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Bhatt DR, Braun D, Dizon RA, Shi JM, Weerasinghe S, Sabio A, Reddy S, Lee HC, Ramanathan R, Lakshminrusimha S. Retrospective study of preterm infants exposed to inhaled nitric oxide in Kaiser Permanente Southern California: morbidity, mortality and follow-up. J Perinatol 2024:10.1038/s41372-024-02051-w. [PMID: 39025953 DOI: 10.1038/s41372-024-02051-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: 02/27/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE Describe characteristics of preterm infants exposed to inhaled nitric oxide (iNO) in Kaiser Permanente Southern California. STUDY DESIGN Case review of preterm infants <34-weeks exposed to iNO during 2010-2020 including respiratory and echocardiographic status, NICU course, and 12-month follow-up. RESULTS 270 infants, 2.63% of births<34 weeks, (median, range: 26.1, 225/7-336/7 weeks gestation) were exposed to iNO. Median FiO2 at iNO initiation was 1.0 (IQR 0.94-1.0). Pulmonary hypertension (PH) was not associated with risk-adjusted 2 h oxygenation response or improved survival. Mortality to NICU discharge was 37.4%. Median cost of iNO was $7,695/patient. Discharged survivors experienced frequent rehospitalization (34.9%), use of supplemental oxygen, sildenafil, diuretics, bronchodilators, and steroids. Four infants had persistent PH. Five infants died after NICU discharge. CONCLUSIONS Preterm infants receiving iNO have high mortality and 1st year morbidity. As currently used, iNO may be an indicator of respiratory disease severity rather than mediator of improved outcomes.
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Affiliation(s)
- Dilip R Bhatt
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - David Braun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Roman Angelo Dizon
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Jiaxiao M Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Alex Sabio
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Siva Reddy
- Fontana Medical Center, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Henry C Lee
- University of California, San Diego, CA, USA
| | - Rangasamy Ramanathan
- Division of Neonatology, Cedars Sinai Guerin Children's, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Cookson MW, Kinsella JP. Inhaled Nitric Oxide in Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:95-111. [PMID: 38325949 PMCID: PMC10954355 DOI: 10.1016/j.clp.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pivotal trials investigating the use of inhaled nitric oxide (iNO) in the 1990s led to approval by the Food and Drug Administration in 1999. Inhaled nitric oxide is the only approved pulmonary vasodilator for persistent pulmonary hypertension of the newborn (PPHN). Selective pulmonary vasodilation with iNO in near-term and term neonates with PPHN is safe, and targeted use of iNO in less mature neonates with pulmonary hypertension (PH) can be beneficial. This review addresses a brief history of iNO, clinical features of neonatal PH, and the clinical application of iNO.
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Affiliation(s)
- Michael W Cookson
- Department of Pediatrics, Section of Neonatology, University of Colorado, Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA; Department of Pediatrics, Pediatric Heart Lung Center, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
| | - John P Kinsella
- Department of Pediatrics, Section of Neonatology, University of Colorado, Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA; Department of Pediatrics, Pediatric Heart Lung Center, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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Minamitani Y, Kato S, Hosokawa M, Nakashima T, Iwatani S, Nakao A, Suzuki D, Ota E, Nakanishi H. Inhaled nitric oxide therapy for preterm infants after 7 days of age: a scoping review protocol. BMJ Open 2024; 14:e080298. [PMID: 38373859 PMCID: PMC10882299 DOI: 10.1136/bmjopen-2023-080298] [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] [Received: 09/26/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
INTRODUCTION Inhaled nitric oxide (iNO) use is recommended for persistent pulmonary hypertension of the newborn in term and late preterm infants. Recently, iNO therapy to prevent bronchopulmonary dysplasia (BPD) or rescue for hypoxic respiratory failure and pulmonary hypertension secondary to BPD has increasingly been used in preterm infants after 7 days of postnatal age (in the postacute phase), despite its off-label use. However, the initiation criteria of iNO therapy for preterm infants in the postacute phase are varied. The aim of this scoping review is to identify the clinical and/or echo findings at the initiation of iNO therapy in preterm infants in the postacute phase. METHODS AND ANALYSIS We will search PubMed, Embase and the Japanese database 'Ichushi.' The following studies will be included in the review: randomised controlled trials, prospective/retrospective cohort studies, case-control studies and case series on iNO therapy for preterm infants in the postacute phase; studies published between January 2003 and August 2023; studies conducted in developed countries and studies written in English or Japanese. We will independently screen, extract and chart data using the population-concept-context framework following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We will summarise the characteristics and findings of the included studies. ETHICS AND DISSEMINATION Obtaining an institutional review board approval is not required because of the nature of this review. A final report of review findings will be published and disseminated through a peer-reviewed journal and presentation at relevant conferences. TRIAL REGISTRATION NUMBER UMIN000051498.
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Affiliation(s)
- Yohei Minamitani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Shin Kato
- Department of Pediatrics, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Miku Hosokawa
- Department of Neonatology, Japanese Red Cross Medical Center, Shibuya, Japan
| | - Toshinori Nakashima
- Department of Pediatrics, National Hospital Organization Kokura Medical Center, Kitakyushu, Fukuoka, Japan
| | - Sota Iwatani
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Atsushi Nakao
- Department of Neonatology, Japanese Red Cross Medical Center, Shibuya, Japan
| | - Daichi Suzuki
- Department of Nursing, Kanagawa Institute of Technology, Atsugi, Kanagawa, Japan
| | - Erika Ota
- Global School of Nursing Science, Global Health Nursing, St. Luke's International University, Chuo-ku, Tokyo, Japan
- The Tokyo Foundation for Policy Research, Minato-ku, Tokyo, Japan
| | - Hidehiko Nakanishi
- Research and Development Center for New Medical Frontiers, Department of Advanced Medicine, Division of Neonatal Intensive Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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Gurram Venkata SKR, Lodha A, Hicks M, Jain A, Lapointe A, Makary H, Kanungo J, Lee KS, Ye X, Shah PS, Soraisham AS. Neurodevelopmental outcomes of preterm neonates receiving rescue inhaled nitric oxide in the first week of age: a cohort study. Arch Dis Child Fetal Neonatal Ed 2024; 109:211-216. [PMID: 37890983 DOI: 10.1136/archdischild-2023-325418] [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] [Received: 02/03/2023] [Accepted: 09/11/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE To assess the neurodevelopmental outcomes of preterm neonates who received inhaled nitric oxide (iNO) in the first week of age for hypoxaemic respiratory failure (HRF). METHODS In this retrospective cohort study, we included neonates born at <29 weeks gestational age (GA) between January 2010 and December 2018 who had a neurodevelopmental assessment at 18-24 months corrected age (CA) at one of the Canadian Neonatal Follow-Up Network clinics. The primary outcome was neurodevelopmental impairment (NDI). We performed propensity score-matched analysis to compare the outcomes of those who received and did not receive iNO. RESULTS Of the 5612 eligible neonates, 460 (8.2%) received iNO in the first week of age. Maternal age, receipt of antenatal corticosteroids, GA and birth weight were lower in the iNO group compared with the no-iNO group. Neonates in the iNO group had higher illness severity scores and higher rates of preterm prolonged rupture of membranes and were small for GA. Severe brain injury, bronchopulmonary dysplasia and mortality were higher in the iNO group. Of the 4889 survivors, 3754 (77%) neonates had follow-up data at 18-24 months CA. After propensity score matching, surviving infants who received rescue iNO were not associated with higher odds of NDI (adjusted OR 1.34; 95% CI 0.85 to 2.12). CONCLUSIONS In preterm neonates <29 weeks GA with HRF, rescue iNO use was not associated with worse neurodevelopmental outcomes among survivors who were assessed at 18-24 months CA.
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Affiliation(s)
| | - Abhay Lodha
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Matthew Hicks
- Pediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Amish Jain
- Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anie Lapointe
- Pediatrics, University of Montreal Faculty of Medicine, Montreal, Quebec, Canada
| | - Hala Makary
- Pediatrics, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Jaideep Kanungo
- Pediatrics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Kyong-Soon Lee
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Xiang Ye
- Maternal-Infant Care Research Centre, Mount Sinai Hospital Pediatrics, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Amuchou S Soraisham
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Kaplish D, Vagha JD, Meshram RJ, Lohiya S. A Comprehensive Review of Inhaled Nitric Oxide Therapy: Current Trends, Challenges, and Future Directions. Cureus 2024; 16:e53558. [PMID: 38445143 PMCID: PMC10913844 DOI: 10.7759/cureus.53558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/04/2024] [Indexed: 03/07/2024] Open
Abstract
This comprehensive review explores the multifaceted landscape of inhaled nitric oxide (iNO) therapy, tracing its historical evolution, mechanisms of action, clinical applications, challenges, and future directions. The nitric oxide signaling pathway, characterized by vasodilatory effects and anti-inflammatory properties, forms the foundation of iNO's therapeutic efficacy. Clinical applications are found in neonatal respiratory distress syndrome, pulmonary hypertension, and acute respiratory distress syndrome, showcasing its versatility. However, challenges, including cost considerations, technical intricacies, safety concerns, and resistance, highlight the nuanced landscape surrounding iNO therapy. Implications for clinical practice underscore the need for a tailored and evidence-based approach, considering individual patient characteristics and indications. Recommendations for future research emphasize ongoing exploration, novel indications, and the development of targeted therapies. In conclusion, this review positions iNO as a dynamic and adaptable intervention, poised to reshape therapeutic strategies and enhance patient outcomes in critical care.
