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Memisoglu A, Hinton M, Elsayed Y, Graham R, Dakshinamurti S. Assessment of Autoregulation of the Cerebral Circulation during Acute Lung Injury in a Neonatal Porcine Model. CHILDREN (BASEL, SWITZERLAND) 2024; 11:611. [PMID: 38790606 PMCID: PMC11119854 DOI: 10.3390/children11050611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024]
Abstract
In neonates with acute lung injury (ALI), targeting lower oxygenation saturations is suggested to limit oxygen toxicity while maintaining vital organ function. Although thresholds for cerebral autoregulation are studied for the management of premature infants, the impact of hypoxia on hemodynamics, tissue oxygen consumption and extraction is not well understood in term infants with ALI. We examined hemodynamics, cerebral autoregulation and fractional oxygen extraction, as measured by near-infrared spectroscopy (NIRS) and blood gases, in a neonatal porcine oleic acid injury model of moderate ALI. We hypothesized that in ALI animals, cerebral oxygen extraction would be increased to a greater degree than kidney or gut oxygen extraction as indicative of the brain's adaptive efforts to increase cerebral oxygen extraction at the expense of splanchnic end organs. Fifteen anesthetized, ventilated 5-day-old neonatal piglets were divided into moderate lung injury by treatment with oleic acid or control (sham injection). The degree of lung injury was quantified at baseline and after establishment of ALI by blood gases, ventilation parameters and calculated oxygenation deficit, hemodynamic indices by echocardiography and lung injury score by ultrasound. PaCO2 was maintained constant during ventilation. Cerebral, renal and gut oxygenation was determined by NIRS during stepwise decreases in inspired oxygen from 50% to 21%, correlated with PaO2 and PvO2; changes in fractional oxygen extraction (ΔFOE) were calculated from NIRS and from regional blood gas samples. The proportion of cerebral autoregulation impairment attributable to blood pressure, and to hypoxemia, was calculated from autoregulation nomograms. ALI manifested as hypoxemia with increasing intrapulmonary shunt fraction, decreased lung compliance and increased resistance, and marked increase in lung ultrasound score. Brain, gut and renal NIRS, obtained from probes placed over the anterior skull, central abdomen and flank, respectively, correlated with concurrent SVC (brain) or IVC (gut, renal) PvO2 and SvO2. Cerebral autoregulation was impaired after ALI as a function of blood pressure at all FiO2 steps, but predominantly by hypoxemia at FiO2 < 40%. Cerebral ΔFOE was higher in ALI animals at all FiO2 steps. We conclude that in an animal model of neonatal ALI, cerebrovascular blood flow regulation is primarily dependent on oxygenation. There is not a defined oxygenation threshold below which cerebral autoregulation is impaired in ALI. Cerebral oxygen extraction is enhanced in ALI, reflecting compensation for exhausted cerebral autoregulation due to the degree of hypoxemia and/or hypotension, thereby protecting against tissue hypoxia.
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Affiliation(s)
- Asli Memisoglu
- Biology of Breathing Theme, Children’s Hospital Research Institute of Manitoba, Winnipeg, MB R3E 3P4, Canada; (A.M.); (M.H.)
| | - Martha Hinton
- Biology of Breathing Theme, Children’s Hospital Research Institute of Manitoba, Winnipeg, MB R3E 3P4, Canada; (A.M.); (M.H.)
- Department of Physiology, University of Manitoba, 745 Bannatyne Ave., Winnipeg, MB R3E 0J9, Canada
| | - Yasser Elsayed
- Section of Neonatology, Department of Pediatrics, Women’s Hospital, Health Sciences Centre, 665 William Ave., Winnipeg, MB R3E 0L8, Canada;
| | - Ruth Graham
- Departments of Anesthesiology, Perioperative and Pain Medicine, Health Sciences Centre, 671 William Ave., Winnipeg, MB R3E 0Z3, Canada;
| | - Shyamala Dakshinamurti
- Biology of Breathing Theme, Children’s Hospital Research Institute of Manitoba, Winnipeg, MB R3E 3P4, Canada; (A.M.); (M.H.)
