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Fei Q, Pan J, Zhang F, Lin Y, Yuan T. Comparison of Different Treatments of Persistent Pulmonary Hypertension of the Newborn: A Systematic Review and Network Meta-Analysis. Crit Care Med 2024; 52:e314-e322. [PMID: 38363176 DOI: 10.1097/ccm.0000000000006227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Persistent pulmonary hypertension of the newborn (PPHN) is a life-threatening disease. Despite being considered the gold standard treatment scheme, inhaled nitric oxide (iNO) is not readily available in settings with limited resources. Therefore, in recent years, research on related drugs is being actively pursued. Herein, we aimed to use random-effects network meta-analysis to evaluate the efficacy and associated mortality of different PPHN therapies. DATA SOURCES We electronically searched the PubMed, Embase, and Cochrane Library for data up to January 27, 2023. STUDY SELECTION Randomized controlled trials involving neonates with PPHN assessing efficacy and mortality of various treatments. DATA EXTRACTION Details of study population, treatments, and outcomes were extracted. DATA SYNTHESIS Direct pairwise comparisons and a network meta-analysis was performed under random effects. The ranking probability was further assessed based on the surface under the cumulative ranking curve (SUCRA). We analyzed 23 randomized clinical trials involving 902 newborns with PPHN. Sixteen different treatment strategies were compared with each other and conventional therapy (CON). A median concentration of 10-20 parts per million (ppm) iNO (MNO) coupled with sildenafil orally administered at a dose of 1-3 mg/kg/dose every 6-8 hours (OSID) demonstrated the best efficacy (MNO + OSID vs. CON: odds ratio [OR] = 27.53, 95% CI, 2.36-321.75; SUCRA = 0.818, ranking first; moderate quality). OSID combined with milrinone administered IV also performed well in terms of efficacy (OSID + milrinone vs. CON: OR = 25.13, 95% CI = 1.67-377.78; SUCRA = 0.811, ranking second; low quality) and mortality reduction (CON vs. OSID + milrinone: OR = 25.13, 95% CI = 1.67-377.78; SUCRA = 0.786, ranking last; low quality). CONCLUSIONS MNO + OSID is the most effective PPHN treatment. If iNO is not available, OSID + milrinone is preferred.
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Affiliation(s)
- Qiang Fei
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jiarong Pan
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Feizhou Zhang
- Department of Pneumology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yu Lin
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Tianming Yuan
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Tsoi SM, Steurer M, Nawaytou H, Cheung S, Keller RL, Fineman JR. Defining the Typical Course of Persistent Pulmonary Hypertension of the Newborn (PPHN): when to think beyond reversible causes. J Pediatr 2024:114131. [PMID: 38823627 DOI: 10.1016/j.jpeds.2024.114131] [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: 03/07/2024] [Revised: 04/17/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVES To describe the typical clinical course of reversible PPHN from perinatal etiologies and compare that with the clinical course of PPHN due to underlying fetal developmental etiologies. STUDY DESIGN This was a single-center, retrospective cohort study of liveborn newborns either born or transferred to our facility for higher level of care between 2015 through 2020 with gestational age ≥35 weeks and a clinical diagnosis of PPHN in the electronic health record (EHR). Newborns with complex congenital heart disease and congenital diaphragmatic hernia were excluded. Using all data available at time of collection, newborns were stratified into 2 groups by PPHN etiology - perinatal and fetal developmental causes. Primary outcomes were age at initiation, discontinuation, and total duration of extracorporeal life support (ECLS), mechanical ventilation, supplemental oxygen, iNO, inotropic support, and PGE. Our secondary outcome was age at echocardiographic resolution of pulmonary hypertension. Groups were compared by t-test. Time-to-event Kaplan Meier curves described and compared (log-rank test) discontinuation of each therapy. RESULTS Sixty-four (72%) newborns had perinatal etiologies whereas 24 (28%) had fetal developmental etiologies. The resolution of perinatal PPHN was more rapid compared with fetal developmental PPHN. By 10 days of age, more neonates were off inotropes (98% vs 29%, p<0.01), decannulated from ECLS (100% vs 0%, p<0.01), extubated (75% vs 37%, p<0.01), and had echocardiographic resolution of PH (35% vs 7%, p=0.02). CONCLUSIONS An atypical PPHN course, characterized by persistent targeted therapies in the second week of life, warrants further work-up for fetal developmental causes.
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Affiliation(s)
- Stephanie M Tsoi
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
| | - Martina Steurer
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA; Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Hythem Nawaytou
- Division of Cardiology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Shannon Cheung
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Roberta L Keller
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Jeffrey R Fineman
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
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Radman M, McGuire J, Sharek P, Baden H, Koth A, DiGeronimo R, Migita D, Barry D, Johnson JB, Rutman L, Vora S. Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway. Pediatr Crit Care Med 2024:00130478-990000000-00346. [PMID: 38786980 DOI: 10.1097/pcc.0000000000003544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization. DESIGN A quality improvement study using a prospective cohort design with historical controls. SETTING Four hundred seven-bed free standing quaternary care academic children's hospital. PATIENTS All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022. INTERVENTIONS Unit-specific standard approaches to iNO initiation and weaning. MEASUREMENTS AND MAIN RESULTS Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (-24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings. CONCLUSIONS Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.
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Affiliation(s)
- Monique Radman
- Division of Cardiac Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - John McGuire
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Paul Sharek
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Harris Baden
- Division of Cardiac Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Andy Koth
- Division of Cardiac Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Darren Migita
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Dwight Barry
- Clinical Analytics, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - James B Johnson
- Clinical Analytics, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Lori Rutman
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Surabhi Vora
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
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Kashaki M, Mohazzab A, Radgoudarzi M, Bordbar A, Dabbagh S. Study on the comparison between Bosentan and Macitentan in the treatment of persistent pulmonary hypertension of the newborns, simultaneously on sildenafil: A randomized double-blinded non-inferiority parallel clinical trial. Pediatr Neonatol 2024:S1875-9572(24)00077-9. [PMID: 38797632 DOI: 10.1016/j.pedneo.2023.12.007] [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: 07/19/2023] [Revised: 10/30/2023] [Accepted: 12/05/2023] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Persistent Pulmonary Hypertension of the newborn (PPHN) is characterized by sustained elevated Pulmonary Artery Pressure (PAP). Drug resistance and the adverse effects of current therapeutic agents warrant investigation of other targeted therapies. Bosentan has shown benefits in affected neonates. However, trials reported the association with unwanted effects. Thus, in this study, we assess another agent in the same family, Macitentan. However, its efficacy in the treatment of PPHN is not yet reported. Hence, this study evaluated the effect of Macitentan compared to Bosentan in terms of efficacy and safety in the treatment of PPHN. METHODS This randomized, double-blinded non-inferiority clinical trial was conducted in Shahid Akbar Abadi hospital, Tehran, Iran. Sixty clinically stable neonates with signs suggestive of PPHN were randomly allocated into two groups (n = 30 in each group) and they received either Bosentan 1 mg/kg/dose BD (twice daily) or Macitentan 1 mg/kg/dose BD simultaneously with sildenafil. The echocardiographic and laboratory indices of efficacy and safety were compared between groups. SPAP (systolic pulmonary artery pressure) was used to assess the non-inferiority of the Macitentan compared to the Bosentan in their respective doses used in the study. RESULTS Participants' mean (SD) age was 3.53 (1.21) days, and 55% were female. No mortality case occurred. SPAP was reduced in both Bosentan and Macitenan groups with the mean difference in SPAP of 9 (95% CI: 7.34-10.65) in Bosentan and SPAP mean difference of 14 (95% CI: 12.12-15.86) in Macitentan group. Categorical comparison of primary outcome improvement showed that Macitentan was superior to Bosentan with a 10% non-inferiority margin. Similar results were obtained in other echocardiographic indices. Also, no significant alterations were observed in laboratory safety parameters. CONCLUSION Macitentan 1 mg/kg/dose BD (twice daily) is non-inferior to Bosentan 1 mg/kg/dose BD in improving echo outcomes of PPHN and it was even more effective in improving some of these. Also, it is non-inferior to Bosentan in terms of safety. TRIAL REGISTRY NUMBER: (IRCT20160120026115N9).
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Affiliation(s)
- Mandana Kashaki
- Shahid Akbar Abadi Clinical Research Development Unit (ShACRDU), School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Arash Mohazzab
- Equally first author, School of Public Health, Iran University of Medical sciences, Tehran, Iran
| | - Mohammad Radgoudarzi
- Department of Pediatrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Bordbar
- Shahid Akbar Abadi Clinical Research Development Unit (ShACRDU), School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Sama Dabbagh
- Shahid Akbar Abadi Hospital, Bagh-Ferdous St. Mowlavi St., Tehran, Iran.
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Galis R, Mudura D, Trif P, Diggikar S, Prasath A, Ognean ML, Mazela J, Lacatusu A, Ramanathan R, Kramer BW, Singh Y. Milrinone in persistent pulmonary hypertension of newborn: a scoping review. Pediatr Res 2024:10.1038/s41390-024-03234-z. [PMID: 38745027 DOI: 10.1038/s41390-024-03234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/06/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a common neonatal condition in newborns admitted to the neonatal intensive care units (NICUs). PPHN has still a high mortality and morbidity. Inhaled nitric oxide (iNO) is the first line vasodilator therapy for PPHN in high income countries. In low-to-middle income countries (LMICs), availability of iNO remains scarce and expensive. The purpose of this scoping review was to evaluate the current existing literature for milrinone therapy in PPHN and to identify the knowledge gaps in milrinone use in infants with PPHN. The available evidence for milrinone remains limited both as monotherapy and as an adjuvant to iNO. The studies were heterogeneous, conducted in different settings, with different populations and more importantly the endpoints of these trials were short-term outcomes such as changes in oxygenation and blood pressure. Large prospective studies investigating long-term outcomes, mortality, and the need for Extracorporeal membrane oxygenation (ECMO) are warranted. Randomized controlled trials with milrinone as monotherapy are needed in LMICs where iNO availability remains limited. IMPACT: Milrinone has a potential role in the management of PPHN both as an adjuvant to iNO as well as a monotherapy. This scoping review identified the problems existing in the published literature on milrinone and the barriers to generalization of these results. Multi-centre randomized controlled trials on milrinone, especially involving centers from low- and middle-income countries are needed, where it can be evaluated as first-line pulmonary vasodilator therapy.
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Affiliation(s)
- Radu Galis
- Department of Neonatology, Emergency County Hospital Bihor, Oradea, Romania.
