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Ouellet S, Drolet C, Morissette G, Pellerin A, Hébert A. Vasopressin in newborns with refractory acute pulmonary hypertension. Pediatr Res 2024; 95:1572-1577. [PMID: 38212386 DOI: 10.1038/s41390-023-02995-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/20/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Acute pulmonary hypertension (aPH) in newborns can be life threatening and challenging to manage. In newborns with refractory aPH, there is currently limited therapeutic agents. METHODS Retrospective single-center cohort study in newborns less than one month old who were treated with vasopressin for a minimum of one hour in the context of refractory aPH in the neonatal and pediatric intensive care units of a tertiary university center between 2016 and 2022. The objective was to evaluate the efficacy and safety of vasopressin in newborns as an adjuvant treatment for refractory aPH. RESULTS Twenty-five patients met inclusion criteria. In patients who received vasopressin, oxygenation index improved from 28.4 to 14.4 (p = 0.004) after twelve hours of continuous infusion. Oxygen requirements (FiO2) decreased from 0.91 to 0.50 (p = 0.004) and mean arterial pressure increased from 41 to 51 mmHg (p = 0.001). In our cohort, 68% of patients presented an episode of hyponatremia (serum sodium <130 mmol/L). CONCLUSIONS The use of vasopressin may be associated with improvement in oxygenation and hemodynamic status of neonatal patients with aPH refractory to initial therapy. Further prospective studies are needed to establish the safety profile of vasopressin in newborns, particularly in preterm infants. IMPACT Vasopressin may be an effective cardiotropic agent to improve oxygenation and hemodynamic status in newborns with acute pulmonary hypertension. Careful monitoring of serum sodium levels are warranted in newborns who are receiving vasopressin infusion. This provides additional evidence for the consideration of vasopressin in newborns with acute pulmonary hypertension refractory to inhaled nitric oxide.
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Affiliation(s)
- Simon Ouellet
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
| | - Christine Drolet
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Canada
| | - Geneviève Morissette
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
- Division of Pediatric Intensive Care, CHU de Québec, Université Laval, Quebec City, Canada
| | - Annie Pellerin
- Department of Pharmacy, CHU de Québec, Université Laval, Quebec City, Canada
| | - Audrey Hébert
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada.
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Canada.
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de Jager J, Brouwer F, Reijman J, van der Palen RLF, Steggerda SJ, Visser R, Te Pas AB, Dekker J. Occurrence of hyperoxia during iNO treatment for persistent pulmonary hypertension of the newborn: a cohort study. Eur J Pediatr 2024; 183:2455-2461. [PMID: 38470520 PMCID: PMC11035448 DOI: 10.1007/s00431-024-05506-6] [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: 01/13/2024] [Revised: 02/16/2024] [Accepted: 03/02/2024] [Indexed: 03/14/2024]
Abstract
High concentrations of oxygen are often needed to optimize oxygenation in infants with persistent pulmonary hypertension (PPHN), but this can also increase the risk of hyperoxemia. We determined the occurrence of hyperoxemia in infants treated for PPHN. Medical records of infants ≥ 34 + 0 weeks gestational age (GA) who received inhaled nitric oxide (iNO) were retrospectively reviewed for oxygenation parameters during iNO therapy. Oxygen was manually titrated to target arterial oxygen tension (PaO2) 10-13 kPa and peripheral oxygen saturation (SpO2) 92-98%. The main study outcomes were the incidence and duration of hyperoxemia and hypoxemia and the fraction of inspired oxygen (FiO2). A total of 181 infants were included. The median FiO2 was 0.43 (IQR 0.34-0.56) and the maximum FiO2 was 1.0 in 156/181 (86%) infants, resulting in at least one PaO2 > 13 kPa in 149/181 (82%) infants, of which 46/149 (31%) infants had minimal one PaO2 > 30 kPa. SpO2 was > 98% in 179/181 (99%) infants for 17.7% (8.2-35.6%) of the iNO time. PaO2 < 10 kPa occurred in 160/181 (88%) infants, of which 81/160 (51%) infants had minimal one PaO2 < 6.7 kPa. SpO2 was < 92% in 169/181 (93%) infants for 1.6% (0.5-4.3%) of the iNO time. Conclusion: While treatment of PPHN is focused on preventing and reversing hypoxemia, hyperoxemia occurs inadvertently in most patients. What is Known: • High concentrations of oxygen are often needed to prevent hypoxemia-induced deterioration of PPHN, but this can also increase the risk of hyperoxemia. • Infants with persistent pulmonary hypertension may be particularly vulnerable to the toxic effects of oxygen, and hyperoxemia could further induce pulmonary vasoconstriction, potentially worsening the condition. What is New: • Hyperoxemia occurs in the majority of infants with PPHN during treatment with iNO. • Infants with PPHN spent a considerably longer period with saturations above the target range compared to saturations below the target range.