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Affiliation(s)
- Divyanshi Kaplish
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jayant D Vagha
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Revat J Meshram
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sham Lohiya
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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6
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Bartman CM, Schiliro M, Nesbitt L, Lee KK, Prakash YS, Pabelick CM. Exogenous hydrogen sulfide attenuates hyperoxia effects on neonatal mouse airways. Am J Physiol Lung Cell Mol Physiol 2024; 326:L52-L64. [PMID: 37987780 PMCID: PMC11279744 DOI: 10.1152/ajplung.00196.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
Supplemental O2 remains a necessary intervention for many premature infants (<34 wk gestation). Even moderate hyperoxia (<60% O2) poses a risk for subsequent airway disease, thereby predisposing premature infants to pediatric asthma involving chronic inflammation, airway hyperresponsiveness (AHR), airway remodeling, and airflow obstruction. Moderate hyperoxia promotes AHR via effects on airway smooth muscle (ASM), a cell type that also contributes to impaired bronchodilation and remodeling (proliferation, altered extracellular matrix). Understanding mechanisms by which O2 initiates long-term airway changes in prematurity is critical for therapeutic advancements for wheezing disorders and asthma in babies and children. Immature or dysfunctional antioxidant systems in the underdeveloped lungs of premature infants thereby heightens susceptibility to oxidative stress from O2. The novel gasotransmitter hydrogen sulfide (H2S) is involved in antioxidant defense and has vasodilatory effects with oxidative stress. We previously showed that exogenous H2S exhibits bronchodilatory effects in human developing airway in the context of hyperoxia exposure. Here, we proposed that exogenous H2S would attenuate effects of O2 on airway contractility, thickness, and remodeling in mice exposed to hyperoxia during the neonatal period. Using functional [flexiVent; precision-cut lung slices (PCLS)] and structural (histology; immunofluorescence) analyses, we show that H2S donors mitigate the effects of O2 on developing airway structure and function, with moderate O2 and H2S effects on developing mouse airways showing a sex difference. Our study demonstrates the potential applicability of low-dose H2S toward alleviating the detrimental effects of hyperoxia on the premature lung.NEW & NOTEWORTHY Chronic airway disease is a short- and long-term consequence of premature birth. Understanding effects of O2 exposure during the perinatal period is key to identify targetable mechanisms that initiate and sustain adverse airway changes. Our findings show a beneficial effect of exogenous H2S on developing mouse airway structure and function with notable sex differences. H2S donors alleviate effects of O2 on airway hyperreactivity, contractility, airway smooth muscle thickness, and extracellular matrix deposition.
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Affiliation(s)
- Colleen M Bartman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Marta Schiliro
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Anesthesiology and Critical Care Medicine, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Lisa Nesbitt
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
| | - Kenge K Lee
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
| | - Y S Prakash
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
| | - Christina M Pabelick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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7
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Osman A. The early use of inhaled nitric oxide in premature infants requiring respiratory support. Ann Med 2023; 55:2266633. [PMID: 38079494 PMCID: PMC10880562 DOI: 10.1080/07853890.2023.2266633] [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] [Received: 08/08/2022] [Accepted: 09/28/2023] [Indexed: 12/18/2023] Open
Abstract
Background: Earlier studies on the use of inhaled nitric oxide (iNO) for premature infants born at <34 weeks of gestation requiring respiratory support did not provide conclusive evidence of benefit. National guidelines generally discouraged the use in this population. More recent national guidelines endorsed the use of iNO in premature infants with hypoxic respiratory failure (HRF) associated with persistent pulmonary hypertension of the newborn (PPHN).Recent Studies: Two recently published observational studies evaluated the effect of administering iNO on oxygenation in the first week of life. These studies compared premature infants born at the gestational age (GA) of <34 weeks with HRF associated with PPHN to term and late preterm infants born at the GA of ≥34 weeks who received iNO. Both studies showed a similar effect of iNO on oxygenation in the two infant cohorts. The response rate in the premature infant cohort was 59% in the first study and 90% in the second. The mean response time was 9.2 h and 10.3 h, and the mean duration of therapy was 3.5 days and 8.2 days, respectively.Conclusion: The results of these studies support a trial of iNO in premature infants with persistent hypoxia despite optimum respiratory support. Obtaining a timely echocardiogram to exclude cardiac diseases and diagnose PPHN is logistically challenging for many clinicians, thus, a clinical diagnosis of PPHN might have to be made in these situations. Questions remain regarding the optimum dose of iNO and the duration of the initial iNO trial in these patients.KEY MESSAGESIn the most recently published studies, the improvement of oxygenation in iNO-treated infants born at <34 weeks of gestation with HRF and PPHN physiology was as effective as in infants born ≥34 weeks.These studies provide evidence supporting a trial of iNO in the subpopulation of premature infants with HRF associated with PPHN.
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Affiliation(s)
- Ahmed Osman
- The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
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Dyess NF, Palmer C, Soll RF, Clark RH, Abman SH, Kinsella JP. Practices and Outcomes from a Prospective, Multicenter Registry for Preterm Newborns with Pulmonary Hypertension. J Pediatr 2023; 262:113614. [PMID: 37478902 DOI: 10.1016/j.jpeds.2023.113614] [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] [Received: 04/06/2023] [Revised: 06/14/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE To describe current treatment practices of preterm infants with early hypoxemic respiratory failure (HRF) and pulmonary hypertension (PH) and their association with patient outcomes. STUDY DESIGN We developed a prospective, observational, multicenter clinical registry of preterm newborns <34 weeks' gestation with HRF and PH, based on either clinical or echocardiographic evidence during the first 72 hours of life, from 28 neonatal intensive care units in the US from 2017 through 2022. The primary end point was mortality among those who did or did not receive PH-targeted treatment, and the secondary end points included comparisons of major morbidities. Variables were compared using t tests, Wilcoxon rank-sum tests, Fisher exact tests, and χ² tests. RESULTS We analyzed the results of 224 preterm infants enrolled in the registry. Of which, 84% (188/224) received PH-targeted treatment, most commonly inhaled nitric oxide (iNO). Early mortality in this cohort was high, as 33% (71/224) of this sample died in the first month of life, and 77% of survivors (105/137) developed bronchopulmonary dysplasia. Infants who received PH-targeted treatment had higher oxygenation indices at the time of enrollment (28.16 [IQR: 13.94, 42.5] vs 15.46 [IQR: 11.94, 26.15]; P = .0064). Patient outcomes did not differ between those who did or did not receive PH-targeted therapy. CONCLUSIONS Early-onset HRF with PH in preterm infants is associated with a high early mortality and a high risk of developing bronchopulmonary dysplasia. iNO is commonly used to treat early-onset PH in preterm infants with HRF. In comparison with untreated infants with lower oxygenation indices, iNO treatment in severe PH may prevent poorer outcomes.
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Affiliation(s)
- Nicolle Fernández Dyess
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, CO.
| | - Claire Palmer
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, CO
| | - Roger F Soll
- Department of Pediatrics, Division of Neonatology, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Reese H Clark
- Pediatrix Center for Research, Education, Quality and Safety (CREQS), Pediatrix Medical Group, Sunrise, FL
| | - Steven H Abman
- Department of Pediatrics, Section of Pulmonology, University of Colorado School of Medicine, Aurora, CO
| | - John P Kinsella
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, CO
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9
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梁 国, 林 新. [Recent research on inhaled nitric oxide in preterm infants with a gestational age of <34 weeks]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:982-988. [PMID: 37718407 PMCID: PMC10511234 DOI: 10.7499/j.issn.1008-8830.2303146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/03/2023] [Indexed: 09/19/2023]
Abstract
Nitric oxide is a messenger molecule for vasodilation of vascular smooth muscle cells, and inhaled nitric oxide (iNO) can dilate pulmonary blood vessels and reduce pulmonary vascular resistance, thereby reducing pulmonary artery pressure, but with no influence on systemic circulation pressure. Guidelines in China and overseas recommend the use of iNO in full-term infants and late preterm infants, and it has been proved that it has a marked effect on persistent pulmonary hypertension and hypoxic respiratory failure in such infants. However, recent studies have shown that there is an increase in the off-label use of iNO in preterm infants with a gestational age of <34 weeks. This article reviews the research progress on the efficacy, safety, timing, dose, and withdrawal mode of iNO and its combination with vasoactive drugs in the treatment of preterm infants with a gestational age of <34 weeks in China and overseas, so as to provide a reference for clinical application.
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10
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Pizzuto MF, Laughon MM, Jackson WM. Current and emerging pharmacotherapies for the treatment of pulmonary arterial hypertension in infants. Expert Opin Pharmacother 2023; 24:1875-1886. [PMID: 37707346 PMCID: PMC10843401 DOI: 10.1080/14656566.2023.2257598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a complex condition that encompasses an array of underlying disease processes and affects a diverse population of infants, including those with congenital heart disease, congenital diaphragmatic hernia, persistent PH of the newborn, and those with lung disease such as bronchopulmonary dysplasia. While there are treatments available to adults with PH, limited data exists for infants, especially for the newer medications. Therapies that target the three main pathophysiologic pathways of pulmonary hypertension appear to benefit infants, but which are best for each individual disease process is unclear. AREAS COVERED A review of the therapies to treat pulmonary hypertension is covered in this article including the prostacyclin pathway, endothelin pathway, and the nitric oxide pathway. Other adjunctive treatments are also discussed. Findings are based on a PubMed literature search of research papers spanning 1990-2023 and a search of ongoing trials registered with clinicaltrials.gov. EXPERT OPINION Overall therapies seem to improve outcomes with most infants with PH. However, given the diverse population of infants with PH, it is imperative to understand the basis for the PH in individual patients and understand which therapies can be applicable. Further research into tailored therapy for the specific populations is warranted.
