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Meyer S, Bay J, Franz AR, Erhardt H, Klein L, Petzinger J, Binder C, Kirschenhofer S, Stein A, Hüning B, Heep A, Cloppenburg E, Muyimbwa J, Ott T, Sandkötter J, Teig N, Wiegand S, Schroth M, Kick A, Wurm D, Gebauer C, Linnemann K, Kittel J, Wieg C, Kiechl-Kohlendorfer U, Schmidt S, Böttger R, Thomas W, Brevis Nunez F, Stockmann A, Kriebel T, Müller A, Klotz D, Morhart P, Nohr D, Biesalski HK, Giannopoulou EZ, Hilt S, Poryo M, Wagenpfeil S, Haiden N, Ruckes C, Ehrlich A, Gortner L. Early postnatal high-dose fat-soluble enteral vitamin A supplementation for moderate or severe bronchopulmonary dysplasia or death in extremely low birthweight infants (NeoVitaA): a multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00073-0. [PMID: 38643780 DOI: 10.1016/s2213-2600(24)00073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Vitamin A plays a key role in lung development, but there is no consensus regarding the optimal vitamin A dose and administration route in extremely low birthweight (ELBW) infants. We aimed to assess whether early postnatal additional high-dose fat-soluble enteral vitamin A supplementation versus placebo would lower the rate of moderate or severe bronchopulmonary dysplasia or death in ELBW infants receiving recommended basic enteral vitamin A supplementation. METHODS This prospective, multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial conducted at 29 neonatal intensive care units in Austria and Germany assessed early high-dose enteral vitamin A supplementation (5000 international units [IU]/kg per day) or placebo (peanut oil) for 28 days in ELBW infants. Eligible infants had a birthweight of more than 400 g and less than 1000 g; gestational age at birth of 32+0 weeks postmenstrual age or younger; and the need for mechanical ventilation, non-invasive respiratory support, or supplemental oxygen within the first 72 h of postnatal age after admission to the neonatal intensive care unit. Participants were randomly assigned by block randomisation with variable block sizes (two and four). All participants received basic vitamin A supplementation (1000 IU/kg per day). The composite primary endpoint was moderate or severe bronchopulmonary dysplasia or death at 36 weeks postmenstrual age, analysed in the intention-to-treat population. This trial was registered with EudraCT, 2013-001998-24. FINDINGS Between March 2, 2015, and Feb 27, 2022, 3066 infants were screened for eligibility at the participating centres. 915 infants were included and randomly assigned to the high-dose vitamin A group (n=449) or the control group (n=466). Mean gestational age was 26·5 weeks (SD 2·0) and mean birthweight was 765 g (162). Moderate or severe bronchopulmonary dysplasia or death occurred in 171 (38%) of 449 infants in the high-dose vitamin A group versus 178 (38%) of 466 infants in the control group (adjusted odds ratio 0·99, 95% CI 0·73-1·55). The number of participants with at least one adverse event was similar between groups (256 [57%] of 449 in the high-dose vitamin A group and 281 [60%] of 466 in the control group). Serum retinol concentrations at baseline, at the end of intervention, and at 36 weeks postmenstrual age were similar in the two groups. INTERPRETATION Early postnatal high-dose fat-soluble enteral vitamin A supplementation in ELBW infants was safe, but did not change the rate of moderate or severe bronchopulmonary dysplasia or death and did not substantially increase serum retinol concentrations. FUNDING Deutsche Forschungsgemeinschaft and European Clinical Research Infrastructures Network (ECRIN).
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Affiliation(s)
- Sascha Meyer
- Clinical Centre Karlsruhe, Franz-Lust Clinic for Paediatrics, Karlsruhe, Germany.
| | - Johannes Bay
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Axel R Franz
- University Hospital Tübingen, Neonatology and Center for Paediatric Clinical Studies, Department for Paediatrics, Tübingen, Germany
| | - Harald Erhardt
- Department of Paediatrics and Adolescent Medicine, Division of Neonatology and Pediatric Intensive Care Medicine, University Medical Center Ulm, Ulm, Germany
| | - Lars Klein
- Department of General Paediatrics and Neonatology, Justus-Liebig-Universität, Giessen, Germany
| | - Jutta Petzinger
- Department of General Paediatrics and Neonatology, Justus-Liebig-Universität, Giessen, Germany
| | - Christoph Binder
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Susanne Kirschenhofer
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Anja Stein
- University Hospital Essen, Clinic for Paediatrics I, Department for Neonatology, Essen, Germany
| | - Britta Hüning
- University Hospital Essen, Clinic for Paediatrics I, Department for Neonatology, Essen, Germany
| | - Axel Heep
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Eva Cloppenburg
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Julia Muyimbwa
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Torsten Ott
- University Hospital Münster, Clinic for Paediatrics, Department for Neonatology, Münster, Germany
| | - Julia Sandkötter
- University Hospital Münster, Clinic for Paediatrics, Department for Neonatology, Münster, Germany
| | - Norbert Teig
- University Hospital Bochum, Children's Hospital-St Josef-Hospital, Department for Neonatology and Paediatric Intensive Care, Bochum, Germany
| | - Susanne Wiegand
- University Hospital Bochum, Children's Hospital-St Josef-Hospital, Department for Neonatology and Paediatric Intensive Care, Bochum, Germany
| | - Michael Schroth
- Cnopf'sche Kinderklinik, Clinic for Neonatology and Paediatric Intensive Care, Nürnberg, Germany
| | - Andrea Kick
- Cnopf'sche Kinderklinik, Clinic for Neonatology and Paediatric Intensive Care, Nürnberg, Germany
| | - Donald Wurm
- Clinical Centre Saarbrücken, Clinic for Paediatrics, Saarbrücken, Germany
| | - Corinna Gebauer
- University Hospital Leipzig, Center of Paediatrics, Department for Neonatology, Leipzig, Germany
| | - Knud Linnemann
- University Hospital Greifswald, Center for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Greifswald, Germany
| | - Jochen Kittel
- Barmherzige Brüder Hospital Regensburg, Clinic St Hedwig, Clinic for Paediatrics, Regensburg, Germany
| | - Christian Wieg
- Clinical Centre Aschaffenburg-Alzenau, Clinic for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Aschaffenburg, Germany
| | | | - Susanne Schmidt
- LMU Clinic for Paediatrics, Haunersches Kinderspital, Munich, Germany
| | - Ralf Böttger
- University Hospital Magdeburg, Clinic for Paediatrics, Magdeburg, Germany
| | - Wolfgang Thomas
- Hospital Mutterhaus der Borromäerinnen, Clinic for Paediatrics, Trier, Germany
| | - Francisco Brevis Nunez
- Sana Hospital Duisburg, Clinic for Paediatrics, Department of Paediatric Intensive Care, Duisburg, Germany
| | - Antje Stockmann
- Evangelical Hospital Oberhausen, Center of Paediatrics, Department of Neonatology, Oberhausen, Germany
| | - Thomas Kriebel
- Westpfalz-Klinikum Kaiserslautern, Department of Paediatrics, Kaiserslautern, Germany
| | - Andreas Müller
- University Hospital Bonn, Eltern-Kind-Zentrum (ELKI), Neonatology/Paediatric Intensive Care, Bonn, Germany
| | - Daniel Klotz
- University Hospital Freiburg, Centre for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Freiburg, Germany
| | - Patrick Morhart
- Center of Paediatrics, Department for Neonatology and Paediatric Intensive Care, Erlangen, Germany
| | | | | | - Eleni Z Giannopoulou
- University Hospital Ulm, Clinic for Paediatrics, Paediatric Endocrinology and Diabetology, Ulm, Germany
| | - Susanne Hilt
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Martin Poryo
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatric Cardiology, Homburg, Germany
| | - Stefan Wagenpfeil
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Nadja Haiden
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Christian Ruckes
- Interdisziplinäres Zentrum Klinische Studien (IZKS), Universitätsmedizin Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Anne Ehrlich
- Interdisziplinäres Zentrum Klinische Studien (IZKS), Universitätsmedizin Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ludwig Gortner
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
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Feng Z, Wu X, Xu X, Cui Q, Wu F. Efficacy of inhaled nitric oxide in preterm infants ≤ 34 weeks: a systematic review and meta-analysis of randomized controlled trials. Front Pharmacol 2024; 14:1268795. [PMID: 38273818 PMCID: PMC10808707 DOI: 10.3389/fphar.2023.1268795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Background: The effect of inhaled nitric oxide (iNO) in neonates >34 weeks on improving respiration is well documented. However, the efficacy of iNO in preterm infants ≤34 weeks remains controversial. Objectives: The main purpose of this review is to assess the effectiveness and safety of iNO treatment in preterm infants ≤34 weeks. Search methods: We systematically searched PubMed, Embase and Cochrane Libraries from their inception to 1 June 2023. We also reviewed the reference lists of retrieved studies. Selection criteria: Our study involved randomized controlled trials on preterm infants ≤34 weeks, especially those receiving iNO treatment, and mainly assessed outcomes such as bronchopulmonary dysplasia (BPD) and mortality. Two authors independently reviewed these trials, extracted data, and evaluated study biases. Disagreements were resolved by consensus. We used the GRADE method to assess evidence quality. Results: Our research included a total of 17 studies involving 4,080 neonates and 7 follow-up studies. The synthesis of results showed that in neonates, iNO treatment reduced the incidence of BPD (RR: 0.92; 95% CI: 0.86-0.98). It also decreased the composite outcome of death or BPD (RR: 0.94; 95% CI: 0.90-0.98), without increasing the risk of short-term (such as intraventricular hemorrhage, periventricular leukomalacia) and long-term neurological outcomes (including Bayley mental developmental index <70, cerebral palsy and neurodevelopmental impairment). Furthermore, iNO did not significantly affect other neonatal complications like sepsis, pulmonary hemorrhage, necrotizing enterocolitis, and symptomatic patent ductus arteriosus. Subgroup analysis revealed that iNO significantly reduced BPD incidence in neonates at 36 weeks under specific intervention conditions, including age less than 3 days, birth weight over 1,000 g, iNO dose of 10 ppm or higher, or treatment duration exceeding 7 days (p < 0.05). Conclusion: Inhaled NO reduced the incidence of BPD in neonates at 36 weeks of gestation, and the effect of the treatment depended on neonatal age, birth weight, duration and dose of iNO. Therefore, iNO can be considered a promising treatment for the potential prevention of BPD in premature infants. More data, however, would be needed to support nitric oxide registration in this specific patient population, to minimize its off-label use.
