1
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Aleem S, Greenberg RG. Accurate Prediction of Bronchopulmonary Dysplasia: Are We There Yet? J Pediatr 2023; 258:113389. [PMID: 36933768 DOI: 10.1016/j.jpeds.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 03/20/2023]
Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
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2
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Zannin E, Stoecklin B, Choi JY, Simpson SJ, Veneroni C, Dellaca RL, Pillow JJ. Ventilatory response and stability of oxygen saturation during a hypoxic challenge in very preterm infants. Pediatr Pulmonol 2023; 58:1454-1462. [PMID: 36748837 DOI: 10.1002/ppul.26343] [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: 11/02/2022] [Revised: 01/17/2023] [Accepted: 02/05/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preterm infants have immature control of breathing and impaired pulmonary gas exchange. We hypothesized that infants with bronchopulmonary dysplasia (BPD) have a blunted ventilatory response and peripheral oxygen saturation (SpO2 ) instability during a hypoxic challenge. METHODS We evaluated the response to hypoxia in 57 very preterm infants (38 no BPD, 10 mild BPD, 9 moderate-to-severe BPD) at 36 weeks' postmenstrual age. The fraction of inspired oxygen (FI O2 ) was reduced stepwise at 5-min intervals to achieve peripheral SpO2 between 86% and 95%. The lowest permissible FI O2 and SpO2 were 0.14% and 86%. We recorded SpO2 , FI O2 , and the respiratory signal (respiratory inductive plethysmography). We calculated respiratory rate (RR), tidal volume (VT ), minute ventilation (VE ), and respiratory drive (ratio between VT and inspiratory time, VT /TI ). SpO2 variability was expressed as the interquartile range (IQR). RESULTS FI O2 was reduced from a median (Q1, Q3) of 0.21 (0.21, 0.21) to 0.17 (0.17, 0.18). We observed a marked individual variability in the ventilatory response to the hypoxic challenge, regardless of BPD severity. At the lowest permissible FI O2 , 37 (65%) infants reduced their VE , and 20 (35%) increased minute ventilation; 20 infants (35%) developed periodic breathing associated with increased SpO2 IQR and lower SpO2 minima, and 16 (28%) exhibited an oscillatory pattern in VE and SpO2 without end-expiratory pauses, regardless of BPD severity. CONCLUSION In very preterm infants, a mild hypoxic challenge reduced ventilation, increased SpO2 variability and periodic breathing regardless of BPD severity.
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Affiliation(s)
- Emanuela Zannin
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy.,Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Benjamin Stoecklin
- School of Human Sciences, University of Western Australia, Perth, Australia.,Department of Neonatology, Children's Lung Health, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Jane Y Choi
- School of Human Sciences, University of Western Australia, Perth, Australia.,Children's Lung Health, Wal-yan Respiratory Centre, Telethon Kids Institute, Perth, Australia
| | - Shannon J Simpson
- Children's Lung Health, Wal-yan Respiratory Centre, Telethon Kids Institute, Perth, Australia.,School of Physiotherapy and Exercise Science, Curtin School of Allied Health, Curtin University, Perth, Australia
| | - Chiara Veneroni
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Raffaele L Dellaca
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Jane J Pillow
- School of Human Sciences, University of Western Australia, Perth, Australia.,Children's Lung Health, Wal-yan Respiratory Centre, Telethon Kids Institute, Perth, Australia
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3
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Weinstock J, Xuchen X, Arroyo M, Aguilar H, Kahanowitch R, Gutierrez MJ, Nino G. The Next Frontier of Prematurity: Predicting Respiratory Morbidity During the First Two Years of Life in Extremely Premature Babies. Cureus 2022; 14:e23505. [PMID: 35494974 PMCID: PMC9045466 DOI: 10.7759/cureus.23505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/05/2022] Open
Abstract
Background Advances in perinatal and neonatal medicine have led to an increasing number of infants surviving extreme prematurity (≤27 weeks gestational age, GA). The goal of this study was to examine the respiratory outcomes after neonatal intensive care unit (NICU) discharge of this vulnerable population. We hypothesized that the rates of respiratory hospitalizations are disproportionally higher in the subset of infants born ≤27 weeks GA relative to premature infants born 28-32 weeks GA. Methodology A retrospective longitudinal study of severe premature children (≤32 weeks GA, n = 183) was conducted. We subdivided our sample into extremely preterm infants (≤27 weeks GA; n = 101) and those born very preterm (28-32 weeks GA; n = 82). Our main outcome was the presence of respiratory hospitalizations within 24 months of NICU discharge. Results Extremely premature infants had more than three times higher odds of respiratory hospitalization at 24 months relative to infants born 28-32 weeks GA (adjusted odds ratio = 3.4; 95% confidence interval = 1.8, 6.4; p < 0.01). The increased risk of respiratory hospitalization in extremely premature infants was independent of GA. Regression models identified that the duration of supplemental oxygen and Black/African American ethnicity were significant predictors of respiratory hospitalizations in both prematurity groups independent of gender and birth weight. Conclusions The results support that babies born ≤27 weeks GA represent a distinct high-risk group of severely premature infants that needs novel preventive strategies and targeted interventions to improve their respiratory outcomes after NICU discharge.