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Affiliation(s)
- Justine de Jager
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Fleur Brouwer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Reijman
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Roel L F van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Remco Visser
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Singh P, Deshpande S, Nagpal R, Garegrat R, Gupta S, Suryawanshi P. Management of neonatal pulmonary hypertension-a survey of neonatal intensive care units in India. BMC Pediatr 2023; 23:149. [PMID: 37004003 PMCID: PMC10064718 DOI: 10.1186/s12887-023-03964-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Persistent pulmonary hypertension of the newborn (PPHN) is a common neonatal condition associated with significant morbidity and mortality. First-line diagnostic and treatment options such as echocardiography and inhaled nitric oxide (iNO) are not routinely available in resource limited settings and alternative treatment modalities need to be utilized. This study was conducted to assess current diagnostic and management strategies used for PPHN in Indian neonatal intensive care units (NICUs). METHODS A questionnaire in multiple choice question format was sent to practising neonatologists in India via an online survey tool between July to August 2021. Information pertaining to demographic data, diagnostic criteria and management strategies of PPHN was requested. The responses were collated and information processed. RESULTS There were 118 respondent NICUs (response rate 74%). The majority of neonatal units (65%) admitted an average of 1-3 patients of PPHN per month. Targeted neonatal echocardiography (TnECHO) was practised in 80% of the units. Most common management strategies being followed were pulmonary vasodilators (88.1%), inotropes (85.6%), conventional ventilation (68.6%) and high frequency ventilation (59.3%). The most preferred pulmonary vasodilator was sildenafil (79%) and inotropic agent was milrinone (32%). Only 25% of respondents reported use of iNO. None of the participating units used extracorporeal membrane oxygenation. CONCLUSION We found wide variability in management practices of PPHN across Indian NICUs. Non-selective pulmonary vasodilators are more widely used than iNO. There is an urgent need for structured TnECHO training programs and evidence based national guidelines for standardized management of PPHN as per availability of resources in India. Additional research on low cost alternative therapies to iNO in Indian settings might be helpful.
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Affiliation(s)
- Pari Singh
- Bharati Vidyapeeth Deemed University, Pune, India
| | | | - Rema Nagpal
- B. J. Medical College & Sassoon Hospital, Pune, India
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More K, Soni R, Gupta S. The role of bedside functional echocardiography in the assessment and management of pulmonary hypertension. Semin Fetal Neonatal Med 2022; 27:101366. [PMID: 35718687 DOI: 10.1016/j.siny.2022.101366] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension is an emergency in neonatal intensive care units with high morbidity and mortality. Its timely assessment and management is crucial for intact survival. Over the last couple of decades, there have been significant advances in management and techniques, which have resulted in improved survival. The use of neonatologist-performed echocardiography (NPE) is now increasingly utilized on neonatal intensive care units to understand the pathophysiology of the disease and to direct the treatment to the underlying cause. Its use is now established not only in cases of congenital diaphragmatic hernia and in the newborn with refractory hypoxemia, but also in other conditions such as bronchopulmonary dysplasia and the premature infant with difficulty in oxygenation. The use of NPE, however, requires the availability of trained personnel, equipment, and a close working relationship with pediatric cardiology.
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Affiliation(s)
- Kiran More
- Division of Neonatology, Sidra Medicine, Doha, Qatar; Department of Neonatology, BJ Wadia Children Hospital, Mumbai, India
| | - Roopali Soni
- Neonatal Unit, Mediclinic Parkview Hospital, Dubai, United Arab Emirates
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Doha, Qatar; Durham University, United Kingdom.