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland.
| | - Diana Mudura
- Department of Neonatology, Emergency County Hospital Bihor, Oradea, Romania
| | - Paula Trif
- Department of Neonatology, Emergency County Hospital Bihor, Oradea, Romania
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea, Romania
| | | | - Arun Prasath
- University of Texas Southwestern, Dallas, TX, USA
| | - Maria Livia Ognean
- Faculty of Medicine, Lucian Blaga University Sibiu, Sibiu, Romania
- Neonatology Department, Clinical County Emergency Hospital Sibiu, Sibiu, Romania
| | - Jan Mazela
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Adrian Lacatusu
- Pediatrics Department, Bega Clinic, Emergency County Hospital Timisoara, Timișoara, Romania
- Victor Babes University, Timisoara, Romania
| | - Rangasamy Ramanathan
- Division of Neonatology, Cedars Sinai Guerin Children's, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Boris W Kramer
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Yogen Singh
- Department of Pediatrics, Division of Neonatology, UC Davis Children's Hospital, UC Davis Health, Sacramento, CA, USA
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Cookson MW, Kinsella JP. Inhaled Nitric Oxide in Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:95-111. [PMID: 38325949 PMCID: PMC10954355 DOI: 10.1016/j.clp.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pivotal trials investigating the use of inhaled nitric oxide (iNO) in the 1990s led to approval by the Food and Drug Administration in 1999. Inhaled nitric oxide is the only approved pulmonary vasodilator for persistent pulmonary hypertension of the newborn (PPHN). Selective pulmonary vasodilation with iNO in near-term and term neonates with PPHN is safe, and targeted use of iNO in less mature neonates with pulmonary hypertension (PH) can be beneficial. This review addresses a brief history of iNO, clinical features of neonatal PH, and the clinical application of iNO.
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Affiliation(s)
- Michael W Cookson
- Department of Pediatrics, Section of Neonatology, University of Colorado, Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA; Department of Pediatrics, Pediatric Heart Lung Center, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
| | - John P Kinsella
- Department of Pediatrics, Section of Neonatology, University of Colorado, Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA; Department of Pediatrics, Pediatric Heart Lung Center, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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7
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Feng Z, Wu X, Xu X, Cui Q, Wu F. Efficacy of inhaled nitric oxide in preterm infants ≤ 34 weeks: a systematic review and meta-analysis of randomized controlled trials. Front Pharmacol 2024; 14:1268795. [PMID: 38273818 PMCID: PMC10808707 DOI: 10.3389/fphar.2023.1268795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Background: The effect of inhaled nitric oxide (iNO) in neonates >34 weeks on improving respiration is well documented. However, the efficacy of iNO in preterm infants ≤34 weeks remains controversial. Objectives: The main purpose of this review is to assess the effectiveness and safety of iNO treatment in preterm infants ≤34 weeks. Search methods: We systematically searched PubMed, Embase and Cochrane Libraries from their inception to 1 June 2023. We also reviewed the reference lists of retrieved studies. Selection criteria: Our study involved randomized controlled trials on preterm infants ≤34 weeks, especially those receiving iNO treatment, and mainly assessed outcomes such as bronchopulmonary dysplasia (BPD) and mortality. Two authors independently reviewed these trials, extracted data, and evaluated study biases. Disagreements were resolved by consensus. We used the GRADE method to assess evidence quality. Results: Our research included a total of 17 studies involving 4,080 neonates and 7 follow-up studies. The synthesis of results showed that in neonates, iNO treatment reduced the incidence of BPD (RR: 0.92; 95% CI: 0.86-0.98). It also decreased the composite outcome of death or BPD (RR: 0.94; 95% CI: 0.90-0.98), without increasing the risk of short-term (such as intraventricular hemorrhage, periventricular leukomalacia) and long-term neurological outcomes (including Bayley mental developmental index <70, cerebral palsy and neurodevelopmental impairment). Furthermore, iNO did not significantly affect other neonatal complications like sepsis, pulmonary hemorrhage, necrotizing enterocolitis, and symptomatic patent ductus arteriosus. Subgroup analysis revealed that iNO significantly reduced BPD incidence in neonates at 36 weeks under specific intervention conditions, including age less than 3 days, birth weight over 1,000 g, iNO dose of 10 ppm or higher, or treatment duration exceeding 7 days (p < 0.05). Conclusion: Inhaled NO reduced the incidence of BPD in neonates at 36 weeks of gestation, and the effect of the treatment depended on neonatal age, birth weight, duration and dose of iNO. Therefore, iNO can be considered a promising treatment for the potential prevention of BPD in premature infants. More data, however, would be needed to support nitric oxide registration in this specific patient population, to minimize its off-label use.
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Affiliation(s)
- Zhoushan Feng
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Xiaohong Wu
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Xiaona Xu
- Department of Obstetrics and Gynecology, School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiliang Cui
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
| | - Fan Wu
- Department of Neonatology, Guangzhou Key Laboratory of Neonatal Intestinal Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, Guangzhou, China
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8
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Pérez‐Peñate GM, Juliá‐Serdá G, Galván‐Fernández H, Alemán‐Segura D, León‐Marrero F, Garcia‐Quintana A, de Larrinoa IR, Ortega‐Trujillo JR, Gómez‐Sánchez MÁ. Safety of inhaled nitric oxide withdrawal in severe chronic pulmonary hypertension. Pulm Circ 2024; 14:e12344. [PMID: 38468631 PMCID: PMC10925723 DOI: 10.1002/pul2.12344] [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: 08/23/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 03/13/2024] Open
Abstract
Inhaled nitric oxide (iNO) is a potent and selective pulmonary vasodilator with a safety concern due to rebound pulmonary hypertension (PH) associated with its withdrawal. We report short-term pulsed iNO in patients with severe pulmonary arterial hypertension (PAH) and nonoperable chronic thromboembolic PH (nCTEPH). This is a retrospective analysis of 33 patients: 22 with PAH and 11 with nCTEPH. We assessed hemodynamic, echocardiographic, and other noninvasive variables to evaluate safety and efficacy of iNO. We performed an iNO withdrawal test during right heart catheterization and after 3 days of iNO treatment. iNO significantly improved all variables examined in 22 patients with PAH and 11 with nCTEPH. Two patterns of response were observed after sudden iNO withdrawal. Twenty-nine patients (88%) showed minimal hemodynamic, oxygenation and clinical changes. Four patients (12%) had a reduction in cardiac index ≥20% and PaO2 ≥ 5%, three patients did not show clinical deterioration, and one patient developed hemodynamic collapse that needed iNO administration. This retrospective study suggests that short-term iNO improves hemodynamics and clinical conditions in some patients with PAH an nCTPEH. However, pulsed iNO withdrawal PH rebound could be a serious concern in these patients. Given the lack of evidence, we do not recommend the use of pulsed iNO in the treatment of patients with chronic PH.
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Affiliation(s)
- Gregorio Miguel Pérez‐Peñate
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos IIIMadridSpain
| | - Gabriel Juliá‐Serdá
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | - Helena Galván‐Fernández
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | - Desireé Alemán‐Segura
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | - Fernando León‐Marrero
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | | | | | | | - Miguel Ángel Gómez‐Sánchez
- Department of RheumatologyHospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
- Department of CardiologyCentro Médico EboraSaludTalavera de la ReinaToledoSpain
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9
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Ball MK, Seabrook RB, Bonachea EM, Chen B, Fathi O, Nankervis CA, Osman A, Schlegel AB, Magers J, Kulpa T, Sharpin P, Snyder ML, Gajarski RJ, Nandi D, Backes CH. Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2023; 40:1495-1508. [PMID: 34852367 DOI: 10.1055/a-1711-0778] [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] [Indexed: 10/19/2022]
Abstract
Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..