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Affiliation(s)
- Matthew F. Pizzuto
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Matthew M. Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Wesley M. Jackson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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11
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Mirza H, Mandell EW, Kinsella JP, McNamara PJ, Abman SH. Pulmonary Vascular Phenotypes of Prematurity: The Path to Precision Medicine. J Pediatr 2023; 259:113444. [PMID: 37105409 PMCID: PMC10524716 DOI: 10.1016/j.jpeds.2023.113444] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/07/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Abstract
Pulmonary hypertension (PH) is associated with significant morbidities and high mortality in preterm infants, yet mechanisms contributing to the pathogenesis of PH, the impact of early pulmonary vascular disease (PVD) on the risk for BPD, the role for PH-targeted drug therapies, and long-term pulmonary vascular sequelae remain poorly understood. PVD is not a homogeneous disease, rather, PVD in the setting of prematurity includes various phenotypes as based on underlying pathophysiology, the severity of associated PH, the timing of disease onset, its contribution to hemodynamic and respiratory status, late outcomes, and other features. As with term newborns, severe hypoxemia with acute respiratory failure (HRF) in preterm infants can be due to marked elevation of pulmonary artery pressure with extrapulmonary shunt, traditionally referred to as persistent pulmonary hypertension of the newborn (PPHN). Transient and less severe levels of PH can also be observed during the early transition after birth without evidence of severe HRF, representing physiologic PH or delayed pulmonary vascular transition in preterm infants. Importantly, echocardiographic evidence of early PH has been strongly associated with the subsequent development of bronchopulmonary dysplasia (BPD), late PH, and chronic respiratory disease during infancy and early childhood. Late PH beyond the first postnatal months in preterm in neonates with established BPD is further associated with poor outcomes, especially as related to BPD severity. In addition, echocardiographic signs of PVD can further persist throughout childhood and may lead to chronic PH of variable severity and cardiac maldevelopment in prematurely born young adults. This review discusses the importance of characterizing diverse pulmonary vascular phenotypes in preterm infants to better guide clinical care and research, and to enhance the development of more precise therapeutic strategies to optimize early and late outcomes of preterm infants.
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Affiliation(s)
- Hussnain Mirza
- Section of Neonatology, Department of Pediatrics, Advent Health for Children/UCF College of Medicine, Orlando, FL
| | - Erica W Mandell
- Pediatric Heart Lung Center and Section of Neonatology, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Pediatric Heart Lung Center and Section of Neonatology, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa School of Medicine, Iowa City, IA
| | - Steven H Abman
- Pediatric Heart Lung Center and Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO.
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12
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Fike CD, Aschner JL. Pharmacotherapy for Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia: Past, Present, and Future. Pharmaceuticals (Basel) 2023; 16:503. [PMID: 37111262 PMCID: PMC10141152 DOI: 10.3390/ph16040503] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
Approximately 8-42% of premature infants with chronic lung disease of prematurity, bronchopulmonary dysplasia (BPD), develop pulmonary hypertension (PH). Infants with BPD-PH carry alarmingly high mortality rates of up to 47%. Effective PH-targeted pharmacotherapies are desperately needed for these infants. Although many PH-targeted pharmacotherapies are commonly used to treat BPD-PH, all current use is off-label. Moreover, all current recommendations for the use of any PH-targeted therapy in infants with BPD-PH are based on expert opinion and consensus statements. Randomized Control Trials (RCTs) are needed to determine the efficacy of PH-targeted treatments in premature infants with or at risk of BPD-PH. Prior to performing efficacy RCTs, studies need to be conducted to obtain pharmacokinetic, pharmacodynamic, and safety data for any pharmacotherapy used in this understudied and fragile patient population. This review will discuss current and needed treatment strategies, identify knowledge deficits, and delineate both challenges to be overcome and approaches to be taken to develop effective PH-targeted pharmacotherapies that will improve outcomes for premature infants with or at risk of developing BPD-PH.
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Affiliation(s)
- Candice D. Fike
- Department of Pediatrics, University of Utah Health, Salt Lake City, UT 84108, USA
| | - Judy L. Aschner
- Department of Pediatrics, Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack, NJ 07601, USA
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
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13
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Boly TJ, Dagle JM, Klein JM, Rios DR, McNamara PJ, Giesinger RE. Response categorization and outcomes in extremely premature infants born at 22-26 weeks gestation that received inhaled nitric oxide for hypoxic respiratory failure. J Perinatol 2023; 43:324-331. [PMID: 36509816 PMCID: PMC10173872 DOI: 10.1038/s41372-022-01582-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the outcomes of extremely premature infants who received inhaled nitric oxide(iNO) for hypoxic respiratory failure(HRF). STUDY DESIGN Retrospective analysis of 107 infants born 22-26 weeks gestation who received iNO for HRF at a single institution. Infants were categorized as positive, negative, or no responders based on change in FiO2 or OI. Underlying physiology was determined using Echocardiography/Radiography/Biochemistry. RESULTS 63% of infants had a positive response; they received iNO earlier and were more likely to have acute pulmonary hypertension(PH). Positive response correlated with decreased incidence of death or grade 3 BPD at 36 weeks postmenstrual age, as compared to a negative response. CONCLUSIONS Extremely premature infants have a positive response rate to iNO comparable to term infants when used for PH in the transitional period. Infants with a negative response to iNO had worse outcomes, necessitating the determination of the underlying physiology of HRF prior to iNO initiation.
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Affiliation(s)
- Timothy J Boly
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- Department of Biochemistry, University of Iowa, Iowa City, IA, USA
| | - Jonathan M Klein
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Danielle R Rios
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
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14
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Dumpa V, Avulakunta I, Bhandari V. Respiratory management in the premature neonate. Expert Rev Respir Med 2023; 17:155-170. [PMID: 36803028 DOI: 10.1080/17476348.2023.2183843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. AREAS COVERED Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. EXPERT OPINION Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Indirapriya Avulakunta
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, the Children's Regional Hospital at Cooper, Camden, NJ, USA
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15
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Oka S, Nishimura E, Ozawa J, Haga M, Miyahara N, Sakatani S, Minamitani Y, Namba F. Therapeutic response of iNO in preterm infants with hypoxemic respiratory failure. Pediatr Int 2023; 65:e15423. [PMID: 36412230 DOI: 10.1111/ped.15423] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) has been used as a rescue treatment for preterm infants with hypoxemic respiratory failure (HRF). However, its effectiveness remains debatable. Thus, in this study, we aimed to examine the impact of iNO therapy on HRF in extremely preterm infants. METHODS A retrospective observational study was performed. Extremely preterm infants admitted to our neonatal intensive care unit who received iNO therapy later in their postnatal life were included. The oxygen saturation index (OSI) was used as an index of the severity of respiratory failure. RESULTS In total, 30 extremely preterm infants were included in this study. Oxygenation was enhanced after the administration of iNO in infants with HRF. The OSI decreased by more than 20% in 12 patients (40%, positive responder) and did not decrease in 17 patients (57%, negative responder) within the first 6 h of treatment. The iNO initiation day was the significant independent factor associated with a positive response to iNO therapy in extremely preterm infants with HRF. CONCLUSIONS iNO therapy was effective in enhancing oxygenation in extremely preterm infants with HRF. Earlier use of iNO was the significant factor associated with a positive therapeutic response to iNO, implying that iNO may be more effective in pulmonary vessels which are less damaged by shorter-term mechanical ventilation.
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Affiliation(s)
- Shuntaro Oka
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Eri Nishimura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Junichi Ozawa
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Mitsuhiro Haga
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Naoyuki Miyahara
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shun Sakatani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan.,Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yohei Minamitani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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16
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Nakanishi H, Isayama T, Kokubo M, Hirano S, Kusuda S. Inhaled Nitric Oxide Therapy in the Post-Acute Phase in Extremely Preterm Infants: A Japanese Cohort Study. J Pediatr 2023; 252:61-67.e5. [PMID: 36116533 DOI: 10.1016/j.jpeds.2022.07.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the trends in inhaled nitric oxide (iNO) utilization in the late phase of hospitalization in a large Japanese cohort of extremely preterm infants and evaluate its benefit on long-term outcomes. STUDY DESIGN This was a retrospective multicenter cohort study of 15 977 extremely preterm infants born at <28 weeks of gestational age between 2003 and 2016, in the Neonatal Research Network, Japan. Demographic characteristics, morbidity, and mortality were compared between extremely preterm infants with and without post-acute iNO therapy. Multivariable logistic analysis was performed to determine factors associated with post-acute iNO and its impact on neurodevelopmental outcomes at 3 years of age. RESULTS Post-acute iNO utilization rates increased from 0.3% in 2009 to 1.9% in 2016, even under strict insurance coverage rules starting in 2009. Gestational age (1-week increment; aOR 0.82, 95% CI 0.76-0.88), small for gestational age (1.47, 1.08-1.99), histologic chorioamnionitis (1.50, 1.21-1.86), 5-minute Apgar score <4 (1.51, 1.10-2.07), air leak (1.92, 1.30-2.83), and bubbly/cystic appearance on chest X-Ray (1.68, 1.37-2.06) were associated with post-acute iNO. Post-acute iNO was not associated with neurodevelopmental outcomes at 3 years of age. CONCLUSIONS The increasing post-acute iNO utilization rate among extremely preterm infants has been concurrent with improved survival rates of extremely preterm infants in Japan. Infants treated with post-acute iNO had more severe disease and complications than the comparison group, but there were no differences in neurodevelopmental outcome at 3 years. This suggests post-acute iNO may benefit extremely preterm infants.
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Affiliation(s)
- Hidehiko Nakanishi
- Research and Development Center for New Medical Frontiers, Department of Advanced Medicine, Division of Neonatal Intensive Care Medicine, Kitasato University School of Medicine, Kanagawa, Japan.
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masayo Kokubo
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan
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17
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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18
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Use of Inhaled Nitric Oxide in Preterm Infants: Is There Sufficient Evidence? Indian J Pediatr 2022; 89:262-266. [PMID: 34287800 DOI: 10.1007/s12098-021-03827-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/27/2021] [Indexed: 10/20/2022]
Abstract
Nitric oxide (NO) is a potent vasodilator. The inhaled form (iNO) improves outcomes in term infants with persistent pulmonary hypertension of the newborn (PPHN) or bronchopulmonary dysplasia-associated pulmonary hypertension in preterm infants. However, in preterm infants, the risks and benefits of iNO use are controversial. Substantial evidence reveals no significant impact on survival or other morbidities in preterm infants with iNO treatment, independent of indication, timing, or duration of use. Many scientific organizations do not recommend the use of iNO in preterm infants, except in unique clinical circumstances with echocardiographic findings of PPHN in the setting of presumed pulmonary hypoplasia.
