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Qiu J, Di Fiore JM, Krishnamurthi N, Indic P, Carroll JL, Claure N, Kemp JS, Dennery PA, Ambalavanan N, Weese-Mayer DE, Maria Hibbs A, Martin RJ, Bancalari E, Hamvas A, Randall Moorman J, Lake DE. Highly comparative time series analysis of oxygen saturation and heart rate to predict respiratory outcomes in extremely preterm infants. Physiol Meas 2024; 45:055025. [PMID: 38772400 DOI: 10.1088/1361-6579/ad4e91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/21/2024] [Indexed: 05/23/2024]
Abstract
Objective.Highly comparative time series analysis (HCTSA) is a novel approach involving massive feature extraction using publicly available code from many disciplines. The Prematurity-Related Ventilatory Control (Pre-Vent) observational multicenter prospective study collected bedside monitor data from>700extremely preterm infants to identify physiologic features that predict respiratory outcomes.Approach. We calculated a subset of 33 HCTSA features on>7 M 10 min windows of oxygen saturation (SPO2) and heart rate (HR) from the Pre-Vent cohort to quantify predictive performance. This subset included representatives previously identified using unsupervised clustering on>3500HCTSA algorithms. We hypothesized that the best HCTSA algorithms would compare favorably to optimal PreVent physiologic predictor IH90_DPE (duration per event of intermittent hypoxemia events below 90%).Main Results.The top HCTSA features were from a cluster of algorithms associated with the autocorrelation of SPO2 time series and identified low frequency patterns of desaturation as high risk. These features had comparable performance to and were highly correlated with IH90_DPE but perhaps measure the physiologic status of an infant in a more robust way that warrants further investigation. The top HR HCTSA features were symbolic transformation measures that had previously been identified as strong predictors of neonatal mortality. HR metrics were only important predictors at early days of life which was likely due to the larger proportion of infants whose outcome was death by any cause. A simple HCTSA model using 3 top features outperformed IH90_DPE at day of life 7 (.778 versus .729) but was essentially equivalent at day of life 28 (.849 versus .850).Significance. These results validated the utility of a representative HCTSA approach but also provides additional evidence supporting IH90_DPE as an optimal predictor of respiratory outcomes.
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Affiliation(s)
- Jiaxing Qiu
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America
| | - Narayanan Krishnamurthi
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX, United States of America
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, United States of America
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Department of Pediatrics, Providence, RI, United States of America
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Aaron Hamvas
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Department of Pediatrics, Chicago, IL, United States of America
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Borenstein-Levin L, Haj A, Riskin A, Dinur G, Littner Y, Hochwald O, Kugelman A. Oxygenation Instability during Bolus versus Continuous Feeding among Very Low Birth Weight Premature Infants, Supported by Noninvasive Ventilation: A Randomized Prospective Study. Am J Perinatol 2024; 41:e2341-e2347. [PMID: 37494585 DOI: 10.1055/s-0043-1771257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE This study aimed to compare oxygenation instability, as documented by the oxygen saturation (SpO2) histograms, during bolus (over 30 minutes) versus continuous (over 2 hours) feeding among very low birth weight (VLBW) premature infants, supported with noninvasive ventilation (NIV). STUDY DESIGN This was a randomized prospective study. VLBW infants supported with NIV received three consecutive feeds in a random order of bolus-continuous-bolus or continuous-bolus-continuous. During each feed, 30 minutes and 2 hours histograms were documented. RESULTS Twenty-four infants (birth weight [mean ± standard deviation, SD] 820 ± 168 g, gestational age [mean ± SD] 27.0 ± 1.6 weeks) were included in our study (12 infants started with bolus feeding and 12 with continuous feeding) and 72 histograms were obtained (36 during bolus feeding and 36 during continuous feeding). No differences in mean fraction of inspired oxygen (FiO2), and number of apnea events were observed between the two feeding modes. Oxygenation instability as assessed by time spent in different SpO2 ranges and histogram types (stable or unstable) was comparable during bolus and continuous feedings. Changing feeding mode from bolus to continuous or vice versa did not significantly change the oxygenation instability of the group, though individual infants did show a consistence response to feeding length changes. CONCLUSION Among VLBW infants supported with NIV, oxygenation instability, as documented by SpO2 histograms, was comparable between bolus and continuous feedings. Individual infants may benefit from specific feeding length, and this can be easily demonstrated by the SpO2 histograms. KEY POINTS · Feeding length did not affect oxygenation instability of preterm infants on noninvasive respiratory Support.. · Oxygen saturation histograms allow objective quantification of oxygenation instability at the bedside.. · Individual infants benefit from specific feeding length, as demonstrated by SpO2 histograms..
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Affiliation(s)
- Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ahmad Haj
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yoav Littner
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Liu X, Mohtasebi M, Safavi P, Fathi F, Haratbar SR, Chen L, Chen J, Bada HS, Chen L, Abu Jawdeh EG, Yu G. Wearable fiber-free optical sensor for continuous monitoring of neonatal cerebral blood flow and oxygenation. Pediatr Res 2024:10.1038/s41390-024-03137-z. [PMID: 38503982 DOI: 10.1038/s41390-024-03137-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Unstable cerebral hemodynamics places preterm infants at high risk of brain injury. We adapted an innovative, fiber-free, wearable diffuse speckle contrast flow-oximetry (DSCFO) device for continuous monitoring of both cerebral blood flow (CBF) and oxygenation in neonatal piglets and preterm infants. METHODS DSCFO uses two small laser diodes as focused-point and a tiny CMOS camera as a high-density two-dimensional detector to detect spontaneous spatial fluctuation of diffuse laser speckles for CBF measurement, and light intensity attenuations for cerebral oxygenation measurement. The DSCFO was first validated against the established diffuse correlation spectroscopy (DCS) in neonatal piglets and then utilized for continuous CBF and oxygenation monitoring in preterm infants during intermittent hypoxemia (IH) events. RESULTS Significant correlations between the DSCFO and DCS measurements of CBF variations in neonatal piglets were observed. IH events induced fluctuations in CBF, cerebral oxygenation, and peripheral cardiorespiratory vitals in preterm infants. However, no consistent correlation patterns were observed among peripheral and cerebral monitoring parameters. CONCLUSIONS This pilot study demonstrated the feasibility of DSCFO technology to serve as a low-cost wearable sensor for continuous monitoring of multiple cerebral hemodynamic parameters. The results suggested the importance of multi-parameter measurements for understanding deep insights of peripheral and cerebral regulations. IMPACT The innovative DSCFO technology may serve as a low-cost wearable sensor for continuous bedside monitoring of multiple cerebral hemodynamic parameters in neonatal intensive care units. Concurrent DSCFO and DCS measurements of CBF variations in neonatal piglet models generated consistent results. No consistent correlation patterns were observed among peripheral and cerebral monitoring parameters in preterm neonates, suggesting the importance of multi-parameter measurements for understanding deep insights of peripheral and cerebral regulations during IH events. Integrating and correlating multiple cerebral functional parameters with clinical outcomes may identify biomarkers for prediction and management of IH associated brain injury.
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Affiliation(s)
- Xuhui Liu
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Mehrana Mohtasebi
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Pegah Safavi
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Faraneh Fathi
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | | | - Li Chen
- Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Jin Chen
- Department of Internal Medicine and Department of Computer Science, Institute for Biomedical Informatics, University of Kentucky, Lexington, KY, USA
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Lei Chen
- Department of Physiology and the Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, USA
| | - Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA.
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Hibbs AM, Chen Z, Minich NM, Martin RJ, Raffay TM, MacFarlane PM, Di Fiore JM. Association between Intermittent Hypoxemia and NICU Length of Stay in Preterm Infants. Neonatology 2024; 121:327-335. [PMID: 38437802 PMCID: PMC11147692 DOI: 10.1159/000535264] [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: 10/09/2023] [Accepted: 11/14/2023] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Length of hospitalization varies widely in preterm infants and can be affected by multiple maternal and neonatal factors including respiratory instability. Therefore, we aimed to determine the association between postnatal intermittent hypoxemia (IH) and prolonged hospitalization. METHODS This prospective single-center cohort study followed infants born at <31 weeks of gestational age through 2 years corrected age with detailed oxygen saturation data captured from days 7 to 30 of age. RESULTS 51/164 (31%) of infants were discharged after 400/7 weeks of corrected gestational age (CGA). A greater average daily number of IH events (OR per 10 events/day 1.33 [95% CI 1.03-1.72]), duration of events (OR per minute 1.14 [1.07-1.21]), and percent time with oxygen saturation <80% (OR per percent 1.88 [1.25-2.85]) on days 7-30 of age were all significantly associated with prolonged hospitalization past 400/7 weeks CGA. In survival analyses, infants with a greater average daily number of IH events (HR per 10 events/day 0.89 [0.81-0.98]), percent time with oxygen saturation <80% (HR per percent 0.79 [0.67-0.94]), and duration of events (HR per minute 0.93 [0.91-0.95]) on days 7-30 of age all had significantly lower probability of earlier discharge. In addition, there was a significant interaction with gestational age; the association between IH and prolonged hospitalization was stronger in more mature infants (p = 0.024). CONCLUSIONS Physiological instability on days 7-30 of age, as manifested by IH, is significantly associated with prolonged hospitalization. IH likely represents both a marker of initial severity of illness and the beginning of biological cascades, leading to prematurity-associated morbidities.
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Affiliation(s)
- Anna Maria Hibbs
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nori M Minich
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Martin
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas M Raffay
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Peter M MacFarlane
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Juliann M Di Fiore
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
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Weese-Mayer DE, Di Fiore JM, Lake DE, Hibbs AM, Claure N, Qiu J, Ambalavanan N, Bancalari E, Kemp JS, Zimmet AM, Carroll JL, Martin RJ, Krahn KN, Hamvas A, Ratcliffe SJ, Krishnamurthi N, Indic P, Dormishian A, Dennery PA, Moorman JR. Maturation of cardioventilatory physiological trajectories in extremely preterm infants. Pediatr Res 2024; 95:1060-1069. [PMID: 37857848 DOI: 10.1038/s41390-023-02839-0] [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: 04/13/2023] [Revised: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND In extremely preterm infants, persistence of cardioventilatory events is associated with long-term morbidity. Therefore, the objective was to characterize physiologic growth curves of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants during the first few months of life. METHODS The Prematurity-Related Ventilatory Control study included 717 preterm infants <29 weeks gestation. Waveforms were downloaded from bedside monitors with a novel sharing analytics strategy utilized to run software locally, with summary data sent to the Data Coordinating Center for compilation. RESULTS Apnea, periodic breathing, and intermittent hypoxemia events rose from day 3 of life then fell to near-resolution by 8-12 weeks of age. Apnea/intermittent hypoxemia were inversely correlated with gestational age, peaking at 3-4 weeks of age. Periodic breathing was positively correlated with gestational age peaking at 31-33 weeks postmenstrual age. Females had more periodic breathing but less intermittent hypoxemia/bradycardia. White infants had more apnea/periodic breathing/intermittent hypoxemia. Infants never receiving mechanical ventilation followed similar postnatal trajectories but with less apnea and intermittent hypoxemia, and more periodic breathing. CONCLUSIONS Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. IMPACT Physiologic curves of cardiorespiratory events in extremely preterm-born infants offer (1) objective measures to assess individual patient courses and (2) guides for research into control of ventilation, biomarkers and outcomes. Presented are updated maturational trajectories of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in 717 infants born <29 weeks gestation from the multi-site NHLBI-funded Pre-Vent study. Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. Different time courses for apnea and periodic breathing suggest different maturational mechanisms.