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Affiliation(s)
- Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ruth B Seabrook
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Elizabeth M Bonachea
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Bernadette Chen
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics Pulmonary Hypertension Group, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Omid Fathi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Craig A Nankervis
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ahmed Osman
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy B Schlegel
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jacqueline Magers
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Taylor Kulpa
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Paula Sharpin
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Mary Lindsay Snyder
- Division of Neonatology Nationwide Children's Hospital Neonatal Intensive Care Unit, Neonatal Service Line, Columbus, Ohio
| | - Robert J Gajarski
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Deipanjan Nandi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Carl H Backes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Department of Pediatrics, Columbus, Ohio
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10
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Fraga MV, Dysart KC, Stoller JZ, Huber M, Fedec A, Mercer-Rosa L, Kirpalani H. Echocardiographic Assessment of Pulmonary Arterial Hypertension Following Inhaled Nitric Oxide in Infants with Severe Bronchopulmonary Dysplasia. Neonatology 2023; 120:633-641. [PMID: 37573771 DOI: 10.1159/000531586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is an effective pulmonary vasodilator. However, the efficacy of iNO in former premature infants with established bronchopulmonary dysplasia (BPD) has not been studied. This study aimed to determine the efficacy of iNO in reducing pulmonary artery pressure in infants with severe BPD as measured by echocardiography. STUDY DESIGN Prospective, observational study enrolling infants born at less than 32 weeks gestation and in whom (1) iNO therapy was initiated after admission to our institution, or (2) at the outside institution less than 48 h before transfer and received an echocardiogram prior to iNO initiation, and (3) had severe BPD. Data were collected at three time-points: (1) before iNO; (2) 12-48 h after initiation of iNO; and (3) 48-168 h after initiation of iNO. The primary outcome was the effect of iNO on pulmonary artery pressure measured by echocardiography in patients with severe BPD between 48 and 168 h after initiating iNO therapy. RESULTS Of 37 enrolled, 81% had echocardiographic evidence of pulmonary arterial hypertension (PAH) before iNO and 56% after 48 h of iNO (p = 0.04). FiO2 requirements were significantly different between time-points (1) and (3) (p = 0.05). There were no significant differences between Tricuspid Annular Plane Systolic Excursion (TAPSE) Z-Scores, time to peak velocity: right ventricular ejection time (TPV:RVET), and ventilator changes. CONCLUSIONS Although we found a statistically significant reduction of PAH between time-point (1) and (3), future trials are needed to further guide clinical care.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jason Z Stoller
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew Huber
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anysia Fedec
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Emeritus Professor of Pediatrics, Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Emeritus Professor of Pediatrics, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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11
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Redaelli S, Pozzi M, Giani M, Magliocca A, Fumagalli R, Foti G, Berra L, Rezoagli E. Inhaled Nitric Oxide in Acute Respiratory Distress Syndrome Subsets: Rationale and Clinical Applications. J Aerosol Med Pulm Drug Deliv 2023; 36:112-126. [PMID: 37083488 PMCID: PMC10402704 DOI: 10.1089/jamp.2022.0058] [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: 09/21/2022] [Accepted: 03/13/2023] [Indexed: 04/22/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition, characterized by diffuse inflammatory lung injury. Since the coronavirus disease 2019 (COVID-19) pandemic spread worldwide, the most common cause of ARDS has been the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Both the COVID-19-associated ARDS and the ARDS related to other causes-also defined as classical ARDS-are burdened by high mortality and morbidity. For these reasons, effective therapeutic interventions are urgently needed. Among them, inhaled nitric oxide (iNO) has been studied in patients with ARDS since 1993 and it is currently under investigation. In this review, we aim at describing the biological and pharmacological rationale of iNO treatment in ARDS by elucidating similarities and differences between classical and COVID-19 ARDS. Thereafter, we present the available evidence on the use of iNO in clinical practice in both types of respiratory failure. Overall, iNO seems a promising agent as it could improve the ventilation/perfusion mismatch, gas exchange impairment, and right ventricular failure, which are reported in ARDS. In addition, iNO may act as a viricidal agent and prevent lung hyperinflammation and thrombosis of the pulmonary vasculature in the specific setting of COVID-19 ARDS. However, the current evidence on the effects of iNO on outcomes is limited and clinical studies are yet to demonstrate any survival benefit by administering iNO in ARDS.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Matteo Pozzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca’ Granda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Respiratory Care Department, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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12
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Verma S, Lumba R, Kazmi SH, Vaz MJ, Prakash SS, Bailey SM, Mally PV, Randis TM. Effects of Inhaled Iloprost for the Management of Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2022; 39:1441-1448. [PMID: 33477175 DOI: 10.1055/s-0040-1722653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The study aimed to evaluate the effects of inhaled iloprost on oxygenation indices in neonates with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN We conducted a retrospective chart review of 30 patients with PPHN from January 2014 to November 2018, who did not respond to inhaled nitric oxide (iNO) alone and received inhaled iloprost. Twenty-two patients met the inclusion criteria and eight patients were excluded from the study (complex cardiac disease and extreme prematurity). Patients were categorized as responders or nonresponders (patients who required extracorporeal membrane oxygenation or died). Oxygenation index, mean airway pressure (MAP), and arterial partial pressure of oxygen (PaO2) were recorded. RESULTS Among a total of 22 patients who were included in the study, 10 were classified as nonresponders as they required either extracorporeal membrane oxygenation or died. Gestational age and gender did not differ between responders and nonresponders. The median PaO2 was lower (37 vs. 42 mm Hg; p < 0.05) and median MAP was higher (20 vs. 17 cm H2O; p < 0.02) in nonresponders compared with responders just prior to initiating iloprost. Iloprost responders had a significant increase in median PaO2 and decrease in median oxygenation index in the 24 hours after initiating treatment (p < 0.05), with no significant change in required mean airway pressure over that same period. There was no change in vasopressor use or clinically significant worsening of platelets count, liver, and kidney functions after initiating iloprost. CONCLUSION Inhaled iloprost is well tolerated and seems to have beneficial effects in improving oxygenation indices in neonates with PPHN who do not respond to iNO. There is a need of well-designed prospective trials to further ascertain the benefits of using inhaled iloprost as an adjunct treatment in neonates with PPHN who do not respond to iNO alone. KEY POINTS · Inhaled iloprost seems to have beneficial effects in improving oxygenation indices in PPHN.. · Inhaled iloprost is generally well tolerated in newborns with PPHN.. · There is a need for prospective randomized controlled trials to further ascertain the benefits of using inhaled iloprost..
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Affiliation(s)
- Sourabh Verma
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Rishi Lumba
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Sadaf H Kazmi
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Michelle J Vaz
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | | | - Sean M Bailey
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Tara M Randis
- Division of Neonatology, Departments of Pediatrics and Molecular Medicine, University of South Florida, Tampa, Florida
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13
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Lacroix PG, Malfant I, Labra-Vázquez P, Fárfan N, Ramos-Ortiz G. Two-photon absorption-based delivery of nitric oxide from ruthenium nitrosyl complexes. Dalton Trans 2022; 51:14833-14841. [PMID: 36169419 DOI: 10.1039/d2dt02553a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Since the discovery of the numerous physiological roles exhibited by nitric oxide (NO), ruthenium nitrosyl (RuNO) complexes have been regarded as one of the most promising NO donors, stable, well tolerated by the body and capable of releasing NO locally and quantitatively, under light irradiation. This release can be achieved by two-photon absorption (TPA) processes, which allow the irradiation to be performed in the near infrared domain, where light has its maximum depth of penetration in biological tissues. This review provides a short introduction on the biological properties of NO, on RuNO complexes with photo-releasing capabilities, and on the origin of TPA properties in molecules. Then, the RuNO complexes with TPA capabilities are thoroughly discussed either as monometallic or polymetallic species.
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Affiliation(s)
- Pascal G Lacroix
- Laboratoire de Chimie de Coordination du CNRS, 205 route de Narbonne, F-31077 Toulouse, France.
| | - Isabelle Malfant
- Laboratoire de Chimie de Coordination du CNRS, 205 route de Narbonne, F-31077 Toulouse, France.
| | - Pablo Labra-Vázquez
- Laboratoire de Chimie de Coordination du CNRS, 205 route de Narbonne, F-31077 Toulouse, France. .,Facultad de Química, Departamento de Química Orgánica, Universidad Nacional Autónoma de México, 04510 México D.F., Mexico
| | - Norberto Fárfan
- Facultad de Química, Departamento de Química Orgánica, Universidad Nacional Autónoma de México, 04510 México D.F., Mexico
| | - Gabriel Ramos-Ortiz
- Centro de Investigaciones en Óptica (CIO), A.P. 1-948, 37000 León, Gto, Mexico
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14
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VARDAR G, AKSOY OKAN M, TOPÇUOĞLU S, KARADAĞ N, ÖZALKAYA E, OZGUN KARATEPE H, KARATEKİN G. Controversies in neonatology: The efficacy of inhaled nitric oxide in preterm infants with persistent pulmonary hypertension. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1104799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: There is limited and conflicting information in literature regarding use of inhaled nitric oxide (iNO) in preterm infants. In this study we examined the characteristics of preterm infants with persistent pulmonary hypertension (PHT) who responded and did not respond to iNO therapy .
Material and Method: We retrospectively reviewed data of infants
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Affiliation(s)
- Gonca VARDAR
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Meliha AKSOY OKAN
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Sevilay TOPÇUOĞLU
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Nilgün KARADAĞ
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Elif ÖZALKAYA
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Hande OZGUN KARATEPE
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Güner KARATEKİN
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
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15
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Mahmood B. Persistent pulmonary hypertension of newborn. Semin Pediatr Surg 2022; 31:151202. [PMID: 36038220 DOI: 10.1016/j.sempedsurg.2022.151202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Burhan Mahmood
- Division of Newborn Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pennsylvania, USA.
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16
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Redaelli S, Magliocca A, Malhotra R, Ristagno G, Citerio G, Bellani G, Berra L, Rezoagli E. Nitric oxide: Clinical applications in critically ill patients. Nitric Oxide 2022; 121:20-33. [PMID: 35123061 PMCID: PMC10189363 DOI: 10.1016/j.niox.2022.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/19/2022]
Abstract
Inhaled nitric oxide (iNO) acts as a selective pulmonary vasodilator and it is currently approved by the FDA for the treatment of persistent pulmonary hypertension of the newborn. iNO has been demonstrated to effectively decrease pulmonary artery pressure and improve oxygenation, while decreasing extracorporeal life support use in hypoxic newborns affected by persistent pulmonary hypertension. Also, iNO seems a safe treatment with limited side effects. Despite the promising beneficial effects of NO in the preclinical literature, there is still a lack of high quality evidence for the use of iNO in clinical settings. A variety of clinical applications have been suggested in and out of the critical care environment, aiming to use iNO in respiratory failure and pulmonary hypertension of adults or as a preventative measure of hemolysis-induced vasoconstriction, ischemia/reperfusion injury and as a potential treatment of renal failure associated with cardiopulmonary bypass. In this narrative review we aim to present a comprehensive summary of the potential use of iNO in several clinical conditions with its suggested benefits, including its recent application in the scenario of the COVID-19 pandemic. Randomized controlled trials, meta-analyses, guidelines, observational studies and case-series were reported and the main findings summarized. Furthermore, we will describe the toxicity profile of NO and discuss an innovative proposed strategy to produce iNO. Overall, iNO exhibits a wide range of potential clinical benefits, that certainly warrants further efforts with randomized clinical trials to determine specific therapeutic roles of iNO.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy.
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17
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Daniyan O, Ezeanosike O, Obu D, Ujunwa F. Use of off-label compounded oral sildenafil in the management of persistent pulmonary hypertension of the newborn: A case report. J Cardiovasc Thorac Res 2022; 14:141-143. [PMID: 35935381 PMCID: PMC9339734 DOI: 10.34172/jcvtr.2022.03] [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] [Received: 12/14/2020] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Abstract
We report a case of a newborn with persistent pulmonary hypertension (PPHN) due to meconium aspiration syndrome with associated lung collapse. Echocardiogram revealed features of persistent pulmonary hypertension. He was treated with compounded oral sildenafil. Oral sildenafil has proven to be effective and safe in the management of PPHN in neonates with persistent pulmonary hypertension. Therefore, in situations where inhaled nitric oxide is not available it may be used as an alternative therapy in PPHN. Further randomized controlled studies are needed to determine its efficacy and pharmacokinetics.