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4
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Mammel D, Kemp J. Prematurity, the diagnosis of bronchopulmonary dysplasia, and maturation of ventilatory control. Pediatr Pulmonol 2021; 56:3533-3545. [PMID: 34042316 DOI: 10.1002/ppul.25519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022]
Abstract
Infants born before 32 weeks gestational age and receiving respiratory support at 36 weeks postmenstrual age (PMA) are diagnosed with bronchopulmonary dysplasia (BPD). This label suggests that their need for supplemental oxygen (O2 ) is primarily due to acquired dysplasia of airways and airspaces, and that the supplemental O2 is treating residual parenchymal lung disease. However, emerging evidence suggests that immature ventilatory control may also contribute to the need for supplemental O2 at 36 weeks PMA. In all newborns, maturation of ventilatory control continues ex utero and is a plastic process. Among premature infants, supplemental O2 mitigates the hypoxemic effects of delayed maturation of ventilatory control, as well as reduces the duration and frequency of periodic breathing events. Nevertheless, prematurity is associated with altered and occasionally aberrant maturation of ventilatory control. Infants born prematurely, with or without a diagnosis of BPD, are more prone to long-lasting effects of dysfunctional ventilatory control. This review addresses normal and abnormal maturation of ventilatory control and suggests how aberrant maturation complicates assigning the diagnosis of BPD. Greater awareness of the interaction between parenchymal lung disease and delayed maturation of ventilatory control is essential to understanding why a given premature infant requires and is benefitting from supplemental O2 at 36 weeks PMA.
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Affiliation(s)
- Daniel Mammel
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - James Kemp
- Department of Pediatrics, Allergy and Pulmonary Medicine, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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5
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in infants and is associated with increased mortality, respiratory morbidity, neurodevelopmental impairment, and increased healthcare costs. In parallel with advances made in the field of neonatal intensive care, the phenotype of BPD has evolved from a fibrocystic disease affecting late preterm infants to one of impaired parenchymal development and dysregulated vascular growth predominantly affecting infants born before 29 weeks' gestational age. BPD has been shown to have significant lifelong consequences. Adults with BPD have been found to have abnormal lung function tests, reduced exercise tolerance, and may be at increased risk for developing chronic obstructive pulmonary disease. Evidence shows that BPD occurs secondary to genetic-environmental interactions in an immature lung. In this review, we evaluate the various clinical definitions, imaging modalities, and biomarker data that are helpful in making an early diagnosis of BPD. In addition, we evaluate recent evidence about the prevention and treatment of BPD. We discuss the invasive and non-invasive ventilation strategies and pharmacological agents used in the early, evolving, and established phases of BPD.