- Department of Physiology, University of Manitoba, 745 Bannatyne Ave., Winnipeg, MB R3E 0J9, Canada
- Section of Neonatology, Department of Pediatrics, Women’s Hospital, Health Sciences Centre, 665 William Ave., Winnipeg, MB R3E 0L8, Canada;
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Huizing MJ, Hundscheid TM, Bartoš F, Villamor E. A Bayesian Reanalysis of the Overall and Sex-Disaggregated Results of the Neonatal Oxygenation Prospective Meta-Analysis (NeOProM). Antioxidants (Basel) 2024; 13:509. [PMID: 38790614 PMCID: PMC11117690 DOI: 10.3390/antiox13050509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
Data from the Neonatal Oxygenation Prospective Meta-analysis (NeOProM) indicate that targeting a higher (91-95%) versus lower (85-89%) pulse oximeter saturation (SpO2) range may reduce mortality and necrotizing enterocolitis (NEC) and increase retinopathy of prematurity (ROP). Aiming to re-evaluate the strength of this evidence, we conducted a Bayesian reanalysis of the NeOProM data. We used Bayes factors (BFs) to evaluate the likelihood of the data under the combination of models assuming the presence vs. absence of effect, heterogeneity, and moderation by sex. The Bayesian reanalysis showed moderate evidence in favor of no differences between SpO2 targets (BF10 = 0.30) in death or major disability, but moderate evidence (BF10 = 3.60) in favor of a lower mortality in the higher SpO2 group. Evidence in favor of differences was observed for bronchopulmonary dysplasia (BPD) (BF10 = 14.44, lower rate with lower SpO2), severe NEC (BF10 = 9.94), and treated ROP (BF10 = 3.36). The only outcome with moderate evidence in favor of sex differences was BPD. This reanalysis of the NeOProM trials confirmed that exposure to a lower versus higher SpO2 range is associated with a higher mortality and risk of NEC, but a lower risk of ROP and BPD. The Bayesian approach can help in assessing the strength of evidence supporting clinical decisions.
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Affiliation(s)
- Maurice Jacob Huizing
- Division of Neonatology, MosaKids Children’s Hospital, Maastricht University Medical Center (MUMC+), Research Institute for Oncology and Reproduction (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands
| | - Tamara Maria Hundscheid
- Division of Neonatology, MosaKids Children’s Hospital, Maastricht University Medical Center (MUMC+), Research Institute for Oncology and Reproduction (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands
| | - František Bartoš
- Department of Psychology, University of Amsterdam, 1001 NK Amsterdam, The Netherlands
| | - Eduardo Villamor
- Division of Neonatology, MosaKids Children’s Hospital, Maastricht University Medical Center (MUMC+), Research Institute for Oncology and Reproduction (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands
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Vento M. Adequate nutrition for bronchopulmonary dysplasia, but do not forget oxygen. Pediatr Res 2024:10.1038/s41390-024-03205-4. [PMID: 38594423 DOI: 10.1038/s41390-024-03205-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Maximo Vento
- Instituto de Investigación Sanitaria La Fe (IISLAFE), (Health Research Institute La Fe), Avenida de Fernando Abril Martorell 106, 46026, Valencia, Spain.