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Affiliation(s)
- Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
| | - Douglas E Lake
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jiaxing Qiu
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James S Kemp
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Amanda M Zimmet
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Katy N Krahn
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aaron Hamvas
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Neonatology, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Narayanan Krishnamurthi
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas Tyler, Tyler, TX, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phyllis A Dennery
- Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - J Randall Moorman
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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Qiu J, Di Fiore JM, Krishnamurthi N, Indic P, Carroll JL, Claure N, Kemp JS, Dennery PA, Ambalavanan N, Weese-Mayer DE, Hibbs AM, Martin RJ, Bancalari E, Hamvas A, Randall Moorman J, Lake DE. Highly comparative time series analysis of oxygen saturation and heart rate to predict respiratory outcomes in extremely preterm infants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.24.24301724. [PMID: 38343830 PMCID: PMC10854343 DOI: 10.1101/2024.01.24.24301724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Objective Highly comparative time series analysis (HCTSA) is a novel approach involving massive feature extraction using publicly available code from many disciplines. The Prematurity-Related Ventilatory Control (Pre-Vent) observational multicenter prospective study collected bedside monitor data from > 700 extremely preterm infants to identify physiologic features that predict respiratory outcomes. We calculated a subset of 33 HCTSA features on > 7M 10-minute windows of oxygen saturation (SPO2) and heart rate (HR) from the Pre-Vent cohort to quantify predictive performance. This subset included representatives previously identified using unsupervised clustering on > 3500 HCTSA algorithms. Performance of each feature was measured by individual area under the receiver operating curve (AUC) at various days of life and binary respiratory outcomes. These were compared to optimal PreVent physiologic predictor IH90 DPE, the duration per event of intermittent hypoxemia events with threshold of 90%. Main Results The top HCTSA features were from a cluster of algorithms associated with the autocorrelation of SPO2 time series and identified low frequency patterns of desaturation as high risk. These features had comparable performance to and were highly correlated with IH90_DPE but perhaps measure the physiologic status of an infant in a more robust way that warrants further investigation. The top HR HCTSA features were symbolic transformation measures that had previously been identified as strong predictors of neonatal mortality. HR metrics were only important predictors at early days of life which was likely due to the larger proportion of infants whose outcome was death by any cause. A simple HCTSA model using 3 top features outperformed IH90_DPE at day of life 7 (.778 versus .729) but was essentially equivalent at day of life 28 (.849 versus .850). These results validated the utility of a representative HCTSA approach but also provides additional evidence supporting IH90_DPE as an optimal predictor of respiratory outcomes.
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Affiliation(s)
- Jiaxing Qiu
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Narayanan Krishnamurthi
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO
| | - Phyllis A Dennery
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Department of Pediatrics, Chicago, IL
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
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Harer MW, Griffin R, Askenazi DJ, Fuloria M, Guillet R, Hanna M, Schuh MP, Slagle C, Woroniecki R, Charlton JR. Caffeine and kidney function at two years in former extremely low gestational age neonates. Pediatr Res 2024; 95:257-266. [PMID: 37660176 DOI: 10.1038/s41390-023-02792-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/25/2023] [Accepted: 08/09/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Extremely low gestational age neonates (ELGANs) are at risk for chronic kidney disease. The long-term kidney effects of neonatal caffeine are unknown. We hypothesize that prolonged caffeine exposure will improve kidney function at 22-26 months. METHODS Secondary analysis of the Preterm Erythropoietin Neuroprotection Trial of neonates <28 weeks' gestation. Participants included if any kidney outcomes were collected at 22-26 months corrected age. Exposure was post-menstrual age of caffeine discontinuation. PRIMARY OUTCOMES 'reduced eGFR' <90 ml/min/1.73 m2, 'albuminuria' (>30 mg albumin/g creatinine), or 'elevated blood pressure' (BP) >95th %tile. A general estimating equation logistic regression model stratified by bronchopulmonary dysplasia (BPD) status was used. RESULTS 598 participants had at least one kidney metric at follow up. Within the whole cohort, postmenstrual age of caffeine discontinuation was not associated with any abnormal measures of kidney function at 2 years. In the stratified analysis, for each additional week of caffeine, the no BPD group had a 21% decreased adjusted odds of eGFR <90 ml/min/1.73m2 (aOR 0.78; CI 0.62-0.99) and the BPD group had a 15% increased adjusted odds of elevated BP (aOR 1.15; CI: 1.05-1.25). CONCLUSIONS Longer caffeine exposure during the neonatal period is associated with differential kidney outcomes at 22-26 months dependent on BPD status. IMPACT In participants born <28 weeks' gestation, discontinuation of caffeine at a later post menstrual age was not associated with abnormal kidney outcomes at 22-26 months corrected age. When assessed at 2 years of age, later discontinuation of caffeine in children born <28 weeks' gestation was associated with a greater risk of reduced eGFR in those without a history of BPD and an increased odds of hypertension in those with a history of BPD. More work is necessary to understand the long-term impact of caffeine on the developing kidney.
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Affiliation(s)
- Matthew W Harer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Russell Griffin
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mamta Fuloria
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ronnie Guillet
- Department of Pediatrics, University of Rochester, Rochester, NY, USA
| | - Mina Hanna
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Meredith P Schuh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Cara Slagle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert Woroniecki
- Department of Pediatrics, Stony Brook University, Stony Brook, NY, USA
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Kim F, Bateman DA, Garey D, Goldshtrom N, Isler JR, Sahni R, Wallman-Stokes A. Association between intermittent hypoxemia and neurodevelopmental outcomes in extremely premature infants: A single-center experience. Early Hum Dev 2024; 188:105919. [PMID: 38118389 DOI: 10.1016/j.earlhumdev.2023.105919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/03/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVE To describe the association between intermittent hypoxemic events (IHEs) and severe neurodevelopmental impairment (SNDI) or death in extremely premature infants. STUDY DESIGN Retrospective study of extremely premature infants 230/7-276/7 weeks gestational age (GA) and birthweight (BW) ≤1250 grams (g) admitted to a level IV neonatal intensive care unit (NICU) from 2013 to 2017. IHEs, defined as events with SpO2 ≤ 80 % lasting 10 s to 5 min, were algorithmically identified using data extracted from bedside monitors at 2 s intervals (0.5 Hz). The primary outcome was SNDI at 18-24 months corrected age (CA), defined as a Bayley-III motor, language or cognitive composite score ≤69, or death before discharge while the secondary outcome was SNDI alone. We used mixed-effects regression models to evaluate the relationship between mean daily IHE rate per postnatal week of life for the first 12 weeks and the outcomes, and logistic regression models to assess the association between outcomes and summary measures of hypoxic burden for the entire NICU hospitalization. RESULTS The mortality rate was 7 % (18/249) during NICU hospitalization. Of 249 infants born during this time period, IHE and neurodevelopmental outcome data were fully available for 65 infants (mean GA 26 ± 1.4 weeks, mean birth weight (BW) 738 ± 199 g. The outcome of SNDI alone occurred in 34 % (22/65) with a majority demonstrating motor or language delay on the Bayley-III. Although mean daily IHE rate/week was not associated with SNDI or death, total IHE duration was associated with increased odds of SNDI (OR (95 % CI) 1.03 (1.01, 1.05), p = 0.008) in models adjusted for GA. CONCLUSIONS In a cohort of extremely premature infants 23-27 weeks GA, each hour of total IHE duration (SpO2 ≤ 80 %) was associated with a 2.7 % (0.7 %, 4.8 %) increase in the odds of SNDI at 18-24 months CA.
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Affiliation(s)
- Faith Kim
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America.
| | - David A Bateman
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Donna Garey
- Department of Pediatrics, Phoenix Children's Medical Group, Phoenix, AZ, United States of America
| | - Nimrod Goldshtrom
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Joseph R Isler
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Rakesh Sahni
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Aaron Wallman-Stokes
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT, United States of America
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Dormishian A, Schott A, Aguilar AC, Jimenez V, Bancalari E, Tolosa J, Claure N. Etiology and Mechanism of Intermittent Hypoxemia Episodes in Spontaneously Breathing Extremely Premature Infants. J Pediatr 2023; 262:113623. [PMID: 37473988 PMCID: PMC10794559 DOI: 10.1016/j.jpeds.2023.113623] [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: 03/21/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To evaluate the mechanisms leading to intermittent hypoxemia (IH) episodes in spontaneously breathing extremely premature infants at 32 weeks and 36 weeks postmenstrual age (PMA). METHODS We studied spontaneously breathing premature infants born at 23-28 weeks of gestational age who presented with IH episodes while on noninvasive respiratory support at 32 or 36 weeks PMA. Daytime recordings of arterial oxygen saturation (SpO2), esophageal pressure, respiratory inductive plethysmography of the abdomen, chest wall, and their sum were obtained during 4 hours at 32 weeks and 36 weeks PMA. IH episodes (SpO2 <90% for ≥5 seconds) and severe IH episodes (SpO2 < 80% for ≥5 seconds) were classified as resulting from apnea, active exhalation and breath holding, reduced tidal volume (VT), or reduced respiratory rate (RR) during the preceding 60 seconds. RESULTS Fifty-one infants with a mean gestational age of 25.9 ± 1.5 weeks and a mean birth weight of 846 ± 185 g were included. Of these, 31 and 41 were included in the analysis at 32 weeks and 36 weeks PMA, respectively. At both 32 weeks and 36 weeks PMA, greater proportions of all IH episodes and severe IH episodes were associated with active exhalation and breath holding than with apnea, reduced RR, or reduced VT. The severity and duration of the IH episodes did not differ between mechanisms. CONCLUSIONS In this group of premature infants, the predominant mechanism associated with daytime IH was active exhalation and breath holding. This etiology is more closely associated with behavioral factors than abnormal respiratory control and can have implications for prevention.
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Affiliation(s)
- Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL; Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL
| | - Alini Schott
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Ana Cecilia Aguilar
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Vicente Jimenez
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Jose Tolosa
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center, Miami, FL; Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL.