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Affiliation(s)
- Zhoushan Feng
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Xiaohong Wu
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Xiaona Xu
- Department of Obstetrics and Gynecology, School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiliang Cui
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Fan Wu
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
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Balsamo F, Li B, Chusilp S, Lee D, Biouss G, Lee C, Maynes JT, Pierro A. Argon inhalation attenuates systemic inflammation and rescues lung architecture during experimental neonatal sepsis. Pediatr Surg Int 2023; 40:21. [PMID: 38108911 DOI: 10.1007/s00383-023-05596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE Neonatal sepsis is a systemic inflammatory infection common in premature infants and a leading cause of mortality. Argon is an emerging interest in the field of noble gas therapy. Neonates with severe sepsis are frequently mechanically ventilated creating an opportunity for inhalation therapy. We aimed to investigate argon inhalation as a novel experimental therapy in neonatal sepsis. METHODS Sepsis was established in C57BL/6 neonatal mice by a lipopolysaccharide intraperitoneal injection on postnatal day 9. Septic pup mice were exposed to room air as well as non-septic controls. In the argon group, septic pup mice were exposed to argon (70% Ar, 30% O2) for 6 h in a temperature-controlled environment. RESULTS At 6 h, survival was significantly enhanced when septic mice received argon compared to septic controls. Serum profiles of cytokine release were significantly attenuated as well as lung architecture restored. CONCLUSIONS Our findings suggest that argon inhalation as a novel treatment for neonatal sepsis, reducing mortality and counteracting the acute systemic inflammatory response in the blood and preserving the architecture of the lung. This research can contribute to a paradigm shift in the treatment and outcome of neonates with sepsis.
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Affiliation(s)
- Felicia Balsamo
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Bo Li
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Sinobol Chusilp
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Dorothy Lee
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - George Biouss
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Carol Lee
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Jason T Maynes
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Biochemistry, Faculty of Medicine , University of Toronto, Toronto, Canada
| | - Agostino Pierro
- Translational Medicine Program, Division of General and Thoracic Surgery, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada.
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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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Fu M, Hu Z, Yu G, Luo Y, Xiong X, Yang Q, Song W, Yu Y, Yang T. Predictors of extubation failure in newborns: a systematic review and meta-analysis. Ital J Pediatr 2023; 49:133. [PMID: 37784184 PMCID: PMC10546653 DOI: 10.1186/s13052-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023] Open
Abstract
Extubation failure (EF) is a significant concern in mechanically ventilated newborns, and predicting its occurrence is an ongoing area of research. To investigate the predictors of EF in newborns undergoing planned extubation, we conducted a systematic review and meta-analysis. A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for studies published in English from the inception of each database to March 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. Thirty-four studies were included, 10 of which were overall low risk of bias, 15 of moderate risk of bias, and 9 of high risk of bias. The studies reported 43 possible predictors in six broad categories (intrinsic factors; maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; characteristics before and after extubation; and clinical scores and composite indicators). Through a qualitative synthesis of 43 predictors and a quantitative meta-analysis of 19 factors, we identified five definite factors, eight possible factors, and 22 unclear factors related to EF. Definite factors included gestational age, sepsis, pre-extubation pH, pre-extubation FiO2, and respiratory severity score. Possible factors included age at extubation, anemia, inotropic use, mean airway pressure, pre-extubation PCO2, mechanical ventilation duration, Apgar score, and spontaneous breathing trial. With only a few high-quality studies currently available, well-designed and more extensive prospective studies investigating the predictors affecting EF are still needed. In the future, it will be important to explore the possibility of combining multiple predictors or assessment tools to enhance the accuracy of predicting extubation outcomes in clinical practice.
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Affiliation(s)
- Maoling Fu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhenjing Hu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Genzhen Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China.
| | - Ying Luo
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Xiaoju Xiong
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Qiaoyue Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenshuai Song
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yaqi Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ting Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Breinig S, Ehlinger V, Rozé JC, Storme L, Torchin H, Durrmeyer X, Cambonie G, Delacourt C, Jarreau PH, Berthomieu L, Brissaud O, Benhammou V, Gascoin G, Arnaud C, Ancel PY. Pulmonary hypertension among preterm infants born at 22 through 32 weeks gestation in France: Prevalence, survival, morbidity and management in the EPIPAGE-2 cohort study. Early Hum Dev 2023; 184:105837. [PMID: 37595540 DOI: 10.1016/j.earlhumdev.2023.105837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/16/2023] [Accepted: 07/30/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To determine the prevalence, short-term prognosis and pharmacologic management of pulmonary hypertension (PH) among very preterm infants born before 32 weeks gestation (WG). STUDY DESIGN In the EPIPAGE-2 French national prospective population-based cohort of preterm infants born in 2011, those presenting with PH were identified and prevalence was estimated using multiple imputation. The primary outcome was survival without severe morbidity at discharge and was compared between infants with or without PH after adjusting for confounders, using generalized estimating equations models. Subgroup analysis was performed according to gestational age (GA) groups. RESULTS Among 3383 eligible infants, 3222 were analyzed. The prevalence of PH was 6.0 % (95 % CI, 5.2-6.9), 14.5 % in infants born at 22-27+6 WG vs 2.7 % in infants born at 28-31+6 WG (P < .001). The primary outcome (survival without severe morbidity at discharge) occurred in 30.2 % of infants with PH vs 80.2 % of infants without PH (P < .001). Adjusted incidence rate ratios for survival without severe morbidity among infants with PH were 0.42 (0.32-0.57) and 0.52 (0.39-0.69) in infants born at 22-27+6 weeks gestation and those born at 28-31+6 weeks, respectively. Among infants with PH, 92.2 % (95 % CI, 87.7-95.2) received sedation and/or analgesia, 63.5 % (95 % CI, 56.6-69.9) received inhaled NO and 57.6 % (95 % CI, 50.9-64.0) received hemodynamic treatments. CONCLUSION In this population-based cohort of very preterm infants, the prevalence of PH was 6 %. PH was associated with a significant decrease of survival without severe morbidity in this population.
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Affiliation(s)
- Sophie Breinig
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France; Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France.
| | - Virginie Ehlinger
- Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France
| | | | - Laurent Storme
- Neonatal Intensive Care Unit, Lille University Hospital, Lille, France
| | - Heloise Torchin
- Neonatal Intensive Care Unit, Maternité Cochin-Port Royal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Gilles Cambonie
- Neonatal and Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Christophe Delacourt
- Department of Pediatric Pneumology, Necker Children's Hospital, Paris University Hospital, Paris, France
| | - Pierre-Henri Jarreau
- Neonatal Intensive Care Unit, Maternité Cochin-Port Royal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Berthomieu
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, 330 Avenue de Grande-Bretagne, Toulouse Cedex 9, France
| | - Olivier Brissaud
- Neonatal and Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Valérie Benhammou
- INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris, France
| | - Geraldine Gascoin
- Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France; Neonatal Intensive Care Unit, Children's Hospital, Toulouse University Hospital, Toulouse, France
| | - Catherine Arnaud
- Center for Epidemiology and Research in POPulation health (CERPOP), UMR1295, Toulouse University, Inserm, Toulouse, France; Clinical Epidemiology Unit, Toulouse University Hospital, Toulouse, France
| | - Pierre-Yves Ancel
- INSERM, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris, France
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Fraga MV, Dysart KC, Stoller JZ, Huber M, Fedec A, Mercer-Rosa L, Kirpalani H. Echocardiographic Assessment of Pulmonary Arterial Hypertension Following Inhaled Nitric Oxide in Infants with Severe Bronchopulmonary Dysplasia. Neonatology 2023; 120:633-641. [PMID: 37573771 DOI: 10.1159/000531586] [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: 02/06/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is an effective pulmonary vasodilator. However, the efficacy of iNO in former premature infants with established bronchopulmonary dysplasia (BPD) has not been studied. This study aimed to determine the efficacy of iNO in reducing pulmonary artery pressure in infants with severe BPD as measured by echocardiography. STUDY DESIGN Prospective, observational study enrolling infants born at less than 32 weeks gestation and in whom (1) iNO therapy was initiated after admission to our institution, or (2) at the outside institution less than 48 h before transfer and received an echocardiogram prior to iNO initiation, and (3) had severe BPD. Data were collected at three time-points: (1) before iNO; (2) 12-48 h after initiation of iNO; and (3) 48-168 h after initiation of iNO. The primary outcome was the effect of iNO on pulmonary artery pressure measured by echocardiography in patients with severe BPD between 48 and 168 h after initiating iNO therapy. RESULTS Of 37 enrolled, 81% had echocardiographic evidence of pulmonary arterial hypertension (PAH) before iNO and 56% after 48 h of iNO (p = 0.04). FiO2 requirements were significantly different between time-points (1) and (3) (p = 0.05). There were no significant differences between Tricuspid Annular Plane Systolic Excursion (TAPSE) Z-Scores, time to peak velocity: right ventricular ejection time (TPV:RVET), and ventilator changes. CONCLUSIONS Although we found a statistically significant reduction of PAH between time-point (1) and (3), future trials are needed to further guide clinical care.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jason Z Stoller
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew Huber
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anysia Fedec
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Emeritus Professor of Pediatrics, Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Emeritus Professor of Pediatrics, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Noh CY, Chock VY, Bhombal S, Danzer E, Patel N, Dahlen A, Harting MT, Lally KP, Ebanks AH, Van Meurs KP. Early nitric oxide is not associated with improved outcomes in congenital diaphragmatic hernia. Pediatr Res 2023; 93:1899-1906. [PMID: 36725908 DOI: 10.1038/s41390-023-02491-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is widely used for the management of infants with congenital diaphragmatic hernia (CDH); however, evidence of benefit is limited. METHODS This is a multicenter cohort study using data from the Congenital Diaphragmatic Hernia Study Group between 2015 and 2020. The impact of early iNO use in the first 3 days of life prior to ECLS use on mortality or ECLS use was explored using multivariate logistic regression models and subgroup analyses. RESULTS Of the 1777 infants, 863 (48.6%) infants received early iNO treatment. Infants receiving iNO had lower birth weight, larger defect size, more severe pulmonary hypertension, and abnormal ventricular size and function. After controlling for these factors, early iNO use was associated with increased mortality (aOR 2.06, 95% CI 1.05-4.03, P = 0.03) and increased ECLS use (aOR 3.44, 95% CI 2.11-5.60, P < 0.001). Subgroup analyses after stratification by echocardiographic characteristics and defect size revealed no subgroup with a reduction in mortality or ECLS use. CONCLUSIONS Use of iNO in the first 3 days of life prior to ECLS was not associated with a reduction in mortality or ECLS use in either the regression models or the subgroup analyses. The widespread use of iNO in this vulnerable population requires reconsideration. IMPACT Evidence to support widespread use of iNO for infants with congenital diaphragmatic hernia is limited. The use of iNO in the first 3 days of life was associated with significantly increased mortality and ECLS use. Stratification by echocardiographic characteristics and defect size did not reveal a subgroup that benefited from iNO. Even the subset of patients with R-to-L shunts at both ductal and atrial levels, a surrogate for elevated pulmonary arterial pressures in the absence of significantly decreased LV compliance, did not benefit from early iNO use. Early iNO therapy was of no benefit in the management of acute pulmonary hypertension in infants with congenital diaphragmatic hernia, supporting reconsideration of its use in this population.