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Choi HJ, Shin BS, Shin SH, Kim EK, Kim HS. Critical period of oxygen supplementation and invasive ventilation: implications for severe retinopathy of prematurity. Ital J Pediatr 2024; 50:58. [PMID: 38561824 PMCID: PMC10985977 DOI: 10.1186/s13052-024-01629-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Several studies have identified graded oxygen saturation targets to prevent retinopathy of prematurity (ROP), a serious complication in preterm infants. We aimed to analyze the critical period of oxygen supplementation and/or invasive ventilation associated with severe ROP. METHODS This retrospective case-control study included neonates with a gestational age (GA) < 29 weeks. Participants were divided into two groups: treated retinopathy and untreated/no retinopathy. Time-weighted average FiO2 (TWAFiO2) and weekly invasive ventilation were compared between groups by postnatal age (PNA) and postmenstrual age (PMA). The association of treated retinopathy with TWAFiO2 and invasive ventilation was analyzed. RESULTS Data from 287 neonates were analyzed; 98 were treated for ROP and had lower GAs (25.5 vs. 27.4 weeks, p < 0.01) and lower birthweights (747.6 vs. 1014 g, p < 0.001) than those with untreated/no ROP. TWAFiO2 was higher from PMA 26-34 weeks, except for PMA 31 weeks in treated ROP, and higher in the first nine weeks of life in treated ROP. On multiple logistic regression, TWAFiO2 and invasive ventilation were associated with ROP treatment during the first seven weeks PNA. Invasive ventilation was associated with ROP treatment from PMA 26-31 weeks; no association was found for TWAFiO2 and PMA. CONCLUSIONS Amount of oxygen supplementation and/or invasive ventilation during the first 7 weeks of life or up to 31 weeks PMA was associated with development of severe ROP. This period might be candidate timing for strict oxygen supplementation strategies in preterm infants, while concerns of mortality with low oxygen supplementation should be further explored.
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Affiliation(s)
- Ho Jung Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Baek Sup Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
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Weese-Mayer DE, Di Fiore JM, Lake DE, Hibbs AM, Claure N, Qiu J, Ambalavanan N, Bancalari E, Kemp JS, Zimmet AM, Carroll JL, Martin RJ, Krahn KN, Hamvas A, Ratcliffe SJ, Krishnamurthi N, Indic P, Dormishian A, Dennery PA, Moorman JR. Maturation of cardioventilatory physiological trajectories in extremely preterm infants. Pediatr Res 2024; 95:1060-1069. [PMID: 37857848 DOI: 10.1038/s41390-023-02839-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND In extremely preterm infants, persistence of cardioventilatory events is associated with long-term morbidity. Therefore, the objective was to characterize physiologic growth curves of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants during the first few months of life. METHODS The Prematurity-Related Ventilatory Control study included 717 preterm infants <29 weeks gestation. Waveforms were downloaded from bedside monitors with a novel sharing analytics strategy utilized to run software locally, with summary data sent to the Data Coordinating Center for compilation. RESULTS Apnea, periodic breathing, and intermittent hypoxemia events rose from day 3 of life then fell to near-resolution by 8-12 weeks of age. Apnea/intermittent hypoxemia were inversely correlated with gestational age, peaking at 3-4 weeks of age. Periodic breathing was positively correlated with gestational age peaking at 31-33 weeks postmenstrual age. Females had more periodic breathing but less intermittent hypoxemia/bradycardia. White infants had more apnea/periodic breathing/intermittent hypoxemia. Infants never receiving mechanical ventilation followed similar postnatal trajectories but with less apnea and intermittent hypoxemia, and more periodic breathing. CONCLUSIONS Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. IMPACT Physiologic curves of cardiorespiratory events in extremely preterm-born infants offer (1) objective measures to assess individual patient courses and (2) guides for research into control of ventilation, biomarkers and outcomes. Presented are updated maturational trajectories of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in 717 infants born <29 weeks gestation from the multi-site NHLBI-funded Pre-Vent study. Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. Different time courses for apnea and periodic breathing suggest different maturational mechanisms.