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McNamara PJ, Giesinger RE, Lakshminrusimha S. Dopamine and Neonatal Pulmonary Hypertension-Pressing Need for a Better Pressor? J Pediatr 2022; 246:242-250. [PMID: 35314154 DOI: 10.1016/j.jpeds.2022.03.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/07/2022] [Accepted: 03/15/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA.
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA
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Jain A, Giesinger RE, Dakshinamurti S, ElSayed Y, Jankov RP, Weisz DE, Lakshminrusimha S, Mitra S, Mazwi ML, Ting J, Narvey M, McNamara PJ. Care of the critically ill neonate with hypoxemic respiratory failure and acute pulmonary hypertension: framework for practice based on consensus opinion of neonatal hemodynamics working group. J Perinatol 2022; 42:3-13. [PMID: 35013586 DOI: 10.1038/s41372-021-01296-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/17/2021] [Accepted: 12/02/2021] [Indexed: 11/09/2022]
Abstract
Circulatory transition after birth presents a critical period whereby the pulmonary vascular bed and right ventricle must adapt to rapidly changing loading conditions. Failure of postnatal transition may present as hypoxemic respiratory failure, with disordered pulmonary and systemic blood flow. In this review, we present the biological and clinical contributors to pathophysiology and present a management framework.
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Affiliation(s)
- Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | | | - Yasser ElSayed
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Robert P Jankov
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Souvik Mitra
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Mjaye L Mazwi
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Joseph Ting
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Michael Narvey
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
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Randomized Trial of Oxygen Saturation Targets during and after Resuscitation and Reversal of Ductal Flow in an Ovine Model of Meconium Aspiration and Pulmonary Hypertension. CHILDREN-BASEL 2021; 8:children8070594. [PMID: 34356574 PMCID: PMC8305411 DOI: 10.3390/children8070594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022]
Abstract
Neonatal resuscitation (NRP) guidelines suggest targeting 85-95% preductal SpO2 by 10 min after birth. Optimal oxygen saturation (SpO2) targets during resuscitation and in the post-resuscitation management of neonatal meconium aspiration syndrome (MAS) with persistent pulmonary hypertension (PPHN) remains uncertain. Our objective was to compare the time to reversal of ductal flow from fetal pattern (right-to-left), to left-to-right, and to evaluate pulmonary (QPA), carotid (QCA)and ductal (QDA) blood flows between standard (85-94%) and high (95-99%) SpO2 targets during and after resuscitation. Twelve lambs asphyxiated by endotracheal meconium instillation and cord occlusion to induce MAS and PPHN were resuscitated per NRP guidelines and were randomized to either standard (85-94%) or high (95-99%) SpO2 targets. Out of twelve lambs with MAS and PPHN, six each were randomized to standard and high SpO2 targets. Median [interquartile range] time to change in direction of blood flow across the ductus arteriosus from right-to-left, to left-to-right was significantly shorter with high SpO2 target (7.4 (4.4-10.8) min) compared to standard SpO2 target (31.5 (21-66.2) min, p = 0.03). QPA was significantly higher during the first 10 min after birth with higher SpO2 target. At 60 min after birth, the QPA, QCA and QDA were not different between the groups. To conclude, targeting SpO2 of 95-99% during and after resuscitation may hasten reversal of ductal flow in lambs with MAS and PPHN and transiently increase QPA but no differences were observed at 60 min. Clinical studies comparing low and high SpO2 targets assessing hemodynamics and neurodevelopmental outcomes are warranted.