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Affiliation(s)
- Caroline Y Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Enrico Danzer
- Division of Pediatric Surgery, Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil Patel
- Royal Hospital for Children Glasgow, Glasgow, UK
| | - Alex Dahlen
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA
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9
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Zheng Y, Wu Q, Han S. Inhaled nitric oxide in premature infants for preventing bronchopulmonary dysplasia: a meta-analysis. BMC Pediatr 2023; 23:139. [PMID: 36991371 PMCID: PMC10053486 DOI: 10.1186/s12887-023-03923-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 02/20/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The effectiveness of nitric oxide (NO) in reducing the risk of bronchopulmonary dysplasia (BPD) remains debatable. In this study, we performed a meta-analysis to guide clinical decision-making regarding the significance of inhaled NO (iNO) on the potential occurrence and outcomes of BPD in premature infants. METHODS Data from clinical randomized controlled trials (RCTs) published in PubMed, Embase, Cochrane Library, Wanfang, China National Knowledge Infrastructure (CNKI) and Chinese Scientific Journal Database VIP databases for premature infants were searched from inception to March 2022. Review Manager 5.3 statistical software was used for heterogeneity analysis. RESULTS Of the 905 studies retrieved, 11 RCTs met the screening criteria of this study. Our analysis showed that the iNO group was associated with a significantly lower incidence of BPD than the control group (relative risk [RR] = 0.91, 95% confidence interval (CI) 0.85-0.97, P = 0.006). We also observed no significant difference in the incidence of BPD between the two groups at the initial dose of 5 ppm (ppm) (P = 0.09) but those treated with 10 ppm iNO had a significantly lower incidence of BPD (RR = 0.90, 95%CI 0.81-0.99, P = 0.03). However, it should be noted that although the iNO group had an increased risk for necrotizing enterocolitis (NEC) (RR = 1.33, 95%CI 1.04-1.71, P = 0.03), cases treated with an initial dose of 10 ppm revealed no significant difference in the incidence of NEC compared with the control group (P = 0.41), while those treated with an initial dosage of 5 ppm of iNO had a significantly greater NEC rates than the control group (RR = 1.41, 95%CI 1.03-1.91, P = 0.03). Further, we observed no statistically significant differences in the incidence of in-hospital mortality, intraventricular hemorrhage (IVH) (Grade 3/4) or periventricular leukomalacia (PVL) and pulmonary hemorrhage (PH) between the two treatment groups. CONCLUSIONS This meta-analysis of RCTs showed that iNO at an initial dosage of 10 ppm seemed more effective in reducing the risk of BPD than conventional treatment and iNO at an initial dosage of 5 ppm in preterm infants at a gestational age of ≤34 weeks who required respiratory support. However, the incidence of in-hospital mortality and adverse events between the overall iNO group and Control were similar.
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Affiliation(s)
- Yi Zheng
- Department of Pediatrics, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Qi Wu
- Department of Pediatrics, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Shuping Han
- Department of Pediatrics, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China.
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10
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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: 0] [Impact Index Per Article: 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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11
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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: 0] [Impact Index Per Article: 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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12
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Harris C, Greenough A. The prevention and management strategies for neonatal chronic lung disease. Expert Rev Respir Med 2023; 17:143-154. [PMID: 36813477 DOI: 10.1080/17476348.2023.2183842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Survival from even very premature birth is improving, but long-term respiratory morbidity following neonatal chronic lung disease (bronchopulmonary dysplasia (BPD)) has not reduced. Affected infants may require supplementary oxygen at home, because they have more hospital admissions particularly due to viral infections and frequent, troublesome respiratory symptoms requiring treatment. Furthermore, adolescents and adults who had BPD have poorer lung function and exercise capacity. AREAS COVERED Antenatal and postnatal preventative strategies and management of infants with BPD. A literature review was undertaken using PubMed and Web of Science. EXPERT OPINION There are effective preventative strategies which include caffeine, postnatal corticosteroids, vitamin A, and volume guarantee ventilation. Side-effects, however, have appropriately caused clinicians to reduce use of systemically administered corticosteroids to infants only at risk of severe BPD. Promising preventative strategies which need further research are surfactant with budesonide, less invasive surfactant administration (LISA), neurally adjusted ventilatory assist (NAVA) and stem cells. The management of infants with established BPD is under-researched and should include identifying the optimum form of respiratory support on the neonatal unit and at home and which infants will most benefit in the long term from pulmonary vasodilators, diuretics, and bronchodilators.
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Affiliation(s)
- Christopher Harris
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
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13
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Heydarian M, Oak P, Zhang X, Kamgari N, Kindt A, Koschlig M, Pritzke T, Gonzalez-Rodriguez E, Förster K, Morty RE, Häfner F, Hübener C, Flemmer AW, Yildirim AO, Sudheendra D, Tian X, Petrera A, Kirsten H, Ahnert P, Morrell N, Desai TJ, Sucre J, Spiekerkoetter E, Hilgendorff A. Relationship between impaired BMP signalling and clinical risk factors at early-stage vascular injury in the preterm infant. Thorax 2022; 77:1176-1186. [PMID: 35580897 PMCID: PMC9685723 DOI: 10.1136/thoraxjnl-2021-218083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 04/11/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic lung disease, that is, bronchopulmonary dysplasia (BPD) is the most common complication in preterm infants and develops as a consequence of the misguided formation of the gas-exchange area undergoing prenatal and postnatal injury. Subsequent vascular disease and its progression into pulmonary arterial hypertension critically determines long-term outcome in the BPD infant but lacks identification of early, disease-defining changes. METHODS We link impaired bone morphogenetic protein (BMP) signalling to the earliest onset of vascular pathology in the human preterm lung and delineate the specific effects of the most prevalent prenatal and postnatal clinical risk factors for lung injury mimicking clinically relevant conditions in a multilayered animal model using wild-type and transgenic neonatal mice. RESULTS We demonstrate (1) the significant reduction in BMP receptor 2 (BMPR2) expression at the onset of vascular pathology in the lung of preterm infants, later mirrored by reduced plasma BMP protein levels in infants with developing BPD, (2) the rapid impairment (and persistent change) of BMPR2 signalling on postnatal exposure to hyperoxia and mechanical ventilation, aggravated by prenatal cigarette smoke in a preclinical mouse model and (3) a link to defective alveolar septation and matrix remodelling through platelet derived growth factor-receptor alpha deficiency. In a treatment approach, we partially reversed vascular pathology by BMPR2-targeted treatment with FK506 in vitro and in vivo. CONCLUSION We identified impaired BMP signalling as a hallmark of early vascular disease in the injured neonatal lung while outlining its promising potential as a future biomarker or therapeutic target in this growing, high-risk patient population.
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Affiliation(s)
- Motaharehsadat Heydarian
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Prajakta Oak
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Xin Zhang
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Nona Kamgari
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Alida Kindt
- Division of Analytical Biosciences, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Markus Koschlig
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Tina Pritzke
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Erika Gonzalez-Rodriguez
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Kai Förster
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
- Department of Neonatology, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians University, LMU Hospital, Munich, Germany
| | - Rory E Morty
- Department of Translational Pulmonology, University Hospital Heidelberg, Translational Lung Research Center campus of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Friederike Häfner
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Christoph Hübener
- Department of Obstetrics and Gynecology, Ludwig-Maximilians University, LMU Hospital, Munich, Germany
| | - Andreas W Flemmer
- Department of Neonatology, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians University, LMU Hospital, Munich, Germany
| | - Ali Oender Yildirim
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Deepti Sudheendra
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Xuefei Tian
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Agnese Petrera
- Research Unit Protein Science and Metabolomics and Proteomics Core, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Holger Kirsten
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), associated partner of the German Center for Lung Research (DZL), University of Leipzig, Leipzig, Germany
| | - Peter Ahnert
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), associated partner of the German Center for Lung Research (DZL), University of Leipzig, Leipzig, Germany
| | - Nick Morrell
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Tushar J Desai
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Jennifer Sucre
- Mildred Stahlman Division of Neonatology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Edda Spiekerkoetter
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Anne Hilgendorff
- Institute for Lung Biology and Disease and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU), Ludwig-Maximilians University, LMU Hospital, Munich, Germany
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Gianni S, Valsecchi C, Berra L. Therapeutic Gases and Inhaled Anesthetics as Adjunctive Therapies in Critically Ill Patients. Semin Respir Crit Care Med 2022; 43:440-452. [PMID: 35533689 DOI: 10.1055/s-0042-1747966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The administration of exogenous oxygen to support adequate gas exchange is the cornerstone of respiratory care. In the past few years, other gaseous molecules have been introduced in clinical practice to treat the wide variety of physiological derangement seen in critical care patients.Inhaled nitric oxide (NO) is used for its unique selective pulmonary vasodilator effect. Recent studies showed that NO plays a pivotal role in regulating ischemia-reperfusion injury and it has antibacterial and antiviral activity.Helium, due to its low density, is used in patients with upper airway obstruction and lower airway obstruction to facilitate gas flow and to reduce work of breathing.Carbon monoxide (CO) is a poisonous gas that acts as a signaling molecule involved in many biologic pathways. CO's anti-inflammatory and antiproliferative effects are under investigation in the setting of acute respiratory distress and idiopathic pulmonary fibrosis.Inhaled anesthetics are widely used in the operative room setting and, with the development of anesthetic reflectors, are now a valid option for sedation management in the intensive care unit.Many other gases such as xenon, argon, and hydrogen sulfide are under investigation for their neuroprotective and cardioprotective effects in post-cardiac arrest syndrome.With all these therapeutic options available, the clinician must have a clear understanding of the physiologic basis, therapeutic potential, and possible adverse events of these therapeutic gases. In this review, we will present the therapeutic gases other than oxygen used in clinical practice and we will describe other promising therapeutic gases that are in the early phases of investigation.