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Affiliation(s)
- Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
| | - Douglas E Lake
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jiaxing Qiu
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James S Kemp
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Amanda M Zimmet
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Katy N Krahn
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aaron Hamvas
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Neonatology, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Narayanan Krishnamurthi
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas Tyler, Tyler, TX, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phyllis A Dennery
- Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - J Randall Moorman
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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Bachman TE, Iyer NP, Newth CJL, LeMoyne R. Determining an Optimal Oxygen Saturation Target Range Based on Neonatal Maturity: Demonstration of a Decision Tree Analytic. Diagnostics (Basel) 2023; 13:3312. [PMID: 37958208 PMCID: PMC10648394 DOI: 10.3390/diagnostics13213312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/22/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The utility of decision tree machine learning in exploring the interactions among the SpO2 target range, neonatal maturity, and oxemic-risk is demonstrated. METHODS This observational study used 3 years of paired age-SpO2-PaO2 data from a neonatal ICU. The CHAID decision tree method was used to explore the interaction of postmenstrual age (PMA) on the risk of extreme arterial oxygen levels at six different potential SpO2 target ranges (88-92%, 89-93%, 90-94%, 91-95%, 92-96% and 93-97%). Risk was calculated using a severity-weighted average of arterial oxygen outside the normal range for neonates (50-80 mmHg). RESULTS In total, 7500 paired data points within the potential target range envelope were analyzed. The two lowest target ranges were associated with the highest risk, and the ranges of 91-95% and 92-96% were associated with the lowest risk. There were shifts in the risk associated with PMA. All the target ranges showed the lowest risk at ≥42 weeks PMA. The lowest risk for preterm infants was within a target range of 92-96% with a PMA of ≤34 weeks. CONCLUSIONS This study demonstrates the utility of decision tree analytics. These results suggest that SpO2 target ranges that are different from typical range might reduce morbidity and mortality. Further research, including prospective randomized trials, is warranted.
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Affiliation(s)
- Thomas E. Bachman
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic;
| | - Narayan P. Iyer
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA; (N.P.I.); (C.J.L.N.)
| | - Christopher J. L. Newth
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA; (N.P.I.); (C.J.L.N.)
| | - Robert LeMoyne
- Faculty of Biomedical Engineering, Czech Technical University in Prague, 272 01 Kladno, Czech Republic;
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Aggarwal V, Bhatia R, Tan K. Oxygen saturation levels and retinopathy of prematurity in extremely preterm infants - a case control study. BMC Pediatr 2023; 23:449. [PMID: 37684577 PMCID: PMC10486104 DOI: 10.1186/s12887-023-04278-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE To investigate the association of risk factors, including oxygen exposure, for developing retinopathy of prematurity (ROP) in preterm infants at increased risk of ROP. METHODS A case-control study was conducted where each infant born at < 28 weeks gestation with ROP was matched with another without ROP over five years (July 2015 - June 2020). Clinical information about the infants was collected from electronic medical records, including method of oxygen delivery, oxygen saturation (SpO2), fraction of inspired oxygen (FiO2) and mean airway pressure (MAP) measurements. MATLAB was used for a time-averaged analysis. Stata/SE 16.0 was used for statistical analysis. RESULTS 123 ROP/non-ROP pairs were included in this study. The time-averaged SpO2 analysis showed non-ROP group spent more time in hyperoxia than the ROP group (p < 0.001). The non-ROP group had lower respiratory severity scores and analysis when FiO2 > 21% showed that were was no difference in SpO2 between the two groups when the infants were receiving oxygen support. Conditional logistic regressions showed neonatal surgery significantly increased the risk of ROP (OR = 1.4347, p = 0.010), while the influence of birthweight (odds ratio of 0.9965, p = 0.001) and oxygen exposure (OR = 0.9983, p = 0.012) on ROP outcome was found to be negligible as their odds ratios indicated no influence. CONCLUSIONS At times when infants were receiving respiratory support (FiO2 > 21%) the SpO2 data indicated no difference in SpO2 between the ROP and non-ROP groups. Analysis of clinical variables found that neonatal surgery increased the odds of developing ROP.
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Affiliation(s)
- Varnika Aggarwal
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Risha Bhatia
- Department of Paediatrics, Monash University, Melbourne, Australia
- Monash Health, Monash Newborn, Melbourne, Australia
| | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Australia.
- Monash Health, Monash Newborn, Melbourne, Australia.