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19
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Sun S, Zivanovic S, Earnest A, Roehr CC, Tan K. Respiratory management and bronchopulmonary dysplasia in extremely preterm infants: a comparison of practice between centres in Oxford and Melbourne. J Perinatol 2022; 42:53-57. [PMID: 34987168 DOI: 10.1038/s41372-021-01274-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Considerable variation in the care of extremely low gestational age infants (ELGAN) contributes to the variation in incidence of bronchopulmonary dysplasia (BPD). We compared management and outcomes of two neonatal centres with different respiratory support strategies. STUDY DESIGN Retrospective cohort study of infants <28 weeks gestational age treated at two units in Australia and the UK between 2015 and 2017. RESULT Of 492 infants, the overall incidence of BPD for extremely preterm infants was 62.20% and was similar across both sites (64.84% at Monash vs. 60.65% at Oxford). Independent predictors for the development of BPD or mortality included the days on mechanical ventilation (MV, adjusted OR 1.13, 95% Cl 1.07-1.19) and use of inhaled nitric oxide (adjusted OR 13.42, 95% Cl 1.75-103.28). CONCLUSION Primary choice of non-invasive respiratory support had no significant impact on BPD development. Duration of MV and using nitric oxide were independent predictors for death or BPD.
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Affiliation(s)
- Sunjuri Sun
- Department of Paediatrics, School of Clinical Sciences (SCS) at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Sanja Zivanovic
- Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK.,Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Arul Earnest
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK. .,Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Medical Sciences Division, University of Oxford, Oxford, UK.
| | - Kenneth Tan
- Department of Paediatrics, School of Clinical Sciences (SCS) at Monash Health, Monash University, Melbourne, VIC, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
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20
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King WE, Carlo WA, O'Shea TM, Schelonka RL. Cost-effectiveness analysis of heart rate characteristics monitoring to improve survival for very low birth weight infants. FRONTIERS IN HEALTH SERVICES 2022; 2:960945. [PMID: 36925786 PMCID: PMC10012671 DOI: 10.3389/frhs.2022.960945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022]
Abstract
Introduction Over 50,000 very low birth weight (VLBW) infants are born each year in the United States. Despite advances in care, these premature babies are subjected to long stays in a neonatal intensive care unit (NICU), and experience high rates of morbidity and mortality. In a large randomized controlled trial (RCT), heart rate characteristics (HRC) monitoring in addition to standard monitoring decreased all-cause mortality among VLBW infants by 22%. We sought to understand the cost-effectiveness of HRC monitoring to improve survival among VLBW infants. Methods We performed a secondary analysis of cost-effectiveness of heart rate characteristics (HRC) monitoring to improve survival from birth to NICU discharge, up to 120 days using data and outcomes from an RCT of 3,003 VLBW patients. We estimated each patient's cost from a third-party perspective in 2021 USD using the resource utilization data gathered during the RCT (NCT00307333) during their initial stay in the NICU and applied to specific per diem rates. We computed the incremental cost-effectiveness ratio and used non-parametric boot-strapping to evaluate uncertainty. Results The incremental cost-effectiveness ratio of HRC-monitoring was $34,720 per life saved. The 95th percentile of cost to save one additional life through HRC-monitoring was $449,291. Conclusion HRC-monitoring appears cost-effective for increasing survival among VLBW infants.
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Affiliation(s)
- William E King
- Medical Predictive Science Corporation, Charlottesville, VA, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - T Michael O'Shea
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Robert L Schelonka
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States
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21
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Nelin L, Kinsella JP, Courtney SE, Pallotto EK, Tarau E, Potenziano JL. Use of inhaled nitric oxide in preterm vs term/near-term neonates with pulmonary hypertension: results of the PaTTerN registry study. J Perinatol 2022; 42:14-18. [PMID: 34711938 DOI: 10.1038/s41372-021-01252-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate inhaled nitric oxide (iNO) in preterm (PT) vs term/near-term (TNT) neonates with hypoxic respiratory failure (HRF) and pulmonary hypertension (PH) in an observational registry (PaTTerN). STUDY DESIGN Non-inferiority study comparing PT neonates of GA ≥ 27 to <34 weeks vs TNT neonates of GA ≥ 34 to ≤40 weeks with HRF associated with PH, who received iNO for 24-96 h during the first 0-7 days after birth. Primary endpoint: Achieving ≥25% decrease in oxygenation index/surrogate oxygenation index during iNO treatment. RESULTS Of 140 neonates (PT, n = 55; TNT, n = 85), the primary endpoint was achieved in 50 (90.9%) PT vs 75 (88.2%) TNT neonates (difference [95% CI]: 0.027 [-0.033, 0.087]); PT neonates achieved non-inferiority interval, and the study was stopped early based on prespecified criteria. CONCLUSIONS Use of iNO for improving oxygenation in PT neonates with HRF associated with PH is at least as effective as in TNT neonates. CLINICAL TRIAL REGISTRATION #NCT03132428, registered April 27, 2017.
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Affiliation(s)
- Leif Nelin
- The Research Institute at Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA.
| | - John P Kinsella
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Sherry E Courtney
- Arkansas Children's Hospital Research Institute, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR, USA
| | | | - Eva Tarau
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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22
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Inhaled Nitric Oxide at Birth Reduces Pulmonary Vascular Resistance and Improves Oxygenation in Preterm Lambs. CHILDREN-BASEL 2021; 8:children8050378. [PMID: 34064629 PMCID: PMC8150344 DOI: 10.3390/children8050378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022]
Abstract
Resuscitation with 21% O2 may not achieve target oxygenation in preterm infants and in neonates with persistent pulmonary hypertension of the newborn (PPHN). Inhaled nitric oxide (iNO) at birth can reduce pulmonary vascular resistance (PVR) and improve PaO2. We studied the effect of iNO on oxygenation and changes in PVR in preterm lambs with and without PPHN during resuscitation and stabilization at birth. Preterm lambs with and without PPHN (induced by antenatal ductal ligation) were delivered at 134 d gestation (term is 147–150 d). Lambs without PPHN were ventilated with 21% O2, titrated O2 to maintain target oxygenation or 21% O2 + iNO (20 ppm) at birth for 30 min. Preterm lambs with PPHN were ventilated with 50% O2, titrated O2 or 50% O2 + iNO. Resuscitation with 21% O2 in preterm lambs and 50%O2 in PPHN lambs did not achieve target oxygenation. Inhaled NO significantly decreased PVR in all lambs and increased PaO2 in preterm lambs ventilated with 21% O2 similar to that achieved by titrated O2 (41 ± 9% at 30 min). Inhaled NO increased PaO2 to 45 ± 13, 45 ± 20 and 76 ± 11 mmHg with 50% O2, titrated O2 up to 100% and 50% O2 + iNO, respectively, in PPHN lambs. We concluded that iNO at birth reduces PVR and FiO2 required to achieve target PaO2.
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23
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Chandrasekharan P, Lakshminrusimha S, Abman SH. When to say no to inhaled nitric oxide in neonates? Semin Fetal Neonatal Med 2021; 26:101200. [PMID: 33509680 DOI: 10.1016/j.siny.2021.101200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Inhaled nitric oxide (iNO) was approved for use in critically ill term and near-term neonates (>34 weeks gestational age) in 1999 for hypoxic respiratory failure (HRF) with evidence of pulmonary hypertension. In 2011 and 2014, the National Institutes of Health and American Academy of Pediatrics respectively recommended against the use of iNO in preterm infants <34 weeks. However, these guidelines were based on trials conducted with varying inclusion criteria and outcomes. Recent guidelines from the American Thoracic Society/American Heart Association, the Pediatric Pulmonary Hypertension Network (PPHNet) and European Pediatric Pulmonary Vascular Disease Network recommend the use of iNO in preterm neonates with HRF with confirmed pulmonary hypertension. This review discusses the available evidence for off-label use of iNO. Preterm infants with prolonged rupture of membranes and pulmonary hypoplasia appear to respond to iNO. Similarly, preterm infants with physiology of pulmonary hypertension with extrapulmonary right-to-left shunts may potentially have an oxygenation response to iNO. An overview of relative and absolute contraindications for iNO use in neonates is provided. Absolute contraindications to iNO use include a ductal dependent congenital heart disease where systemic circulation is supported by a right-to-left ductal shunt, severe left ventricular dysfunction and severe congenital methemoglobinemia. In preterm infants, we do not recommend the routine use of iNO in HRF due to parenchymal lung disease without pulmonary hypertension and prophylactic use to prevent bronchopulmonary dysplasia. Future randomized trials evaluating iNO in preterm infants with pulmonary hypertension and/or pulmonary hypoplasia are warranted. (233/250 words).
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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24
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Mandell E, Kinsella JP, Abman SH. Persistent pulmonary hypertension of the newborn. Pediatr Pulmonol 2021; 56:661-669. [PMID: 32930508 DOI: 10.1002/ppul.25073] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/07/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a significant clinical problem characterized by refractory and severe hypoxemia secondary to elevated pulmonary vascular resistance resulting in right-to-left extrapulmonary shunting of deoxygenated blood. PPHN is associated with diverse cardiopulmonary disorders and a high early mortality rate for infants with severe PPHN. Surviving infants with PPHN have an increased risk of long-term morbidities. PPHN physiology can be categorized by (1) maladaptation: pulmonary vessels have normal structure and number but have abnormal vasoreactivity; (2) excessive muscularization: increased smooth muscle cell thickness and increased distal extension of muscle to vessels that are usually not muscularized; and (3) underdevelopment: lung hypoplasia associated with decreased pulmonary artery number. Treatment involves adequate lung recruitment, optimization of cardiac output and left ventricular function, and pulmonary vasodilators such as inhaled nitric oxide. Infants who fail to respond to conventional therapy should be evaluated for lethal lung disorders including alveolar-capillary dysplasia, T-box transcription factor 4 gene, thyroid transcription factor-1, ATP-binding cassette A3 gene, and surfactant protein diseases.