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Affiliation(s)
- Olapeju Daniyan
- Department of Paediatrics, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- Corresponding Author: Olapeju Wunmi Daniyan,
| | - Obumneme Ezeanosike
- Department of Paediatrics, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- Department of Paediatrics, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Dorathy Obu
- Department of Paediatrics, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Fortune Ujunwa
- Department of Paediatrics, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- Department of Paediatrics, College of Medicine University of Nigeria, Enugu Campus, Enugu, Nigeria
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18
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Fung C, Z'Graggen WJ, Jakob SM, Gralla J, Haenggi M, Rothen HU, Mordasini P, Lensch M, Söll N, Terpolilli N, Feiler S, Oertel MF, Raabe A, Plesnila N, Takala J, Beck J. Inhaled Nitric Oxide Treatment for Aneurysmal SAH Patients With Delayed Cerebral Ischemia. Front Neurol 2022; 13:817072. [PMID: 35250821 PMCID: PMC8894247 DOI: 10.3389/fneur.2022.817072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
Background We demonstrated experimentally that inhaled nitric oxide (iNO) dilates hypoperfused arterioles, increases tissue perfusion, and improves neurological outcome following subarachnoid hemorrhage (SAH) in mice. We performed a prospective pilot study to evaluate iNO in patients with delayed cerebral ischemia after SAH. Methods SAH patients with delayed cerebral ischemia and hypoperfusion despite conservative treatment were included. iNO was administered at a maximum dose of 40 ppm. The response to iNO was considered positive if: cerebral artery diameter increased by 10% in digital subtraction angiography (DSA), or tissue oxygen partial pressure (PtiO2) increased by > 5 mmHg, or transcranial doppler (TCD) values decreased more than 30 cm/sec, or mean transit time (MTT) decreased below 6.5 secs in CT perfusion (CTP). Patient outcome was assessed at 6 months with the modified Rankin Scale (mRS). Results Seven patients were enrolled between February 2013 and September 2016. Median duration of iNO administration was 23 h. The primary endpoint was reached in all patients (five out of 17 DSA examinations, 19 out of 29 PtiO2 time points, nine out of 26 TCD examinations, three out of five CTP examinations). No adverse events necessitating the cessation of iNO were observed. At 6 months, three patients presented with a mRS score of 0, one patient each with an mRS score of 2 and 3, and two patients had died. Conclusion Administration of iNO in SAH patients is safe. These results call for a larger prospective evaluation.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Ulrich Rothen
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Lensch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Sergej Feiler
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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19
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Nelin L, Kinsella JP, Courtney SE, Pallotto EK, Tarau E, Potenziano JL. Use of inhaled nitric oxide in preterm vs term/near-term neonates with pulmonary hypertension: results of the PaTTerN registry study. J Perinatol 2022; 42:14-18. [PMID: 34711938 DOI: 10.1038/s41372-021-01252-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate inhaled nitric oxide (iNO) in preterm (PT) vs term/near-term (TNT) neonates with hypoxic respiratory failure (HRF) and pulmonary hypertension (PH) in an observational registry (PaTTerN). STUDY DESIGN Non-inferiority study comparing PT neonates of GA ≥ 27 to <34 weeks vs TNT neonates of GA ≥ 34 to ≤40 weeks with HRF associated with PH, who received iNO for 24-96 h during the first 0-7 days after birth. Primary endpoint: Achieving ≥25% decrease in oxygenation index/surrogate oxygenation index during iNO treatment. RESULTS Of 140 neonates (PT, n = 55; TNT, n = 85), the primary endpoint was achieved in 50 (90.9%) PT vs 75 (88.2%) TNT neonates (difference [95% CI]: 0.027 [-0.033, 0.087]); PT neonates achieved non-inferiority interval, and the study was stopped early based on prespecified criteria. CONCLUSIONS Use of iNO for improving oxygenation in PT neonates with HRF associated with PH is at least as effective as in TNT neonates. CLINICAL TRIAL REGISTRATION #NCT03132428, registered April 27, 2017.
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Affiliation(s)
- Leif Nelin
- The Research Institute at Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA.
| | - John P Kinsella
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Sherry E Courtney
- Arkansas Children's Hospital Research Institute, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR, USA
| | | | - Eva Tarau
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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20
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Soni M, Joshi PK, Patel SC, Shreya D, Zamora DI, Patel GS, Grossmann I, Rodriguez K, Sange I. Persistent Pulmonary Hypertension: A Look Into the Future Therapy. Cureus 2021; 13:e20377. [PMID: 35036210 PMCID: PMC8753505 DOI: 10.7759/cureus.20377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/08/2022] Open
Abstract
Persistent pulmonary hypertension (PPHN) of the newborn is a lung parenchymal disorder that causes a wide range of hemodynamic changes in the newborn's systemic circulation. Arising from a multifactorial web of etiology, PPHN is one of the most common reasons for neonatal intensive care unit hospitalization and is associated with increased morbidity and mortality. Historically, multiple treatment modalities have been explored, ranging from oxygen and surfactant therapy to newer upcoming medications like magnesium sulfate and adenosine. This review article has discussed the pathogenesis of PPHN and its relationship with the clinical implications of PPHN, such as heart failure and so on. This article has also explored the diagnostic guidelines and analyzed the existing and the upcoming modalities for treating PPHN.
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21
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Epstein R, Krishnan US. Management of Pulmonary Hypertension in the Pediatric Patient. Cardiol Clin 2021; 40:115-127. [PMID: 34809912 DOI: 10.1016/j.ccl.2021.08.010] [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] [Indexed: 11/16/2022]
Abstract
Pediatric pulmonary hypertension (PH) is a rare disease with historically very high morbidity and mortality. In the past 20 years, there has been a growing recognition that pediatric PH, although having similarities to adult PH, is a unique entity with its own particular pathogeneses, presentation, and management. With better understanding and earlier diagnosis of pediatric PH, and as more medications have become available, survival of children with PH has also significantly improved. This article reviews the various forms of PH in childhood, with a focus on both established and investigational therapies that are available for children with PH.
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Affiliation(s)
- Rebecca Epstein
- Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, CHN 2N, #255, 3959 Broadway, New York, NY 10032, USA
| | - Usha S Krishnan
- Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, CHN 2N, #255, 3959 Broadway, New York, NY 10032, USA.
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22
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Singh Y, Lakshminrusimha S. Pathophysiology and Management of Persistent Pulmonary Hypertension of the Newborn. Clin Perinatol 2021; 48:595-618. [PMID: 34353582 PMCID: PMC8351908 DOI: 10.1016/j.clp.2021.05.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a disorder of circulatory transition resulting in high pulmonary vascular resistance with extrapulmonary right-to-left shunts causing hypoxemia. There has been substantial gain in understanding of pathophysiology of PPHN over the past 2 decades, and biochemical pathways responsible for abnormal vasoconstriction of pulmonary vasculature are now better understood. Easy availability of bedside echocardiography helps in establishing early definitive diagnosis, understanding the pathophysiology and hemodynamic abnormalities, monitoring the disease process, and response to therapeutic intervention. There also has been significant advancement in specific management of PPHN targeted at deranged biochemical pathways and hemodynamic instability.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Cambridge University Hospitals NHS Foundation Trust and University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Satyan Lakshminrusimha
- Department of Pediatrics, UC Davis Children's Hospital, UC Davis Health, Sacramento, CA 95817, USA.
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23
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Mukherjee D, Konduri GG. Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment. Compr Physiol 2021; 11:2135-2190. [PMID: 34190343 DOI: 10.1002/cphy.c200023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.
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Affiliation(s)
- Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
| | - Girija G Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Wisconsin, Milwaukee, Wisconsin, 53226, USA
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24
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Poitras EL, Gust SL, Kerr PM, Plane F. Repurposing of the PDE5 Inhibitor Sildenafil for the Treatment of Persistent Pulmonary Hypertension in Neonates. Curr Med Chem 2021; 28:2418-2437. [PMID: 32964819 DOI: 10.2174/0929867327666200923151924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/21/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022]
Abstract
Nitric oxide (NO), an important endogenous signaling molecule released from vascular endothelial cells and nerves, activates the enzyme soluble guanylate cyclase to catalyze the production of cyclic guanosine monophosphate (cGMP) from guanosine triphosphate. cGMP, in turn, activates protein kinase G to phosphorylate a range of effector proteins in smooth muscle cells that reduce intracellular Ca2+ levels to inhibit both contractility and proliferation. The enzyme phosphodiesterase type 5 (PDE5) curtails the actions of cGMP by hydrolyzing it into inactive 5'-GMP. Small molecule PDE5 inhibitors (PDE5is), such as sildenafil, prolong the availability of cGMP and therefore, enhance NO-mediated signaling. PDE5is are the first-line treatment for erectile dysfunction but are also now approved for the treatment of pulmonary arterial hypertension (PAH) in adults. Persistent pulmonary hypertension in neonates (PPHN) is currently treated with inhaled NO, but this is an expensive option and around 1/3 of newborns are unresponsive, resulting in the need for alternative approaches. Here the development, chemistry and pharmacology of PDE5is, the use of sildenafil for erectile dysfunction and PAH, are summarized and then current evidence for the utility of further repurposing of sildenafil, as a treatment for PPHN, is critically reviewed.
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Affiliation(s)
- Erika L Poitras
- Department of Pharmacology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada
| | - Stephen L Gust
- Department of Pharmacology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada
| | - Paul M Kerr
- Faculty of Nursing, Robbins Health Learning Centre, MacEwan University, Edmonton, Alberta T5J 4S2, Canada
| | - Frances Plane
- Department of Pharmacology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada
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25
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Cai YM, Zhang YD, Yang L. NO donors and NO delivery methods for controlling biofilms in chronic lung infections. Appl Microbiol Biotechnol 2021; 105:3931-3954. [PMID: 33937932 PMCID: PMC8140970 DOI: 10.1007/s00253-021-11274-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/23/2021] [Accepted: 04/05/2021] [Indexed: 12/18/2022]
Abstract
Nitric oxide (NO), the highly reactive radical gas, provides an attractive strategy in the control of microbial infections. NO not only exhibits bactericidal effect at high concentrations but also prevents bacterial attachment and disperses biofilms at low, nontoxic concentrations, rendering bacteria less tolerant to antibiotic treatment. The endogenously generated NO by airway epithelium in healthy populations significantly contributes to the eradication of invading pathogens. However, this pathway is often compromised in patients suffering from chronic lung infections where biofilms dominate. Thus, exogenous supplementation of NO is suggested to improve the therapeutic outcomes of these infectious diseases. Compared to previous reviews focusing on the mechanism of NO-mediated biofilm inhibition, this review explores the applications of NO for inhibiting biofilms in chronic lung infections. It discusses how abnormal levels of NO in the airways contribute to chronic infections in cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD), and primary ciliary dyskinesia (PCD) patients and why exogenous NO can be a promising antibiofilm strategy in clinical settings, as well as current and potential in vivo NO delivery methods. KEY POINTS : • The relationship between abnormal NO levels and biofilm development in lungs • The antibiofilm property of NO and current applications in lungs • Potential NO delivery methods and research directions in the future.
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Affiliation(s)
- Yu-Ming Cai
- Institute for Life Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
| | - Ying-Dan Zhang
- School of Medicine, Southern University of Science and Technology, Shenzhen, 518000, China
| | - Liang Yang
- School of Medicine, Southern University of Science and Technology, Shenzhen, 518000, China.