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Poitras EL, Gust SL, Kerr PM, Plane F. Repurposing of the PDE5 Inhibitor Sildenafil for the Treatment of Persistent Pulmonary Hypertension in Neonates. Curr Med Chem 2021; 28:2418-2437. [PMID: 32964819 DOI: 10.2174/0929867327666200923151924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/21/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022]
Abstract
Nitric oxide (NO), an important endogenous signaling molecule released from vascular endothelial cells and nerves, activates the enzyme soluble guanylate cyclase to catalyze the production of cyclic guanosine monophosphate (cGMP) from guanosine triphosphate. cGMP, in turn, activates protein kinase G to phosphorylate a range of effector proteins in smooth muscle cells that reduce intracellular Ca2+ levels to inhibit both contractility and proliferation. The enzyme phosphodiesterase type 5 (PDE5) curtails the actions of cGMP by hydrolyzing it into inactive 5'-GMP. Small molecule PDE5 inhibitors (PDE5is), such as sildenafil, prolong the availability of cGMP and therefore, enhance NO-mediated signaling. PDE5is are the first-line treatment for erectile dysfunction but are also now approved for the treatment of pulmonary arterial hypertension (PAH) in adults. Persistent pulmonary hypertension in neonates (PPHN) is currently treated with inhaled NO, but this is an expensive option and around 1/3 of newborns are unresponsive, resulting in the need for alternative approaches. Here the development, chemistry and pharmacology of PDE5is, the use of sildenafil for erectile dysfunction and PAH, are summarized and then current evidence for the utility of further repurposing of sildenafil, as a treatment for PPHN, is critically reviewed.
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Affiliation(s)
- Erika L Poitras
- Department of Pharmacology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada
| | - Stephen L Gust
- Department of Pharmacology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada
| | - Paul M Kerr
- Faculty of Nursing, Robbins Health Learning Centre, MacEwan University, Edmonton, Alberta T5J 4S2, Canada
| | - Frances Plane
- Department of Pharmacology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada
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Cardiovascular management following hypoxic-ischemic encephalopathy in North America: need for physiologic consideration. Pediatr Res 2021; 90:600-607. [PMID: 33070162 PMCID: PMC8249436 DOI: 10.1038/s41390-020-01205-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/19/2020] [Accepted: 07/06/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Hypotension and hypoxemic respiratory failure are common among neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Right ventricular (RV) dysfunction is associated with adverse neurodevelopment. Individualized management utilizing targeted neonatal echocardiography (TnECHO) may enhance care. METHODS We evaluated the influence of TnECHO programs on cardiovascular practices in HIE/TH patients utilizing a 77-item REDCap survey. Nominated representatives of TnECHO (n = 19) or non-TnECHO (n = 96) sites were approached. RESULTS Seventy-one (62%) sites responded. Baseline neonatal intensive care unit characteristics and HIE volume were comparable between groups. Most centers monitor invasive blood pressure; however, we identified 17 unique definitions of hypotension. TnECHO centers were likelier to trend systolic/diastolic blood pressure and request earlier echocardiography. TnECHO responders were less likely to use fluid boluses; TnECHO responders more commonly chose an inotrope first-line, while non-TnECHO centers used a vasopressor. For HRF, TnECHO centers chose vasopressors with a favorable pulmonary vascular profile. Non-TnECHO centers used more dopamine and more extracorporeal membrane oxygen for patients with HRF. CONCLUSIONS Cardiovascular practices in neonates with HIE differ between centers with and without TnECHO. Consensus regarding the definition of hypotension is lacking and dopamine use is common. The merits of these practices among these patients, who frequently have comorbid pulmonary hypertension and RV dysfunction, need prospective evaluation. IMPACT Cardiovascular care following HIE while undergoing therapeutic hypothermia varies between centers with access to trained hemodynamics specialists and those without. Because cardiovascular dysfunction is associated with brain injury, precision medicine-based care may be an avenue to improving outcomes. Therapeutic hypothermia has introduced new physiological considerations and enhanced survival. It is essential that hemodynamic strategies evolve to keep pace; however, little literature exists. Lack of consensus regarding fundamental definitions (e.g., hypotension) highlights the importance of collaboration among the scientific community to advance the field. The value of enhanced cardiovascular care guided by hemodynamic specialists requires prospective evaluation.