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Affiliation(s)
- Margaret Gilfillan
- Division of Neonatology, St Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anita Bhandari
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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6
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Nino G, Mansoor A, Perez GF, Arroyo M, Xuchen X, Weinstock J, Kyle Salka, Said M, Acuña-Cordero R, Sossa-Briceño MP, Rodríguez-Martínez CE, Linguraru M. Validation of a new predictive model to improve risk stratification in bronchopulmonary dysplasia. Sci Rep 2020; 10:613. [PMID: 31953419 PMCID: PMC6969113 DOI: 10.1038/s41598-019-56355-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/08/2019] [Indexed: 11/09/2022] Open
Abstract
We need a better risk stratification system for the increasing number of survivors of extreme prematurity suffering the most severe forms of bronchopulmonary dysplasia (BPD). However, there is still a paucity of studies providing scientific evidence to guide future updates of BPD severity definitions. Our goal was to validate a new predictive model for BPD severity that incorporates respiratory assessments beyond 36 weeks postmenstrual age (PMA). We hypothesized that this approach improves BPD risk assessment, particularly in extremely premature infants. This is a longitudinal cohort of premature infants (≤32 weeks PMA, n = 188; Washington D.C). We performed receiver operating characteristic analysis to define optimal BPD severity levels using the duration of supplementary O2 as predictor and respiratory hospitalization after discharge as outcome. Internal validation included lung X-ray imaging and phenotypical characterization of BPD severity levels. External validation was conducted in an independent longitudinal cohort of premature infants (≤36 weeks PMA, n = 130; Bogota). We found that incorporating the total number of days requiring O2 (without restricting at 36 weeks PMA) improved the prediction of respiratory outcomes according to BPD severity. In addition, we defined a new severity category (level IV) with prolonged exposure to supplemental O2 (≥120 days) that has the highest risk of respiratory hospitalizations after discharge. We confirmed these findings in our validation cohort using ambulatory determination of O2 requirements. In conclusion, a new predictive model for BPD severity that incorporates respiratory assessments beyond 36 weeks improves risk stratification and should be considered when updating current BPD severity definitions.
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Affiliation(s)
- Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine. Children's National Medical Center, George Washington University, Washington, DC, USA. .,Department of Pediatrics, George Washington University, Washington, DC, USA.
| | - Awais Mansoor
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC, USA
| | - Geovanny F Perez
- Division of Pediatric Pulmonary and Sleep Medicine. Children's National Medical Center, George Washington University, Washington, DC, USA.,Department of Pediatrics, George Washington University, Washington, DC, USA
| | - Maria Arroyo
- Division of Pediatric Pulmonary and Sleep Medicine. Children's National Medical Center, George Washington University, Washington, DC, USA.,Department of Pediatrics, George Washington University, Washington, DC, USA
| | - Xilei Xuchen
- Division of Pediatric Pulmonary and Sleep Medicine. Children's National Medical Center, George Washington University, Washington, DC, USA.,Department of Pediatrics, George Washington University, Washington, DC, USA
| | - Jered Weinstock
- Division of Pediatric Pulmonary and Sleep Medicine. Children's National Medical Center, George Washington University, Washington, DC, USA.,Department of Pediatrics, George Washington University, Washington, DC, USA
| | - Kyle Salka
- Division of Pediatric Pulmonary and Sleep Medicine. Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Mariam Said
- Division of Neonatology. Children's National Medical Center, George Washington University, Washington, DC, USA.,Department of Pediatrics, George Washington University, Washington, DC, USA
| | - Ranniery Acuña-Cordero
- Department of Pediatric Pulmonology, Hospital Militar Central, Department of Pediatrics, School of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Carlos E Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Marius Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC, USA.,Department of Pediatrics, George Washington University, Washington, DC, USA.,Department of Radiology, George Washington University, Washington, DC, USA.,Department of Biomedical Engineering, George Washington University, Washington, DC, USA
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7
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Hoover J, Wambach J, Vachharajani A, Warner B, Carroll JL, Kemp JS. Postmenstrual age at discharge in premature infants with and without ventilatory pattern instability. J Perinatol 2020; 40:157-162. [PMID: 31611617 PMCID: PMC7480785 DOI: 10.1038/s41372-019-0530-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/17/2019] [Accepted: 08/19/2019] [Indexed: 01/01/2023]
Abstract
RATIONALE To determine if ventilatory pattern instability, manifested as periodic breathing (PB) during physiologic challenge testing, affects postmenstrual age (PMA) at discharge. METHODS Eighty infants underwent challenge testing at 36 weeks PMA. Infants breathing supplemental O2 received a room air challenge (RAC, N = 51); those breathing ambient air underwent a hypoxic challenge test (HCT, N = 29). Infants were assigned one of four ventilatory control phenotypes based on the presence or absence of PB during their test, and if they passed or failed because of hypoxemia during the challenge test. RESULTS There were no clinical or demographic differences between groups. Infants who passed their challenge testing were, on average, discharged 1.6 weeks sooner than those who failed. The groups of ventilatory control phenotypes differed in PMA at discharge (p = 0.0020), but those with PB were younger by PMA at discharge. CONCLUSIONS Ventilatory pattern instability did not prolong time to discharge. Passing either challenge was associated with earlier discharge, suggesting these tests might identify infants who can have nasal cannula support removed and be safely discharged sooner. Most of the infants who failed their challenge tests with PB were receiving nasal cannula support. Nasal cannula support may be not only treating hypoxemia due to bronchopulmonary dysplasia (BPD), but also mitigating their ventilatory pattern instability.