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10
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Alarcon-Martinez T, Latremouille S, Kovacs L, Kearney RE, Sant'Anna GM, Shalish W. Clinical usefulness of reintubation criteria in extremely preterm infants: a cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 108:643-648. [PMID: 37193586 DOI: 10.1136/archdischild-2022-325245] [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: 12/15/2022] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To describe the thresholds of instability used by clinicians at reintubation and evaluate the accuracy of different combinations of criteria in predicting reintubation decisions. DESIGN Secondary analysis using data obtained from the prospective observational Automated Prediction of Extubation Readiness study (NCT01909947) between 2013 and 2018. SETTING Multicentre (three neonatal intensive care units). PATIENTS Infants with birth weight ≤1250 g, mechanically ventilated and undergoing their first planned extubation were included. INTERVENTIONS After extubation, hourly O2 requirements, blood gas values and occurrence of cardiorespiratory events requiring intervention were recorded for 14 days or until reintubation, whichever came first. MAIN OUTCOME MEASURES Thresholds at reintubation were described and grouped into four categories: increased O2, respiratory acidosis, frequent cardiorespiratory events and severe cardiorespiratory events (requiring positive pressure ventilation). An automated algorithm was used to generate multiple combinations of criteria from the four categories and compute their accuracies in capturing reintubated infants (sensitivity) without including non-reintubated infants (specificity). RESULTS 55 infants were reintubated (median gestational age 25.2 weeks (IQR 24.5-26.1 weeks), birth weight 750 g (IQR 640-880 g)), with highly variable thresholds at reintubation. After extubation, reintubated infants had significantly greater O2 needs, lower pH, higher pCO2 and more frequent and severe cardiorespiratory events compared with non-reintubated infants. After evaluating 123 374 combinations of reintubation criteria, Youden indices ranged from 0 to 0.46, suggesting low accuracy. This was primarily attributable to the poor agreement between clinicians on the number of cardiorespiratory events at which to reintubate. CONCLUSIONS Criteria used for reintubation in clinical practice are highly variable, with no combination accurately predicting the decision to reintubate.
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Affiliation(s)
- Tugba Alarcon-Martinez
- Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia
| | | | - Lajos Kovacs
- Department of Neonatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Robert E Kearney
- Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | | | - Wissam Shalish
- Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
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11
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Raffay TM, Di Fiore JM, Chen Z, Sánchez-Illana Á, Vento M, Piñeiro-Ramos JD, Kuligowski J, Martin RJ, Tatsuoka C, Minich NM, MacFarlane PM, Hibbs AM. Hypoxemia events in preterm neonates are associated with urine oxidative biomarkers. Pediatr Res 2023; 94:1444-1450. [PMID: 37188801 DOI: 10.1038/s41390-023-02646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intermittent hypoxemia (IH) events are common in preterm neonates and are associated with adverse outcomes. Animal IH models can induce oxidative stress. We hypothesized that an association exists between IH and elevated peroxidation products in preterm neonates. METHODS Time in hypoxemia, frequency of IH, and duration of IH events were assessed from a prospective cohort of 170 neonates (<31 weeks gestation). Urine was collected at 1 week and 1 month. Samples were analyzed for lipid, protein, and DNA oxidation biomarkers. RESULTS At 1 week, adjusted multiple quantile regression showed positive associations between several hypoxemia parameters with various individual quantiles of isofurans, neurofurans, dihomo-isoprostanes, dihomo-isofurans, and ortho-tyrosine and a negative correlation with dihomo-isoprostanes and meta-tyrosine. At 1 month, positive associations were found between several hypoxemia parameters with quantiles of isoprostanes, dihomo-isoprostanes and dihomo-isofurans and a negative correlation with isoprostanes, isofurans, neuroprostanes, and meta-tyrosine. CONCLUSIONS Preterm neonates experience oxidative damage to lipids, proteins, and DNA that can be analyzed from urine samples. Our single-center data suggest that specific markers of oxidative stress may be related to IH exposure. Future studies are needed to better understand mechanisms and relationships to morbidities of prematurity. IMPACT Hypoxemia events are frequent in preterm infants and are associated with poor outcomes. The mechanisms by which hypoxemia events result in adverse neural and respiratory outcomes may include oxidative stress to lipids, proteins, and DNA. This study begins to explore associations between hypoxemia parameters and products of oxidative stress in preterm infants. Oxidative stress biomarkers may assist in identifying high-risk neonates.
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Affiliation(s)
- Thomas M Raffay
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Ángel Sánchez-Illana
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Analytical Chemistry, Universtitat de València, Burjassot, Spain
| | - Maximo Vento
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Division of Neonatology, University & Polytechnic Hospital La Fe (HULAFE), Valencia, Spain
| | | | - Julia Kuligowski
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Richard J Martin
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Nori M Minich
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Peter M MacFarlane
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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12
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MacFarlane PM, Martin RJ, Di Fiore JM, Raffay TM, Tatsuoka C, Chen Z, Minich N, Quintas G, Sánchez-Illana Á, Kuligowski J, Piñeiro-Ramos JD, Vento M, Hibbs AM. Plasma serotonergic biomarkers are associated with hypoxemia events in preterm neonates. Pediatr Res 2023; 94:1436-1443. [PMID: 37188799 DOI: 10.1038/s41390-023-02620-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/15/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Hypoxemia is a physiological manifestation of immature respiratory control in preterm neonates, which is likely impacted by neurotransmitter imbalances. We investigated relationships between plasma levels of the neurotransmitter serotonin (5-HT), metabolites of tryptophan (TRP), and parameters of hypoxemia in preterm neonates. METHODS TRP, 5-HT, 5-hydroxyindoleacetic acid (5-HIAA), and kynurenic acid (KA) were analyzed in platelet-poor plasma at ~1 week and ~1 month of life from a prospective cohort of 168 preterm neonates <31 weeks gestational age (GA). Frequency of intermittent hypoxemia (IH) events and percent time hypoxemic (<80%) were analyzed in a 6 h window after the blood draw. RESULTS At 1 week, infants with detectable plasma 5-HT had fewer IH events (OR (95% CI) = 0.52 (0.29, 0.31)) and less percent time <80% (OR (95% CI) = 0.54 (0.31, 0.95)) compared to infants with undetectable 5-HT. A similar relationship occurred at 1 month. At 1 week, infants with higher KA showed greater percent time <80% (OR (95% CI) = 1.90 (1.03, 3.50)). TRP, 5-HIAA or KA were not associated with IH frequency at either postnatal age. IH frequency and percent time <80% were positively associated with GA < 29 weeks. CONCLUSIONS Circulating neuromodulators 5-HT and KA might represent biomarkers of immature respiratory control contributing to hypoxemia in preterm neonates. IMPACT Hypoxemia events are frequent in preterm infants and are associated with poor outcomes. Mechanisms driving hypoxemia such as immature respiratory control may include central and peripheral imbalances in modulatory neurotransmitters. This study found associations between the plasma neuromodulators serotonin and kynurenic acid and parameters of hypoxemia in preterm neonates. Imbalances in plasma biomarkers affecting respiratory control may help identify neonates at risk of short- and long-term adverse outcomes.
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Affiliation(s)
- Peter Mathew MacFarlane
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.
| | - Richard John Martin
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Juliann Marie Di Fiore
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Thomas Michael Raffay
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Curtis Tatsuoka
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Nori Minich
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Guillermo Quintas
- Health and Biomedicine, Leitat Technological Center, Carrer de la Innovació, 2, 08225, Terrassa, Spain
- Analytical Unit, Health Research Institute La Fe, Avda Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Ángel Sánchez-Illana
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), University & Polytechnic Hospita La Fe (HULAFE), Valencia, Spain
- Department of Analytical Chemistry, Chemistry Faculty, Universtitat de València, Burjassot, Spain
| | - Julia Kuligowski
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), University & Polytechnic Hospita La Fe (HULAFE), Valencia, Spain
| | - José David Piñeiro-Ramos
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), University & Polytechnic Hospita La Fe (HULAFE), Valencia, Spain
| | - Maximo Vento
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), University & Polytechnic Hospita La Fe (HULAFE), Valencia, Spain
| | - Anna Maria Hibbs
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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13
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Liu X, Mohtasebi M, Safavi P, Fathi F, Haratbar SR, Chen L, Chen J, Bada HS, Chen L, Abu Jawdeh EG, Yu G. A Wearable Fiber-Free Optical Sensor for Continuous Monitoring of Neonatal Cerebral Blood Flow and Oxygenation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.21.23295914. [PMID: 37790418 PMCID: PMC10543216 DOI: 10.1101/2023.09.21.23295914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Impact The innovative DSCFO technology may serve as a low-cost wearable sensor for continuous bedside monitoring of multiple cerebral hemodynamic parameters in neonatal intensive care units.Concurrent DSCFO and DCS measurements of CBF variations in neonatal piglet models generated consistent results.No consistent correlation patterns were observed among peripheral and cerebral monitoring parameters in preterm neonates, suggesting the importance of multi-parameter measurements for understanding deep insights of peripheral and cerebral regulations during IH events.Integrating and correlating multiple cerebral functional parameters with clinical outcomes may identify biomarkers for prediction and management of IH associated brain injury. Background Unstable cerebral hemodynamics places preterm infants at high risk of brain injury. We adapted an innovative, fiber-free, wearable diffuse speckle contrast flow-oximetry (DSCFO) device for continuous monitoring of both cerebral blood flow (CBF) and oxygenation in neonatal piglets and preterm infants. Methods DSCFO uses two small laser diodes as focused-point and a tiny CMOS camera as a high-density two-dimensional detector to detect spontaneous spatial fluctuation of diffuse laser speckles for CBF measurement, and light intensity attenuations for cerebral oxygenation measurement. The DSCFO was first validated against the established diffuse correlation spectroscopy (DCS) in neonatal piglets and then utilized for continuous CBF and oxygenation monitoring in preterm infants during intermittent hypoxemia (IH) events. Results Consistent results between the DSCFO and DCS measurements of CBF variations in neonatal piglets were observed. IH events induced fluctuations in CBF, cerebral oxygenation, and peripheral cardiorespiratory vitals in preterm infants. However, no consistent correlation patterns were observed among peripheral and cerebral monitoring parameters. Conclusions This pilot study demonstrated the feasibility of DSCFO technology to serve as a low-cost wearable sensor for continuous monitoring of multiple cerebral hemodynamic parameters. The results suggested the importance of multi-parameter measurements for understanding deep insights of peripheral and cerebral regulations.
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14
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Mandala VK, Bollaboina SKY, Changala B, Kotha R, Kasula L. Intermittent Hypoxia in Preterm Neonates and Its Effect on Neonatal Morbidity and Mortality: A Systematic Review. Cureus 2023; 15:e45561. [PMID: 37868466 PMCID: PMC10586711 DOI: 10.7759/cureus.45561] [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] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
The goal of the present systematic review was to investigate the occurrence patterns of intermittent hypoxemia in newborns throughout the early postnatal period as well as the link between neonatal intermittent hypoxemia exposure and harmful consequences such as neonatal morbidity and death. We collected data from 2014 to 2023 using several abstracting, referencing, and indexing database libraries in the field of medical sciences. A total of 715 papers were evaluated by both authors, and only seven articles met the specified review criteria after a thorough analysis. In preterm neonates with intermittent hypoxia (IH), severe morbidities such as bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), motor impairment, and cognitive delay were found. Only one study that extended to 18 months noted mortality. The length and occurrence of intermittent hypoxemia and the stage of premature neonates at the time of delivery are all closely associated with these morbidities. Therefore, it becomes important to continuously measure the patterns of occurrence of intermittent hypoxemia during early postnatal life to avoid its long-term morbidity and mortality impact.
