
- a Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , UK.,c NIHR Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London , London , UK
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19
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Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in premature infants who require mechanical ventilation and oxygen therapy. Despite advances in neonatal care resulting in improved survival and decreased morbidity, limited progress has been made in reducing rates of BPD. Therapeutic options to protect the vulnerable developing lung are limited as are strategies to treat lung injury, resulting in ongoing concerns for long-term pulmonary morbidity after preterm birth. Lung protective strategies and optimal nutrition are recognized to improve pulmonary outcomes. However, characterization of late outcomes is challenged by rapid advances in neonatal care. As a result, current adult survivors reflect outdated medical practices. Although neonatal pulmonary disease tends to improve with growth, compromised respiratory health has been documented in young adult survivors of BPD. With improved survival of premature infants but limited progress in reducing rates of disease, BPD represents a growing burden on health care systems. [Pediatr Ann. 2019;48(4):e148-e153.].
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20
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Michael Z, Spyropoulos F, Ghanta S, Christou H. Bronchopulmonary Dysplasia: An Update of Current Pharmacologic Therapies and New Approaches. Clin Med Insights Pediatr 2018; 12:1179556518817322. [PMID: 30574005 PMCID: PMC6295761 DOI: 10.1177/1179556518817322] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/03/2018] [Indexed: 12/21/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) remains the most prevalent long-term morbidity of surviving extremely preterm infants and is associated with significant health care utilization in infancy and beyond. Recent advances in neonatal care have resulted in improved survival of extremely low birth weight (ELBW) infants; however, the incidence of BPD has not been substantially impacted by novel interventions in this vulnerable population. The multifactorial cause of BPD requires a multi-pronged approach for prevention and treatment. New approaches in assisted ventilation, optimal nutrition, and pharmacologic interventions are currently being evaluated. The focus of this review is the current state of the evidence for pharmacotherapy in BPD. Promising future approaches in need of further study will also be reviewed.
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Affiliation(s)
- Zoe Michael
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fotios Spyropoulos
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Sailaja Ghanta
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Helen Christou
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
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21
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Yang YC, Mao J, Li J. [Research progress in drug therapy for bronchopulmonary dysplasia in preterm infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:67-71. [PMID: 29335086 PMCID: PMC7390319 DOI: 10.7499/j.issn.1008-8830.2018.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/29/2017] [Indexed: 06/07/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common long-term complication in surviving extremely preterm infants. This may lead to pulmonary hypertension, increase late neonatal mortality, and cause abnormal neural development. There is still controversy over the efficacy, as well as advantages and disadvantages, of drug therapy for BPD in preterm infants. This article reviews the research progress in the drug therapy for BPD.
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Affiliation(s)
- Yu-Chen Yang
- Department of Neonatology, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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22
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Nelin LD, Logan JW. The use of inhaled corticosteroids in chronically ventilated preterm infants. Semin Fetal Neonatal Med 2017; 22:296-301. [PMID: 28768578 DOI: 10.1016/j.siny.2017.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the most usual reason for preterm infants to require chronic mechanical ventilation. Inflammation is a key factor underlying the lung injury leading to the development of BPD, and the rationale for use of corticosteroids in the management of ventilator-dependent preterm infants is based on their anti-inflammatory effects. Because systemic corticosteroids are associated with significant adverse effects in preterm infants, attention has turned to the use of inhaled corticosteroids (ICS) as a potentially safer therapy for BPD. The aim of this review is to discuss what is known about the efficacy and safety of ICS in chronically ventilated preterm infants. However, this has been a challenge since there is a paucity of high-grade evidence for the use of ICS in these patients. Thus, there is a real need for well-powered randomized controlled trials examining short- and long-term outcomes of ICS use in this population.
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Affiliation(s)
- Leif D Nelin
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA.
| | - J Wells Logan
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA
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23
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Liszewski MC, Stanescu AL, Phillips GS, Lee EY. Respiratory Distress in Neonates. Radiol Clin North Am 2017; 55:629-644. [DOI: 10.1016/j.rcl.2017.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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24
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Royce SG, Nold MF, Bui C, Donovan C, Lam M, Lamanna E, Rudloff I, Bourke JE, Nold-Petry CA. Airway Remodeling and Hyperreactivity in a Model of Bronchopulmonary Dysplasia and Their Modulation by IL-1 Receptor Antagonist. Am J Respir Cell Mol Biol 2017; 55:858-868. [PMID: 27482635 DOI: 10.1165/rcmb.2016-0031oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic disease of extreme prematurity that has serious long-term consequences including increased asthma risk. We earlier identified IL-1 receptor antagonist (IL-1Ra) as a potent inhibitor of murine BPD induced by combining perinatal inflammation (intraperitoneal LPS to pregnant dams) and exposure of pups to hyperoxia (fraction of inspired oxygen = 0.65). In this study, we determined whether airway remodeling and hyperresponsiveness similar to asthma are evident in this model, and whether IL-1Ra is protective. During 28-day exposure to air or hyperoxia, pups received vehicle or 10 mg/kg IL-1Ra by daily subcutaneous injection. Lungs were then prepared for histology and morphometry of alveoli and airways, or for real-time PCR, or inflated with agarose to prepare precision-cut lung slices to visualize ex vivo intrapulmonary airway contraction and relaxation by phase-contrast microscopy. In pups reared under normoxic conditions, IL-1Ra treatment did not affect alveolar or airway structure or airway responses. Pups reared in hyperoxia developed a severe BPD-like lung disease, with fewer, larger alveoli, increased subepithelial collagen, and increased expression of α-smooth muscle actin and cyclin D1. After hyperoxia, methacholine elicited contraction with similar potency but with an increased maximum reduction in lumen area (air, 44%; hyperoxia, 89%), whereas dilator responses to salbutamol were maintained. IL-1Ra treatment prevented hyperoxia-induced alveolar disruption and airway fibrosis but, surprisingly, not the increase in methacholine-induced airway contraction. The current study is the first to demonstrate ex vivo airway hyperreactivity caused by systemic maternal inflammation and postnatal hyperoxia, and it reveals further preclinical mechanistic insights into IL-1Ra as a treatment targeting key pathophysiological features of BPD.