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Affiliation(s)
- Jeffery Hoover
- Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA.
| | - Jennifer Wambach
- Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Akshaya Vachharajani
- Division of Neonatology, University of Missouri in Columbia, Columbia, MO 65211, USA
| | - Barbara Warner
- Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - John L. Carroll
- Division of Pulmonary and Sleep Medicine, University of Arkansas for Medical Sciences, Fayetteville, AR 72701, USA
| | - James S. Kemp
- Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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8
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Dennery PA, Di Fiore JM, Ambalavanan N, Bancalari E, Carroll JL, Claure N, Hamvas A, Hibbs AM, Indic P, Kemp J, Krahn KN, Lake D, Laposky A, Martin RJ, Natarajan A, Rand C, Schau M, Weese-Mayer DE, Zimmet AM, Moorman JR. Pre-Vent: the prematurity-related ventilatory control study. Pediatr Res 2019; 85:769-776. [PMID: 30733614 PMCID: PMC6503843 DOI: 10.1038/s41390-019-0317-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The increasing incidence of bronchopulmonary dysplasia in premature babies may be due in part to immature ventilatory control, contributing to hypoxemia. The latter responds to ventilation and/or oxygen therapy, treatments associated with adverse sequelae. This is an overview of the Prematurity-Related Ventilatory Control Study which aims to analyze the under-utilized cardiorespiratory continuous waveform monitoring data to delineate mechanisms of immature ventilatory control in preterm infants and identify predictive markers. METHODS Continuous ECG, heart rate, respiratory, and oxygen saturation data will be collected throughout the NICU stay in 500 infants < 29 wks gestation across 5 centers. Mild permissive hypercapnia, and hyperoxia and/or hypoxia assessments will be conducted in a subcohort of infants along with inpatient questionnaires, urine, serum, and DNA samples. RESULTS Primary outcomes will be respiratory status at 40 wks and quantitative measures of immature breathing plotted on a standard curve for infants matched at 36-37 wks. Physiologic and/or biologic determinants will be collected to enhance the predictive model linking ventilatory control to outcomes. CONCLUSIONS By incorporating bedside monitoring variables along with biomarkers that predict respiratory outcomes we aim to elucidate individualized cardiopulmonary phenotypes and mechanisms of ventilatory control contributing to adverse respiratory outcomes in premature infants.
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Affiliation(s)
- Phyllis A. Dennery
- Brown University, Warren Alpert School of Medicine, Hasbro Children’s Hospital, Providence, RI,Address for Correspondence Phyllis A. Dennery, MD, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Office of the Chair, Hasbro Children’s Hospital, 593 Eddy Street, Suite 125 / Providence, RI 02903, (401) 444-5648,
| | - Juliann M. Di Fiore
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Namasivayam Ambalavanan
- University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics Molecular and Cellular Pathology, and Cell, Developmental, and Integrative Biology, Birmingham, AL
| | - Eduardo Bancalari
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - John L. Carroll
- University of Arkansas for Medical Science, Department of Pediatrics, Little Rock, AR
| | - Nelson Claure
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - Aaron Hamvas
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Anna Maria Hibbs
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Premananda Indic
- University of Texas Tyler, Department of Electrical Engineering, University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics, Tyler, TX
| | - James Kemp
- Washington University School of Medicine in St. Louis, Department of Pediatrics, St. Louis, MO
| | - Katy N. Krahn
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Douglas Lake
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Aaron Laposky
- National Institute of Health, National Center of Sleep Disorders Research, Bethesda, MD
| | - Richard J. Martin
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Aruna Natarajan
- Division of Lung Diseases, National Heart Lung and Blood Institute, National Institute of Health, Bethesda, MD
| | - Casey Rand
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Molly Schau
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Debra E. Weese-Mayer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Amanda M. Zimmet
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - J. Randall Moorman
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
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9