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Affiliation(s)
- Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Sakaria RP, Dhanireddy R. Pharmacotherapy in Bronchopulmonary Dysplasia: What Is the Evidence? Front Pediatr 2022; 10:820259. [PMID: 35356441 PMCID: PMC8959440 DOI: 10.3389/fped.2022.820259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Bronchopulmonary Dysplasia (BPD) is a multifactorial disease affecting over 35% of extremely preterm infants born each year. Despite the advances made in understanding the pathogenesis of this disease over the last five decades, BPD remains one of the major causes of morbidity and mortality in this population, and the incidence of the disease increases with decreasing gestational age. As inflammation is one of the key drivers in the pathogenesis, it has been targeted by majority of pharmacological and non-pharmacological methods to prevent BPD. Most extremely premature infants receive a myriad of medications during their stay in the neonatal intensive care unit in an effort to prevent or manage BPD, with corticosteroids, caffeine, and diuretics being the most commonly used medications. However, there is no consensus regarding their use and benefits in this population. This review summarizes the available literature regarding these medications and aims to provide neonatologists and neonatal providers with evidence-based recommendations.
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Affiliation(s)
- Rishika P. Sakaria
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, United States
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16
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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: 7] [Impact Index Per Article: 3.5] [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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17
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Meyer S. Comment on Roger F Soll, Colleen Ovelman, William McGuire. The future of Cochrane Neonatal. Early Hum Dev 2020 Nov;150:105191. doi: 10.1016/j.earlhumdev.2020.105191. Epub 2020 Sep 12. Early Hum Dev 2021; 163:105246. [PMID: 33191005 DOI: 10.1016/j.earlhumdev.2020.105246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Sascha Meyer
- University Children's Hospital of Saarland, Department of General Pediatrics and Neonatology, Building 9, 66421 Homburg, Germany
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18
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Relationship Between the Respiratory Severity Score and Extubation Failure in Very-Low-Birth-Weight Premature Infants. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:382-390. [PMID: 34712081 PMCID: PMC8526227 DOI: 10.14744/semb.2021.92693] [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: 05/04/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022]
Abstract
Objective: The objective of the study is to investigate the utility of the respiratory severity score (RSS), an easy-to-use, non-invasive respiratory failure assessment tool that does not require arterial blood sampling, for predicting extubation failure in very-low-birth-weight premature infants. Methods: Demographic characteristics, clinical course, and neonatal morbidities were retrospectively analyzed. Data were obtained from the files of infants who were admitted to our unit between February 2016 and September 2020, were born before 30 weeks’ gestation, and had a birth weight <1250 g. Extubation success was defined as no need for reintubation for 72 h after extubation. RSS and RSS/kg values before each patient’s first planned extubation were calculated. RSS values before extubation and risk factors for extubation failure were compared between infants in the successful and failed extubation groups. Results: Our study enrolled 142 infants who met the inclusion criteria. The extubation failure rate was 30.2% (43/142). Early gestation, low birth weight, male sex, high RSS, grade ≥3 intraventricular hemorrhage, late-onset sepsis, low weight at the time of extubation, and postmenstrual age at the time of extubation were identified as risk factors for extubation failure. In the logistic regression analysis including these risk factors, RSS/kg remained a significant risk factor, along with late-onset sepsis (OR 25.7 [95% CI: 5.70–115.76]; p<0.001). In the receiver operating characteristic analysis of RSS values, at a cutoff value of 2.13 (area under the curve: 82.5%), RSS/kg had 77% sensitivity and 78% specificity (p<0.001). The duration of mechanical ventilation and hospital stay were prolonged in infants with extubation failure. The incidence rates of stage ≥3 retinopathy of prematurity and stage ≥2 necrotizing enterocolitis were also higher. Conclusions: High RSS and RSS/kg values were closely associated with extubation failure and can be used as a non-invasive assessment tool to support clinical decision-making, and thus reduce the rate of extubation failure.
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19
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Yue L, Lu X, Dennery PA, Yao H. Metabolic dysregulation in bronchopulmonary dysplasia: Implications for identification of biomarkers and therapeutic approaches. Redox Biol 2021; 48:102104. [PMID: 34417157 PMCID: PMC8710987 DOI: 10.1016/j.redox.2021.102104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/03/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in premature infants. Accumulating evidence shows that dysregulated metabolism of glucose, lipids and amino acids are observed in premature infants. Animal and cell studies demonstrate that abnormal metabolism of these substrates results in apoptosis, inflammation, reduced migration, abnormal proliferation or senescence in response to hyperoxic exposure, and that rectifying metabolic dysfunction attenuates neonatal hyperoxia-induced alveolar simplification and vascular dysgenesis in the lung. BPD is often associated with several comorbidities, including pulmonary hypertension and neurodevelopmental abnormalities, which significantly increase the morbidity and mortality of this disease. Here, we discuss recent progress on dysregulated metabolism of glucose, lipids and amino acids in premature infants with BPD and in related in vivo and in vitro models. These findings suggest that metabolic dysregulation may serve as a biomarker of BPD and plays important roles in the pathogenesis of this disease. We also highlight that targeting metabolic pathways could be employed in the prevention and treatment of BPD.
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Affiliation(s)
- Li Yue
- Department of Orthopedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Xuexin Lu
- Department of Pediatrics, Ascension St. John Hospital, Detroit, MI, USA
| | - Phyllis A Dennery
- Department of Molecular Biology, Cell Biology & Biochemistry, Division of Biology and Medicine, Brown University, Providence, RI, USA; Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hongwei Yao
- Department of Molecular Biology, Cell Biology & Biochemistry, Division of Biology and Medicine, Brown University, Providence, RI, USA.
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20
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Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
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Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
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21
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
| | - Girija G Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
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22
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Hsu JF, Yang MC, Chu SM, Yang LY, Chiang MC, Lai MY, Huang HR, Pan YB, Fu RH, Tsai MH. Therapeutic effects and outcomes of rescue high-frequency oscillatory ventilation for premature infants with severe refractory respiratory failure. Sci Rep 2021; 11:8471. [PMID: 33875758 PMCID: PMC8055989 DOI: 10.1038/s41598-021-88231-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/09/2021] [Indexed: 11/23/2022] Open
Abstract
Despite wide application of high frequency oscillatory ventilation (HFOV) in neonates with respiratory distress, little has been reported about its rescue use in preterm infants. We aimed to evaluate the therapeutic effects of HFOV in preterm neonates with refractory respiratory failure and investigate the independent risk factors of in-hospital mortality. We retrospectively analyzed data collected prospectively (January 2011–December 2018) in four neonatal intensive care units of two tertiary-level medical centers in Taiwan. All premature infants (gestational age 24–34 weeks) receiving HFOV as rescue therapy for refractory respiratory failure were included. A total of 668 preterm neonates with refractory respiratory failure were enrolled. The median (IQR) gestational age and birth weight were 27.3 (25.3–31.0) weeks and 915.0 (710.0–1380.0) g, respectively. Pre-HFOV use of cardiac inotropic agents and inhaled nitric oxide were 70.5% and 23.4%, respectively. The oxygenation index (OI), FiO2, and AaDO2 were markedly increased after HFOV initiation (all p < 0.001), and can be decreased within 24–48 h (all p < 0.001) after use of HFOV. 375 (56.1%) patients had a good response to HFOV within 3 days. The final in-hospital mortality rate was 34.7%. No association was found between specific primary pulmonary disease and survival in multivariate analysis. We found preterm neonates with gestational age < 28 weeks, occurrences of sepsis, severe hypotension, multiple organ dysfunctions, initial higher severity of respiratory failure and response to HFOV within the first 72 h were independently associated with final in-hospital mortality. The mortality rate of preterm neonates with severe respiratory failure remains high after rescue HFOV treatment. Aggressive therapeutic interventions to treat sepsis and prevent organ dysfunctions are the suggested strategies to optimize outcomes.
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Affiliation(s)
- Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - 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, Taoyüan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Lan-Yan Yang
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Yu-Bin Pan
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, No.707, Gongye Rd., Sansheng, Mailiao Township, Yunlin, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyüan, Taiwan.
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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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Liu K, Wang H, Yu SJ, Tu GW, Luo Z. Inhaled pulmonary vasodilators: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:597. [PMID: 33987295 PMCID: PMC8105872 DOI: 10.21037/atm-20-4895] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023]
Abstract
Pulmonary hypertension (PH) is a severe disease that affects people of all ages. It can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and pulmonary disorders. Inhaled pulmonary vasodilators (IPV) can reduce pulmonary vascular resistance (PVR) and improve RV function with minimal systemic effects. IPV includes inhaled nitric oxide (iNO), inhaled aerosolized prostacyclin, or analogs, including epoprostenol, iloprost, treprostinil, and other vasodilators. In addition to pulmonary vasodilating effects, IPV can also be used to improve oxygenation, reduce inflammation, and protect cell. Off-label use of IPV is common in daily clinical practice. However, evidence supporting the inhalational administration of these medications is limited, inconclusive, and controversial regarding their safety and efficacy. We conducted a search for relevant papers published up to May 2020 in four databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical using and updated evidence of IPV. iNO is widely used in neonates, pediatrics, and adults with different cardiopulmonary diseases. The limitations of iNO include high cost, flat dose-response, risk of significant rebound PH after withdrawal, and the requirement of complex technology for monitoring. The literature suggests that inhaled aerosolized epoprostenol, iloprost, treprostinil and others such as milrinone and levosimendan may be similar to iNO. More research of IPV is needed to determine acceptable inclusion criteria, long-term outcomes, and management strategies including time, dose, and duration.