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Verma S, Bailey SM. Mitigating Risks for Racial Bias in Pulse Oximetry on Children. JAMA Pediatr 2023; 177:982. [PMID: 37459120 DOI: 10.1001/jamapediatrics.2023.2292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Sourabh Verma
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Sean M Bailey
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York
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Wilinska M, Bachman TE, Piwowarczyk P, Kostuch M, Tousty J, Berła K, Hajdar R, Skrzypek M. Routine use of automated FiO 2 control in Poland: prospective registry and survey. Front Pediatr 2023; 11:1213310. [PMID: 37719452 PMCID: PMC10502171 DOI: 10.3389/fped.2023.1213310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Objective The performance of automated control of inspired oxygen (A-FiO2) has been confirmed in dozens of studies but reports of routine use are limited. Broadly adopted in Poland, our aim is to share that experience. Methods We used a prospectively planned observational study of the performance, general use patterns, unit practices, and problems with A-FiO2, based on a web registry of case reports, complemented by surveys of subjective impressions. Results In 2019, a total of 92 A-FiO2 systems were in routine use in 38 centers. Of the 38 centers, 20 had agreed in 2013 to participate in the project. In these centers, A-FiO2 was applied in infants of all weights, but some centers restricted its use to weaning from oxygen and unstable infants. A cohort had reported their experience with each use (5/20 centers, 593 cases). A quarter of those infants were managed with a lower target range and three-quarters with alarms looser than European guidelines for manual SpO2 control. The perceived primary advantages of A-FiO2 were as follows: keeping the readings in the target range, reducing exposure to SpO2 extremes, reducing risk from nurse distraction, reducing workload, and reducing alarm fatigue. Practices did evolve with experience, including implementing changes in the alarm strategy, indications for use, and target range. The potential for over-reliance on automation was cited as a risk. There were a few reports of limited effectiveness (moderate 12/593 and poor 2/593). Conclusions Automated oxygen control is broadly perceived by users as an improvement in controlling SpO2 with infrequent problems.
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Affiliation(s)
- M. Wilinska
- Department of Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - T. E. Bachman
- Department Medical Technology, School of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - P. Piwowarczyk
- Clinical Department of Neonatology, Independent Public Hospital, Warsaw, Poland
| | - M. Kostuch
- Department of Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - J. Tousty
- Department of Neonatology and Intensive Neonatal Care, Pomeranian Medical University, Szczecin, Poland
| | - K. Berła
- Department of Neonatology, Complex of Health Care Facilities, Ostrow Wielkopolski, Poland
| | - R. Hajdar
- Department of Neonatology, Provincial Specialist Hospital, Biala Podlaska, Poland
| | - M. Skrzypek
- Department of Biostatistics Medical University of Silesia, School of Health Sciences in Bytom, Bytom, Poland
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Poets CF, Nelin L. Predicting Pulmonary Outcomes in Extremely Preterm Infants from Recordings of Cardiorespiratory Data: A Question of Chicken and Egg. Am J Respir Crit Care Med 2023; 208:11-12. [PMID: 37219238 PMCID: PMC10870852 DOI: 10.1164/rccm.202305-0809ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Affiliation(s)
- Christian F Poets
- Department of Neonatology Tübingen Children's Hospital Tübingen, Germany
| | - Leif Nelin
- Nationwide Children's Hospital Columbus, Ohio
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11
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Lee SS, El Ters N, Vesoulis ZA, Zempel JM, Mathur AM. Variable Association of Physiologic Changes With Electrographic Seizure-Like Events in Infants Born Preterm. J Pediatr 2023; 257:113348. [PMID: 36801212 PMCID: PMC10575679 DOI: 10.1016/j.jpeds.2022.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To determine the incidence of seizure-like events in a cohort of infants born preterm as well as the prevalence of associated vital sign changes (heart rate [HR], respiratory rate, and pulse oximetry [SpO2]). STUDY DESIGN We performed prospective conventional video electroencephalogram monitoring on infants born at 23-30 weeks of gestational age during the first 4 postnatal days. For detected seizure-like events, simultaneously captured vital sign data were analyzed during the pre-event baseline and during the event. Significant vital sign changes were defined as HR or respiratory rate >±2 SD from the infant's own baseline physiologic mean, derived from a 10-minute interval before the seizure-like event. Significant change in SpO2 was defined as oxygen desaturation during the event with a mean SpO2 <88%. RESULTS Our sample included 48 infants with median gestational age of 28 weeks (IQR 26-29) and birth weight of 1125 g (IQR 963-1265). Twelve (25%) infants had seizure-like discharges with a total of 201 events; 83% (10/12) of infants had vital sign changes during these events, and 50% (6/12) had significant vital sign changes during the majority of the seizure-like events. Concurrent HR changes occurred the most frequently. CONCLUSIONS Individual infant variability was observed in the prevalence of concurrent vital sign changes with electroencephalographic seizure-like events. Physiologic changes associated with preterm electrographic seizure-like events should be investigated further as a potential biomarker to assess the clinical significance of such events in the preterm population.