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Affiliation(s)
| | | | | | - Rakesh Kotha
- Neonatology, Osmania Medical College, Hyderabad, IND
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15
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Marcelino M, Cai CL, Wadowski S, Aranda JV, Beharry KD. Biomarkers of lung alveolarization and microvascular maturation in response to intermittent hypoxia and/or early antioxidant/fish oil supplementation in neonatal rats. Pediatr Pulmonol 2023; 58:2352-2363. [PMID: 37265429 PMCID: PMC10463793 DOI: 10.1002/ppul.26495] [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: 09/19/2022] [Revised: 04/11/2023] [Accepted: 05/14/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Extremely preterm infants experience frequent intermittent hypoxia (IH) episodes during oxygen therapy which causes significant damage to the lungs and curtails important signaling pathways that regulate normal lung alveolarization and microvascular maturation. We tested the hypothesis that early supplementation with fish oil and/or antioxidants in rats exposed to neonatal IH improves expression of lung biomarkers of alveolarization and microvascular maturation, and reduces IH-induced lung injury. STUDY DESIGN/METHODS From birth (P0) to P14, rat pups were exposed to room air (RA) or neonatal IH during which they received daily oral supplementation with either: (1) olive oil (OO) (control); (2) Coenzyme Q10 (CoQ10) in OO; (3) fish oil; (4) glutathione nanoparticles (nGSH); or (5) fish oil +CoQ10. At P14 pups were placed in RA until P21 with no further treatment. RA controls were similarly treated. Lung growth and alveolarization, histopathology, apoptosis, oxidative stress and biomarkers of alveolarization and microvascular maturation were determined. RESULTS Neonatal IH was associated with reduced lung weights and severe histopathological outcomes. These effects were curtailed with fish oil and nGSH. nGSH was also protective against apoptosis, while CoQ10 prevented IH-induced ROS production. Of all treatments, nGSH and CoQ10 + fish oil-induced vascular endothelial growth factor165 and CD31 (Platelet endothelial cell adhesion molecule-1), which are associated with angiogenesis. CoQ10 + fish oil improved alveolarization in RA and IH despite evidence of hemorrhage. CONCLUSIONS The benefits of nGSH and CoQ10 + fish oil suggest an antioxidant effect which may be required to curtail IH-induced lung injury. Further clinical assessment of the effectiveness of nGSH is warranted.
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Affiliation(s)
- Matthew Marcelino
- State University of New York Downstate Health Sciences University, College of Medicine, Brooklyn, NY 11203
| | - Charles L. Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
| | - Stephen Wadowski
- Department of Pediatrics, Division of Pediatric Pulmonology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
| | - Jacob V. Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
| | - Kay D. Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, 11203
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16
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Poets CF, Nelin L. Predicting Pulmonary Outcomes in Extremely Preterm Infants from Recordings of Cardiorespiratory Data: A Question of Chicken and Egg. Am J Respir Crit Care Med 2023; 208:11-12. [PMID: 37219238 PMCID: PMC10870852 DOI: 10.1164/rccm.202305-0809ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Affiliation(s)
- Christian F Poets
- Department of Neonatology Tübingen Children's Hospital Tübingen, Germany
| | - Leif Nelin
- Nationwide Children's Hospital Columbus, Ohio
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17
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Ambalavanan N, Weese-Mayer DE, Hibbs AM, Claure N, Carroll JL, Moorman JR, Bancalari E, Hamvas A, Martin RJ, Di Fiore JM, Indic P, Kemp JS, Dormishian A, Krahn KN, Qiu J, Dennery PA, Ratcliffe SJ, Troendle JF, Lake DE. Cardiorespiratory Monitoring Data to Predict Respiratory Outcomes in Extremely Preterm Infants. Am J Respir Crit Care Med 2023; 208:79-97. [PMID: 37219236 PMCID: PMC10870840 DOI: 10.1164/rccm.202210-1971oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/01/2023] [Indexed: 05/24/2023] Open
Abstract
Rationale: Immature control of breathing is associated with apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants. However, it is not clear if such events independently predict worse respiratory outcome. Objectives: To determine if analysis of cardiorespiratory monitoring data can predict unfavorable respiratory outcomes at 40 weeks postmenstrual age (PMA) and other outcomes, such as bronchopulmonary dysplasia at 36 weeks PMA. Methods: The Prematurity-related Ventilatory Control (Pre-Vent) study was an observational multicenter prospective cohort study including infants born at <29 weeks of gestation with continuous cardiorespiratory monitoring. The primary outcome was either "favorable" (alive and previously discharged or inpatient and off respiratory medications/O2/support at 40 wk PMA) or "unfavorable" (either deceased or inpatient/previously discharged on respiratory medications/O2/support at 40 wk PMA). Measurements and Main Results: A total of 717 infants were evaluated (median birth weight, 850 g; gestation, 26.4 wk), 53.7% of whom had a favorable outcome and 46.3% of whom had an unfavorable outcome. Physiologic data predicted unfavorable outcome, with accuracy improving with advancing age (area under the curve, 0.79 at Day 7, 0.85 at Day 28 and 32 wk PMA). The physiologic variable that contributed most to prediction was intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <90%. Models with clinical data alone or combining physiologic and clinical data also had good accuracy, with areas under the curve of 0.84-0.85 at Days 7 and 14 and 0.86-0.88 at Day 28 and 32 weeks PMA. Intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <80% was the major physiologic predictor of severe bronchopulmonary dysplasia and death or mechanical ventilation at 40 weeks PMA. Conclusions: Physiologic data are independently associated with unfavorable respiratory outcome in extremely preterm infants.
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Affiliation(s)
| | - Debra E. Weese-Mayer
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anna Maria Hibbs
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - John L. Carroll
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Aaron Hamvas
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard J. Martin
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Juliann M. Di Fiore
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - James S. Kemp
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | | | - Jiaxing Qiu
- University of Virginia, Charlottesville, Virginia
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18
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Zhang EY, Bartman CM, Prakash YS, Pabelick CM, Vogel ER. Oxygen and mechanical stretch in the developing lung: risk factors for neonatal and pediatric lung disease. Front Med (Lausanne) 2023; 10:1214108. [PMID: 37404808 PMCID: PMC10315587 DOI: 10.3389/fmed.2023.1214108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
Chronic airway diseases, such as wheezing and asthma, remain significant sources of morbidity and mortality in the pediatric population. This is especially true for preterm infants who are impacted both by immature pulmonary development as well as disproportionate exposure to perinatal insults that may increase the risk of developing airway disease. Chronic pediatric airway disease is characterized by alterations in airway structure (remodeling) and function (increased airway hyperresponsiveness), similar to adult asthma. One of the most common perinatal risk factors for development of airway disease is respiratory support in the form of supplemental oxygen, mechanical ventilation, and/or CPAP. While clinical practice currently seeks to minimize oxygen exposure to decrease the risk of bronchopulmonary dysplasia (BPD), there is mounting evidence that lower levels of oxygen may carry risk for development of chronic airway, rather than alveolar disease. In addition, stretch exposure due to mechanical ventilation or CPAP may also play a role in development of chronic airway disease. Here, we summarize the current knowledge of the impact of perinatal oxygen and mechanical respiratory support on the development of chronic pediatric lung disease, with particular focus on pediatric airway disease. We further highlight mechanisms that could be explored as potential targets for novel therapies in the pediatric population.
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Affiliation(s)
- Emily Y. Zhang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Colleen M. Bartman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Y. S. Prakash
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Christina M. Pabelick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Elizabeth R. Vogel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
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19
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Ramirez LA, Mohamed R, Marin T, Brands MW, Snyder E, Sullivan JC. Perinatal intermittent hypoxia increases early susceptibility to ANG II-induced hypertension in adult male but not in female Sprague-Dawley rats. Am J Physiol Renal Physiol 2023; 324:F483-F493. [PMID: 36951371 PMCID: PMC10151053 DOI: 10.1152/ajprenal.00308.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/15/2023] [Accepted: 03/16/2023] [Indexed: 03/24/2023] Open
Abstract
Prenatal, perinatal, and adulthood exposure to chronic intermittent hypoxia (IH) increases blood pressure in rodents. Males exposed to chronic IH have higher blood pressure versus females. However, it is unknown if this same-sex difference exists with acute perinatal IH. We tested the hypothesis that acute perinatal IH increases baseline blood pressure and enhances sensitivity to angiotensin II (ANG II)-induced hypertension in male Sprague-Dawley rats. Male and female pups were randomized to control (room air) or IH (10 min of ∼10% O2 for 3 times/day) for the first 8 days of life. IH decreased oxygen saturation, as confirmed via a pulse oximeter. Pups were weaned at postnatal day 21. Blood pressure was measured via telemetry beginning at 14 wk of age and analyzed separately into light and dark phases to assess circadian rhythm. Osmotic minipumps to deliver ANG II were implanted at 15 wk of age. Perinatal IH exposure did not alter baseline blood pressure. One week of ANG II treatment increased blood pressure in light and dark periods in males exposed to IH versus control; there was no effect in females. Blood pressure among the groups was comparable following 2 wk of ANG II infusion. Perinatal IH did not change the circadian rhythm. Following ANG II treatment, indexes of renal injury were measured. Perinatal IH did not alter kidney size, structure, nephron number, or creatinine clearance. These data indicate that acute perinatal IH enhances early ANG II-induced hypertension in males, independent of nephron loss or decreases in body weight or kidney function.NEW & NOTEWORTHY The impact of acute intermittent hypoxia (IH) in early life on blood pressure in adulthood is unknown. This study used a new model exposing female and male rat pups to acute IH in the first 8 days of life, without exposing the dam. Although baseline blood pressure was not altered in adulthood, IH increased susceptibility to angiotensin II hypertension only in males, supporting increased susceptibility of males exposed to IH to a second cardiovascular stressor.