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Ren CL, Feng R, Davis SD, Eichenwald E, Jobe A, Moore PE, Panitch HB, Sharp JK, Kisling J, Clem C. Tidal Breathing Measurements at Discharge and Clinical Outcomes in Extremely Low Gestational Age Neonates. Ann Am Thorac Soc 2018; 15:1311-1319. [PMID: 30088802 PMCID: PMC6322016 DOI: 10.1513/annalsats.201802-112oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/07/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The relationship between respiratory function at hospital discharge and the severity of later respiratory disease in extremely low gestational age neonates is not well defined. OBJECTIVES To test the hypothesis that tidal breathing measurements near the time of hospital discharge differ between extremely premature infants with bronchopulmonary dysplasia (BPD) or respiratory disease in the first year of life and those without these conditions. METHODS Study subjects were part of the PROP (Prematurity and Respiratory Outcomes Program) study, a longitudinal cohort study of infants born at less than 29 gestational weeks followed from birth to 1 year of age. Respiratory inductance plethysmography was used for tidal breathing measurements before and after inhaled albuterol 1 week before anticipated hospital discharge. Infants were breathing spontaneously and were receiving less than or equal to 1 L/min nasal cannula flow at 21% to 100% fraction of inspired oxygen. A survey of respiratory morbidity was administered to caregivers at 3, 6, 9, and 12 months corrected age to assess for respiratory disease. We compared tidal breathing measurements in infants with and without BPD (oxygen requirement at 36 wk) and with and without respiratory disease in the first year of life. Measurements were also performed in a comparison cohort of term infants. RESULTS A total of 765 infants survived to 36 weeks postmenstrual age, with research-quality tidal breathing data in 452 out of 564 tested (80.1%). Among these 452 infants, the rate of postdischarge respiratory disease was 65.7%. Compared with a group of 18 term infants, PROP infants had abnormal tidal breathing patterns. However, there were no clinically significant differences in tidal breathing measurements in PROP infants who had BPD or who had respiratory disease in the first year of life compared with those without these diagnoses. Bronchodilator response was not significantly associated with respiratory disease in the first year of life. CONCLUSIONS Extremely premature infants receiving less than 1 L/min nasal cannula support at 21% to 100% fraction of inspired oxygen have tidal breathing measurements that differ from term infants, but these measurements do not differentiate those preterm infants who have BPD or will have respiratory disease in the first year of life from those who do not. Clinical trial registered with www.clinicaltrials.gov (NCT01435187).
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Affiliation(s)
- Clement L. Ren
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - Rui Feng
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stephanie D. Davis
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - Eric Eichenwald
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Jobe
- Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul E. Moore
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Jeff Kisling
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - Charles Clem
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - on behalf of the Prematurity and Respiratory Outcomes Program*
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Children’s Hospital Medical Center, Cincinnati, Ohio
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Texas Children’s Hospital, Houston, Texas; and
- Washington University, St. Louis, Missouri
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10
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Ortiz LE, McGrath-Morrow SA, Sterni LM, Collaco JM. Sleep disordered breathing in bronchopulmonary dysplasia. Pediatr Pulmonol 2017; 52:1583-1591. [PMID: 29064170 PMCID: PMC5693767 DOI: 10.1002/ppul.23769] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/20/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are limited data on the effect of bronchopulmonary dysplasia (BPD) on sleep disordered breathing (SDB). We hypothesized that both the severity of prematurity and BPD would increase the likelihood of SDB in early childhood. Our secondary aim was to evaluate the association of demographic factors on the development of SDB. METHODS This is a retrospective study of patient factors and overnight polysomnogram (PSG) data of children enrolled in our BPD registry between 2008 and 2015. Association between PSG results and studied variables was assessed using multiple linear regression analysis. RESULTS One-hundred-forty children underwent at least one sleep study on room air. The mean respiratory disturbance index (RDI) was elevated at 9.9 events/hr (SD: 10.1). The mean obstructive apnea-hypopnea index (OAHI) was 6.5 (9.1) events/hr and the mean central event rate of 3.0 (3.7) events/hr. RDI had decreased by 22% or 1.5 events/hour (95%CI: 0.6, 1.9) with each year of age (P = 0.005). Subjects with more severe respiratory disease had 38% more central events (P = 0.02). Infants exposed to secondhand smoke had 2.4% lower (P = 0.04) oxygen saturation nadirs and a pattern for more desaturation events. Non-white subjects were found to have 33% higher OAHI (P = 0.05), while white subjects had a 61% higher rate of central events (P < 0.001). CONCLUSIONS RDI was elevated in a selected BPD population compared to norms for non-preterm children. BPD severity, smoke exposure, and race may augment the severity of SDB. RDI improved with age but was still elevated by age 4, suggesting that this population is at risk for the sequelae of SDB.