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Zhang W, Wu YE, Yang XY, Shi J, van den Anker J, Song LL, Zhao W. Oral drugs used to treat persistent pulmonary hypertension of the newborn. Expert Rev Clin Pharmacol 2020; 13:1295-1308. [PMID: 33180564 DOI: 10.1080/17512433.2020.1850257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Persistent Pulmonary Hypertension of the Newborn (PPHN) is a life-threatening neonatal condition, mostly treated with inhaled nitric oxide (iNO), intravenous prostaglandins, oral bosentan, sildenafil and tadalafil. However, the utility of non-oral agents is limited in PPHN for their side effects and inconvenient deliveries. Therefore, oral agents such as bosentan, sildenafil and tadalafil are becoming appealing for their satisfactory efficacy, easy mode of administration and acceptable side effects. Areas covered: We conducted a comprehensive search on Pubmed, Scopus, Web of Sciences concerning the use of bosentan, sildenafil and tadalafil to treat PPHN and summarized their efficacy, safety and pharmacokinetics. Expert opinion: Current randomized controlled trials (RCTs) have demonstrated the favorable responses and tolerable side effects of bosentan and sildenafil. Nevertheless, those RCTs are small and only one study has described the pharmacokinetics of sildenafil in neonates. Accordingly, bosentan, sildenafil and tadalafil remain off-label in clinical use. More well-designed RCTs with large samples and long-term follow-up and pharmacometrics studies are needed to demonstrate the efficacy, safety and pharmacokinetics of bosentan, sildenafil and tadalafil in PPHN.
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Affiliation(s)
- Wei Zhang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University , Jinan, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University , Jinan, China
| | - Xiao-Yan Yang
- Department of Pediatrics, West China Second University Hospital, Sichuan University , Chengdu, China
| | - Jing Shi
- Department of Pediatrics, West China Second University Hospital, Sichuan University , Chengdu, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital , Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics & Precision Medicine, The George Washington University School of Medicine and Health Sciences , Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital , Basel, Switzerland
| | - Lin-Lin Song
- Department of Clinical Pharmacy, Clinical Trial Center, Shandong Provincial Qianfoshan Hospital, the First Affiliated Hospital of Shandong First Medical University , Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University , Jinan, China.,Department of Clinical Pharmacy, Clinical Trial Center, Shandong Provincial Qianfoshan Hospital, the First Affiliated Hospital of Shandong First Medical University , Jinan, China
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Rawat M, Chandrasekharan P, Gugino SF, Koenigsknecht C, Nielsen L, Wedgwood S, Mathew B, Nair J, Steinhorn R, Lakshminrusimha S. Optimal Oxygen Targets in Term Lambs with Meconium Aspiration Syndrome and Pulmonary Hypertension. Am J Respir Cell Mol Biol 2020; 63:510-518. [PMID: 32609558 PMCID: PMC7528912 DOI: 10.1165/rcmb.2019-0449oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/01/2020] [Indexed: 12/13/2022] Open
Abstract
Optimal oxygen saturation as measured by pulse oximetry (SpO2) in neonatal lung injury, such as meconium aspiration syndrome (MAS) and persistent pulmonary hypertension of newborn (PPHN), is not known. Our goal was to determine the SpO2 range in lambs with MAS and PPHN that results in the highest brain oxygen delivery (bDO2) and pulmonary blood flow (Qp) and the lowest pulmonary vascular resistance and oxidative stress. Meconium was instilled into endotracheal tubes in 25 near-term gestation lambs, and the umbilical cord was occluded to induce asphyxia and gasping, causing MAS and PPHN. Lambs were randomized into four groups and ventilated for 6 hours with fixed fraction of inspired oxygen (FiO2) = 1.0 irrespective of SpO2, and three groups had FiO2 titrated to keep preductal SpO2 between 85% and 89%, 90% and 94%, and 95% and 99%, respectively. Tissues were collected to measure nitric oxide synthase activity, 3-nitrotyrosine, and 8-isoprostanes. Throughout the 6-hour exposure period, lambs in the 95-99% SpO2 target group had the highest Qp, lowest pulmonary vascular resistance, and highest bDO2 but were exposed to higher FiO2 (0.5 ± 0.21 vs. 0.29 ± 0.17) with higher lung 3-nitrotyrosine (0.67 [interquartile range (IQR), 0.43-0.73] ng/mcg protein vs. 0.1 [IQR, 0.09-0.2] ng/mcg protein) and lower lung nitric oxide synthase activity (196 [IQR, 192-201] mMol nitrite/mg protein vs. 270 [IQR, 227-280] mMol nitrite/mg protein) compared with the 90-94% target group. Brain 3-nitrotyrosine was lower in the 85-89% target group, and brain/lung 8-isoprostane levels were not significantly different. In term lambs with MAS and PPHN, Qp and bDO2 through the first 6 hours are higher with target SpO2 in the 95-99% range. However, the 90-94% target range is associated with significantly lower FiO2 and lung oxidative stress. Clinical trials comparing the 90-94% versus the 95-99% SpO2 target range in term infants with PPHN are warranted.