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26
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Agarwal P, Shankaran S, Laptook AR, Chowdhury D, Lakshminrusimha S, Bonifacio SL, Natarajan G, Chawla S, Keszler M, Heyne RJ, Ambalavanan N, Walsh MC, Das A, Van Meurs KP. Outcomes of infants with hypoxic ischemic encephalopathy and persistent pulmonary hypertension of the newborn: results from three NICHD studies. J Perinatol 2021; 41:502-511. [PMID: 33402707 PMCID: PMC7954876 DOI: 10.1038/s41372-020-00905-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/18/2020] [Accepted: 12/01/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the association of persistent pulmonary hypertension of the newborn (PPHN) with death or disability among infants with moderate or severe hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia. METHODS We compared infants with and without PPHN enrolled in the hypothermia arm from three randomized controlled trials (RCTs): Induced Hypothermia trial, "usual care" arm of Optimizing Cooling trial, and Late Hypothermia trial. Primary outcome was death or disability at 18-22 months adjusted for severity of HIE, center, and RCT. RESULTS Among 280 infants, 67 (24%) were diagnosed with PPHN. Among infants with and without PPHN, death or disability was 47% vs. 29% (adjusted OR: 1.65, 0.86-3.14) and death was 26% vs. 12% (adjusted OR: 2.04, 0.92-4.53), respectively. CONCLUSIONS PPHN in infants with moderate or severe HIE was not associated with a statistically significant increase in primary outcome. These results should be interpreted with caution given the limited sample size.
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Affiliation(s)
- Prashant Agarwal
- Department of Pediatrics, Wayne State University, Detroit, MI, USA.
| | | | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Dhuly Chowdhury
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of Buffalo Women’s and Children’s Hospital of Buffalo, Buffalo, NY,University of California at Davis, Sacramento, CA
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | | | - Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, MI
| | - Martin Keszler
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
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27
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DeWitt AL, Acker J, Larkin TA, Potenziano JL, Schmidt JM. Compatibility and Safety Implications Associated with Interfacing Medical Devices in Neonatal Respiratory Care: A Case Example Using the Inhaled Nitric Oxide Delivery System. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:27-35. [PMID: 33628066 PMCID: PMC7899041 DOI: 10.2147/mder.s268477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/19/2021] [Indexed: 11/23/2022] Open
Abstract
Over the past decade, international organizations have instituted strict regulations for the safe use of connected medical devices. The International Organization for Standardization and the Medical Device Single Audit Program instituted certifications to ensure that connected devices are compatible and operate within their proper clinical parameters. These efforts came about, in part, as a consequence of clinicians’ decisions to use nonstandard, modified, or improvised devices for purposes outside the original manufacturers’ approved parameters. Unapproved device modifications can be associated with increased risk of dosing errors, monitoring errors, tubing misconnections and serious or potentially fatal adverse events; furthermore, health care providers who implement unapproved device modifications may assume legal and financial liability should harm come to patients as a consequence of the modification. Using the inhaled nitric oxide delivery system as an example, the objective of this paper is to raise awareness of the potential dangers associated with unapproved modification and interfacing of therapeutic gas delivery systems and ventilators in the neonatal intensive care unit setting. The paper also highlights the rationale and necessity for rigorous validation processes that ensure that interfaced medical devices perform as intended in the clinical setting.
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Affiliation(s)
| | - Jaron Acker
- Medical Device Marketing, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Thomas A Larkin
- Device Engineering R&D, Mallinckrodt Pharmaceuticals Ireland Ltd., Dublin, Ireland
| | - Jim L Potenziano
- Scientific Affairs, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
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28
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Salas M, Potenziano JL, Acker J. Rationale for Use of an FDA-Cleared Delivery System for Administration of Inhaled Nitric Oxide in Patients Undergoing Magnetic Resonance Imaging. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:1-7. [PMID: 33442306 PMCID: PMC7800703 DOI: 10.2147/mder.s265099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Inhaled nitric oxide (iNO) is a pulmonary vasodilator approved for use to improve lung function in neonates >34 weeks' gestational age with hypoxic respiratory failure and pulmonary hypertension. Infants with severe respiratory disease frequently require magnetic resonance imaging (MRI) scans for evaluation of treatment and diagnosis of concurrent disease processes. Until 2015, incompatibility between the standard iNO delivery system components and the magnetic field within the MRI setting required iNO treatment to be interrupted for MRI, which could increase risk of deoxygenation and rebound pulmonary hypertension. In some cases, patients had to forego or delay MRI in order to maintain uninterrupted iNO delivery. The US Food and Drug Administration cleared the first iNO delivery system specifically modified for conditional use with MRI scanners (INOmax DSIR ® Plus MRI) in 2015, based on the determination that the MRI-cleared system met the performance standards equivalent to the standard system. The system design and manufacturer risk management activities, as well as the regulatory requirements for clearance and continued use, provide necessary safeguards to ensure that high-risk neonates receive uninterrupted iNO in a safe manner. Anecdotal reports suggest that adoption of the MRI-cleared system may help optimize care for critically ill neonates who require concurrent administration of iNO and MRI scanning. Further research will be necessary to quantify the nature and magnitude of clinical improvements associated with adoption of the MRI iNO delivery system.
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Affiliation(s)
- Mauro Salas
- Clinical Specialist, Children's National Health System, Washington, DC, USA
| | - Jim L Potenziano
- Scientific Affairs, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Jaron Acker
- Medical Device Marketing, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
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29
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Ha J, Lee EH, Park HK, Choi BM. Clinical Status of Inhaled Nitric Oxide Treatment in Infants with Persistent Pulmonary Hypertension of the Newborn in Korea: Post-Marketing Surveillance Results. NEONATAL MEDICINE 2020. [DOI: 10.5385/nm.2020.27.2.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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30
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Hoyle ES, Slee SL, Subhedar NV. Variation in the definition of pulmonary hypertension and clinical indications for the use of nitric oxide in neonatal clinical trials. Acta Paediatr 2020; 109:930-934. [PMID: 31614025 DOI: 10.1111/apa.15058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/07/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
AIM Pulmonary hypertension (PH) frequently complicates neonatal hypoxaemic respiratory failure, but is inconsistently defined. We aimed to describe the variation among randomised controlled trials (RCTs) of inhaled nitric oxide (iNO), in relation to the definition of PH and/or hypoxaemic respiratory failure used to select patients for trial inclusion. METHODS PubMed, Cochrane Library and ClinicalTrials.gov were systematically searched for RCTs of iNO in neonates. Included studies were assessed for clinical and/or echocardiography criteria used to define PH/hypoxaemic respiratory failure. RESULTS Thirty-two trials were included in this review, of which 23 enrolled infants ≥34 weeks' gestation. Echocardiographic diagnosis was used in 21 studies, but there was considerable variation in the echocardiographic parameters used to diagnose PH. The most commonly used indices included markers of tricuspid regurgitation and extrapulmonary shunt. CONCLUSION There is wide variation in the definition of PH used to select infants for inclusion into RCTs of iNO therapy in neonates. We recommend that an international consensus be reached on which parameters should be used and the thresholds defining severity of disease.
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Affiliation(s)
- Emily S. Hoyle
- Neonatal Intensive Care Unit Liverpool Women’s Hospital Liverpool UK
| | - Samantha L. Slee
- Neonatal Intensive Care Unit Liverpool Women’s Hospital Liverpool UK
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Abstract
Pulmonary arterial hypertension (PAH) is a rare disease in infants and children that is associated with significant morbidity and mortality. The disease is characterized by progressive pulmonary vascular functional and structural changes resulting in increased pulmonary vascular resistance and eventual right heart failure and death. In many pediatric patients, PAH is idiopathic or associated with congenital heart disease and rarely is associated with other conditions such as connective tissue or thromboembolic disease. PAH associated with developmental lung diseases such as bronchopulmonary dysplasia or congenital diaphragmatic hernia is increasingly more recognized in infants and children. Although treatment of the underlying disease and reversal of advanced structural changes have not yet been achieved with current therapy, quality of life and survival have improved significantly. Targeted pulmonary vasodilator therapies, including endothelin receptor antagonists, prostacyclin analogs, and phosphodiesterase type 5 inhibitors have resulted in hemodynamic and functional improvement in children. The management of pediatric PAH remains challenging as treatment decisions depend largely on results from evidence-based adult studies and the clinical experience of pediatric experts. This article reviews the current drug therapies and their use in the management of PAH in children.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erika E Vorhies
- Division of Pediatric Cardiology, Department of Pediatrics, University of Calgary Cumming School of Medicine, Alberta Children's Hospital, Calgary, Canada
| | - David Dunbar Ivy
- B100, Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO, 80045, USA.
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Gien J, Nuxoll C, Kinsella JP. Inhaled Nitric Oxide in Emergency Medical Transport of the Newborn. Neoreviews 2020; 21:e157-e164. [PMID: 32123120 DOI: 10.1542/neo.21-3-e157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Randomized controlled trials in the 1990s confirmed the safety and efficacy of inhaled nitric oxide (iNO) in near-term and term newborns with hypoxemic respiratory failure and pulmonary hypertension, demonstrating improved oxygenation and reduced need for extracorporeal membrane oxygenation (ECMO) therapy. However, in about 30% to 40% of sick newborns, these improvements in oxygenation and hemodynamics are not sustained and affected infants often require rapid transfer to an ECMO center despite the initiation of iNO. Abrupt discontinuation of iNO therapy before transport in patients who have had little apparent clinical benefit can be harmful because of acute deterioration with severe hypoxemia. Thus, continued use of iNO therapy during hospital transfer of infants with pulmonary hypertension is important. In this review, we describe: 1) the history of iNO use during transport; 2) a practical approach to iNO during transport; and 3) guidelines for the initiation of iNO before or during transport.
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Affiliation(s)
- Jason Gien
- Section of Neonatology, University of Colorado School of Medicine, Aurora, CO
- Children's Hospital Colorado, Aurora, CO
| | | | - John P Kinsella
- Section of Neonatology, University of Colorado School of Medicine, Aurora, CO
- Children's Hospital Colorado, Aurora, CO
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Garrido F, Gonzalez‐Caballero JL, Lomax R, Dady I. The immediate efficacy of inhaled nitric oxide treatment in preterm infants with acute respiratory failure during neonatal transport. Acta Paediatr 2020; 109:309-313. [PMID: 31373038 DOI: 10.1111/apa.14958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/16/2019] [Accepted: 07/31/2019] [Indexed: 02/02/2023]
Abstract
AIM The aim of our review was to describe the clinical response to inhaled nitric oxide (iNO) in a series of preterm babies in respiratory failure during uplift transfers to a neonatal intensive care unit. METHODS We performed a retrospective review of critical newborns with gestational age <34+0 weeks transferred from January 2013 to December 2018. Data were extracted from our Clinical Information System for transport. The primary measure of this review was to assess whether a significant improvement in the oxygenation saturation index (OSI) occurred following the use of iNO. RESULTS Thirty preterm babies <34+0 weeks were included in our review. OSI, as a measure of oxygenation, did not statistically improve as an immediate response to iNO from referral to receiving hospital (17.1 vs 16.4; P = .7). We found that pH (7.15 vs 7.29; P = .004) and pCO2 (8.1 vs 6.3; P = .05) significantly improved probably based on ventilation management. CONCLUSION Following the recommendations of the American Academy of Paediatrics and other organizations, iNO should not routinely be used during the neonatal transfer of preterm babies <34+0 in respiratory failure. We need to conduct further studies to establish which selected preterm patients would benefit from being treated with iNO.