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Affiliation(s)
- Luis E Ortiz
- Johns Hopkins Medical Institutions, Baltimore, Maryland
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11
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Keller RL, Feng R, DeMauro SB, Ferkol T, Hardie W, Rogers EE, Stevens TP, Voynow JA, Bellamy SL, Shaw PA, Moore PE. Bronchopulmonary Dysplasia and Perinatal Characteristics Predict 1-Year Respiratory Outcomes in Newborns Born at Extremely Low Gestational Age: A Prospective Cohort Study. J Pediatr 2017; 187:89-97.e3. [PMID: 28528221 PMCID: PMC5533632 DOI: 10.1016/j.jpeds.2017.04.026] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/22/2017] [Accepted: 04/11/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess the utility of clinical predictors of persistent respiratory morbidity in extremely low gestational age newborns (ELGANs). STUDY DESIGN We enrolled ELGANs (<29 weeks' gestation) at ≤7 postnatal days and collected antenatal and neonatal clinical data through 36 weeks' postmenstrual age. We surveyed caregivers at 3, 6, 9, and 12 months' corrected age to identify postdischarge respiratory morbidity, defined as hospitalization, home support (oxygen, tracheostomy, ventilation), medications, or symptoms (cough/wheeze). Infants were classified as having postprematurity respiratory disease (PRD, the primary study outcome) if respiratory morbidity persisted over ≥2 questionnaires. Infants were classified with severe respiratory morbidity if there were multiple hospitalizations, exposure to systemic steroids or pulmonary vasodilators, home oxygen after 3 months or mechanical ventilation, or symptoms despite inhaled corticosteroids. Mixed-effects models generated with data available at 1 day (perinatal) and 36 weeks' postmenstrual age were assessed for predictive accuracy. RESULTS Of 724 infants (918 ± 234 g, 26.7 ± 1.4 weeks' gestational age) classified for the primary outcome, 68.6% had PRD; 245 of 704 (34.8%) were classified as severe. Male sex, intrauterine growth restriction, maternal smoking, race/ethnicity, intubation at birth, and public insurance were retained in perinatal and 36-week models for both PRD and respiratory morbidity severity. The perinatal model accurately predicted PRD (c-statistic 0.858). Neither the 36-week model nor the addition of bronchopulmonary dysplasia to the perinatal model improved accuracy (0.856, 0.860); c-statistic for BPD alone was 0.907. CONCLUSION Both bronchopulmonary dysplasia and perinatal clinical data accurately identify ELGANs at risk for persistent and severe respiratory morbidity at 1 year. TRIAL REGISTRATION ClinicalTrials.gov: NCT01435187.
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Affiliation(s)
- Roberta L. Keller
- Pediatrics/Neonatology, University of California San Francisco, Benioff Children’s Hospital, San Francisco CA
| | - Rui Feng
- Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia PA
| | - Sara B. DeMauro
- Pediatrics/Neonatology, University of Pennsylvania, Philadelphia PA
| | - Thomas Ferkol
- Departments of Pediatrics and Cell Biology and Physiology, Washington University, St. Louis MO
| | - William Hardie
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | - Elizabeth E. Rogers
- Pediatrics/Neonatology, University of California San Francisco, Benioff Children’s Hospital, San Francisco CA
| | - Timothy P. Stevens
- Department of Pediatrics, University of Rochester, Golisano Children’s Hospital, Rochester NY
| | - Judith A. Voynow
- Department of Pediatrics, Virginia Commonwealth University, Richmond VA
| | | | - Pamela A. Shaw
- Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia PA
| | - Paul E. Moore
- Department of Pediatrics/Pediatric Allergy, Immunology and Pulmonary Medicine and Center for Asthma Research, Vanderbilt University, Nashville TN
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Comparisons and Limitations of Current Definitions of Bronchopulmonary Dysplasia for the Prematurity and Respiratory Outcomes Program. Ann Am Thorac Soc 2016; 12:1822-30. [PMID: 26397992 DOI: 10.1513/annalsats.201504-218oc] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