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Affiliation(s)
| | | | - Sylvia F. Gugino
- Department of Pediatrics and
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | | | - Lori Nielsen
- Department of Pediatrics and
- Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | - Stephen Wedgwood
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; and
| | | | | | - Robin Steinhorn
- Department of Pediatrics, Rady Children’s Hospital, University of California San Diego, California
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; and
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Dillard J, Perez M, Chen B. Therapies that enhance pulmonary vascular NO-signaling in the neonate. Nitric Oxide 2019; 95:45-54. [PMID: 31870967 DOI: 10.1016/j.niox.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/25/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
There are several pulmonary hypertensive diseases that affect the neonatal population, including persistent pulmonary hypertension of the newborn (PPHN) and bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension (PH). While the indication for inhaled nitric oxide (iNO) use is for late-preterm and term neonates with PPHN, there is a suboptimal response to this pulmonary vasodilator in ~40% of patients. Additionally, there are no FDA-approved treatments for BPD-associated PH or for preterm infants with PH. Therefore, investigating mechanisms that alter the nitric oxide-signaling pathway has been at the forefront of pulmonary vascular biology research. In this review, we will discuss the various mechanistic pathways that have been targets in neonatal PH, including NO precursors, soluble guanylate cyclase modulators, phosphodiesterase inhibitors and antioxidants. We will review their role in enhancing NO-signaling at the bench, in animal models, as well as highlight their role in the treatment of neonates with PH.
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Affiliation(s)
- Julie Dillard
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
| | - Marta Perez
- Division of Neonatology, Stanley Manne Children's Research Institute, Ann and Robert H Lurie Children's Hospital, Chicago, IL, USA; Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Bernadette Chen
- Pulmonary Hypertension Group, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
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Nakwan N, Jain S, Kumar K, Hosono S, Hammoud M, Elsayed YY, Ariff S, Hasan B, Khowaja W, Poon WB. An Asian multicenter retrospective study on persistent pulmonary hypertension of the newborn: incidence, etiology, diagnosis, treatment and outcome. J Matern Fetal Neonatal Med 2018; 33:2032-2037. [PMID: 30318951 DOI: 10.1080/14767058.2018.1536740] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives: To explore the incidence, etiologies, diagnostic methods, treatment options and outcomes in neonates with persistent pulmonary hypertension of the newborn (PPHN) and to identify mortality risk factors in a study from six Asian countries.Methods: A retrospective chart review of patients with documented PPHN from seven centers in six Asian countries (Japan, Kuwait, India, Pakistan, Singapore, and Thailand) between 1 January, 2014 and 31 December, 2016, was performed.Results: A total of 369 PPHN infants were identified. The incidence of PPHN ranged from 1.2 to 4.6 per 1000 live births. The all-cause mortality rate was 20.6% (76 of 369). Meconium aspiration syndrome was the primary cause of PPHN (24.1%). In most cases (84.8%) echocardiography was used to establish the diagnosis of PPHN. Sildenafil was the most commonly used pulmonary vasodilator (51.2%). Multivariate multiple regression analysis indicated gestational age <34 weeks (adjusted odds ratio (OR) = 3.27; 95% CI 1.56-6.74), congenital diaphragmatic hernia (CDH)/lung hypoplasia (LH) (adjusted OR = 6.13 (95% CI 2.28-16.42)), treatment with high frequency oscillation ventilation (HFOV) with or without inhaled nitric oxide (iNO) (adjusted OR = 3.11 (95% CI 1.52-6.34)), and inotropic agents (adjusted OR = 9.43 (95% CI 2.71-32.83)) were independently associated with increased risk of death.Conclusions: The incidence of PPHN in the current study was higher than in western settings. Birth weight, gestational age, CDH/LH, HFOV/iNO, and inotropic agents were significant mortality risk factors.