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Affiliation(s)
- Erica Mandell
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John P Kinsella
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
- Section of Pulmonary Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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25
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Du Y, Yuan L, Zhou JG, Huang XY, Lin SB, Yuan M, He Y, Mao WY, Ai DY, Chen C. Echocardiography evaluation of bronchopulmonary dysplasia-associated pulmonary hypertension: a retrospective observational cohort study. Transl Pediatr 2021; 10:73-82. [PMID: 33633939 PMCID: PMC7882291 DOI: 10.21037/tp-20-192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Echocardiography has poor accuracy in grading the severity of pulmonary hypertension (PH) compared to cardiac catheterization. However, the relationship between degree of PH and prognostic outcomes remains uncertain. Our primary objective was to determine whether echocardiogram-assessed PH severity is associated with mortality and hospital readmission in the first year of life. METHODS A retrospective cohort study of infants born less than 32 weeks of gestational age with bronchopulmonary dysplasia (BPD) underwent echocardiography was performed. Echocardiograms were performed at 36-38 weeks postmenstrual age. Data during hospitalization and post-discharge collected at 1-year age were analyzed with cox regression models and logistic regression models to identify the association of PH severity with mortality and readmission. Area under curve (AUC) was calculated to examine the accuracy of these models to reflect the likelihood of outcomes. RESULTS Fifty-six of 237 (23.6%) infants were diagnosed as PH. Moderate and severe PH was significantly associated with mortality during the first one year of life (moderate PH vs. none HR =26.58, 95% CI: 4.40-160.78, P<0.001; severe PH vs. none HR =36.49, 95% CI: 5.65-235.84, P<0.001). Male, preeclampsia and inhaled nitric oxide were also associated with mortality. Mild PH was significantly associated with readmission (OR =2.42, 95% CI: 1.12-5.26, P=0.025), but not associated with mortality (HR =2.09, 95% CI: 0.43-10.18, P=0.36). The PH severity model based on echocardiography accurately informed mortality (AUC 0.79). CONCLUSIONS Echocardiogram-assessed PH severity is associated with prognostic outcomes, including mortality and readmission in very preterm infants with BPD. The severity of PH based on echocardiography is a potential predictor of mortality in the first year of life.
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Affiliation(s)
- Yang Du
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Lin Yuan
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Jian-Guo Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xiang-Yuan Huang
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China
| | - Sam Bill Lin
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Meng Yuan
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yue He
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Wei-Ying Mao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Dan-Yang Ai
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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Vieira F, Makoni M, Szyld E, Sekar K. The Controversy Persists: Is There a Qualification Criterion to Utilize Inhaled Nitric Oxide in Pre-term Newborns? Front Pediatr 2021; 9:631765. [PMID: 33869113 PMCID: PMC8044816 DOI: 10.3389/fped.2021.631765] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/01/2021] [Indexed: 11/22/2022] Open
Abstract
Inhaled nitric oxide (iNO) use in premature newborns remains controversial among clinicians. In 2014, the American Academy of Pediatrics, Committee on Fetus and Newborn released a statement that the available data do not support routine iNO use in pre-term newborns. Despite the absence of significant benefits, 2016 California data showed that clinicians continue to utilize iNO in pre-term infants. With studies as recent as January 2017, the Cochrane review confirmed no major advantages of iNO in pre-term newborns. Still, it recognized that a subset of pre-term infants with pulmonary hypertension (PHTN) had not been separately investigated. Furthermore, recent non-randomized controlled trials have suggested that iNO may benefit specific subgroups of pre-term newborns, especially those with PHTN, prolonged rupture of membranes, and antenatal steroid exposure. Those pre-term infants who showed a clinical response to iNO had increased survival without disability. These findings underscore the need for future studies in pre-term newborns with hypoxemic respiratory failure and PHTN. This review will discuss the rationale for using iNO, controversies regarding the diagnosis of PHTN, and additional novel approaches of iNO treatment in perinatal asphyxia and neonatal resuscitation in the pre-term population < 34 weeks gestation.
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Affiliation(s)
- Frederico Vieira
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Marjorie Makoni
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Edgardo Szyld
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Neonatal Perinatal Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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27
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A quality improvement project improving the value of iNO utilization in preterm and term infants. J Perinatol 2021; 41:164-172. [PMID: 32770031 DOI: 10.1038/s41372-020-0768-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/26/2020] [Accepted: 07/28/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Inhaled NO (iNO) is used in the NICU for management of hypoxemic respiratory failure. The cost of iNO is significant and does not consistently improve outcomes in infants <34 weeks. PROJECT DESIGN Our team used The Model for Improvement to design a quality improvement project to utilize iNO for appropriate indications, ensure response to therapy and initiate timely weaning. The project was carried out at a Level IV NICU and successful interventions spread to a smaller Level III NICU. RESULTS This project demonstrated significant improvement in all measures; total iNO hours per month, average iNO hours per patient, and the percentage of prolonged iNO courses. With an estimated cost of $115/h, the cost per patient for iNO use declined by half from $21,620 to $10,580. CONCLUSIONS Our team improved the value of iNO utilization at our institution and spread successful interventions to another NICU in our network.
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Chandrasekharan P, Lakshminrusimha S, Chowdhury D, Van Meurs K, Keszler M, Kirpalani H, Das A, Walsh MC, McGowan EC, Higgins RD. Early Hypoxic Respiratory Failure in Extreme Prematurity: Mortality and Neurodevelopmental Outcomes. Pediatrics 2020; 146:e20193318. [PMID: 32943536 PMCID: PMC7546092 DOI: 10.1542/peds.2019-3318] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the survival and neurodevelopmental impairment (NDI) in extremely low birth weight (ELBW) infants at 18 to 26 months with early hypoxemic respiratory failure (HRF). We also assessed whether African American infants with early HRF had improved outcomes after exposure to inhaled nitric oxide (iNO). METHODS ELBW infants ≤1000 g and gestational age ≤26 weeks with maximal oxygen ≥60% on either day 1 or day 3 were labeled as "early HRF" and born between 2007 and 2015 in the Neonatal Research Network were included. Using a propensity score regression model, we analyzed outcomes and effects of exposure to iNO overall and separately by race. RESULTS Among 7639 ELBW infants born ≤26 weeks, 22.7% had early HRF. Early HRF was associated with a mortality of 51.3%. The incidence of moderate-severe NDI among survivors was 41.2% at 18 to 26 months. Mortality among infants treated with iNO was 59.4%. Female sex (adjusted odds ratio [aOR]: 2.4, 95% confidence interval [CI]: 1.8-3.3), birth weight ≥720 g (aOR: 2.3, 95% CI: 1.7-3.1) and complete course of antenatal steroids (aOR: 1.6, 95% CI: 1.1-2.2) were associated with intact survival. African American infants had a similar incidence of early HRF (21.7% vs 23.3%) but lower exposure to iNO (16.4% vs 21.6%). Among infants with HRF exposed to iNO, intact survival (no death or NDI) was not significantly different between African American and other races (aOR: 1.5, 95% CI: 0.6-3.6). CONCLUSIONS Early HRF in infants ≤26 weeks' gestation is associated with high mortality and NDI at 18 to 26 months. Use of iNO did not decrease mortality or NDI. Outcomes following iNO exposure were not different in African American infants.
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Affiliation(s)
- Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, UBMD, University at Buffalo, Buffalo, New York;
| | | | - Dhuly Chowdhury
- Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland
| | - Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Martin Keszler
- Department of Neonatology, Brown University, Providence, Rhode Island
| | | | - Abhik Das
- Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and
- Department of Global and Community Health, George Mason University, Fairfax, Virginia
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Mohamed AA, Louis D, Surak A, Weisz DE, McNamara PJ, Jain A. Vasopressin for refractory persistent pulmonary hypertension of the newborn in preterm neonates - a case series. J Matern Fetal Neonatal Med 2020; 35:1475-1483. [PMID: 32349572 DOI: 10.1080/14767058.2020.1757642] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: To describe the clinical outcomes following treatment with vasopressin for a sub-cohort of critically ill preterm neonates who have refractory persistent pulmonary hypertension of the newborn (PPHN).Design: Case seriesSetting: Tertiary neonatal intensive care unit, Toronto, Canada.Population: Neonates born <37 weeks gestational age (GA) who received vasopressin for refractory PPHN (lack of response to inhaled nitric oxide) over a 4-year period.Measurements: Changes in physiological indices of cardio-pulmonary stability during vasopressin therapy were analyzed using one-way repeated measures ANOVA, compared to pretreatment values. Data regarding survival to discharge and neurodevelopmental outcomes at 18-24 months were described.Main Results: Thirteen neonates with a mean GA of 31.4 ± 3.3 weeks were included. Vasopressin was initiated at 28.5 ± 4.5 h of age. Overall, oxygenation and hemodynamic variables improved significantly following vasopressin therapy (p < .05 at 24 h vs. pretreatment). Oxygenation failure resolved in 8 cases, of which 7 patients survived (6 without disability). Among the 5 cases where oxygenation failure persisted despite vasopressin, 4 died while one survived with disability.Conclusions: Vasopressin offers promise as a therapy for preterm neonates with refractory PPHN and hemodynamic instability, but prospective investigation is needed.