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Affiliation(s)
- Lindsey A Ramirez
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Riyaz Mohamed
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Terri Marin
- Department of Nursing Science, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Michael W Brands
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Elizabeth Snyder
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Jennifer C Sullivan
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
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20
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Pulse oximetry reliability for detection of hypoxemia under motion in extremely premature infants. Pediatr Res 2023; 93:118-124. [PMID: 35978093 PMCID: PMC9892170 DOI: 10.1038/s41390-022-02258-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Episodes of intermittent hypoxemia (IH) in extremely premature infants are detected by pulse oximetry (SpO2) but motion artifact can cause falsely low readings. OBJECTIVES To evaluate the reliability of SpO2 during IH episodes associated with motion in premature infants of ≤28 weeks GA monitored with 2 pulse oximeters. METHODS IH episodes (defined as SpO2 < 90%, >10 s and SpO2 < 80%, >10 s) were classified by an analytic tool based on distortion caused by motion in the pulse plethysmograph (Pleth) as: A (true hypoxemia), both SpO2 decreased (only one Pleth showed motion); B (false hypoxemia), one SpO2 decreased (Pleth showed motion) and the other didn't (Pleth didn't show motion); C (suspected hypoxemia), both SpO2 decreased (both Pleth showed motion); D (true hypoxemia-motion free), both SpO2 decreased (neither Pleth showed motion). RESULTS In 24-72 h data from 20 infants of 25.4 ± 1.5 weeks GA, 14.1 ± 5.7 episodes with SpO2 < 90% and 7.9 ± 5.5 episodes with SpO2 < 80% per infant were identified. 29 ± 15% of episodes with SpO2 < 90% were type A, 1 ± 2% B, 43 ± 21% C and 27 ± 23% D, while 26 ± 22% of episodes with SpO2 < 80% were type A, 0.3 ± 1.2% B, 45 ± 29% C, and 19 ± 25% D [p < 0.001 type B vs. rest (GLM-repeated measures)]. CONCLUSION In extremely premature infants SpO2 with motion artifact is more likely to indicate true- than false hypoxemia. IMPACT Uncertainty on the effect of motion on SpO2 accuracy during hypoxemia episodes in premature infants can influence the caregiver's trust on SpO2 and influence their response. This study evaluated data from two pulse oximeters used simultaneously in different extremities to determine the reliability of SpO2 during motion artifact in premature infants. Data from this study showed that in extremely premature infants SpO2 is more likely to indicate true- than false hypoxemia during episodes of hypoxemia associated with motion artifact.
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21
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Cheema Z, Kwinta P, Moreira A, Tovar M, Mustafa SB. Big Data for Tiny Patients: A Precision Medicine Approach to Bronchopulmonary Dysplasia. Pediatr Ann 2022; 51:e396-e404. [PMID: 36215088 DOI: 10.3928/19382359-20220803-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease of extreme prematurity. Despite more than 50 years of research, current treatments are ineffective, and clinicians are largely unable to accurately predict which neonates the condition will develop in. A deeper understanding of the molecular mechanisms underlying the characteristic arrest in lung development are warranted. Integrating high-fidelity technology from precision medicine approaches may fill this gap and provide the tools necessary to identify biomarkers and targetable pathways. In this review, we describe insights garnered from current studies using omics for BPD prediction and stratification. We conclude by describing novel programs that will integrate multi-omics in efforts to better understand and treat the pathogenesis of BPD. [Pediatr Ann. 2022;51(10):e396-e404.].
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22
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Bachman TE, Onland W, van Kaam AH, Roubik K, Hummler HD, Lal M, Lista G, Fajardo CA. Frequency and duration of extreme hypoxemic and hyperoxemic episodes during manual and automatic oxygen control in preterm infants: a retrospective cohort analysis from randomized studies. BMC Pediatr 2022; 22:350. [PMID: 35715764 PMCID: PMC9205075 DOI: 10.1186/s12887-022-03407-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Neonatal exposure to episodic hypoxemia and hyperoxemia is highly relevant to outcomes. Our goal was to investigate the differences in the frequency and duration of extreme low and high SpO2 episodes between automated and manual inspired oxygen control. Design Post-hoc analysis of a cohort from prospective randomized cross-over studies. Setting Seven tertiary care neonatal intensive care units. Patients Fifty-eight very preterm neonates (32 or less weeks PMA) receiving respiratory support and supplemental oxygen participating in an automated versus manual oxygen control cross-over trial. Main measures Extreme hypoxemia was defined as a SpO2 < 80%, extreme hyperoxemia as a SpO2 > 98%. Episode duration was categorized as < 5 seconds, between 5 to < 30 seconds, 30 to < 60 seconds, 60 to < 120 seconds, and 120 seconds or longer. Results The infants were of a median postmenstrual age of 29 (28-31) weeks, receiving a median FiO2 of 0.28 (0.25-0.32) with mostly receiving non-invasive respiratory support (83%). While most of the episodes were less than 30 seconds, longer episodes had a marked effect on total time exposure to extremes. The time differences in each of the three longest durations episodes (30, 60, and 120 seconds) were significantly less during automated than during manual control (p < 0.001). Nearly two-third of the reduction of total time spent at the extremes between automated and manual control (3.8 to 2.1% for < 80% SpO2 and 3.0 to 1.6% for > 98% SpO2) was seen in the episodes of at least 60 seconds. Conclusions This study shows that the majority of episodes preterm infants spent in SpO2 extremes are of short duration regardless of manual or automated control. However, the infrequent longer episodes not only contribute the most to the total exposure, but also their reduction in frequency to the improvement associated with automated control.
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Affiliation(s)
- Thomas E Bachman
- Czech Technical University in Prague, School of Biomedical Engineering, Prague, Czech Republic.
| | - Wes Onland
- Emma Children's Hospital, Department of Neonatology, Amsterdam UMC, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Emma Children's Hospital, Department of Neonatology, Amsterdam UMC, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Karel Roubik
- Czech Technical University in Prague, School of Biomedical Engineering, Prague, Czech Republic
| | - Helmut D Hummler
- Department of Neonatology, University Hospital, Tuebingen, Germany
| | - Mithilesh Lal
- James Cook University Hospital, Neonatology, South Tees NHS Trust, Middlesbrough, UK
| | - Gianluca Lista
- Vittore Buzzi Children's Hospital, Neonatology, Milan, Italy
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23
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Shalish W, Keszler M, Davis PG, Sant'Anna GM. Decision to extubate extremely preterm infants: art, science or gamble? Arch Dis Child Fetal Neonatal Ed 2022; 107:105-112. [PMID: 33627331 DOI: 10.1136/archdischild-2020-321282] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 12/15/2022]
Abstract
In the modern era of neonatology, mechanical ventilation has been restricted to a smaller and more immature population of extremely preterm infants. Given the adverse outcomes associated with mechanical ventilation, every effort is made to extubate these infants as early as possible. However, the scientific basis for determining extubation readiness remains imprecise and primarily guided by clinical judgement, which is highly variable and subjective. In the absence of accurate tools to assess extubation readiness, many infants fail their extubation attempt and require reintubation, which also increases complications. Recent advances in the field have led to unravelling some of the complexities surrounding extubation in this population. This review aims to synthesise the available knowledge and provide a more evidence-based approach towards the reporting of extubation outcomes and assessment of extubation readiness in extremely preterm infants.
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Affiliation(s)
- Wissam Shalish
- Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Martin Keszler
- Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Peter G Davis
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
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24
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Kurtom W, Dormishian A, Jain D, Schott A, Aguilar AC, Grieb G, Bancalari E, Claure N. Effect of the Target Range on Arterial Oxygen Saturation Stability in Extremely Premature Infants. Neonatology 2022; 119:638-643. [PMID: 36030769 DOI: 10.1159/000525271] [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: 03/25/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effect of targeting arterial oxygen saturation (SpO2) in the high (93-95%) versus the low portion (90-92%) of the recommended range of 90-95% on oxygenation stability in extremely premature infants. METHODS Premature infants of ≤28 weeks of gestational age who received a fraction of inspired oxygen (FiO2) > 0.21 after day 14 were eligible. FiO2 was adjusted by a dedicated investigator to keep SpO2 between 90-92% and 93-95% for 2 h each in random sequence. Episodes of intermittent hypoxemia (IH) were defined as SpO2 <90% for ≥10 s; severe IH episodes were defined as SpO2 <80% for ≥10 s. Hyperoxemia was defined as SpO2 >95% or >98%. RESULTS Eighteen premature infants were enrolled. Their (mean ± SD) GA was 26 ± 1.5 w. Seven infants were on mechanical ventilation, 4 infants on nasal ventilation, and 7 infants on nasal cannula. They were on a mean FiO2 0.38 ± 0.12 at study entry. Episodes of IH and severe IH were more frequent during the low compared to the high target (36.6 [27.0-41.3] vs. 16.0 [7.8-19.0], p < 0.001; 8.4 ± 9.3 vs. 3.2 ± 4.3, p = 0.002). The proportions of time with SpO2 >95% and >98% were greater with the high target (13.9 ± 11 vs. 34.1 ± 15.4%, p < 0.001; 0.9 [0-5.7] vs. 3.4 [0.5-16.1]%, p = 0.002). CONCLUSION In this group of extremely premature infants, targeting SpO2 at the lower portion of the recommended range resulted in more frequent episodes of IH. However, targeting the higher SpO2 range led to more hyperoxemia. This trade-off warrants further investigation.
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Affiliation(s)
- Waleed Kurtom
- Division of Neonatology, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, Florida, USA
| | - Deepak Jain
- Division of Neonatology, Department of Pediatrics, Pediatrics, Robert W. Johnson School of Medicine Rutgers University, New Brunswick, New Jersey, USA
| | - Alini Schott
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ana Cecilia Aguilar
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gavin Grieb
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, Florida, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, Florida, USA
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25
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Claure N, Bancalari E. New Modes of Respiratory Support for the Premature Infant: Automated Control of Inspired Oxygen Concentration. Clin Perinatol 2021; 48:843-853. [PMID: 34774212 DOI: 10.1016/j.clp.2021.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most extremely premature infants have respiratory instability that can manifest as frequent episodes of intermittent hypoxemia. Although caregivers target clinically recommended ranges of arterial oxygen saturation (oxygen saturation as measured by pulse oximetry [Spo2]), consistent maintenance of these ranges is not always achieved. Excessive administration of supplemental oxygen combined with limited staff resources increases exposure to extreme Spo2 levels. In this population, exposure to hyperoxemia and prolonged episodes of intermittent hypoxemia have been associated with damage to the eye and lung and impaired neurodevelopment. To improve Spo2 targeting, various systems for automated control of inspired oxygen have been developed recently.
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Affiliation(s)
- Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
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26
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Jensen EA, Whyte RK, Schmidt B, Bassler D, Vain NE, Roberts RS. Association between Intermittent Hypoxemia and Severe Bronchopulmonary Dysplasia in Preterm Infants. Am J Respir Crit Care Med 2021; 204:1192-1199. [PMID: 34428130 PMCID: PMC8759313 DOI: 10.1164/rccm.202105-1150oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: Bronchopulmonary dysplasia increases the risk of disability in extremely preterm infants. Although the pathophysiology remains uncertain, prior exposure to intermittent hypoxemia may play a role in this relationship. Objectives: To determine the association between prolonged episodes of intermittent hypoxemia and severe bronchopulmonary dysplasia. Methods: A post hoc analysis of extremely preterm infants in the Canadian Oxygen Trial who survived to 36 weeks' postmenstrual age was performed. Oxygen saturations <80% for ⩾1 minute and the proportion of time per day with hypoxemia were quantified using continuous pulse oximetry data that had been sampled every 10 seconds from within 24 hours of birth until 36 weeks' postmenstrual age. The study outcome was severe bronchopulmonary dysplasia as defined in the 2001 NIH Workshop Summary. Measurements and Main Results: Of 1,018 infants, 332 (32.6%) developed severe bronchopulmonary dysplasia. The median number of hypoxemic episodes ranged from 0.8/day (interquartile range, 0.2-1.1) to 60.2/day (interquartile range, 51.4-70.3) among the least and most affected 10% of infants. Compared with the lowest decile of exposure to hypoxemic episodes, the adjusted relative risk of severe bronchopulmonary dysplasia increased progressively from 1.72 (95% confidence interval, 1.55-1.90) at the 2nd decile to 20.40 (95% confidence interval, 12.88-32.32) at the 10th decile. Similar risk gradients were observed for time in hypoxemia. Significant differences in the rates of hypoxemia between infants with and without severe bronchopulmonary dysplasia emerged within the first week after birth. Conclusions: Prolonged intermittent hypoxemia beginning in the first week after birth was associated with an increased risk of developing severe bronchopulmonary dysplasia among extremely preterm infants. Clinical trial registered with www.isrctn.com (ISRCTN62491227) and www.clinicaltrials.gov (NCT00637169).