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Affiliation(s)
- Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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25
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Bhattacharjee I, Das A, Collin M, Aly H. Predicting outcomes of mechanically ventilated premature infants using respiratory severity score. J Matern Fetal Neonatal Med 2020; 35:4620-4627. [PMID: 33280479 DOI: 10.1080/14767058.2020.1858277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extremely low birth weight (ELBW) infants have significant morbidities and higher mortality. The major morbidities are bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). Release of proinflammatory cytokines has been implicated in the development of systemic inflammation that contributes to BPD aND ROP. Also, cumulative oxygen exposure in the first 3 days of life and use of mechanical ventilation was associated with 3-fold increase in severe IVH. Therefore, early ventilation and oxygenation may contribute significantly to morbidities in ELBW infants. Respiratory severity score (RSS), a product of Mean airway pressure (MAP) and FiO2, is a steady-state noninvasive assessment tool useful in infants to monitor the severity of respiratory failure. We used RSS, in the first 3 days of life of ELBW infants, to predict neonatal morbidities and mortality. STUDY DESIGN In a single-center retrospective cohort study in an urban setting, convenience sampling of ELBW infants meeting the study criteria who were mechanically ventilated at birth for the first 3 days of life were included. Time-weighted average RSS was plotted on receiver-operating characteristic (ROC) curve in the first 3 days of life to predict outcomes. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated. RESULTS A total of 69 infants qualified for the study. RSS in the first 3 days significantly predicted the composite outcome of death, ROP, IVH or BPD with an area under the curve (AUC) of 0.82 (p < 0.001). Individually, RSS predicted death, severe ROP and IVH with an AUC of 0.86, 0.77 and 0.71 respectively; but did not predict severe BPD (AUC 0.61). RSS was more sensitive and specific than each of its component; FiO2 and MAP. Weighted RSS in the first 3 days had high-negative predictive value of 98.1% for death between 7 days and 36 weeks, 94.6% for ROP and 91.7% for IVH. CONCLUSIONS This study is the first to show that RSS in the first 3 days of life is a good predictor of composite neonatal outcomes: severe IVH, BPD, ROP, or mortality. Early RSS had a high positive predictive value for the composite outcome of morbidities/mortality and a high specificity for mortality, ROP, and IVH individually.
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Affiliation(s)
| | - Anirudha Das
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Marc Collin
- Department of Neonatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
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26
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Shah SI, Aboudi D, La Gamma EF, Brumberg HL. Respiratory Severity Score greater than or equal to 2 at birth is associated with an increased risk of mortality in infants with birth weights less than or equal to 1250 g. Pediatr Pulmonol 2020; 55:3304-3311. [PMID: 32915498 DOI: 10.1002/ppul.25069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Respiratory Severity Score (RSS), the product of mean airway pressure and the fraction of inspired oxygen may estimate the severity of neonatal lung disease. We aimed to determine if RSS on the first day of life is associated with mortality and/or comorbidities in infants born less than or equal to 1250 g. METHODS Data were extracted from the NYS Perinatal Data System for premature inborn infants from 2006 to 2016 born between 400 and 1250 g (N = 730). RSS was divided into three categories: less than 2 (low, n = 310), 2-5 (moderate, n = 265), greater than 5 (high, n = 155). The primary outcome was mortality. Logistic regression determined associations with composite outcomes of death or respiratory morbidity (respiratory support after 36 weeks postmenstrual age), death or neurologic morbidity (periventricular leukomalacia) or high-grade intraventricular hemorrhage), and death/severe morbidity (death or neurologic morbidity or respiratory morbidity or stage ≥ III retinopathy of prematurity or necrotizing enterocolitis) by RSS category. RESULTS Birthweight and gestational age were lower with the increasing RSS category (p < .001 for both). Mode of delivery, antenatal steroids, and maternal age did not differ by RSS. In adjusted analyses, there were increased odds of mortality in infants with moderate RSS (odds ratio [95% confidence intervals]: 3.1 (1.7-5.4) and high 4.5 (2.5-8.2). These groups had higher odds of death or respiratory morbidity, death or neurologic morbidity, and death/severe morbidity. CONCLUSION Higher RSS (≥2) is associated with an increased risk of mortality and morbidities in infants born less than or equal to 1250 g.
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Affiliation(s)
- Shetal I Shah
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | - David Aboudi
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | - Edmund F La Gamma
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | - Heather L Brumberg
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
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27
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Bakas AM, Healy HM, Bell KA, Brown DW, Mullen M, Scheid A. Prenatal duct closure leading to severe pulmonary hypertension in a preterm neonate-a case report. Cardiovasc Diagn Ther 2020; 10:1691-1695. [PMID: 33224782 DOI: 10.21037/cdt-20-123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Prenatal closure of the ductus arteriosus (DA) can lead to cardiovascular dysfunction resulting in pulmonary hypertension (PH), progressive right heart failure, fetal hydrops, and fetal or neonatal demise. Supportive therapies-including mechanical ventilation, oxygen, and nitric oxide (NO)-have been employed with variable success among infants born full term, but there is no widely accepted management of prenatal closure of the DA, particularly for preterm infants. We present the case of an infant born at 31 weeks' gestation with right ventricular (RV) dysfunction and PH due to prenatal ductal closure, who was successfully treated with milrinone, resulting in full recovery of cardiac function. Prenatal ductal closure is rare, particularly under 32 weeks gestation, but should be suspected in cases of postnatal hypoxemia in the absence of significant lung disease or structural heart disease. Milrinone may be considered as a therapeutic agent to treat both PH and RV dysfunction in preterm infants status post in utero closure of the DA.
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Affiliation(s)
- Anna M Bakas
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Helen M Healy
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine A Bell
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Mullen
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annette Scheid
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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28
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Greenough A, Decobert F, Field D, Hallman M, Hummler HD, Jonsson B, Sánchez Luna M, Van Overmeire B, Carnielli VP, Potenziano JL, Mercier JC. Inhaled nitric oxide (iNO) for preventing prematurity-related bronchopulmonary dysplasia (BPD): 7-year follow-up of the European Union Nitric Oxide (EUNO) trial. J Perinat Med 2020; 49:104-110. [PMID: 32892178 DOI: 10.1515/jpm-2020-0164] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/08/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Most studies of inhaled nitric oxide (iNO) for prevention of bronchopulmonary dysplasia (BPD) in premature infants have focused on short-term mortality and morbidity. Our aim was to determine the long-term effects of iNO. METHODS A 7-year follow-up was undertaken of infants entered into a multicenter, double-blind, randomized, placebo-controlled trial of iNO for prevention of BPD in premature infants born between 24 and 28 weeks plus six days of gestation. At 7 years, survival and hospital admissions since the 2-year follow-up, home oxygen therapy in the past year, therapies used in the previous month and growth assessments were determined. Questionnaires were used to compare general health, well-being, and quality of life. RESULTS A total of 305 children were assessed. No deaths were reported. Rates of hospitalization for respiratory problems (6.6 vs. 10.5%, iNO and placebo group, respectively) and use of respiratory medications (6.6 vs. 9.2%) were similar. Two patients who received iNO and one who received placebo had received home oxygen therapy. There were no significant differences in any questionnaire-documented health outcomes. CONCLUSIONS iNO for prevention of BPD in very premature infants with respiratory distress did not result in long-term benefits or adverse long-term sequelae. In the light of current evidence, routine use of iNO cannot be recommended for prevention of BPD in preterm infants.
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Affiliation(s)
| | | | - David Field
- University of Leicester Centre for Medicine, Leicester, UK
| | - Mikko Hallman
- University of Oulu and Oulu University Hospital, Oulu, Finland
| | | | - Baldvin Jonsson
- Karolinska University Hospital and Institute, Stockholm, Sweden
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Attenuation of Hyperoxic Lung Injury in Newborn Thioredoxin-1-Overexpressing Mice through the Suppression of Proinflammatory Cytokine mRNA Expression. Biomedicines 2020; 8:biomedicines8030066. [PMID: 32244938 PMCID: PMC7148529 DOI: 10.3390/biomedicines8030066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 12/26/2022] Open
Abstract
The role of thioredoxin-1 (TRX), a small redox-active protein with antioxidant effects, during hyperoxic lung injury in newborns remains undetermined. We investigated TRX impact on hyperoxic lung injury in newborn TRX transgenic (TRX-Tg) and wildtype (WT) mice exposed to 21% or 95% O2 for four days, after which some mice were allowed to recover in room air for up to 14 days. Lung morphology was assessed by hematoxylin/eosin and elastin staining, as well as immunostaining for macrophages. The gene expression levels of proinflammatory cytokines were evaluated using quantitative real-time polymerase chain reaction. During recovery from hyperoxia, TRX-Tg mice exhibited an improved mean linear intercept length and increased number of secondary septa in lungs compared with the WT mice. Neonatal hyperoxia enhanced the mRNA expression levels of proinflammatory cytokines in the lungs of both TRX-Tg and WT mice. However, interleukin-6, monocyte chemoattractant protein-1, and chemokine (C-X-C motif) ligand 2 mRNA expression levels were reduced in the lungs of TRX-Tg mice compared with the WT mice during recovery from hyperoxia. Furthermore, TRX-Tg mice exhibited reduced macrophage infiltration in lungs during recovery. These results suggest that in newborn mice TRX ameliorates hyperoxic lung injury during recovery likely through the suppression of proinflammatory cytokines.