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Affiliation(s)
- Adel A Mohamed
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Deepak Louis
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Aimann Surak
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Dany E Weisz
- Department of Pediatrics, Sunnybrook Hospital, Toronto, Canada
| | | | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
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30
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Yang MC, Hsu JF, Hsiao HF, Yang LY, Pan YB, Lai MY, Chu SM, Huang HR, Chiang MC, Fu RH, Tsai MH. Use of high frequency oscillatory ventilator in neonates with respiratory failure: the clinical practice in Taiwan and early multimodal outcome prediction. Sci Rep 2020; 10:6603. [PMID: 32313052 PMCID: PMC7171122 DOI: 10.1038/s41598-020-63655-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/20/2020] [Indexed: 12/02/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) can be a rescue for neonates with refractory respiratory failure or an early elective therapy for preterm infants with severe respiratory distress syndrome (RDS). However, little is known about the current evolution and therapeutic limitations of HFOV. We therefore aimed to describe its use in clinical practice and predict the risk of mortality for neonates receiving HFOV. A retrospective observational study of all neonates treated with HFOV in a quaternary referral NICU between January 2007 and December 2016 was conducted. We classified these patients into five subgroups based on primary respiratory diagnoses. We performed the logistic regression and decision tree regression analyses to identify independent factors of 30-day mortality following HFOV. A total of 1125 patients who were ever supported on HFOV were enrolled, of whom 64.1% received HFOV as a rescue therapy, 27.2% received it as an elective therapy, and 8.7% received it for air leak. An average oxygenation index (OI) greater than 25 in the first 24 hours after the initiation of HFOV and patients with secondary pulmonary hypertension were found to have the greatest risk of in-hospital mortality (p < 0.0001). The overall in-hospital mortality rate was 25.8% (290/1125). Decision tree regression analysis revealed that neonates with refractory respiratory failure who had a pre-HFOV OI value higher than 20.5 and OI values higher than 21.5, 23.5 and 34 at 2 hours, 6 hours, and 12 hours after the use of HFOV, respectively, had a significantly increased risk of 30-day mortality. We identified the predictors and cutoff points of OI before and after the initiation of HFOV in neonates with respiratory failure, which can be clinically used as a reference for 30-day mortality. Further efforts are still needed to optimize the outcomes.
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Affiliation(s)
- Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan.,School of Business, Executive MBA program in Health Care Management, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan.,School of Business, Executive MBA program in Health Care Management, Chang Gung University, Taoyuan, Taiwan
| | - Lan-Yan Yang
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Bin Pan
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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31
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Lakshminrusimha S, Kinsella JP, Krishnan US, Van Meurs K, Edwards EM, Bhatt DR, Chandrasekharan P, Oei JL, Manja V, Ramanathan R, Abman SH. Just Say No to iNO in Preterms-Really? J Pediatr 2020; 218:243-252. [PMID: 31810629 DOI: 10.1016/j.jpeds.2019.10.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/08/2019] [Accepted: 10/24/2019] [Indexed: 12/28/2022]
Affiliation(s)
| | - John P Kinsella
- Department of Pediatrics, University of Colorado, Aurora, CO
| | | | - Krisa Van Meurs
- Department of Pediatrics, Stanford University, Palo Alto, CA
| | | | | | | | - Ju-Lee Oei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Veena Manja
- Department of Pediatrics, University of California at Davis, Sacramento, CA
| | - Rangasamy Ramanathan
- Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado, Aurora, CO
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32
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Garrido F, Gonzalez‐Caballero JL, Lomax R, Dady I. The immediate efficacy of inhaled nitric oxide treatment in preterm infants with acute respiratory failure during neonatal transport. Acta Paediatr 2020; 109:309-313. [PMID: 31373038 DOI: 10.1111/apa.14958] [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: 04/25/2019] [Revised: 07/16/2019] [Accepted: 07/31/2019] [Indexed: 02/02/2023]
Abstract
AIM The aim of our review was to describe the clinical response to inhaled nitric oxide (iNO) in a series of preterm babies in respiratory failure during uplift transfers to a neonatal intensive care unit. METHODS We performed a retrospective review of critical newborns with gestational age <34+0 weeks transferred from January 2013 to December 2018. Data were extracted from our Clinical Information System for transport. The primary measure of this review was to assess whether a significant improvement in the oxygenation saturation index (OSI) occurred following the use of iNO. RESULTS Thirty preterm babies <34+0 weeks were included in our review. OSI, as a measure of oxygenation, did not statistically improve as an immediate response to iNO from referral to receiving hospital (17.1 vs 16.4; P = .7). We found that pH (7.15 vs 7.29; P = .004) and pCO2 (8.1 vs 6.3; P = .05) significantly improved probably based on ventilation management. CONCLUSION Following the recommendations of the American Academy of Paediatrics and other organizations, iNO should not routinely be used during the neonatal transfer of preterm babies <34+0 in respiratory failure. We need to conduct further studies to establish which selected preterm patients would benefit from being treated with iNO.
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Affiliation(s)
- Felipe Garrido
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
- Newborn Intensive Care Unit Clínica Universidad de Navarra Madrid Spain
| | | | - Rachel Lomax
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
| | - Ian Dady
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
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33
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Philips JB. Past, current and future perspectives of the use of inhaled NO as a primary therapeutic for the newborn. Nitric Oxide 2020; 94:92-94. [DOI: 10.1016/j.niox.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 11/04/2019] [Indexed: 11/27/2022]
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Sherlock LG, Wright CJ, Kinsella JP, Delaney C. Inhaled nitric oxide use in neonates: Balancing what is evidence-based and what is physiologically sound. Nitric Oxide 2019; 95:12-16. [PMID: 31866361 DOI: 10.1016/j.niox.2019.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 12/22/2022]
Abstract
Inhaled nitric oxide is a powerful therapeutic used in neonatology. Its use is evidenced-based for term and near-term infants with persistent pulmonary hypertension; however, it is frequently used off-label both in term and preterm babies. This article reviews the off-label uses of iNO in infants. Rationale is discussed for a selective application of iNO based on physiologically guided principles, and new research avenues are considered.
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Affiliation(s)
- Laurie G Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Cassidy Delaney
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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35
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Chen LJ, Chen JY. Effect of high-frequency oscillatory ventilation combined with volume guarantee on preterm infants with hypoxic respiratory failure. J Chin Med Assoc 2019; 82:861-864. [PMID: 31693534 DOI: 10.1097/jcma.0000000000000146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the effect of volume guarantee (VG) on high-frequency oscillatory ventilation (HFOV) compared with HFOV alone in preterm infants with hypoxic respiratory failure (HRF). METHODS Fifty-two preterm infants with HRF refractory to conventional mechanical ventilation (CMV) were enrolled in this study. Between June 2012 and February 2016, HFOV alone was used as rescue therapy when CMV failed for 34 infants, whereas HFOV combined with VG was used as rescue therapy for the other 18 infants between March 2016 and December 2017. RESULTS HFOV combined with VG resulted in a reduction in the combined outcome of death or bronchopulmonary dysplasia (BPD) (p = 0.017) and also a reduction in episodes of hypercarbia (p = 0.010) compared with HFOV alone. CONCLUSION In this study, the preterm infants with HRF ventilated using HFOV combined with VG had a reduced combined outcome of death or BPD and hypercarbia compared with those who received HFOV alone.
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Affiliation(s)
- Lih-Ju Chen
- Department of Pediatrics, Changhua Christian Children's Hospital, Changhua, Taiwan, ROC
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Jia-Yuh Chen
- Department of Pediatrics, Changhua Christian Children's Hospital, Changhua, Taiwan, ROC
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
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36
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Hsiao HF, Yang MC, Lai MY, Chu SM, Huang HR, Chiang MC, Fu RH, Hsu JF, Tsai MH. The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality. J Clin Med 2019; 8:jcm8081113. [PMID: 31357613 PMCID: PMC6722605 DOI: 10.3390/jcm8081113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/18/2019] [Accepted: 07/24/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The indication of inhaled nitric oxide (iNO) used in preterm infants has not been well defined. Neonates with refractory hypoxemia may benefit from the pulmonary vasodilatory effects of iNO. The aim of this study was to investigate the off-label use of iNO as a rescue therapy. METHODS Between January 2010 and December 2017, all neonates who received iNO as a rescue therapy from a tertiary-level medical center were enrolled, and those who were not diagnosed with persistent pulmonary hypertension of newborn (PPHN) were defined as having received off-label use of iNO. The controls were 636 neonates with severe respiratory failure requiring high-frequency oscillatory ventilation but no iNO. RESULTS A total of 206 neonates who received iNO as a rescue therapy were identified, and 84 (40.8%) had off-label use. The median (interquartile) gestational age was 30.5 (26.3-37.0) weeks. Neonates receiving iNO had significantly more severe respiratory failure and a higher oxygenation index than the controls (p < 0.001). Respiratory distress syndrome and secondary pulmonary hypertension after severe bronchopulmonary dysplasia (BPD) were the most common causes of the off-label iNO prescription. Of the 84 neonates with off-label use of iNO, 53 (63.1%) had initial improvement in oxygenation, but 44 (52.4%) eventually died. The overall mortality rate was 41.7% (86/206). After multivariate logistic regression, extremely preterm (odds ratio [OR] 5.51; p < 0.001), presence of pulmonary hemorrhage (OR 2.51; p = 0.036) and severe hypotension (OR 2.78; p = 0.008) were the independent risk factors for final mortality. CONCLUSIONS iNO is applicable to be an off-label rescue therapy for premature neonates with refractory hypoxemia due to severe pulmonary hypertension and bronchopulmonary dysplasia.
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Affiliation(s)
- Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.