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robin K. Whyte
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Barbara Schmidt
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nestor E. Vain
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; and
- Division of Newborn Medicine, Department of Pediatrics, Hospital Sanatorio Trinidad, Buenos Aires, Argentina
| | - Robin S. Roberts
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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27
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Di Fiore JM, Martin RJ, Raffay TM. Intermittent Hypoxemia and Bronchopulmonary Dysplasia: Manifestations of Immature Respiratory Control and the Preterm Lung. Am J Respir Crit Care Med 2021; 204:1126-1127. [PMID: 34634221 PMCID: PMC8759306 DOI: 10.1164/rccm.202109-2077ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology Rainbow Babies and Children's Hospital Cleveland, Ohio.,Department of Pediatrics Case Western Reserve University Cleveland, Ohio
| | - Richard J Martin
- Division of Neonatology Rainbow Babies and Children's Hospital Cleveland, Ohio.,Department of Pediatrics Case Western Reserve University Cleveland, Ohio
| | - Thomas M Raffay
- Division of Neonatology Rainbow Babies and Children's Hospital Cleveland, Ohio.,Department of Pediatrics Case Western Reserve University Cleveland, Ohio
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28
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Martin RJ, Jobe AH, Bancalari E. What is BPD today and in the next 50 years? Am J Physiol Lung Cell Mol Physiol 2021; 321:L974-L977. [PMID: 34643100 PMCID: PMC8616614 DOI: 10.1152/ajplung.00415.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Richard J Martin
- Case Western Reserve University School of Medicine, University Hospitals/Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Alan H Jobe
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eduardo Bancalari
- Division of Neonatology, University of Miami Miller School of Medicine, Miami, Florida
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29
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Behnke J, Dippel CM, Choi Y, Rekers L, Schmidt A, Lauer T, Dong Y, Behnke J, Zimmer KP, Bellusci S, Ehrhardt H. Oxygen Toxicity to the Immature Lung-Part II: The Unmet Clinical Need for Causal Therapy. Int J Mol Sci 2021; 22:10694. [PMID: 34639034 PMCID: PMC8508961 DOI: 10.3390/ijms221910694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022] Open
Abstract
Oxygen toxicity continues to be one of the inevitable injuries to the immature lung. Reactive oxygen species (ROS) production is the initial step leading to lung injury and, subsequently, the development of bronchopulmonary dysplasia (BPD). Today, BPD remains the most important disease burden following preterm delivery and results in life-long restrictions in lung function and further important health sequelae. Despite the tremendous progress in the pathomechanistic understanding derived from preclinical models, the clinical needs for preventive or curative therapies remain unmet. This review summarizes the clinical progress on guiding oxygen delivery to the preterm infant and elaborates future directions of research that need to take into account both hyperoxia and hypoxia as ROS sources and BPD drivers. Many strategies have been tested within clinical trials based on the mechanistic understanding of ROS actions, but most have failed to prove efficacy. The majority of these studies were tested in an era before the latest modes of non-invasive respiratory support and surfactant application were introduced or were not appropriately powered. A comprehensive re-evaluation of enzymatic, antioxidant, and anti-inflammatory therapies to prevent ROS injury is therefore indispensable. Strategies will only succeed if they are applied in a timely and vigorous manner and with the appropriate outcome measures.
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Affiliation(s)
- Judith Behnke
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Constanze M. Dippel
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Yesi Choi
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Lisa Rekers
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Annesuse Schmidt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Tina Lauer
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Ying Dong
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Jonas Behnke
- Department of Internal Medicine V, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Klinikstrasse 33, 35392 Giessen, Germany;
| | - Klaus-Peter Zimmer
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Saverio Bellusci
- Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center (UGMLC), Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Aulweg 130, 35392 Giessen, Germany;
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
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Abu Jawdeh EG, Huang H, Westgate PM, Patwardhan A, Bada H, Bauer JA, Giannone P. Intermittent Hypoxemia in Preterm Infants: A Potential Proinflammatory Process. Am J Perinatol 2021; 38:1313-1319. [PMID: 32512605 DOI: 10.1055/s-0040-1712951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE A major consequence of prematurity is intermittent hypoxemia (IH). Data from both adult studies and neonatal animal models suggest that IH is proinflammatory; however, there is limited data in preterm infants. Here, we assess the relationship between IH and systemic inflammation, namely, serum C-reactive protein (CRP) in preterm infants. STUDY DESIGN Serum CRP was measured at 30 days of life, at the time of peak IH frequency. IH measures (e.g., per cent time in hypoxemia, frequency, duration) were calculated the week prior to CRP collection. Statistical analyses were based on Spearman's correlation. RESULTS A total of 26 infants were included. Median gestational age and birth weight were 274/7 weeks and 980 g, respectively. There were positive correlations between primary IH measures and CRP levels, especially for events longer than 1-minute duration (r range: 0.56-0.74, all p < 0.01). CONCLUSION We demonstrate that IH is associated with increased CRP for the first time in preterm infants. Our findings are consistent with studies from adults and neonatal animal models suggesting that IH is a proinflammatory process. KEY POINTS · IH events are common.. · IH is associated with elevated C-reactive protein.. · Longer IH events (>1 min) are of most significance..
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Affiliation(s)
- Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Hong Huang
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky
| | - Abhijit Patwardhan
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, Lexington, Kentucky
| | - Henrietta Bada
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - John A Bauer
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Peter Giannone
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
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Dylag AM, Haak J, Warren R, Yee M, Pryhuber GS, O'Reilly MA. Low Dose Hyperoxia Primes Airways for Fibrosis in Mice after Influenza A Infection. Am J Physiol Lung Cell Mol Physiol 2021; 321:L750-L763. [PMID: 34323115 DOI: 10.1152/ajplung.00289.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
It is well known that supplemental oxygen used to treat preterm infants in respiratory distress is associated with permanently disrupting lung development and the host response to influenza A virus (IAV). However, many infants who go home with normally functioning lungs are also at risk for hyperreactivity after a respiratory viral infection. We recently reported a new, low-dose hyperoxia mouse model (40% for 8 days; 40x8) that causes a transient change in lung function that resolves, rendering 40x8 adult animals functionally indistinguishable from room air controls. Here we reported that when infected with IAV, 40x8 mice display an early transient activation of TGFβ signaling and later airway hyperreactivity associated with peribronchial inflammation (profibrotic macrophages) and fibrosis compared to infected room air controls, suggesting neonatal oxygen induced hidden molecular changes that prime the lung for hyperreactive airways disease. While searching for potential activators of TGFβ signaling, we discovered that thrombospondin-1 (TSP-1) is elevated in naïve 40x8 mice compared to controls and localized to lung megakaryocytes and platelets before and during IAV infection. Elevated TSP-1 was also identified in human autopsy samples of former preterm infants with bronchopulmonary dysplasia. These findings reveal how low doses of oxygen that do not durably change lung function may prime it for hyperreactive airways disease by changing expression of genes, such as TSP-1, thus helping to explain why former preterm infants who have normal lung function are susceptible to airway obstruction and increased morbidity after viral infection.
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Affiliation(s)
- Andrew M Dylag
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
| | - Jeannie Haak
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
| | - Rachel Warren
- Department of Microbiology and Immunology, University of Rochester, Rochester, NY, United States
| | - Min Yee
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
| | - Gloria S Pryhuber
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
| | - Michael A O'Reilly
- Department of Pediatrics, University of Rochester, Rochester, NY, United States
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32
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Raffay TM, Brasher M, Place BC, Patwardhan A, Giannone PJ, Bada H, Westgate PM, Abu Jawdeh EG. Response to first dose of inhaled albuterol in mechanically ventilated preterm infants. J Perinatol 2021; 41:1704-1710. [PMID: 34035457 PMCID: PMC8147907 DOI: 10.1038/s41372-021-01071-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Bronchodilator responses among preterm infants are heterogeneous. Bedside measurements may identify responders. STUDY DESIGN Respiratory measurements (Resistance, Compliance, FiO2) and pulse oximetry (SpO2) patterns were downloaded from infants <30 weeks gestational age during the first 2 months of life. Mechanically ventilated infants who received albuterol were included (n = 33). Measurements were compared before and after first albuterol. Secondary analyses assessed subsequent doses. RESULTS Median gestation and birthweight were 25 3/7 weeks and 730 g, respectively. Mean Resistance decreased post-albuterol (p = 0.007). Sixty-eight percent of infants were responders based on decreased Resistance. Compliance and FiO2 did not significantly differ. Percent time in hypoxemia (SpO2 < 85%) decreased post albuterol (p < 0.02). In responders, Resistance changes diminished with subsequent administration (all p = 0.01). CONCLUSIONS Ventilator resistance decreased in two-thirds of preterm infants, consistent with studies that utilized formal pulmonary function testing. Albuterol had a variable effect on delivered FiO2; however, hypoxemia may be useful in evaluating albuterol response.
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Affiliation(s)
- Thomas M Raffay
- Pediatrics/Neonatology, UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Mandy Brasher
- Pediatrics/Neonatology, University of Kentucky, Lexington, KY, USA
| | - Brooke C Place
- Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | | | - Peter J Giannone
- Pediatrics/Neonatology, University of Kentucky, Lexington, KY, USA
| | - Henrietta Bada
- Pediatrics/Neonatology, University of Kentucky, Lexington, KY, USA
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Raffay TM, Bonilla-Fernandez K, Jafri A, Sopi RB, Smith LA, Cui F, O'Reilly M, Zhang R, Hodges CA, MacFarlane PM, Deutsch G, Martin RJ, Gaston B. Bronchopulmonary Dysplasia and Pulmonary Hypertension. The Role of Smooth Muscle adh5. Am J Respir Cell Mol Biol 2021; 65:70-80. [PMID: 33780653 DOI: 10.1165/rcmb.2020-0289oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is characterized by alveolar simplification, airway hyperreactivity, and pulmonary hypertension. In our BPD model, we have investigated the metabolism of the bronchodilator and pulmonary vasodilator GSNO (S-nitrosoglutathione). We have shown the GSNO catabolic enzyme encoded by adh5 (alcohol dehydrogenase-5), GSNO reductase, is epigenetically upregulated in hyperoxia. Here, we investigated the distribution of GSNO reductase expression in human BPD and created an animal model that recapitulates the human data. Blinded comparisons of GSNO reductase protein expression were performed in human lung tissues from infants and children with and without BPD. BPD phenotypes were evaluated in global (adh5-/-) and conditional smooth muscle (smooth muscle/adh5-/-) adh5 knockout mice. GSNO reductase was prominently expressed in the airways and vessels of human BPD subjects. Compared with controls, expression was greater in BPD smooth muscle, particularly in vascular smooth muscle (2.4-fold; P = 0.003). The BPD mouse model of neonatal hyperoxia caused significant alveolar simplification, airway hyperreactivity, and right ventricular and vessel hypertrophy. Global adh5-/- mice were protected from all three aspects of BPD, whereas smooth muscle/adh5-/- mice were only protected from pulmonary hypertensive changes. These data suggest adh5 is required for the development of BPD. Expression in the pulmonary vasculature is relevant to the pathophysiology of BPD-associated pulmonary hypertension. GSNO-mimetic agents or GSNO reductase inhibitors, both of which are currently in clinical trials for other conditions, could be considered for further study in BPD.