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30
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Meyer S. Evidence-Based Medicine in Neonatology: The Need for Multifaceted Improvements. Neonatology 2020; 117:123-124. [PMID: 31454816 DOI: 10.1159/000502490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/05/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Sascha Meyer
- Department of General Paediatrics and Neonatology, University Children´s Hospital of Saarland, Homburg, Germany,
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31
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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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Jawad S, Modi N, Prevost AT, Gale C. A systematic review identifying common data items in neonatal trials and assessing their completeness in routinely recorded United Kingdom national neonatal data. Trials 2019; 20:731. [PMID: 31842960 PMCID: PMC6915866 DOI: 10.1186/s13063-019-3849-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 10/25/2019] [Indexed: 01/04/2023] Open
Abstract
Background We aimed to test whether a common set of key data items reported across high-impact neonatal clinical trials could be identified, and to quantify their completeness in routinely recorded United Kingdom neonatal data held in the National Neonatal Research Database (NNRD). Methods We systematically reviewed neonatal clinical trials published in four high-impact medical journals over 10 years (2006–2015) and extracted baseline characteristics, stratification items and potential confounders used to adjust primary outcomes. Completeness was examined using data held in the NNRD for identified data items, for infants admitted to neonatal units in 2015. The NNRD is a repository of routinely recorded data extracted from neonatal Electronic Patient Records (EPR) of all admissions to National Health Service (NHS) Neonatal Units in England, Wales and Scotland. We defined missing data as an empty field or an implausible value. We reported common data items as frequencies and percentages alongside percentages of completeness. Results We identified 44 studies involving 32,095 infants and 126 data items. Fourteen data items were reported by more than 20% of studies. Gestational age (95%), sex (93%) and birth weight (91%) were the most common baseline data items. The completeness of data in the NNRD was high for these data with greater than 90% completeness found for 9 of the 14 most common items. Conclusion High-impact neonatal clinical trials share common data items. In the United Kingdom, these items can be obtained at a high level of completeness from routinely recorded data held in the NNRD. The feasibility and efficiency using routinely recorded EPR data, such as that held in the NNRD, for clinical trials, rather than collecting these items anew, should be examined. Trial registration PROSPERO registration number CRD42016046138. Registered prospectively on 17 August 2016.
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Affiliation(s)
- Sena Jawad
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, SW10 9NH, UK
| | - Neena Modi
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, SW10 9NH, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, W12 7RH, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, SW10 9NH, UK.
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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: 4] [Impact Index Per Article: 0.8] [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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Jung YH, Jang J, Kim HS, Shin SH, Choi CW, Kim EK, Kim BI. Respiratory severity score as a predictive factor for severe bronchopulmonary dysplasia or death in extremely preterm infants. BMC Pediatr 2019; 19:121. [PMID: 31014304 PMCID: PMC6480897 DOI: 10.1186/s12887-019-1492-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/08/2019] [Indexed: 11/27/2022] Open
Abstract
Background Despite significant advances in neonatology, bronchopulmonary dysplasia (BPD) remains the most common cause of serious morbidity and mortality in premature infants. The aim of the present study was to determine associations between the respiratory severity score (RSS) with death or BPD in premature infants. Methods This was a retrospective study conducted between January 2010 and December 2014. We enrolled preterm infants with a gestational age of less than 28 weeks who were supported by mechanical ventilation for more than a week during the first 4 weeks of life. We collected the RSS scores on day of life 2, 7, 14, 21 and 28. The correlations between postnatal RSSs and death or severe BPD were analyzed using multivariate logistic regression. Results Of the 138 eligible infants, 66 infants (47.8%) either died or developed severe BPD. The RSS cut-off values for predicting severe BPD or death were 3.0 for postnatal day (PND) 14 with an odds ratio (OR) of 11.265 (p = 0.0006, 95% confidence interval (CI), 2.842 to 44.646), 3.6 for PND 21 with an OR of 15.162 (p = 0.0003, 95% CI, 3.467 to 66.316), and 3.24 for PND 28 with an OR of 10.713 (p = 0.0005, 95% CI, 2.825 to 40.630). Conclusion Strong correlations were observed between the RSSs on PND 14, 21, and 28 and death or subsequent severe BPD. The RSS could provide a simple estimate of severe BPD or death., Further research with a larger study population is necessary to validate the usefulness of the RSS for predicting severe BPD or death. Electronic supplementary material The online version of this article (10.1186/s12887-019-1492-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Young Hwa Jung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
| | - Jinhee Jang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea.
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
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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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Lewis T, Truog W, Norberg M, Ballard PL, Torgerson D. Genetic variation in CRHR1 is associated with short-term respiratory response to corticosteroids in preterm infants at risk for bronchopulmonary dysplasia. Pediatr Res 2019; 85:625-633. [PMID: 30467342 PMCID: PMC6532775 DOI: 10.1038/s41390-018-0235-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 12/02/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is an orphan disease and advances in prevention and treatment are lacking. The clinical efficacy of systemic corticosteroid therapy to reduce the severity of lung disease and BPD is highly variable. Our objective was to assess whether candidate SNPs in corticosteroid metabolism and response genes are associated with short-term phenotypic response to systemic corticosteroids in infants at high risk for BPD. METHODS Pharmacogenetic analysis of data from a large randomized controlled trial (TOLSURF) in infants treated with dexamethasone or hydrocortisone using multivariate linear regression. The primary outcome was a change in respiratory severity score (RSS, mean airway pressure x FiO2) at day 7 of corticosteroid treatment. RESULTS rs7225082 in the intron of CRHR1 is significantly associated with the magnitude of decrease in RSS 7 days after starting treatment with systemic corticosteroid (meta-analysis P = 2.8 × 10-4). Each T allele at rs7225082 is associated with a smaller absolute change in RSS at day 7, i.e., less response to systemic corticosteroids. CONCLUSIONS Genetic variability is associated with corticosteroid responsiveness with regard to respiratory status in preterm infants. Identification of genetic markers of corticosteroid responsiveness may allow for therapeutic individualization, with the goal of optimizing the risk-to-benefit ratio for an individual child.
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Affiliation(s)
- Tamorah Lewis
- Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA.
| | - William Truog
- Children’s Mercy Hospital, Department of Pediatrics,
University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Mike Norberg
- Children’s Mercy Hospital, Department of Pediatrics,
University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Philip L. Ballard
- Department of Pediatrics, University of California San
Francisco, San Francisco, CA
| | - Dara Torgerson
- Department of Pediatrics, University of California San
Francisco, San Francisco, CA
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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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Pasha AB, Chen XQ, Zhou GP. Bronchopulmonary dysplasia: Pathogenesis and treatment. Exp Ther Med 2018; 16:4315-4321. [PMID: 30542380 PMCID: PMC6257511 DOI: 10.3892/etm.2018.6780] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/06/2018] [Indexed: 11/06/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease of infancy, which mostly affects premature infants with significant morbidity and mortality. Premature infants who require to be treated for conditions including respiratory distress syndrome have a higher risk of developing BPD. In spite of the improvement in clinical methods, the incidence of BPD has not reduced. In the present review, the pathogenesis of BPD is described along with the treatments available at present and the role of nursing in the management of BPD. Emerging preventive therapies for BPD are also discussed, including the use of recombinant human superoxide dismutase, which has been proven effective in reducing respiratory injury and its long-term effects.
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Affiliation(s)
- Asfia Banu Pasha
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Xiao-Qing Chen
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Guo-Ping Zhou
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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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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Ellsworth KR, Ellsworth MA, Weaver AL, Mara KC, Clark RH, Carey WA. Association of Early Inhaled Nitric Oxide With the Survival of Preterm Neonates With Pulmonary Hypoplasia. JAMA Pediatr 2018; 172:e180761. [PMID: 29800952 PMCID: PMC6137510 DOI: 10.1001/jamapediatrics.2018.0761] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Pulmonary hypoplasia affects a very small percentage of preterm neonates, but its presence is associated with high rates of mortality. OBJECTIVE To determine whether treatment with inhaled nitric oxide during the first week of life was associated with improved in-hospital survival in a cohort of extremely preterm neonates with pulmonary hypoplasia. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Pediatrix Medical Group's Clinical Data Warehouse, a data set containing information from more than 350 neonatal intensive care units in 35 US states and Puerto Rico. Since inhaled nitric oxide was not randomly prescribed, we used 1-to-1 propensity score matching to reduce the imbalance of measured covariates between the 2 treatment groups. The initial, unmatched cohort included singleton neonates who were born between 22 and 29 weeks' gestation, had a birth weight of 400 g or more, were diagnosed with pulmonary hypoplasia as a cause of their respiratory distress, remained free of major anomalies, and were discharged between January 1, 2000, and December 31, 2014. We defined exposure as the initiation of inhaled nitric oxide on day t in days 0 to 7 of the life of a neonate. Each exposed neonate was matched 1-to-1 to a neonate who had not initiated inhaled nitric oxide on a given day. MAIN OUTCOMES AND MEASURES The primary outcome was mortality defined as death prior to transfer or discharge home. Secondary outcomes were any-stage necrotizing enterocolitis, retinopathy of prematurity requiring treatment, chronic lung disease, and periventricular leukomalacia. RESULTS Among 92 635 neonates in our study sample, we identified 767 (0.8%) with pulmonary hypoplasia who met all study inclusion criteria, of whom 185 (0.2%) were exposed to inhaled nitric oxide. Among 151 matched pairs of exposed and unexposed neonates, we did not identify a significant association between inhaled nitric oxide use and mortality (hazard ratio [HR], 0.79; 95% CI, 0.57-1.11). Subgroup analyses of neonates with and without persistent pulmonary hypertension (PPHN) likewise revealed no significant association between inhaled nitric oxide use and mortality (pulmonary hypoplasia with PPHN: HR, 0.67; 95% CI, 0.45-1.01; pulmonary hypoplasia without PPHN: HR, 1.11; 95% CI, 0.61-2.02), but these findings may have been influenced by ascertainment bias. CONCLUSIONS AND RELEVANCE Early treatment with inhaled nitric oxide is not associated with improved survival among extremely preterm neonates with pulmonary hypoplasia. Clinical trials are warranted to clarify the matter.