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Rhine WD, Suzuki S, Potenziano JL, Escalante S, Togari H. An Analysis of Time to Improvement in Oxygenation in Japanese Preterm and Late Preterm or Term Neonates With Hypoxic Respiratory Failure and Pulmonary Hypertension. Clin Ther 2019; 41:910-919. [PMID: 30987776 DOI: 10.1016/j.clinthera.2019.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/07/2019] [Accepted: 03/17/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE We analyzed data from an ongoing registry to determine time to improvement in oxygenation in preterm and late preterm or term neonates with hypoxic respiratory failure and pulmonary hypertension receiving inhaled nitric oxide (iNO) in Japan. METHODS Registry neonates received iNO ≤7 days after birth (February 26, 2010, to October 9, 2012). Efficacy and safety profile data were collected up to 96 h after iNO initiation and, if necessary, every 24 h thereafter and before iNO discontinuation. Patients were stratified by gestational age (GA), oxygenation index (OI), and shunt direction at baseline. FINDINGS Data were evaluated for 1106 neonates (431 with a GA <34 weeks and 675 with a GA of ≥34 weeks). Sixty percent of patients had improved OI; rates were similar for those with GAs of <34 versus ≥34 weeks (61% vs 59%). Overall, mean time to improvement was 11.4 h and tended to be shorter in the groups with a GA <34 weeks versus ≥34 weeks (9.2 vs 12.9 h). Thirty percent of responding neonates required >1 h to achieve improvement in oxygenation. Neonates with higher baseline OI had the greatest decrease in OI during the first hour of treatment. The mortality rate was higher among iNO-treated patients with a baseline OI ≥25 versus those with OI ≥15 to <25 (25% vs 12%; P = 0.0073). IMPLICATIONS iNO treatment provided acute, sustained improvement in oxygenation in neonates with GAs <34 and ≥34 weeks; 70% of patients had improvement within 1 h, but the remaining 30% took >1 h to respond. Initiation of iNO at lower OIs was associated with reduced mortality compared with higher OI.
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Affiliation(s)
- William D Rhine
- Department of Pediatrics-Neonatology, Stanford University School of Medicine, Palo Alto, CA, USA.
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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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Vayalthrikkovil S, Vorhies E, Stritzke A, Bashir RA, Mohammad K, Kamaluddeen M, Thomas S, Al Awad E, Murthy P, Soraisham A. Prospective study of pulmonary hypertension in preterm infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2019; 54:171-178. [PMID: 30549454 DOI: 10.1002/ppul.24211] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/03/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the prevalence, risk factors, and optimal timing of echocardiogram for pulmonary hypertension (PH) in infants with bronchopulmonary dysplasia (BPD). DESIGN In this prospective study, infants with gestational age (GA) <30 weeks admitted to a tertiary NICU between July 2015 and June 2017 who required positive pressure ventilation or oxygen therapy at ≥28 days of life were evaluated with serial echocardiograms at study enrollment (4-6 weeks of age), 32 weeks (only for ≤25 weeks), 36, and 40 weeks post-menstrual age (PMA) for PH. RESULTS Of 126 infants (mean birth weight 858 ± 221 g; mean GA 26.1 ± 1.6 wks), 48 (38%) developed PH at any time during their hospital stay. The first study echocardiogram was performed at a median age of 31 weeks PMA. The prevalence of PH was 36/126 (28.5%) at enrollment, at 6/30 (20%) at 32 weeks, 24/111 (21.6%) at 36 weeks, and 10/59 (17%) at 40 weeks. No new cases of PH were identified at 40 weeks. At 36 weeks, none of the infants with mild BPD had PH, whereas 20% of moderate and 32% of severe BPD infants had PH. After controlling for confounding variables severe BPD (OR 3.31, 95%CI 1.12, 9.74), and ventilator associated pneumonia (VAP) (OR 17.9, 95%CI 3.9, 82.11) remained independent risk factors for BPD-associated PH. CONCLUSION Echocardiographic screening for PH can be safely restricted to infants with moderate or severe BPD at 36 weeks PMA. We identified VAP as an independent risk factor for PH.
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Affiliation(s)
- Sakeer Vayalthrikkovil
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, Neonatology, Renai Medicity, Cochin, Kerala, India
| | - Erika Vorhies
- Department of Pediatrics, Section of Pediatric Cardiology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Amelie Stritzke
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada
| | - Rani A Bashir
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, Neonatology, Renai Medicity, Cochin, Kerala, India
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Majeeda Kamaluddeen
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Essa Al Awad
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Prashanth Murthy
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Amuchou Soraisham
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada
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Manja V, Guyatt G, Lakshminrusimha S, Jack S, Kirpalani H, Zupancic JAF, Dukhovny D, You JJ, Monteiro S. Factors influencing decision making in neonatology: inhaled nitric oxide in preterm infants. J Perinatol 2019; 39:86-94. [PMID: 30353082 PMCID: PMC6298829 DOI: 10.1038/s41372-018-0258-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We studied decision making regarding inhaled nitric oxide (iNO) in preterm infants with Pulmonary Hypertension (PH). STUDY DESIGN We asked members of the AAP-Society of Neonatal-Perinatal Medicine and Division-Chiefs to select from three management options- initiate iNO, engage parents in shared decision making or not consider iNO in an extremely preterm with PH followed by rating of factors influencing their decision. RESULTS Three hundred and four respondents (9%) completed the survey; 36.5% chose to initiate iNO, 42% to engage parents, and 21.5% did not consider iNO. Provider's prior experience, safety, and patient-centered care were rated higher by those who initiated or offered iNO; lack of effectiveness and cost considerations by participants who did not chose iNO. CONCLUSIONS Most neonatologists offer or initiate iNO therapy based on their individual experience. The minority who chose not to consider iNO placed higher value on lack of effectiveness and cost. These results demonstrate a tension between evidence and pathophysiology-based-therapy/personal experience.
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Affiliation(s)
- Veena Manja
- Departments of Surgery and Pediatrics, University of California at Davis, Sacramento, CA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Satyan Lakshminrusimha
- Departments of Surgery and Pediatrics, University of California at Davis, Sacramento, CA, USA.
- Department of Pediatrics, UC Davis Medical Center, 2516 Stockton Blvd, Sacramento, CA, USA.
| | - Susan Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Haresh Kirpalani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine,, Philadelphia, PA, USA
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - John J You
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Pandya S, Baser O, Wan GJ, Lovelace B, Potenziano J, Pham AT, Huang X, Wang L. The Burden of Hypoxic Respiratory Failure in Preterm and Term/Near-term Infants in the United States 2011-2015. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:130-141. [PMID: 32685586 PMCID: PMC7299458 DOI: 10.36469/9682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This study quantified the burden of hypoxic respiratory failure (HRF)/persistent pulmonary hypertension of newborn (PPHN) in preterm and term/near-term infants (T/NTs) by examining health care resource utilization (HRU) and charges in the United States. METHODS Preterms and T/NTs (≤34 and >34 weeks of gestation, respectively) having HRF/PPHN, with/without meconium aspiration in inpatient setting from January 1, 2011-October 31, 2015 were identified from the Vizient database (first hospitalization=index hospitalization). Comorbidities, treatments, HRU, and charges during index hospitalization were evaluated among preterms and T/NTs with HRF/PPHN. Logistic regression was performed to evaluate mortality-related factors. RESULTS This retrospective study included 504 preterms and 414 T/NTs with HRF/PPHN. Preterms were more likely to have respiratory distress syndrome, neonatal jaundice, and anemia of prematurity than T/NTs. Preterms had significantly longer inpatient stays (54.1 vs 29.0 days), time in a neonatal intensive care unit (34.1 vs 17.5 days), time on ventilation (4.7 vs 2.2 days), and higher total hospitalization charges ($613 350 vs $422 558) (all P<0.001). Similar rates were observed for use of antibiotics (96.2% vs 95.4%), sildenafil (9.5% vs 8.2%), or inhaled nitric oxide (93.8% vs 94.2%). Preterms had a significantly higher likelihood of mortality than T/NTs (odds ratio: 3.6, 95% confidence interval: 2.3-5.0). CONCLUSIONS The findings of more severe comorbidities, higher HRU, hospitalization charges, and mortality in preterms than in T/NTs underscore the significant clinical and economic burden of HRF/PPHN among infants. The results show significant unmet medical need; further research is warranted to determine new treatments and real-world evidence for improved patient outcomes.
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Affiliation(s)
| | - Onur Baser
- Department of Internal Medicine, the University of Michigan, Ann Arbor, MI
| | | | | | | | - An T Pham
- School of Pharmacy, University of California San Francisco, San Francisco, CA
| | | | - Li Wang
- STATinMED Research, Plano, TX
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42
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Arsan S, Korkmaz A, Oğuz S. Turkish Neonatal Society guideline on prevention and management of bronchopulmonary dysplasia. TURK PEDIATRI ARSIVI 2018; 53:S138-S150. [PMID: 31236027 PMCID: PMC6568289 DOI: 10.5152/turkpediatriars.2018.01814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Scientific and technological advances in perinatology and neonatology have led to an increased rate of survival and decreased incidences of various neonatal morbidities. However, the incidence of bronchopulmonary dysplasia has remained almost the same for years in very-low-birth-weight preterm infants. Although bronchopulmonary dysplasia is the leading cause of chronic respiratory morbidity in small preterms, no substantial improvement has been achieved in prevention and treatment strategies to date. Currently, postnatal very-low-dose corticosteroids, caffeine, and vitamin A seem to be the drugs of choice, and stem cell therapy appears to be the most promising treatment modality for the future. In this guideline, which was prepared by the Turkish Neonatal Society, recent evidence-based recommendations for the prevention and treatment of bronchopulmonary dysplasia are summarized.
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Affiliation(s)
- Saadet Arsan
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Ayşe Korkmaz
- Division of Neonatology, Department of Pediatrics, Acıbadem University, Faculty of Medicine, İstanbul, Turkey
| | - Suna Oğuz
- Zekai Tahir Burak Women’s Health Practice and Research Center, Health Sciences University, Ankara, Turkey
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43
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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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44
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Collura CA, Mara KC, Weaver AL, Clark RH, Carey WA. Outcomes of early inhaled nitric oxide use in premature African American neonates. J Perinatol 2018; 38:1657-1665. [PMID: 30275545 DOI: 10.1038/s41372-018-0232-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/02/2018] [Accepted: 08/15/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Meta-analysis of individual-patient clinical trial data suggests that inhaled nitric oxide (iNO) improves respiratory outcomes in premature African American neonates. We hypothesized that early iNO therapy would be associated with lower mortality and less chronic lung disease (CLD) in extremely premature African American neonates. STUDY DESIGN We conducted a retrospective cohort study of propensity score- and race-matched neonates 22-29 weeks gestation who were mechanically ventilated for treatment of respiratory distress and associated pulmonary hypertension (RDS + PPHN). We evaluated the association of iNO within 7 days of life with in-hospital mortality and CLD, using Cox proportional hazards regression and logistic regression, respectively. RESULT Among 178 matched pairs of African American patients, iNO was not associated with lower mortality (HR = 0.94, 95% CI 0.69-1.30) or less CLD (OR = 0.94, 95% CI 0.47-1.87). CONCLUSIONS Early, off-label iNO use is not associated with improved outcomes in premature African American neonates with RDS + PPHN.