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Affiliation(s)
- Simon G Royce
- 1 Biomedicine Discovery Institute, Department of Pharmacology
| | - Marcel F Nold
- 2 Ritchie Centre, Hudson Institute of Medical Research, and.,3 Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Christine Bui
- 2 Ritchie Centre, Hudson Institute of Medical Research, and.,3 Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Chantal Donovan
- 1 Biomedicine Discovery Institute, Department of Pharmacology
| | - Maggie Lam
- 1 Biomedicine Discovery Institute, Department of Pharmacology
| | - Emma Lamanna
- 1 Biomedicine Discovery Institute, Department of Pharmacology
| | - Ina Rudloff
- 2 Ritchie Centre, Hudson Institute of Medical Research, and.,3 Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Jane E Bourke
- 1 Biomedicine Discovery Institute, Department of Pharmacology
| | - Claudia A Nold-Petry
- 2 Ritchie Centre, Hudson Institute of Medical Research, and.,3 Department of Paediatrics, Monash University, Clayton, Victoria, Australia
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25
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Davidson LM, Berkelhamer SK. Bronchopulmonary Dysplasia: Chronic Lung Disease of Infancy and Long-Term Pulmonary Outcomes. J Clin Med 2017; 6:E4. [PMID: 28067830 PMCID: PMC5294957 DOI: 10.3390/jcm6010004] [Citation(s) in RCA: 235] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/28/2016] [Accepted: 12/28/2016] [Indexed: 12/16/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in premature infants who required mechanical ventilation and oxygen therapy for acute respiratory distress. While advances in neonatal care have resulted in improved survival rates of premature infants, limited progress has been made in reducing rates of BPD. Lack of progress may in part be attributed to the limited therapeutic options available for prevention and treatment of BPD. Several lung-protective strategies have been shown to reduce risks, including use of non-invasive support, as well as early extubation and volume ventilation when intubation is required. These approaches, along with optimal nutrition and medical therapy, decrease risk of BPD; however, impacts on long-term outcomes are poorly defined. Characterization of late outcomes remain a challenge as rapid advances in medical management result in current adult BPD survivors representing outdated neonatal care. While pulmonary disease improves with growth, long-term follow-up studies raise concerns for persistent pulmonary dysfunction; asthma-like symptoms and exercise intolerance in young adults after BPD. Abnormal ventilatory responses and pulmonary hypertension can further complicate disease. These pulmonary morbidities, combined with environmental and infectious exposures, may result in significant long-term pulmonary sequalae and represent a growing burden on health systems. Additional longitudinal studies are needed to determine outcomes beyond the second decade, and define risk factors and optimal treatment for late sequalae of disease.
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Affiliation(s)
- Lauren M Davidson
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY 14228, USA.
| | - Sara K Berkelhamer
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY 14228, USA.
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26
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McGuire JK, Schwingshackl A, Anand KJS. Editorial: ARDS: Reaching for the Horizon. Front Pediatr 2017; 5:100. [PMID: 28555176 PMCID: PMC5430045 DOI: 10.3389/fped.2017.00100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 04/18/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- John K McGuire
- Pediatric Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Andreas Schwingshackl
- Pediatric Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, USA
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27
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Bassler D. Inhaled budesonide for the prevention of bronchopulmonary dysplasia. J Matern Fetal Neonatal Med 2016; 30:2372-2374. [PMID: 27756156 DOI: 10.1080/14767058.2016.1248937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Theoretically, administration of inhaled corticosteroids may allow for beneficial effects on the pulmonary system of infants with evolving or established bronchopulmonary dysplasia (BPD) with a lower risk of undesirable side effects compared to systemic corticosteroids. However, before deciding whether to use inhaled corticosteroids for BPD in routine clinical practice, the available randomized study data need to be considered. Currently published systematic reviews from the Cochrane Collaboration conclude that there is no role for inhaled corticosteroids in neither prevention nor treatment of BPD outside clinical trials. In contrast multiple observational studies indicate that a large number of preterm infants in Europe, North America and East Asia receive inhaled corticosteroids for this indication in routine clinical care. This discrepancy between evidence and practice prompted a large randomized controlled trial (RCT) investigating the role of inhaled budesonide for the prevention of BPD which was recently published and showed a significant reduction in the incidence of BPD. However, the primary outcome (a composite of death or BPD at 36 weeks postmenstrual age) was only of borderline significance as a result of a non-significant trend to increased mortality in the budesonide group. Results of the long-term follow up from this study should be considered when defining the future role of inhaled corticosteroids for BPD. Additionally, updated systematic reviews will help to determine whether the observed mortality difference between the two comparison groups represents truth or artifact.
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Affiliation(s)
- Dirk Bassler
- a Department of Neonatology , University Hospital Zurich and University of Zurich , Zurich , Switzerland
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