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Affiliation(s)
| | | | - Amy L. Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Reese H. Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - William A. Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
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Mirza H, Garcia JA, Crawford E, Pepe J, Zussman M, Wadhawan R, Oh W. Natural History of Postnatal Cardiopulmonary Adaptation in Infants Born Extremely Preterm and Risk for Death or Bronchopulmonary Dysplasia. J Pediatr 2018; 198:187-193.e1. [PMID: 29625730 DOI: 10.1016/j.jpeds.2018.02.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 01/04/2018] [Accepted: 02/13/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To study the natural history of postnatal cardiopulmonary adaptation in infants born extremely preterm and establish its association with death or bronchopulmonary dysplasia (BPD). STUDY DESIGN This was a prospective, observational, cohort study of infants born extremely preterm (<29 weeks). Initial echocardiogram was performed at <48 hours of life, followed by serial echocardiograms every 24-48 hours until 14 days of life. Resolution or no resolution of pulmonary hypertension (PH) at 72-96 hours was considered normal or delayed postnatal cardiopulmonary adaptation, respectively. PH between 96 hours and 14 days was defined as subsequent PH. Elevated pulmonary artery pressure throughout the 14 days of life was considered persistent PH. BPD was assessed at 36 weeks of postmenstrual age. RESULTS Sixty infants were enrolled; 2 died before a sequential echocardiogram could be done at 72-96 hours. Normal and delayed cardiopulmonary adaptation were noted in 26 (45%) and 32 (55%) infants, respectively. Five patterns of postnatal cardiopulmonary adaptation were recognized: normal without subsequent PH (n = 20), normal with subsequent PH (n = 6), delayed adaptation without subsequent PH (n = 6), delayed adaptation with subsequent PH (n = 16), and persistent PH (n = 10). Infants with delayed cardiopulmonary adaptation were of lower gestation and birth weight and required prolonged ventilation and supplemental oxygen (P < .05). On multivariate analysis, the incidence of death or BPD was significantly greater among infants with delayed adaptation (P < .001). CONCLUSION Infants born extremely preterm have normal or delayed postnatal cardiopulmonary adaptation that can be complicated by subsequent or persistent PH. Delayed cardiopulmonary adaptation is associated independently with death or BPD.
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Affiliation(s)
- Hussnain Mirza
- Center for Neonatal Care, Florida Hospital for Children/University of Central Florida College of Medicine, Orlando, FL.
| | - Jorge A Garcia
- Division of Pediatric Cardiology, Florida Hospital for Children, Orlando, FL
| | - Elizabeth Crawford
- Division of Pediatric Echocardiography, Florida Hospital Cardiovascular Institute, Orlando, FL
| | - Julie Pepe
- Office of Research Advancement and Support, Florida Hospital, Orlando, FL
| | - Matthew Zussman
- Division of Pediatric Cardiology, Florida Hospital for Children, Orlando, FL
| | - Rajan Wadhawan
- Center for Neonatal Care, Florida Hospital for Children/University of Central Florida College of Medicine, Orlando, FL
| | - William Oh
- Center for Pediatric Research, Florida Hospital for Children, Orlando, FL
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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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"Good things come in small packages": application of exosome-based therapeutics in neonatal lung injury. Pediatr Res 2018; 83:298-307. [PMID: 28985201 PMCID: PMC5876073 DOI: 10.1038/pr.2017.256] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/29/2017] [Indexed: 02/07/2023]
Abstract
Infants born at very low gestational age contribute disproportionately to neonatal morbidity and mortality. Advancements in antenatal steroid therapies and surfactant replacement have favored the survival of infants with ever-more immature lungs. Despite such advances in medical care, cardiopulmonary and neurological impairment prevail in constituting the major adverse outcomes for neonatal intensive care unit survivors. With no single effective therapy for either the prevention or treatment of such neonatal disorders, the need for new tools to treat and reduce risk of further complications associated with extreme preterm birth is urgent. Mesenchymal stem/stromal cell (MSC)-based approaches have shown promise in numerous experimental models of lung injury relevant to neonatology. Recent studies have highlighted that the therapeutic potential of MSCs is harnessed in their secretome, and that the therapeutic vector therein is represented by the exosomes released by MSCs. In this review, we summarize the development and significance of stem cell-based therapies for neonatal diseases, focusing on preclinical models of neonatal lung injury. We emphasize the development of MSC exosome-based therapeutics and comment on the challenges in bringing these promising interventions to clinic.
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Poryo M, Boeckh JC, Gortner L, Zemlin M, Duppré P, Ebrahimi-Fakhari D, Wagenpfeil S, Heckmann M, Mildenberger E, Hilgendorff A, Flemmer AW, Frey G, Meyer S. Ante-, peri- and postnatal factors associated with intraventricular hemorrhage in very premature infants. Early Hum Dev 2018; 116:1-8. [PMID: 29091782 DOI: 10.1016/j.earlhumdev.2017.08.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/21/2017] [Accepted: 08/25/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is one of the most serious complications in preterm infants and is associated with neurological sequelae and mortality. Over the past few decades, the rate of IVH has decreased due to improved neonatal intensive care. However, up to 15-25% of very and extremely premature infants (<32 and <28weeks of pregnancy (WOP) respectively) still suffer from IVH. STUDY PURPOSE The aim of this study was to perform an updated, multicenter analysis to identify ante-, peri, and postnatal factors other than gestational age/birth weight associated with IVH of any grade in a large cohort of very and extremely premature infants. METHODS We performed a retrospective analysis in a prospectively conducted multicenter cohort study between 01/01/1998-31/12/2012 at 5 level 3 perinatal centers. All relevant ante-, peri- and neonatal data were collected and univariate as well as multivariate logistic regression analysis was performed. RESULTS 765 inborn infants with a gestational age<32 WOP were enrolled into this study (369 (48.2%) female; 396 (51.8%) male). Birth weight ranged from 315g to 2200g (mean 1149.7g, SD 371.9g); 279 (36.5%) were born ≤27+6 WOP and 486 (63.5%)≥28+0 WOP. IVH was seen in 177 (23.1%) patients. Multivariate analysis revealed that in addition to higher gestational age (OR 0.7, CI [0.6-0.8]), antenatal steroid treatment (OR 0.3, CI [0.2-0.6]) and caesarian section without uterine contraction (OR 0.6, CI [0.4-0.9]) were associated with a lower rate of IVH while RDS (OR 5.6, CI [1.3-24.2]), pneumothorax (OR 2.8, CI [1.4-5.5]) and use of catecholamines (OR 2.7, CI [1.7-4.5]) were associated with an increased risk of IVH. After exclusion of gestational age and birth weight from multivariate analysis, early onset sepsis (OR 1.6, CI [1.01-2.7]) and patent ductus arteriosus (OR 1.9, CI [1.1-3.1]) were associated with a higher rate of IVH. In addition, univariate analysis revealed that Apgar scores at 5min (p<0.001), BDP/ROP/NEC (p<0.001), mechanical ventilation (p<0.001) and inhalative nitric oxide (p<0.001) were significantly associated with IVH. CONCLUSIONS Our comprehensive analysis demonstrated that the occurrence of IVH in very premature infants is significantly associated with ante-, peri- and postnatal factors being either related to the degree of immaturity or indicating a critical clinical course after birth. The analysis reiterates the necessity for a very close cooperation between obstetricians and neonatologists to reduce the incidence of IVH in this susceptible cohort.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Judith Caroline Boeckh
- Department of Internal Medicine, Katharinenhospital Klinikum Stuttgart, Stuttgart, Germany
| | - Ludwig Gortner
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Michael Zemlin
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Perrine Duppré
- University of Saarland, Medical School, Homburg/Saar, Germany
| | | | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Campus Homburg/Saar, Germany
| | - Matthias Heckmann
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, Germany
| | - Eva Mildenberger
- Department of Neonatology, University Medical Center, Johannes Gutenberg University Mainz, Germany
| | - Anne Hilgendorff
- Department of Neonatology, University Medical Center, Ludwig-Maximilian-University Munich, Germany
| | - Andreas W Flemmer
- Department of Neonatology, University Medical Center, Ludwig-Maximilian-University Munich, Germany
| | - Georg Frey
- Department of Pediatric Cardiology and Neonatology, Darmstaedter Kinderkliniken Prinzessin Margaret, Darmstadt, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany; Department of Pediatric Neurology, Saarland University Medical Center, Homburg/Saar, Germany
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Hasan SU, Potenziano J, Konduri GG, Perez JA, Van Meurs KP, Walker MW, Yoder BA. Effect of Inhaled Nitric Oxide on Survival Without Bronchopulmonary Dysplasia in Preterm Infants: A Randomized Clinical Trial. JAMA Pediatr 2017; 171:1081-1089. [PMID: 28973344 PMCID: PMC5710365 DOI: 10.1001/jamapediatrics.2017.2618] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) occurs in approximately 40% of infants born at younger than 30 weeks' gestation and is associated with adverse pulmonary and neurodevelopmental outcomes. OBJECTIVE To test whether administration of inhaled nitric oxide to preterm infants requiring positive pressure respiratory support on postnatal days 5 to 14 improves the rate of survival without BPD. DESIGN, SETTING, AND PARTICIPANTS This intent-to-treat study was a randomized clinical trial performed at 33 US and Canadian neonatal intensive care units. Participants included 451 neonates younger than 30 weeks' gestation with birth weight less than 1250 g receiving mechanical ventilation or positive pressure respiratory support on postnatal days 5 to 14. Enrollment spanned from December 23, 2009, to April 23, 2012, and neurodevelopmental outcome studies were completed by April 4, 2014. INTERVENTIONS Placebo (nitrogen) or inhaled nitric oxide initiated at 20 ppm was decreased to 10 ppm between 72 and 96 hours after starting treatment and then to 5 ppm on day 10 or 11. Infants remained on the 5-ppm dose until completion of therapy (24 days). MAIN OUTCOMES AND MEASURES The primary outcome was the rate of survival without BPD at 36 weeks' postmenstrual age (PMA). Secondary outcomes included BPD severity, postnatal corticosteroid use, respiratory support, survival, and neurodevelopmental outcomes at 18 to 24 months' PMA. RESULTS In total, 222 infants (52.3% male [n = 116]) received placebo, and 229 infants (50.2% male [n = 115]) received inhaled nitric oxide. Their mean (SD) gestation was 25.6 (1.5) vs 25.6 (1.4) weeks, and their mean (SD) birth weight was 750 (164) vs 724 (160) g. Survival without BPD at 36 weeks' PMA was similar between the placebo and inhaled nitric oxide groups (31.5% [n = 70] vs 34.9% [n = 80]) (odds ratio, 1.17; 95% CI, 0.79-1.73). Rates for severe BPD (26.6% [55 of 207] vs 20.5% [43 of 210]) and postnatal corticosteroid use for BPD (41.0% [91 of 222] vs 41.5% [95 of 229]) and the mean (SD) days of positive pressure respiratory support (55 [40] vs 54 [42]), oxygen therapy (88 [41] vs 91 [59]), and hospitalization (105 [37] vs 108 [54]) were equivalent between the 2 groups. No differences in the incidence of common morbidities were observed. Respiratory outcomes on discharge to home, at 1 year, and at age 18 to 24 months' PMA and neurodevelopmental assessments at 18 to 24 months' PMA did not differ between groups. CONCLUSIONS AND RELEVANCE Inhaled nitric oxide, initiated at 20 ppm on postnatal days 5 to 14 to high-risk preterm infants and continued for 24 days, appears to be safe but did not improve survival without BPD at 36 weeks' PMA or respiratory and neurodevelopmental outcomes at 18 to 24 months' PMA. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00931632.