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Affiliation(s)
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Reese H Clark
- Center for Research, Education & Quality, Pediatrix Medical Group, Sunrise, FL, USA
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, MN, USA.
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45
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Rallis D, Deierl A, Atreja G, Chaban B, Banerjee J. The efficacy of inhaled nitric oxide treatment in premature infants with acute pulmonary hypertension. Early Hum Dev 2018; 127:1-5. [PMID: 30205295 DOI: 10.1016/j.earlhumdev.2018.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/01/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although inhaled nitric oxide (iNO) therapy in term infants with pulmonary hypertension (PHT) has demonstrated definite benefit, the use of iNO in preterm infants remains inconclusive. AIMS To evaluate the impact of iNO treatment in premature infants with acute PHT. STUDY DESIGN Retrospective cohort. SUBJECTS Infants < 34 weeks' gestational age, admitted during 2010-2016 to two neonatal units, having treated with iNO for confirmed PHT. A positive response was defined by FiO2 reduction ≥20% within 3-h post iNO initiation. Early PHT was defined when developed within the first 72 h of age. OUTCOME MEASURES The primary outcome was the evaluation of the acute response to iNO administration. Secondary outcomes included the comparison of neonatal characteristics and outcomes between positive and negative responders, and early or late PHT infants. RESULTS Of the 55 infants of our cohort, 39 (71%) had a positive response to iNO administration. No differences noted regarding bronchopulmonary dysplasia, intraventricular haemorrhage or other morbidities; however, positive responders had significantly higher survival rate in overall (77 vs 21%, p = 0.001) and within early PHT subgroup (74 vs 33%, p = 0.044). Regression analysis revealed that oligohydramnios (OR 2.834, 95%CI 1.652-6.070) and early PHT (OR 1.953, 95%CI 1.377-2.930) were significantly related with a positive response. CONCLUSIONS Preterm infants with confirmed acute PHT respond in significant proportion to the iNO administration, especially in the background of oligohydramnios or the development of early PHT.
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Affiliation(s)
- Dimitrios Rallis
- Imperial College Healthcare NHS Trust, Neonatal Unit, London, UK.
| | - Aniko Deierl
- Imperial College Healthcare NHS Trust, Neonatal Unit, London, UK
| | - Gaurav Atreja
- Imperial College Healthcare NHS Trust, Neonatal Unit, London, UK
| | - Badr Chaban
- Imperial College Healthcare NHS Trust, Neonatal Unit, London, UK
| | - Jayanta Banerjee
- Imperial College Healthcare NHS Trust, Neonatal Unit, London, UK
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46
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Chandrasekharan P, Manja V, Lakshminrusimha S. Potential Benefits of Inhaled Nitric Oxide in Pulmonary Hypoplasia in Premature Neonates. JAMA Pediatr 2018; 172:1102-1103. [PMID: 30242392 DOI: 10.1001/jamapediatrics.2018.2892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, Oishei Children's Hospital, University at Buffalo, Buffalo, New York
| | - Veena Manja
- Department of Surgery, University of California, Davis, Sacramento.,Department of Medicine, Northern California Health Care System, Mather
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47
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Dedja A, Gucciardi A, Giordano G, Maria Di Gangi I, Porzionato A, Navaglia F, Baraldi E, Grisafi D, Zaramella P. Lipopolysaccharide-induced chorioamnionitis and postnatal lung injury: The beneficial effects of L-citrulline in newborn rats. Exp Lung Res 2018; 44:226-240. [DOI: 10.1080/01902148.2018.1497730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Arben Dedja
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University of Padova, Padova, Italy
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Antonina Gucciardi
- Mass Spectrometry and Metabolomic Laboratory, Department of Women's and Children's Health, University of Padova, Italy
| | - Giuseppe Giordano
- Mass Spectrometry and Metabolomic Laboratory, Department of Women's and Children's Health, University of Padova, Italy
| | - Iole Maria Di Gangi
- Mass Spectrometry and Metabolomic Laboratory, Department of Women's and Children's Health, University of Padova, Italy
| | - Andrea Porzionato
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Filippo Navaglia
- Department of Laboratory Medicine, University-Hospital, Padova, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University of Padova, Padova, Italy
| | - Davide Grisafi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University of Padova, Padova, Italy
| | - Patrizia Zaramella
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University of Padova, Padova, Italy
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Suzuki S, Togari H, Potenziano JL, Schreiber MD. Efficacy of inhaled nitric oxide in neonates with hypoxic respiratory failure and pulmonary hypertension: the Japanese experience. J Perinat Med 2018; 46:657-663. [PMID: 28926340 DOI: 10.1515/jpm-2017-0040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/21/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyze data from a registry of Japanese neonates with hypoxic respiratory failure associated with pulmonary hypertension (PH) to compare the effectiveness of inhaled nitric oxide (iNO) in neonates born <34 weeks vs. ≥34 weeks gestational age (GA). MATERIALS AND METHODS iNO was administered according to approved Japanese product labeling. Study data were collected before iNO administration and at predefined intervals until discontinuation. RESULTS A total of 1,114 neonates were included (n=431, <34 weeks GA; n=675, ≥34 weeks GA; n=8, missing age data). Mean decrease from baseline oxygenation index (OI) was similar in both age groups. OI reduction was more pronounced in the <34 weeks subgroups with baseline OI ≥25. Survival rates were similar in the <34 weeks GA and ≥34 weeks GA groups stratified by baseline OI (OI<15, 89% vs. 93%; 15≤OI<25, 85% vs. 91%; 25≤OI≤40, 73% vs. 79%; OI>40, 64% vs. 66%). CONCLUSION iNO improved oxygenation in preterm neonates as effectively as in late preterm and term neonates, without negative impact on survival. If clinically significant PH is present, as measured by pulse oximetry or echocardiography, a therapeutic trial of iNO might be indicated for preterm neonates.
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Affiliation(s)
- Satoshi Suzuki
- Department of Neonatology, Nagoya City West Medical Center, Nagoya, Japan
| | - Hajime Togari
- Department of Neonatology, Nagoya City West Medical Center, Nagoya, Japan
| | | | - Michael D Schreiber
- Department of Pediatrics, Chief, Section of Neonatology, The University of Chicago, Comer Children's Hospital, 5721 S. Maryland Avenue, Chicago, IL 60637,USA
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49
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Pabelick CM, Thompson MA, Britt RD. Effects of Hyperoxia on the Developing Airway and Pulmonary Vasculature. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 967:179-194. [PMID: 29047087 DOI: 10.1007/978-3-319-63245-2_11] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although it is necessary and part of standard practice, supplemental oxygen (40-90% O2) or hyperoxia is a significant contributing factor to development of bronchopulmonary dysplasia, persistent pulmonary hypertension, recurrent wheezing, and asthma in preterm infants. This chapter discusses hyperoxia and the role of redox signaling in the context of neonatal lung growth and disease. Here, we discuss how hyperoxia promotes dysfunction in the airway and the known redox-mediated mechanisms that are important for postnatal vascular and alveolar development. Whether in the airway or alveoli, redox pathways are important and greatly influence the neonatal lung.
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Affiliation(s)
- Christina M Pabelick
- Department of Anesthesiology, College of Medicine, Mayo Clinic, 4-184 W Jos SMH, 200 First St SW, Rochester, MN, 55905, USA. .,Departments Physiology and Biomedical Engineering, College of Medicine, Mayo Clinic, 4-184 W Jos SMH, 200 First St SW, Rochester, MN, 55905, USA.
| | - Michael A Thompson
- Department of Anesthesiology, College of Medicine, Mayo Clinic, 4-184 W Jos SMH, 200 First St SW, Rochester, MN, 55905, USA
| | - Rodney D Britt
- Departments Physiology and Biomedical Engineering, College of Medicine, Mayo Clinic, 4-184 W Jos SMH, 200 First St SW, Rochester, MN, 55905, USA
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Carey WA, Weaver AL, Mara KC, Clark RH. Inhaled Nitric Oxide in Extremely Premature Neonates With Respiratory Distress Syndrome. Pediatrics 2018; 141:peds.2017-3108. [PMID: 29439205 DOI: 10.1542/peds.2017-3108] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is increasingly prescribed to extremely premature neonates with respiratory distress syndrome (RDS). Most of this off-label use occurs during the first week of life. We studied this practice, hypothesizing that it would not be associated with improved survival. METHODS We queried the Pediatrix Medical Group Clinical Data Warehouse to identify all neonates born at 22 to 29 weeks' gestation from 2004 to 2014. In our study sample, we included singletons who required mechanical ventilation for treatment of RDS and excluded those with anomalies. The primary outcome was death before discharge. Through a sequential risk set approach, each patient who received iNO during the first 7 days of life ("case patient") was matched by using propensity scores to a patient who had not received iNO at a chronological age before the case patient's iNO initiation age (defined as the index age for the matched pair). The association between iNO status and in-hospital mortality was evaluated in a Cox proportional hazards regression model by using age as the time scale with patients entering the risk set at their respective index age. RESULTS Among 37 909 neonates in our study sample, we identified 993 (2.6%) who received iNO. The 2 matched cohorts each contained 971 patients. We did not observe a significant association between iNO exposure and mortality (hazard ratio, 1.08; 95% confidence interval, 0.94-1.25; P = .29). CONCLUSIONS Off-label prescription of iNO is not associated with reduced in-hospital mortality among extremely premature neonates with RDS.
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Affiliation(s)
| | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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