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Affiliation(s)
- Felipe Garrido
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
- Newborn Intensive Care Unit Clínica Universidad de Navarra Madrid Spain
| | | | - Rachel Lomax
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
| | - Ian Dady
- Connect NW, St. Mary's Hospital, Newborn Intensive Care Services Manchester University NHS Foundation Trust Manchester UK
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Sherlock LG, Wright CJ, Kinsella JP, Delaney C. Inhaled nitric oxide use in neonates: Balancing what is evidence-based and what is physiologically sound. Nitric Oxide 2019; 95:12-16. [PMID: 31866361 DOI: 10.1016/j.niox.2019.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 12/22/2022]
Abstract
Inhaled nitric oxide is a powerful therapeutic used in neonatology. Its use is evidenced-based for term and near-term infants with persistent pulmonary hypertension; however, it is frequently used off-label both in term and preterm babies. This article reviews the off-label uses of iNO in infants. Rationale is discussed for a selective application of iNO based on physiologically guided principles, and new research avenues are considered.
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Affiliation(s)
- Laurie G Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Cassidy Delaney
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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Wang X, Li B, Ma Y, Zhang H. Effect of NO inhalation on ECMO use rate and mortality in infants born at or near term with respiratory failure. Medicine (Baltimore) 2019; 98:e17139. [PMID: 31593077 PMCID: PMC6799754 DOI: 10.1097/md.0000000000017139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The molecular studies showed that Nitric oxide (NO) is an essential factor which regulates pulmonary artery tension. However, the conclusions of existing clinical studies were inconsistent. OBJECTIVE This meta-analysis is aimed to determine whether the inhalation of NO could improve oxygenation and reduce rate of death and use of extracorporeal membrane oxygenation (ECMO). METHODS The strategies used to search PubMed, The Cochrane Central Register of Controlled trials in the Cochrane Library, Embase, Web of science, Clinical Trials Registry, and China Biology Medicine disc, from inception to February, 2018. The primary outcomes were death or use of ECMO, death before hospital discharge, use of ECMO before hospital discharge, change in PaO2 after treatment. We assess the risk of bias in each included study by Cochrane Handbook, and calculated typical estimates of RR, each with its 95% CI, and for continuous outcomes, WMD or a summary estimate for SMD, each with its 95% CI. RESULTS Nine randomized controlled trials (RCTs) with a total of 856 participants were included in this meta-analysis. This meta-analysis revealed that the experimental group had significantly lower death or use of ECMO (RR 0.66, 95% CI 0.57-0.77, I = 0%, P < .00001) and lower use of ECMO before hospital discharge (RR 0.89, 95% CI 0.50-0.71, I = 0%, P < .00001) compared to control group. And in the infants without diaphragmatic hernia, experimental group had significantly higher change in PaO2 after treatment (MD 50.40, 95% CI 32.14-68.66, P < .00001). The meta-analysis also showing a tendency to improve in the death before hospital discharge (RR 0.89, 95% CI 0.60-1.31, I = 0%, P = .55) and the change in PaO2 after treatment of the infants with diaphragmatic hernia (MD 6.70, 95% CI -2.32 to 15.72, P < .00001, P = .15), but no difference between experimental group and control group. CONCLUSION We found that NO inhalation can improve oxygenation and reduce rate of death and use of ECMO in this meta-analysis. Therefore, we recommend the use of NO inhalation for infants born at or near term with respiratory failure.
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Gaudard P, Barbanti C, Rozec B, Mauriat P, M'rini M, Cambonie G, Liet JM, Girard C, Leger PL, Assaf Z, Damas P, Loron G, Lecourt L, Amour J, Pouard P. New Modalities for the Administration of Inhaled Nitric Oxide in Intensive Care Units After Cardiac Surgery or for Neonatal Indications: A Prospective Observational Study. Anesth Analg 2019; 126:1234-1240. [PMID: 29341967 DOI: 10.1213/ane.0000000000002813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nitric oxide (NO) has a well-known efficacy in pulmonary hypertension (PH), with wide use for 20 years in many countries. The objective of this study was to describe the current use of NO in real life and the gap with the guidelines. METHODS This is a multicenter, prospective, observational study on inhaled NO administered through an integrated delivery and monitoring device and indicated for PH according to the market authorizations. The characteristics of NO therapy and ventilation modes were observed. Concomitant pulmonary vasodilator treatments, safety data, and outcome were also collected. Quantitative data are expressed as median (25th, 75th percentile). RESULTS Over 1 year, 236 patients were included from 14 equipped and trained centers: 117 adults and 81 children with PH associated with cardiac surgery and 38 neonates with persistent PH of the newborn. Inhaled NO was initiated before intensive care unit (ICU) admission in 57%, 12.7%, and 38.9% with an initial dose of 10 (10, 15) ppm, 20 (18, 20) ppm, and 17 (11, 20) ppm, and a median duration of administration of 3.9 (1.9, 6.1) days, 3.8 (1.8, 6.8) days, and 3.1 (1.0, 5.7) days, respectively, for the adult population, pediatric cardiac group, and newborns. The treatment was performed using administration synchronized to the mechanical ventilation. The dose was gradually decreased before withdrawal in 86% of the cases according to the usual procedure of each center. Adverse events included rebound effect for 3.4% (95% confidence interval [CI], 0.9%-8.5%) of adults, 1.2% (95% CI, 0.0%-6.7%) of children, and 2.6% (95% CI, 0.1%-13.8%) of neonates and methemoglobinemia exceeded 2.5% for 5 of 62 monitored patients. Other pulmonary vasodilators were associated with NO in 23% of adults, 95% of children, and 23.7% of neonates. ICU stay was respectively 10 (6, 22) days, 7.5 (5.5, 15) days, and 9 (8, 15) days and ICU mortality was 22.2%, 6.2%, and 7.9% for adults, children, and neonates, respectively. CONCLUSIONS This study confirms the safety of NO therapy in the 3 populations with a low rate of rebound effect. Gradual withdrawal of NO combined with pulmonary vasodilators are current practices in this population. The use of last-generation NO devices allowed good compliance with recommendations.
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Affiliation(s)
- Philippe Gaudard
- From the Cardiothoracic Intensive Care Unit, Centre Hospitalier Universitaire de Montpellier, and PhyMedExp, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Claudio Barbanti
- Pediatric Cardiac Intensive Care, Anesthesia and Perfusion Unit, Reference Centre for Complex Congenital Cardiac Disease, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bertrand Rozec
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Philippe Mauriat
- Congenital Cardiac Surgery Unit, Department of Anesthesia and Intensive Care II, Maison du Haut Lévêque - Groupe Hospitalier Sud, Pessac, France
| | | | - Gilles Cambonie
- Neonatal and pediatric Intensive Care Unit, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Jean Michel Liet
- Pediatric Intensive Care Unit, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Claude Girard
- Cardiovascular Intensive Care Unit, Centre Hospitalier Universitaire Bocage Central, Dijon, France
| | | | - Ziad Assaf
- Pediatric Cardiac Intensive Care, Anesthesia and Perfusion Unit, Reference Centre for Complex Congenital Cardiac Disease, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Damas
- Intensive Care Unit, Centre Hospitalier Universitaire de Liège, Liège, Belgique
| | - Gauthier Loron
- Neonatal Intensive Care Unit, Centre Hospitalier Universitaire de Reims, Reims, France
| | | | - Julien Amour
- Sorbonne Universités, UPMC Univ Paris 06, UMR INSERM 1166, IHU ICAN, and Department of Anesthesiology and Critical Care Medicine, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Pouard
- Pediatric Cardiac Intensive Care, Anesthesia and Perfusion Unit, Reference Centre for Complex Congenital Cardiac Disease, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
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Bentur L, Gur M, Ashkenazi M, Livnat-Levanon G, Mizrahi M, Tal A, Ghaffari A, Geffen Y, Aviram M, Efrati O. Pilot study to test inhaled nitric oxide in cystic fibrosis patients with refractory Mycobacterium abscessus lung infection. J Cyst Fibros 2019; 19:225-231. [PMID: 31129068 DOI: 10.1016/j.jcf.2019.05.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Airways of Cystic Fibrosis (CF) patients are Nitric Oxide (NO) deficient which may contribute to impaired lung function and infection clearance. Mycobacterium abscessus (M. abscessus) infection prevalence is increasing in CF patients and is associated with increased morbidity and mortality. Here, we assess the safety and efficacy of intermittent inhaled NO (iNO) as adjuvant therapy in CF patients with refractory M. abscessus lung infection. METHODS A prospective, open-label pilot study of iNO (160 ppm) administered five times/day during hospitalization (14 days), and three times/day during ambulatory treatment (7 days) was conducted. The primary outcome was safety measured by NO-related adverse events (AEs). Secondary outcomes were six-minute walk distance (6MWD), forced expiratory volume in 1 s (FEV1), and M. abscessus burden in airways. RESULTS Nine subjects were recruited. INO at 160 ppm was well-tolerated and no iNO-related SAEs were observed during the study. Mean FEV1 and 6WMD were increased relative to baseline during NO treatment. M. abscessus culture conversion was not achieved, but 3/9 patients experienced at least one negative culture during the study. Mean time to positivity in M. abscessus culture, and qPCR analysis showed reductions in sputum bacterial load. The study was not powered to achieve statistical significance in FEV1, 6WMD, and bacterial load. CONCLUSIONS Intermittent iNO at 160 ppm is well tolerated and safe and led to increases in mean 6MWD and FEV1. INO exhibited potential antibacterial activity against M. abscessus. Further evaluation of secondary endpoints in a larger cohort of CF patients is warranted to demonstrate statistical significance.