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Affiliation(s)
| | - Koby Bonilla-Fernandez
- Division of Pediatric Pulmonology, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital and Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio.,San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | - Anjum Jafri
- Division of Pediatric Pulmonology, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital and Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Laura A Smith
- Department of Pediatrics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana
| | - Feifei Cui
- Division of Pediatric Pulmonology, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital and Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Rongli Zhang
- Department of Medicine, Institute for Transformative Molecular Medicine, Cardiovascular Research Institute, University Hospitals Cleveland Medical Center, and
| | - Craig A Hodges
- Department of Genetics, Case Western Reserve University, Cleveland, Ohio; and
| | | | - Gail Deutsch
- Department of Pathology, Seattle Children's Hospital & University of Washington, Seattle, Washington
| | | | - Benjamin Gaston
- Division of Pediatric Pulmonology, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital and Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio.,Department of Pediatrics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana
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Conlon S, Di Fiore JM, Martin RJ. Are we over-treating hypoxic spells in preterm infants? Semin Fetal Neonatal Med 2021; 26:101227. [PMID: 33736905 DOI: 10.1016/j.siny.2021.101227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.
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Affiliation(s)
- Steven Conlon
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Richard J Martin
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
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35
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Di Fiore JM, Raffay TM. The relationship between intermittent hypoxemia events and neural outcomes in neonates. Exp Neurol 2021; 342:113753. [PMID: 33984336 DOI: 10.1016/j.expneurol.2021.113753] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 04/06/2021] [Accepted: 05/07/2021] [Indexed: 12/20/2022]
Abstract
This brief review examines 1) patterns of intermittent hypoxemia in extremely preterm infants during early postnatal life, 2) the relationship between neonatal intermittent hypoxemia exposure and outcomes in both human and animal models, 3) potential mechanistic pathways, and 4) future alterations in clinical care that may reduce morbidity. Intermittent hypoxemia events are pervasive in extremely preterm infants (<28 weeks gestation at birth) during early postnatal life. An increased frequency of intermittent hypoxemia events has been associated with a range of poor neural outcomes including language and cognitive delays, motor impairment, retinopathy of prematurity, impaired control of breathing, and intraventricular hemorrhage. Neonatal rodent models have shown that exposure to short repetitive cycles of hypoxia induce a pathophysiological cascade. However, not all patterns of intermittent hypoxia are deleterious and some may even improve neurodevelopmental outcomes. Therapeutic interventions include supplemental oxygen, pressure support and pharmacologic drugs but prolonged hyperoxia and pressure exposure have been associated with cardiopulmonary morbidity. Therefore, it becomes imperative to distinguish high risk from neutral and/or even beneficial patterns of intermittent hypoxemia during early postnatal life. Identification of such patterns could improve clinical care with targeted interventions for high-risk patterns and minimal or no exposure to treatment modalities for low-risk patterns.
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Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America
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Schiliro M, Bartman CM, Pabelick C. Understanding hydrogen sulfide signaling in neonatal airway disease. Expert Rev Respir Med 2021; 15:351-372. [PMID: 33086886 PMCID: PMC10599633 DOI: 10.1080/17476348.2021.1840981] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Airway dysfunction leading to chronic lung disease is a common consequence of premature birth and mechanisms responsible for early and progressive airway remodeling are not completely understood. Current therapeutic options are only partially effective in reducing the burden of neonatal airway disease and premature decline of lung function. Gasotransmitter hydrogen sulfide (H2S) has been recently recognized for its therapeutic potential in lung diseases. AREAS COVERED Contradictory to its well-known toxicity at high concentrations, H2S has been characterized to have anti-inflammatory, antioxidant, and antiapoptotic properties at physiological concentrations. In the respiratory system, endogenous H2S production participates in late lung development and exogenous H2S administration has a protective role in a variety of diseases such as acute lung injury and chronic pulmonary hypertension and fibrosis. Literature searches performed using NCBI PubMed without publication date limitations were used to construct this review, which highlights the dichotomous role of H2S in the lung, and explores its promising beneficial effects in lung diseases. EXPERT OPINION The emerging role of H2S in pathways involved in chronic lung disease of prematurity along with its recent use in animal models of BPD highlight H2S as a potential novel candidate in protecting lung function following preterm birth.
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Affiliation(s)
- Marta Schiliro
- Departments of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Christina Pabelick
- Departments of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Immature control of breathing and apnea of prematurity: the known and unknown. J Perinatol 2021; 41:2111-2123. [PMID: 33712716 PMCID: PMC7952819 DOI: 10.1038/s41372-021-01010-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
This narrative review provides a broad perspective on immature control of breathing, which is universal in infants born premature. The degree of immaturity and severity of clinical symptoms are inversely correlated with gestational age. This immaturity presents as prolonged apneas with associated bradycardia or desaturation, or brief respiratory pauses, periodic breathing, and intermittent hypoxia. These manifestations are encompassed within the clinical diagnosis of apnea of prematurity, but there is no consensus on minimum criteria required for diagnosis. Common treatment strategies include caffeine and noninvasive respiratory support, but other therapies have also been advocated with varying effectiveness. There is considerable variability in when and how to initiate and discontinue treatment. There are significant knowledge gaps regarding effective strategies to quantify the severity of clinical manifestations of immature breathing, which prevent us from better understanding the long-term potential adverse outcomes, including neurodevelopment and sudden unexpected infant death.
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38
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Miller-Barmak A, Riskin A, Hochwald O, Haddad J, Dinur G, Vortman R, Kugelman A, Borenstein-Levin L. Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support. J Pediatr 2020; 226:123-128. [PMID: 32615194 DOI: 10.1016/j.jpeds.2020.06.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO2) histograms. STUDY DESIGN Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO2 ranges. RESULTS The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO2 ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO2 >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]). CONCLUSIONS Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO2 histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO2 ranges.
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Affiliation(s)
- Adi Miller-Barmak
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Arieh Riskin
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Julie Haddad
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rita Vortman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Raffay TM, Martin RJ. Preemie Brains Don't Like Mechanical Ventilation! J Pediatr 2020; 226:12-14. [PMID: 32525040 PMCID: PMC8793350 DOI: 10.1016/j.jpeds.2020.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Thomas M Raffay
- Division of Neonatology Department of Pediatrics, UH Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio.
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40
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Shah VP, Raffay TM, Martin RJ, Vento M, Sánchez-Illana Á, Piñeiro-Ramos JD, Kuligowski J, Di Fiore JM. The Relationship between Oxidative Stress, Intermittent Hypoxemia, and Hospital Duration in Moderate Preterm Infants. Neonatology 2020; 117:577-583. [PMID: 32799210 PMCID: PMC7854776 DOI: 10.1159/000509038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/27/2020] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Lipid peroxidation products are present following oxidation of polyunsaturated fatty acids in the eye, brain, and various cell membranes. Elevated levels of lipid peroxidation products and increased intermittent hypoxemia (IH) events have been associated with adverse outcomes in extremely preterm infants. The moderate preterm newborn has a still-developing oxidant defense system and immature respiratory control, but little is known about lipid peroxidation levels and IH in this larger and more common preterm population. OBJECTIVE To determine the association between oxidative stress and IH in moderate preterm infants. METHOD Oxygen saturation was continuously monitored in 51 moderate preterm infants (i.e., 31 + 0/7 to 33 + 6/7 weeks' gestation). Urine samples were collected at the end of the first and second weeks of life. Samples were analyzed for total lipid peroxidation products (neurofurans, isofurans, neuroprostanes, isoprostanes, and di-homo-isofurans). RESULT At week 1, there was a correlation between increased IH frequency and neurofurans (p < 0.04) and di-homo-isofurans (p < 0.003). At week 2, there was no correlation between IH and lipid peroxidation markers. Ele-vations in neurofurans, isofurans, neuroprostanes, and di-homo-isofurans in the first and/or second week of life were associated with a longer stay in hospital. CONCLUSION Elevations in lipid peroxidation biomarkers in moderate preterm infants during their first weeks of life are associated with a higher frequency of IH and prolonged hospitalization.
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Affiliation(s)
- Vidhi P Shah
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Martin
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Máximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | | | | | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | - Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA,
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA,
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Kovatis KZ, Di Fiore JM, Martin RJ, Abbasi S, Chaundhary AS, Hoover S, Zhang Z, Kirpalani H. Effect of Blood Transfusions on Intermittent Hypoxic Episodes in a Prospective Study of Very Low Birth Weight Infants. J Pediatr 2020; 222:65-70. [PMID: 32423683 DOI: 10.1016/j.jpeds.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/18/2020] [Accepted: 03/09/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To compare the number of intermittent hypoxia events before and after packed red blood cell (pRBC) and non-pRBC transfusions in very low birth weight infants, and to compare the time spent with saturations of ≤85% before and after transfusions in the same population. STUDY DESIGN This prospective observational study was conducted from April 2014 to August 2017. It included 92 transfusions (81 pRBC, 11 non-pRBC) from 41 very low birth weight infants between 230/7 and 286/7 weeks of gestation. The primary outcome was number of intermittent hypoxia events. Secondary outcomes included the percent time of Peripheral capillary oxygen saturation (SpO2)of ≤85%, ≤80%, and ≤75%. A mixed ANOVA model was used to examine the relationship between event rate and covariates. RESULTS The mean number of intermittent hypoxia events per hour decreased from 5.27 ± 5.02 events per hour before pRBC transfusion to 3.61 ± 3.17 per hour after pRBC transfusions (P < .01) and intermittent hypoxia did not change after non-RBC transfusions (before, 4.45 ± 3.19 vs after, 4.47 ± 2.78; P = NS). The percent time with saturations of ≤80% and ≤75% significantly decreased after pRBC transfusions (P = .01). The time with saturations of ≤85% did not significantly change after non-pRBC transfusion. CONCLUSIONS In very low birth weight infants with a hematocrit of 20%-42%, pRBC transfusions are associated with decreased frequency of intermittent hypoxia. No such diminution of intermittent hypoxia events was observed in infants who had received a non-pRBC transfusion. This finding suggests that the observed beneficial effects of RBC transfusions on apnea and its clinical manifestations of intermittent hypoxia are mediated through an enhanced oxygen carrying capacity.