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Affiliation(s)
- Shabih U. Hasan
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
| | | | | | - Jose A. Perez
- Department of Neonatology, Winnie Palmer Hospital, Pediatrix Medical Group, Orlando, Florida
| | - Krisa P. Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California,Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - M. Whit Walker
- Division of Neonatology, Department of Pediatrics, University of South Carolina School of Medicine, Greenville
| | - Bradley A. Yoder
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
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Diagnostic Approach to Pulmonary Hypertension in Premature Neonates. CHILDREN-BASEL 2017; 4:children4090075. [PMID: 28837121 PMCID: PMC5615265 DOI: 10.3390/children4090075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/01/2017] [Accepted: 08/09/2017] [Indexed: 02/01/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease in premature infants following respiratory distress at birth. With increasing survival of extremely low birth weight infants, alveolar simplification is the defining lung characteristic of infants with BPD, and along with pulmonary hypertension, increasingly contributes to both respiratory morbidity and mortality in these infants. Growth restricted infants, infants born to mothers with oligohydramnios or following prolonged preterm rupture of membranes are at particular risk for early onset pulmonary hypertension. Altered vascular and alveolar growth particularly in canalicular and early saccular stages of lung development following mechanical ventilation and oxygen therapy, results in developmental lung arrest leading to BPD with pulmonary hypertension (PH). Early recognition of PH in infants with risk factors is important for optimal management of these infants. Screening tools for early diagnosis of PH are evolving; however, echocardiography is the mainstay for non-invasive diagnosis of PH in infants. Cardiac computed tomography (CT) and magnetic resonance are being used as imaging modalities, however their role in improving outcomes in these patients is uncertain. Follow-up of infants at risk for PH will help not only in early diagnosis, but also in appropriate management of these infants. Aggressive management of lung disease, avoidance of hypoxemic episodes, and optimal nutrition determine the progression of PH, as epigenetic factors may have significant effects, particularly in growth-restricted infants. Infants with diagnosis of PH are managed with pulmonary vasodilators and those resistant to therapy need to be worked up for the presence of cardio-vascular anomalies. The management of infants and toddlers with PH, especially following premature birth is an emerging field. Nonetheless, combination therapies in a multi-disciplinary setting improves outcomes for these infants.
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Nobile S, Marchionni P, Carnielli VP. Neonatal outcome of small for gestational age preterm infants. Eur J Pediatr 2017; 176:1083-1088. [PMID: 28660312 DOI: 10.1007/s00431-017-2957-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 11/30/2022]
Abstract
UNLABELLED Small for gestational age (SGA) preterm neonates (birth weight < -2 SDS) are considered to have increased risk of bronchopulmonary dysplasia (BPD) compared to appropriate for GA (AGA) neonates. It is unclear if SGA infants have increased risk for respiratory distress syndrome (RDS) and mortality. We analyzed data from 515 neonates born <30 weeks GA, 98(19%) were SGA. SGA were compared to AGA by univariate analysis and logistic regression analysis (LRA). Significant variables at univariate analysis were IUGR (67 vs 7%, p = 0.000), chorioamnionitis (1 vs 13%, p = 0.017), pre-eclampsia (62 vs 18%, p = 0.000), surfactant retreatment (47 vs 25%, p = 0.000), BPD (32 vs 20%, p = 0.015), death (30 vs 12%, p = 0.000), SatO2/FiO2 on day 3 (376 vs 433, p = 0.013), and SatO2/FiO2 ratio on day 28 (400 vs 448, p = 0.000). LRA found the following associations: regarding mortality, a decreased Sat/FiO2 ratio on day 3 (OR 1.99, 95% CI 1.26-3.16, p = 0.003); regarding BPD, surfactant retreatment (3.70, 2.11-6.49, p = 0.000), being SGA (2.69, 1.36-5.36, p = 0.005), decreasing GA (1.05, 1.03-1.08, p = 0.000), decreasing SatO2/FiO2 ratio on day 3 (1.25, 1.11-1.40, p = 0.000); and regarding severe RDS, pre-eclampsia (2.68, 1.58-4.55, p = 0.000) and decreasing GA (1.06, 1.04-1.08, p = 0.000). CONCLUSIONS In our cohort of preterm infants, being SGA was significantly associated with BPD, but not with increased risk of mortality or RDS due to multiple pathophysiologic mechanisms. What is Known: • Small for gestational age preterm neonates are considered to have increased risk of bronchopulmonary dysplasia (BPD) compared to appropriate for GA neonates. • It is still unclear if SGA infants have increased risk for respiratory distress syndrome (RDS) and mortality. What is New: • In our cohort of 515 preterm infants (19% SGA), being SGA was significantly associated with BPD, but not with increased risk of mortality or RDS. • These results may be explained by the heterogeneity of mechanisms leading to SGA condition and by multiple mechanisms involving lung growth impairment and other factors.
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Affiliation(s)
- Stefano Nobile
- Department of Maternal and Child Health, Salesi Children's Hospital, Ancona, Italy.
| | - Paolo Marchionni
- Department of Maternal and Child Health, Salesi Children's Hospital, Ancona, Italy.,Department of Industrial Engineering and Mathematical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Virgilio P Carnielli
- Department of Maternal and Child Health, Salesi Children's Hospital, Ancona, Italy
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Avant D, Baer G, Moore J, Zheng P, Sorbello A, Ariagno R, Yao L, Burckart GJ, Wang J. Neonatal Safety Information Reported to the FDA During Drug Development Studies. Ther Innov Regul Sci 2017; 2017:1-9. [PMID: 28804696 DOI: 10.1177/2168479017716713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Relatively few neonatal drug development studies have been conducted, but an increase is expected with the enactment of the Food and Drug Administration Safety and Innovation Act (FDASIA). Understanding the safety of drugs studied in neonates is complicated by the unique nature of the population and the level of illness. The objective of this study was to examine neonatal safety data submitted to the FDA in studies pursuant to the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA) between 1998 and 2015. METHODS FDA databases were searched for BPCA and/or PREA studies that enrolled neonates. Studies that enrolled a minimum of 3 neonates were analyzed for the presence and content of neonatal safety data. RESULTS The analysis identified 40 drugs that were studied in 3 or more neonates. Of the 40 drugs, 36 drugs received a pediatric labeling change as a result of studies between 1998 and 2015, that included information from studies including neonates. Fourteen drugs were approved for use in neonates. Clinical trials for 20 of the drugs reported serious adverse events (SAEs) in neonates. The SAEs primarily involved cardiovascular events such as bradycardia and/or hypotension or laboratory abnormalities such as anemia, neutropenia, and electrolyte disturbances. Deaths were reported during studies of 9 drugs. CONCLUSIONS Our analysis revealed that SAEs were reported in studies involving 20 of the 40 drugs evaluated in neonates, with deaths identified in 9 of those studies. Patients enrolled in studies were often critically ill, which complicated determination of whether an adverse event was drug-related. We conclude that the traditional means for collecting safety information in drug development trials needs to be adjusted for neonates and will require the collaboration of regulators, industry, and the clinical and research communities to establish appropriate definitions and reporting strategies for the neonatal population.
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Affiliation(s)
- Debbie Avant
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gerri Baer
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jason Moore
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA.,Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Panli Zheng
- University of North Carolina School of Pharmacy, Chapel Hill, NC, USA
| | - Alfred Sorbello
- Office of Translational Sciences, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ron Ariagno
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - Lynne Yao
- Division of Pediatric and Maternal Health, Office of New Drugs, CDER, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA
| | - Jian Wang
- Office of Drug Evaluation IV, CDER, US Food and Drug Administration, Silver Spring, MD, USA
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Desselas E, Pansieri C, Leroux S, Bonati M, Jacqz-Aigrain E. Drug versus placebo randomized controlled trials in neonates: A review of ClinicalTrials.gov registry. PLoS One 2017; 12:e0171760. [PMID: 28192509 PMCID: PMC5305102 DOI: 10.1371/journal.pone.0171760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/25/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite specific initiatives and identified needs, most neonatal drugs are still used off-label, with variable dosage administrations and schedules. In high risk preterm and term neonates, drug evaluation is challenging and randomized controlled trials (RCT) are difficult to conduct and even more is the use of a placebo, required in the absence of a reference validated drug to be used as comparator. METHODS We analyzed the complete ClinicalTrials.gov registry 1) to describe neonatal RCT involving a placebo, 2) to report on the medical context and ethical aspects of placebo use. RESULTS Placebo versus drug RCT (n = 146), either prevention trials (n = 57, 39%) or therapeutic interventions (n = 89, 61%), represent more than a third of neonatal trials registered in the National Institute of Health clinical trial database (USA) since 1999. They mainly concerned preterm infants, evaluating complications of prematurity. Most trials were conducted in the USA, were single centered, and funded by non-profit organizations. For the three top drug trials evaluating steroids (n = 13, 9.6%), erythropoietin (EPO, n = 10, 6.8%) and nitric oxide (NO, n = 9, 6.2%), the objectives of the trial and follow-up were analyzed in more details. CONCLUSION Although a matter of debate, the use of placebo should be promoted in neonates to evaluate a potential new treatment, in the absence of reference drug. Analysis of the trials evaluating steroids showed that long-term follow-up of exposed patients, although required by international guidelines, is frequently missing and should be planned to collect additional information and optimize drug evaluation in these high-risk patients.
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Affiliation(s)
- Emilie Desselas
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Claudia Pansieri
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Stephanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Maurizio Bonati
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
- Université Paris 7 Diderot, Paris, France
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Ling R, Greenough A. Advances in emerging treatment options to prevent bronchopulmonary dysplasia. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1281736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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