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Affiliation(s)
- Lea Bentur
- Pediatric Pulmonary Institute and CF Center, Ruth Children's Hospital, Rambam Health Care Campus, POB 9602, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel.
| | - Michal Gur
- Pediatric Pulmonary Institute and CF Center, Ruth Children's Hospital, Rambam Health Care Campus, POB 9602, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Moshe Ashkenazi
- Pediatric Pulmonary Institute and National CF Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer 52621, Ramat-Gan, Israel; Pediatric Pulmonary Unit, Soroka University Medical Center POB 151, Beer-Sheva, Israel
| | - Galit Livnat-Levanon
- Pediatric Pulmonology Unit and CF Center, Lady Davis Carmel Medical Center, Haifa, Israel
| | | | - Asher Tal
- AIT Therapeutics Inc, Garden City, NY 11530, USA
| | | | - Yuval Geffen
- Microbiology Laboratory, Rambam Health Care Campus, POB 9602, Haifa, Israel
| | - Micha Aviram
- Pediatric Pulmonary Unit, Soroka University Medical Center POB 151, Beer-Sheva, Israel
| | - Ori Efrati
- Pediatric Pulmonary Institute and National CF Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer 52621, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel-Aviv University, POB 39040, Tel-Aviv, Israel
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Rhine WD, Suzuki S, Potenziano JL, Escalante S, Togari H. An Analysis of Time to Improvement in Oxygenation in Japanese Preterm and Late Preterm or Term Neonates With Hypoxic Respiratory Failure and Pulmonary Hypertension. Clin Ther 2019; 41:910-919. [PMID: 30987776 DOI: 10.1016/j.clinthera.2019.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/07/2019] [Accepted: 03/17/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE We analyzed data from an ongoing registry to determine time to improvement in oxygenation in preterm and late preterm or term neonates with hypoxic respiratory failure and pulmonary hypertension receiving inhaled nitric oxide (iNO) in Japan. METHODS Registry neonates received iNO ≤7 days after birth (February 26, 2010, to October 9, 2012). Efficacy and safety profile data were collected up to 96 h after iNO initiation and, if necessary, every 24 h thereafter and before iNO discontinuation. Patients were stratified by gestational age (GA), oxygenation index (OI), and shunt direction at baseline. FINDINGS Data were evaluated for 1106 neonates (431 with a GA <34 weeks and 675 with a GA of ≥34 weeks). Sixty percent of patients had improved OI; rates were similar for those with GAs of <34 versus ≥34 weeks (61% vs 59%). Overall, mean time to improvement was 11.4 h and tended to be shorter in the groups with a GA <34 weeks versus ≥34 weeks (9.2 vs 12.9 h). Thirty percent of responding neonates required >1 h to achieve improvement in oxygenation. Neonates with higher baseline OI had the greatest decrease in OI during the first hour of treatment. The mortality rate was higher among iNO-treated patients with a baseline OI ≥25 versus those with OI ≥15 to <25 (25% vs 12%; P = 0.0073). IMPLICATIONS iNO treatment provided acute, sustained improvement in oxygenation in neonates with GAs <34 and ≥34 weeks; 70% of patients had improvement within 1 h, but the remaining 30% took >1 h to respond. Initiation of iNO at lower OIs was associated with reduced mortality compared with higher OI.
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Affiliation(s)
- William D Rhine
- Department of Pediatrics-Neonatology, Stanford University School of Medicine, Palo Alto, CA, USA.
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Inhaled nitric oxide for neonates with persistent pulmonary hypertension of the newborn in the CINRGI study: time to treatment response. BMC Pediatr 2019; 19:17. [PMID: 30636626 PMCID: PMC6330425 DOI: 10.1186/s12887-018-1368-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/07/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Substantial numbers of neonates with hypoxic respiratory failure (HRF) do not immediately respond to inhaled nitric oxide (iNO) and are often labeled as non-responders. This retrospective data analysis assessed time to treatment response in the iNO key registration trial. METHODS Treatment response was defined as a ≥10% increase in partial pressure of arterial oxygen (PaO2) or a ≥10% decrease in oxygenation index (OI) after initiation of study gas without the need for extracorporeal membrane oxygenation (ECMO). The proportion of patients showing a response at 30 min, 1 h, 24 h, and >24 h after iNO or placebo initiation was calculated and stratified by baseline PaO2 and OI. RESULTS Data from 248 patients (iNO: n = 126; placebo: n = 122) were included; 66 patients receiving iNO showed improvement in oxygenation without needing ECMO versus 38 receiving placebo. Of the 66 iNO responders, 73% responded within ≤30 min, 9% within ≤1 h, 12% within ≤24 h, and 6% after 24 h. Of the 38 patients with improvement in oxygenation without needing ECMO while receiving placebo, 53% showed improvement within ≤30 min, 16% within ≤1 h, 29% within ≤24 h, and 3% after 24 h. Baseline disease severity was not predictive of time to response. Of the 48 patients in the iNO treatment group who were classified as non-responders due to eventual need for ECMO and not included in the analysis of responders, 40 (83%) had an initial improvement in oxygenation during iNO therapy. CONCLUSIONS Changes in PaO2 and OI after iNO initiation appear to be imprecise biomarkers of response to therapy in neonates with HRF. In some patients treated with iNO, it took up to 24 h to achieve improvement in oxygenation without need for ECMO, and a majority of those who eventually required ECMO did show an initial improvement in oxygenation during iNO treatment. Thus, reliable, objective, early criteria for iNO response still need to be established, and initial PaO2/OI responses should be interpreted with caution, particularly when considering discontinuing iNO therapy.
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Robinson KM, Yang W, Haidar CE, Hankins JS, Jay DW, Kornegay N, Rubnitz JE, Broeckel U, Cheng C, Pui CH, Jeha S, Relling MV. Concordance between glucose-6-phosphate dehydrogenase (G6PD) genotype and phenotype and rasburicase use in patients with hematologic malignancies. THE PHARMACOGENOMICS JOURNAL 2018; 19:305-314. [PMID: 30206300 PMCID: PMC6414283 DOI: 10.1038/s41397-018-0043-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 06/21/2018] [Accepted: 08/10/2018] [Indexed: 02/02/2023]
Abstract
Phenotypic rather than genotypic tests remain the gold standard for diagnosing glucose-6-phosphate dehydrogenase (G6PD) deficiency. However, with increasing use of genomic arrays and whole exome or genome sequencing, G6PD genetic data are increasingly available. We examined the utility of G6PD genetic data in patients with hematologic malignancies and the association of G6PD genotype and phenotype with rasburicase-induced methemoglobinemia. We analyzed G6PD activity for 990 patients. Genotype data were available from the Affymetrix DMET array (n=379), whole exome sequencing (n=374), and/or the Illumina exome array (n=634) for 645 patients. Medical records of 341 patients with methemoglobin measures were assessed for the administration of rasburicase. We observed 5 non-synonymous SNPs, 4 of which were known to be associated with deficient G6PD activity (WHO Class I-III). Genotyping 367 males resulted in a positive predictive value of 81.8% (47.8–96.8%), and two males with a Class I-III allele having normal activity both received a red blood cell transfusion prior to the activity assay. However, genotyping males had only 39.1% (20.5–61.2%) sensitivity. Two of the 12 heterozygous females had deficient G6PD activity. Rasburicase-induced methemoglobinemia occurred in 6 patients, 5 of whom had at least one Class I-III allele, despite 2 of these having normal G6PD activity. We conclude that although an apparent nondeficient genotype does not necessarily imply a normal phenotype, a deficient genotype result indicates a deficient phenotype in those without transfusions, and may be a useful adjuct to phenotype to prevent adverse drug reactions.
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Affiliation(s)
- Katherine M Robinson
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cyrine E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Dennis W Jay
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nancy Kornegay
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeffrey E Rubnitz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ulrich Broeckel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mary V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Suzuki S, Togari H, Potenziano JL, Schreiber MD. Efficacy of inhaled nitric oxide in neonates with hypoxic respiratory failure and pulmonary hypertension: the Japanese experience. J Perinat Med 2018; 46:657-663. [PMID: 28926340 DOI: 10.1515/jpm-2017-0040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/21/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyze data from a registry of Japanese neonates with hypoxic respiratory failure associated with pulmonary hypertension (PH) to compare the effectiveness of inhaled nitric oxide (iNO) in neonates born <34 weeks vs. ≥34 weeks gestational age (GA). MATERIALS AND METHODS iNO was administered according to approved Japanese product labeling. Study data were collected before iNO administration and at predefined intervals until discontinuation. RESULTS A total of 1,114 neonates were included (n=431, <34 weeks GA; n=675, ≥34 weeks GA; n=8, missing age data). Mean decrease from baseline oxygenation index (OI) was similar in both age groups. OI reduction was more pronounced in the <34 weeks subgroups with baseline OI ≥25. Survival rates were similar in the <34 weeks GA and ≥34 weeks GA groups stratified by baseline OI (OI<15, 89% vs. 93%; 15≤OI<25, 85% vs. 91%; 25≤OI≤40, 73% vs. 79%; OI>40, 64% vs. 66%). CONCLUSION iNO improved oxygenation in preterm neonates as effectively as in late preterm and term neonates, without negative impact on survival. If clinically significant PH is present, as measured by pulse oximetry or echocardiography, a therapeutic trial of iNO might be indicated for preterm neonates.
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Affiliation(s)
- Satoshi Suzuki
- Department of Neonatology, Nagoya City West Medical Center, Nagoya, Japan
| | - Hajime Togari
- Department of Neonatology, Nagoya City West Medical Center, Nagoya, Japan
| | | | - Michael D Schreiber
- Department of Pediatrics, Chief, Section of Neonatology, The University of Chicago, Comer Children's Hospital, 5721 S. Maryland Avenue, Chicago, IL 60637,USA
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Abstract
Background: Although oxygen is the most widely used therapeutic agent in neonatal care, optimal oxygen management remains uncertain. Purpose: We reviewed oxygen physiology and balance, key studies evaluating oxygen saturation targets, and strategies for oxygen use in the neonatal intensive care unit. Results: Oxygen is a potent vasodilator involved in the transition at birth to breathing. Supplemental oxygen is administered to reverse/prevent hypoxia; however, excessive oxygen can be toxic owing to the formation of reactive oxygen species. Current neonatal resuscitation guidelines recommend using room air for term infants in need of support, with titration to achieve oxygen saturation levels similar to uncompromised term infants. In premature infants, targeting a higher oxygen saturation range (eg, 91%-95%) may be safer than targeting a lower range (eg, 85%-89%), but more evidence is needed. In combined analyses, lower oxygen saturation levels increased mortality, suggesting that the higher target may be safer, but higher targets are associated with an increased risk of developing disorders of oxidative stress. Implications for Practice: Need for supplemental oxygen should be assessed according to the American Heart Association guidelines. If appropriate, oxygen should be administered using room air, with the goal of preventing hypoxia and avoiding hyperoxia. Use of oximeter alarms may help achieve this goal. Pulmonary vasodilators may improve oxygenation and reduce supplemental oxygen requirements. Implications for Research: Implementation of wider target ranges for oxygen saturation may be more practical and lead to improved outcomes; however, controlled trials are necessary to determine the impact on mortality and disability.