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Affiliation(s)
- Kelley Z Kovatis
- Department of Neonatology, Christiana Care Health System, Newark, DE.
| | - Juliann M Di Fiore
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Soraya Abbasi
- Division of Neonatology, Pennsylvania Hospital, Philadelphia, PA; Division of Neonatology, University of Pennsylvania, Philadelphia, PA
| | | | - Stephen Hoover
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Zugui Zhang
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
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42
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Martini S, Frabboni G, Rucci P, Czosnyka M, Smielewski P, Galletti S, Vitali F, Faldella G, Austin T, Corvaglia L. Cardiorespiratory Events in Infants Born Preterm during the Transitional Period. J Pediatr 2020; 221:32-38.e2. [PMID: 32446489 DOI: 10.1016/j.jpeds.2020.02.037] [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: 11/27/2019] [Revised: 01/22/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate the features of cardiorespiratory events in infants born preterm during the transitional period, and to evaluate whether different neonatal characteristics may correlate with event type, duration, and severity. STUDY DESIGN Infants with gestational age (GA) <32 weeks and/or birth weight <1500 g were enrolled in this observational prospective study. Heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded continuously over the first 72 hours. Cardiorespiratory events of ≥10 seconds were clustered into isolated desaturation (SpO2 <85%), isolated bradycardia (HR <100 bpm or <70% of baseline), or combined desaturation/bradycardia and classified as mild, moderate, or severe. The daily incidences of isolated desaturation, isolated bradycardia, and combined desaturation and bradycardia were analyzed. The effects of relevant clinical variables on cardiorespiratory event type and severity were assessed using generalized estimating equations. RESULTS Among the 1050 events analyzed, isolated desaturations were the most frequent (n = 625) and isolated bradycardias the least common (n = 171). The number of cardiorespiratory events increased significantly from day 1 to day 2 (P = .028). One in 5 events had severe characteristics; event severity was highest for combined desaturation and bradycardia (P < .001). Compared with other event types, the incidence of combined desaturation and bradycardia was inversely correlated with GA (P = .029) and was higher with the use of continuous positive airway pressure (P = .002). The presence of a hemodynamically significant patent ductus arteriosus was associated with the occurrence of isolated desaturations (P = .001) and with a longer duration of cardiorespiratory events (P = .003). CONCLUSIONS Cardiorespiratory events during transition exhibit distinct types, duration, and severity. Neonatal characteristics are associated with the clinical features of these events, indicating that a tailored clinical approach may reduce the hypoxic burden in preterm infants aged 0-72 hours.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC).
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Paola Rucci
- Division of Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Silvia Galletti
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
| | - Francesca Vitali
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
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43
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Effect of fluctuation of oxygenation on the development of severe retinopathy of prematurity in extremely preterm infants. J Perinatol 2020; 40:515-521. [PMID: 31907394 DOI: 10.1038/s41372-019-0571-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate factors associated with development of severe retinopathy of prematurity (ROP) in extremely preterm (EP) infants. STUDY DESIGN This retrospective cohort study included 213 EP infants (22 + 0 to 27 + 6 weeks gestation) who were admitted to the neonatal intensive care unit of Osaka Women's and Children's Hospital between 2009 and 2017. Multivariable logistic regression analysis was used to identify neonatal factors associated with severe ROP requiring treatment. RESULT After adjustments for gestational age (GA), birth weight, sex, red blood cell transfusion, average SpO2, and fluctuations of SpO2 from birth to 32 weeks postmenstrual age, fluctuations of SpO2 (odds ratio [OR]: 2.10, 95% confidence interval [CI]: 1.03-4.27), and low GA (OR: 0.95, 95% CI: 0.91-0.98) were significantly associated with severe ROP. CONCLUSIONS Fluctuations of SpO2 from birth to 32 weeks postmenstrual age and low GA were significantly associated with development of severe ROP requiring treatment in EP infants.
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44
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Clinical quantification of SpO 2 instability using a new histogram classification system: a clinical study. Pediatr Res 2020; 87:716-720. [PMID: 31539898 DOI: 10.1038/s41390-019-0566-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Oxygenation instability is not quantified or documented despite being common and correlated with neonatal morbidities, retinopathy of prematurity, and adverse 18-month outcomes. METHODS We developed a five-type SpO2 histogram classification system based on the SpO2 difference within the 10-90th cumulative time percentile (A) and the time percentage with SpO2 ≤80% (B). In type 1, A is <5% and in type 5, A and B are ≥10%. We then studied consecutive 12-h SpO2 frequency histograms in all infants ≤34 weeks gestation receiving respiratory support on day 1, over 6 months. RESULTS Six thousand and sixteen histograms were obtained in 73 infants, 28.9 ± 3.0 weeks gestation, and birth weight (BW) 1318.5 ± 495 g. All types were common and did not overlap. Type 3-5 ("unstable") histograms were more common in oxygen or any intubated support. Time in SpO2 <85% and <80% progressively increased in types 3-5. Among histograms in oxygen, the mean (±SD) of SpO2 medians was 92.8 ± 1.9. Infants ≤28 weeks exhibited three phases of SpO2 instability (stable-unstable-stable). Those developing unstable histograms during the first week received longer ventilatory support (median [IQR], 101 [66] vs. 62 [28] days) and supplemental oxygen (62.5 [72] vs. 40.5 [40] days), and more were on ventilatory support at 40 weeks (7/15 vs. 0/10). CONCLUSIONS Classified SpO2 histograms quantify and document SpO2 instability and identify early infants at risk of prolonged respiratory support, while median SpO2 does not.
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45
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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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46
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Abstract
The premature neonate is at high risk for childhood airway hyperreactivity and episodes of wheezing. Intermittent hypoxic events are frequently observed during the first weeks and months of life in these infants. Intermittent hypoxemia has been associated with adverse outcomes in extremely premature infants; including the diagnosis of bronchopulmonary dysplasia, reported wheezing, and use of prescription asthma medications. We review the incidence of intermittent hypoxia, their potential role in short and longer term respiratory morbidity, and the translational newborn models now being used to investigate common pathways by which intermittent hypoxia contributes to respiratory disease.
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Affiliation(s)
- Thomas M. Raffay
- Rainbow Babies & Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106-6010
| | - Richard J. Martin
- Rainbow Babies & Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106-6010
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47
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McDonald FB, Dempsey EM, O'Halloran KD. The impact of preterm adversity on cardiorespiratory function. Exp Physiol 2019; 105:17-43. [PMID: 31626357 DOI: 10.1113/ep087490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
Abstract
NEW FINDINGS What is the topic of this review? We review the influence of prematurity on the cardiorespiratory system and examine the common sequel of alterations in oxygen tension, and immune activation in preterm infants. What advances does it highlight? The review highlights neonatal animal models of intermittent hypoxia, hyperoxia and infection that contribute to our understanding of the effect of stress on neurodevelopment and cardiorespiratory homeostasis. We also focus on some of the important physiological pathways that have a modulatory role on the cardiorespiratory system in early life. ABSTRACT Preterm birth is one of the leading causes of neonatal mortality. Babies that survive early-life stress associated with immaturity have significant prevailing short- and long-term morbidities. Oxygen dysregulation in the first few days and weeks after birth is a primary concern as the cardiorespiratory system slowly adjusts to extrauterine life. Infants exposed to rapid alterations in oxygen tension, including exposures to hypoxia and hyperoxia, have altered redox balance and active immune signalling, leading to altered stress responses that impinge on neurodevelopment and cardiorespiratory homeostasis. In this review, we explore the clinical challenges posed by preterm birth, followed by an examination of the literature on animal models of oxygen dysregulation and immune activation in the context of early-life stress.
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Affiliation(s)
- Fiona B McDonald
- Department of Physiology, School of Medicine, College of Medicine & Health, University College Cork, Cork, Ireland.,Irish Centre for Fetal and Neonatal Translational Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Irish Centre for Fetal and Neonatal Translational Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Paediatrics & Child Health, School of Medicine, College of Medicine & Health, Cork University Hospital, Wilton, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, College of Medicine & Health, University College Cork, Cork, Ireland.,Irish Centre for Fetal and Neonatal Translational Research (INFANT) Research Centre, University College Cork, Cork, Ireland
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48
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Ganguly A, Martin RJ. Vulnerability of the developing airway. Respir Physiol Neurobiol 2019; 270:103263. [PMID: 31386914 DOI: 10.1016/j.resp.2019.103263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/02/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022]
Abstract
Longer term respiratory morbidity is a frequent concern for former preterm infants. Increased airway reactivity and wheezing disorders are extremely common in this population, both in infants who meet diagnostic criteria for bronchopulmonary dysplasia [BPD], and in the absence of this diagnosis. It is, therefore, imperative to gain a better understanding of normal and abnormal postnatal development of the immature airway. Airway hyperreactivity may be secondary to abnormal bronchoalveolar attachments in the face of parenchymal lung injury, or secondary to an imbalance between constrictor and dilator neural pathways. Finally, the airway itself may undergo functional and/or structural changes, including increased airway smooth muscle mass, and changes in airway extracellular matrix which may, in turn, modulate downstream signaling pathways to hyperoxia or pressure exposed vulnerable airways.
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Affiliation(s)
- Abhrajit Ganguly
- Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, United States.
| | - Richard J Martin
- Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, United States.
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49
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Dylag AM, Raffay TM. Rodent models of respiratory control and respiratory system development-Clinical significance. Respir Physiol Neurobiol 2019; 268:103249. [PMID: 31315068 DOI: 10.1016/j.resp.2019.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/24/2019] [Accepted: 06/29/2019] [Indexed: 01/13/2023]
Abstract
The newborn infant's respiratory system must rapidly adapt to extra-uterine life. Neonatal rat and mouse models have been used to investigate early development of respiratory control and reactivity in both health and disease. This review highlights several rodent models of control of breathing and respiratory system development (including pulmonary function), discusses their translational strengths and limitations, and underscores the importance of creating clinically relevant models applicable to the human infant.
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Affiliation(s)
- Andrew M Dylag
- Division of Neonatology, Golisano Children's Hospital, Department of Pediatrics, University of Rochester, Rochester, NY, United States
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies & Children's Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States.
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50
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Intermittent hypoxemia and oxidative stress in preterm infants. Respir Physiol Neurobiol 2019; 266:121-129. [PMID: 31100375 DOI: 10.1016/j.resp.2019.05.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/17/2019] [Accepted: 05/10/2019] [Indexed: 01/11/2023]
Abstract
Intermittent hypoxemia events (IH) are common in extremely preterm infants and are associated with many poor outcomes including retinopathy or prematurity, wheezing, bronchopulmonary dysplasia, cognitive or language delays and motor impairment. More recent data in animal and rodent models have suggested that specific patterns of IH may increase the risk for morbidity. The pathway by which these high risk patterns of IH initiate a pathological cascade is unknown but animal models suggest that oxidative stress may play a role. This review describes early postnatal patterns of IH in preterm infants, their relationship with morbidity, oxidative stress biomarkers relevant to the newborn infant and the relationship between IH and reactive oxygen species.
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