RATIONALE Bronchopulmonary dysplasia is the most common morbidity of prematurity, but the validity and utility of commonly used definitions have been questioned. OBJECTIVES To compare three commonly used definitions of bronchopulmonary dysplasia in a contemporary prospective, multicenter observational cohort of extremely preterm infants. METHODS At 36 weeks postmenstrual age, the following definitions of bronchopulmonary dysplasia were applied to surviving infants with and without imputation: need for supplemental oxygen (Shennan definition), National Institutes of Health Workshop definition, and "physiologic" definition after a room-air challenge. MEASUREMENTS AND MAIN RESULTS Of 765 survivors assessed at 36 weeks, bronchopulmonary dysplasia was diagnosed in 40.8, 58.6, and 32.0% of infants, respectively, with the Shennan, workshop and physiologic definitions. The number of unclassified infants was lowest with the workshop definition (2.1%) and highest with the physiologic definition (16.1%). After assigning infants discharged home in room air before 36 weeks as no bronchopulmonary dysplasia, the modified Shennan definition compared favorably to the workshop definition, with 2.9% unclassified infants. Newer management strategies with nasal cannula flows up to 4 L/min or more and 0.21 FiO2 at 36 weeks obscured classification of bronchopulmonary dysplasia status in 12.4% of infants. CONCLUSIONS Existing definitions of bronchopulmonary dysplasia differ with respect to ease of data collection and number of unclassifiable cases. Contemporary changes in management of infants, such as use of high-flow nasal cannula, limit application of existing definitions and may result in misclassification. A contemporary definition of bronchopulmonary dysplasia that correlates with respiratory morbidity in childhood is needed. Clinical trial registered with www.clinicaltrials.gov (NCT01435187).
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Bouslama M, Adla-Biassette H, Ramanantsoa N, Bourgeois T, Bollen B, Brissaud O, Matrot B, Gressens P, Gallego J. Protective effects of intermittent hypoxia on brain and memory in a mouse model of apnea of prematurity. Front Physiol 2015; 6:313. [PMID: 26582992 PMCID: PMC4631942 DOI: 10.3389/fphys.2015.00313] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/19/2015] [Indexed: 01/15/2023] Open
Abstract
Apnea of prematurity (AOP) is considered a risk factor for neurodevelopmental disorders in children based on epidemiological studies. This idea is supported by studies in newborn rodents in which exposure to intermittent hypoxia (IH) as a model of AOP significantly impairs development. However, the severe IH used in these studies may not fully reflect the broad spectrum of AOP severity. Considering that hypoxia appears neuroprotective under various conditions, we hypothesized that moderate IH would protect the neonatal mouse brain against behavioral stressors and brain damage. On P6, each pup in each litter was randomly assigned to one of three groups: a group exposed to IH while separated from the mother (IH group), a control group exposed to normoxia while separated from the mother (AIR group), and a group of untreated unmanipulated pups left continuously with their mother until weaning (UNT group). Exposure to moderate IH (8% O2) consisted of 20 hypoxic events/hour, 6 h per day from postnatal day 6 (P6) to P10. The stress generated by maternal separation in newborn rodents is known to impair brain development, and we expected this effect to be smaller in the IH group compared to the AIR group. In a separate experiment, we combined maternal separation with excitotoxic brain lesions mimicking those seen in preterm infants. We analyzed memory, angiogenesis, neurogenesis and brain lesion size. In non-lesioned mice, IH stimulated hippocampal angiogenesis and neurogenesis and improved short-term memory indices. In brain-lesioned mice, IH decreased lesion size and prevented memory impairments. Contrary to common perception, IH mimicking moderate apnea may offer neuroprotection, at least in part, against brain lesions and cognitive dysfunctions related to prematurity. AOP may therefore have beneficial effects in some preterm infants. These results support the need for stratification based on AOP severity in clinical trials of treatments for AOP, to determine whether in patients with moderate AOP, these treatments are beneficial or deleterious.
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Affiliation(s)
- Myriam Bouslama
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France
| | - Homa Adla-Biassette
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France ; Department of Pathology, Lariboisière Hospital Paris, France
| | - Nelina Ramanantsoa
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France
| | - Thomas Bourgeois
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France
| | - Bieke Bollen
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France ; Laboratory of Biological Psychology, University of Leuven Leuven, Belgium
| | - Olivier Brissaud
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France ; Neonatal Intensive Care Unit, Bordeaux University Hospital Bordeaux, France
| | - Boris Matrot
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France
| | - Pierre Gressens
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France
| | - Jorge Gallego
- Inserm, U1141, Robert Debré Hospital Paris, France ; Paris Diderot-Paris 7 University Paris, France
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