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Current Practices and Attitudes Regarding Use of Inhaled Nitric Oxide in the NICU: Results From a Survey of Members of the National Association of Neonatal Nurse Practitioners. Adv Neonatal Care 2018; 18:88-97. [PMID: 29465446 PMCID: PMC5895172 DOI: 10.1097/anc.0000000000000470] [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] [Indexed: 12/03/2022]
Abstract
Background: Excessive supplemental oxygen exposure in the neonatal intensive care unit (NICU) can be associated with oxygen-related toxicities, which can lead to negative clinical consequences. Use of inhaled nitric oxide (iNO) can be a successful strategy for avoiding hyperoxia in the NICU. iNO selectively produces pulmonary vasodilation and has been shown to improve oxygenation parameters across the spectrum of disease severity, from mild to very severe, in neonates with hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn. Purpose: An online survey was conducted among members of the National Association of Neonatal Nurse Practitioners to gain insight into the level of understanding and knowledge among neonatal nurse practitioners (NNPs) about optimizing supplemental oxygen exposure and the use of iNO in the NICU setting. Results: Of 937 NNP respondents, 51% reported that their healthcare team typically waits until the fraction of inspired oxygen level is 0.9 or more before adding iNO in patients not responding to oxygen ventilation alone. Among respondents with 1 or more iNO-treated patients per month, only 35% reported they know the oxygenation index level at which iNO should be initiated. Less than 20% of NNPs reported perceived benefits associated with early initiation of iNO for preventing progression to use of extracorporeal membrane oxygenation or reducing the length of hospital stay, and about one-third of respondents reported they believe early iNO use minimizes hyperoxia. Implications for Practice: More education is needed for NNPs regarding the negative effects of oxidative stress in neonates. Implications for Research: Additional clinical trials investigating the most beneficial strategies for avoiding neonatal hyperoxia are warranted.
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Lai MY, Chu SM, Lakshminrusimha S, Lin HC. Beyond the inhaled nitric oxide in persistent pulmonary hypertension of the newborn. Pediatr Neonatol 2018; 59:15-23. [PMID: 28923474 DOI: 10.1016/j.pedneo.2016.09.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 08/16/2016] [Accepted: 09/12/2016] [Indexed: 11/24/2022] Open
Abstract
Persistent pulmonary hypertension (PPHN) is a consequence of failed pulmonary vascular transition at birth and leads to pulmonary hypertension with shunting of deoxygenated blood across the ductus arteriosus (DA) and foramen ovale (FO) resulting in severe hypoxemia, and it may eventually lead to life-threatening circulatory failure. PPHN is a serious event affecting both term and preterm infants in the neonatal intensive care unit. It is often associated with diseases such as congenital diaphragmatic hernia, meconium aspiration, sepsis, congenital pneumonia, birth asphyxia and respiratory distress syndrome. The diagnosis of PPHN should include echocardiographic evidence of increased pulmonary pressure, with demonstrable right-to-left shunt across the DA or FO, and the absence of cyanotic heart diseases. The mainstay therapy of PPHN includes treatment of underlying causes, maintenance of adequate systemic blood pressure, optimized ventilator support for lung recruitment and alveolar ventilation, and pharmacologic measures to increase pulmonary vasodilation and decrease pulmonary vascular resistance. Inhaled nitric oxide has been proved to treat PPHN successfully with improved oxygenation in 60-70% of patients and to significantly reduce the need for extracorporeal membrane oxygenation (ECMO). About 14%-46% of the survivors develop long-term impairments such as hearing deficits, chronic lung disease, cerebral palsy and other neurodevelopmental disabilities.
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Affiliation(s)
- Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, NY, USA
| | - Hung-Chih Lin
- China Medical University Children Hospital, Taiwan; School of Chinese Medicine, China Medical University, Taiwan; Asia University Hospital, Asia University, Taichung, Taiwan.
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Affiliation(s)
- J E Lynch
- Department of Critical Care Nursing, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77551-0528, USA
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The Fetus Can Teach Us: Oxygen and the Pulmonary Vasculature. CHILDREN-BASEL 2017; 4:children4080067. [PMID: 28771211 PMCID: PMC5575589 DOI: 10.3390/children4080067] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/22/2017] [Accepted: 07/31/2017] [Indexed: 11/17/2022]
Abstract
Neonates suffering from pulmonary hypertension of the newborn (PPHN) continue to represent an important proportion of patients requiring intensive neonatal care, and have an increased risk of morbidity and mortality. The human fetus has evolved to maintain a high pulmonary vascular resistance (PVR) in utero to allow the majority of the fetal circulation to bypass the lungs, which do not participate in gas exchange, towards the low resistance placenta. At birth, oxygen plays a major role in decreasing PVR to enhance pulmonary blood flow and establish the lungs as the organ of gas exchange. The failure of PVR to fall following birth results in PPHN, and oxygen remains the mainstay therapeutic intervention in the management of PPHN. Knowledge gaps on what constitutes the optimal oxygenation target leads to a wide variation in practices, and often leads to excessive oxygen use. Owing to the risk of oxygen toxicity, avoiding hyperoxemia is as important as avoiding hypoxemia in the management of PPHN. Current evidence supports maintaining arterial oxygen tension in the range of 50–80 mm Hg, and oxygen saturation between 90–97% in term infants with hypoxemic respiratory failure. Clinical studies evaluating the optimal oxygenation in the treatment of PPHN will be enthusiastically awaited.
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Abstract
Failure of the normal circulatory adaptation to extrauterine life results in persistent pulmonary hypertension of the newborn (PPHN). Although this condition is most often secondary to parenchymal lung disease or lung hypoplasia, it may also be idiopathic. PPHN is characterized by elevated pulmonary vascular resistance with resultant right-to-left shunting of blood and hypoxemia. Although the preliminary diagnosis of PPHN is often based on differential cyanosis and labile hypoxemia, the diagnosis is confirmed by echocardiography. Management strategies include optimal lung recruitment and use of surfactant in patients with parenchymal lung disease, maintaining optimal oxygenation and stable blood pressures, avoidance of respiratory and metabolic acidosis and alkalosis, and pulmonary vasodilator therapy. Extracorporeal membrane oxygenation is considered when medical management fails. Although mortality associated with PPHN has decreased significantly with improvements in medical care, there remains the potential risk for neurodevelopmental disability which warrants close follow-up of affected infants after discharge.
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Affiliation(s)
- Mamta Fuloria
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY, USA
| | - Judy L Aschner
- Departments of Pediatrics and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY, USA.
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Luecke C, McPherson C. Treatment of Persistent Pulmonary Hypertension of the Newborn: Use of Pulmonary Vasodilators in Term Neonates. Neonatal Netw 2017; 36:160-168. [PMID: 28494828 DOI: 10.1891/0730-0832.36.3.160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) represents a challenging condition associated with significant morbidity. A successful transition from intrauterine to extrauterine life is contingent on adequate pulmonary vasodilation. Several pathophysiologies contribute to the failure of this cascade and may result in life-threatening hypoxia and acidosis in the newborn. Management includes optimal respiratory support, adequate sedation and analgesia, and support of vascular tone and cardiac function. Pulmonary vasodilation has the potential to overcome the cycle of hypoxia and acidosis, improving outcome in these infants. Oxygen and inhaled nitric oxide represent the foundation of therapy. Tertiary pulmonary vasodilators represent a greater challenge, selecting between therapies that include prostanoids, sildenafil, and milrinone. Variable levels of evidence exist for each agent. Thorough review of available data informing efficacy and adverse effects contributes to the development of an informed approach to neonates with refractory PPHN.
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Margel D, Mizrahi M, Regev-Shoshani G, KO M, Moshe M, Ozalvo R, Shavit-Grievink L, Baniel J, Kedar D, Yossepowitch O, Lifshitz D, Nadu A, Greenberg D, Av-Gay Y. Nitric oxide charged catheters as a potential strategy for prevention of hospital acquired infections. PLoS One 2017; 12:e0174443. [PMID: 28410367 PMCID: PMC5391919 DOI: 10.1371/journal.pone.0174443] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 03/08/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Catheter-Associated Hospital-Acquired Infections (HAI's) are caused by biofilm-forming bacteria. Using a novel approach, we generated anti-infective barrier on catheters by charging them with Nitric Oxide (NO), a naturally-produced gas molecule. NO is slowly released from the catheter upon contact with physiological fluids, and prevents bacterial colonization and biofilm formation onto catheter surfaces. AIMS AND METHODS The aim of the study was to assess the anti-infective properties of NO-charged catheters exposed to low concentration (up to 103 CFU/ml) of microbial cells in-vitro. We assessed NO-charged tracheal tubes using Pseudomonas aeruginosa, dialysis and biliary catheters using Escherichia coli, and urinary catheters using E. coli, Candida albicans or Enterococcus faecalis. Safety and tolerability of NO-charged urinary catheters were evaluated in a phase 1 clinical study in 12 patients. Six patients were catheterized with NO-charged catheters (NO-group), followed by 6 patients catheterized with regular control catheters (CT-group). Comparison of safety parameters between the study groups was performed. RESULTS NO-charged tracheal, dialysis biliary and urinary catheters prevented P. aeruginosa, E. coli and C. albicans attachment and colonization onto their surfaces and eradicated corresponding planktonic microbial cells in the surrounding media after 24-48 hours, while E. faecalis colonization onto urinary catheters was reduced by 1 log compared to controls. All patients catheterized with an NO-charged urinary catheter successfully completed the study without experiencing NO-related AE's or serious AE's (SAE's). CONCLUSION These data highlight the potential of NO-based technology as potential platform for preventing catheter-associated HAI's.
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Affiliation(s)
- David Margel
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | | | - Gili Regev-Shoshani
- Department of Medicine, Division of Infectious Disease, University of British Columbia, British Columbia Province, Vancouver, Canada
| | - Mary KO
- Department of Medicine, Division of Infectious Disease, University of British Columbia, British Columbia Province, Vancouver, Canada
| | - Maya Moshe
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - Rachel Ozalvo
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - Liat Shavit-Grievink
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - Jack Baniel
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - Daniel Kedar
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - Ofer Yossepowitch
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - David Lifshitz
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | - Andrei Nadu
- Division of Urology, Rabin Medical Center and Tel-Aviv University, Sackler School of Medicine, Petach-Tikva, Israel
| | | | - Yossef Av-Gay
- ENOX Ltd., Habarzel 38, Tel-Aviv, Israel
- Department of Medicine, Division of Infectious Disease, University of British Columbia, British Columbia Province, Vancouver, Canada
- * E-mail:
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Abstract
Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm. The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used. Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO.
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