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Affiliation(s)
- Narongsak Nakwan
- Department of Pediatrics, Hat Yai Medical Education Center, Hat Yai Hospital, Songkhla, Thailand
| | - Suksham Jain
- Department of Pediatrics, Govt. Medical College and Hospital, Chandigarh, India
| | - Kishore Kumar
- Department of Pediatrics, Cloudnine Hospital, Bangalore, India
| | - Shigeharu Hosono
- Division of Neonatology, Department of Perinatal and Neonatal Medicine, Jichi Medical University, Saitama, Japan.,Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Majeda Hammoud
- Department of Pediatrics and Neonatology, Faculty of Medicine, Kuwait University and Al-Sabah Maternity Hospital, Kuwait
| | - Yasser Yahia Elsayed
- Department of Pediatrics and Neonatology, Faculty of Medicine, Kuwait University and Al-Sabah Maternity Hospital, Kuwait
| | - Shabina Ariff
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Babar Hasan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Waqar Khowaja
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Woei Bing Poon
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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Intravenous epoprostenol improves oxygenation index in patients with persistent pulmonary hypertension of the newborn refractory to nitric oxide. J Perinatol 2018; 38:1212-1219. [PMID: 30046179 DOI: 10.1038/s41372-018-0179-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/19/2018] [Accepted: 06/26/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Evaluate the short-term effects of IV epoprostenol in neonates with persistent pulmonary hypertension (PPHN) of the newborn. STUDY DESIGN We reviewed 36 patients with inhaled nitric oxide (iNO) refractory PPHN placed on IV epoprostenol from 2010 to 2015. Patients were categorized as responders or non-responders (who either died or required extracorporeal membranous oxygenation). RESULTS There were 15 responders and 21 non-responders. Pulmonary hypoplasia was the etiology of PPHN for 57% of non-responders vs. 13% of responders. Median oxygenation index (OI) was similar at baseline (41.8 non-responders vs. 36.5 responders, p = 0.41) with responders having a significantly lower OI by 4 h of treatment (42.3 vs. 23.1, p = 0.002). Epoprostenol responders had a median OI decrease of 11.6 within 4 h (p = 0.017) with a significant response persisting through 24 h. CONCLUSION In infants with iNO-refractory PPHN, initiation of IV epoprostenol was associated with a significant and rapid OI reduction among responders.
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The Fetus Can Teach Us: Oxygen and the Pulmonary Vasculature. CHILDREN-BASEL 2017; 4:children4080067. [PMID: 28771211 PMCID: PMC5575589 DOI: 10.3390/children4080067] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/22/2017] [Accepted: 07/31/2017] [Indexed: 11/17/2022]
Abstract
Neonates suffering from pulmonary hypertension of the newborn (PPHN) continue to represent an important proportion of patients requiring intensive neonatal care, and have an increased risk of morbidity and mortality. The human fetus has evolved to maintain a high pulmonary vascular resistance (PVR) in utero to allow the majority of the fetal circulation to bypass the lungs, which do not participate in gas exchange, towards the low resistance placenta. At birth, oxygen plays a major role in decreasing PVR to enhance pulmonary blood flow and establish the lungs as the organ of gas exchange. The failure of PVR to fall following birth results in PPHN, and oxygen remains the mainstay therapeutic intervention in the management of PPHN. Knowledge gaps on what constitutes the optimal oxygenation target leads to a wide variation in practices, and often leads to excessive oxygen use. Owing to the risk of oxygen toxicity, avoiding hyperoxemia is as important as avoiding hypoxemia in the management of PPHN. Current evidence supports maintaining arterial oxygen tension in the range of 50–80 mm Hg, and oxygen saturation between 90–97% in term infants with hypoxemic respiratory failure. Clinical studies evaluating the optimal oxygenation in the treatment of PPHN will be enthusiastically awaited.
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