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Affiliation(s)
- Stephanie S Lee
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Nathalie El Ters
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO.
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO
| | - John M Zempel
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, MO
| | - Amit M Mathur
- Saint Louis University School of Medicine, St Louis, MO
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12
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Prasad M, Ingolfsland EC, Christiansen SP. Modifiable Risk Factors and Preventative Strategies for Severe Retinopathy of Prematurity. Life (Basel) 2023; 13:life13051075. [PMID: 37240719 DOI: 10.3390/life13051075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/28/2023] Open
Abstract
Severe ROP is characterized by the development of retinal fibrovascular proliferation that may progress to retinal detachment. The purpose of this report is to review five of the most common and well-studied perinatal and neonatal modifiable risk factors for the development of severe ROP. Hyperoxemia, hypoxia, and associated prolonged respiratory support are linked to the development of severe ROP. While there is a well-established association between clinical maternal chorioamnionitis and severe ROP, there is greater variability between histologic chorioamnionitis and severe ROP. Neonatal sepsis, including both bacterial and fungal subtypes, are independent predictors of severe ROP in preterm infants. Although there is limited evidence related to platelet transfusions, the risk of severe ROP increases with the number and volume of red blood cell transfusions. Poor postnatal weight gain within the first six weeks of life is also strongly tied to the development of severe ROP. We also discuss preventative strategies that may reduce the risk of severe ROP. Limited evidence-based studies exist regarding the protective effects of caffeine, human milk, and vitamins A and E.
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Affiliation(s)
- Minali Prasad
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Ellen C Ingolfsland
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Stephen P Christiansen
- Departments of Ophthalmology and Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA 02118, USA
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13
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Fevereiro-Martins M, Marques-Neves C, Guimarães H, Bicho M. Retinopathy of prematurity: A review of pathophysiology and signaling pathways. Surv Ophthalmol 2023; 68:175-210. [PMID: 36427559 DOI: 10.1016/j.survophthal.2022.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
Abstract
Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina and a leading cause of visual impairment and childhood blindness worldwide. The disease is characterized by an early stage of retinal microvascular degeneration, followed by neovascularization that can lead to subsequent retinal detachment and permanent visual loss. Several factors play a key role during the different pathological stages of the disease. Oxidative and nitrosative stress and inflammatory processes are important contributors to the early stage of ROP. Nitric oxide synthase and arginase play important roles in ischemia/reperfusion-induced neurovascular degeneration. Destructive neovascularization is driven by mediators of the hypoxia-inducible factor pathway, such as vascular endothelial growth factor and metabolic factors (succinate). The extracellular matrix is involved in hypoxia-induced retinal neovascularization. Vasorepulsive molecules (semaphorin 3A) intervene preventing the revascularization of the avascular zone. This review focuses on current concepts about signaling pathways and their mediators, involved in the pathogenesis of ROP, highlighting new potentially preventive and therapeutic modalities. A better understanding of the intricate molecular mechanisms underlying the pathogenesis of ROP should allow the development of more effective and targeted therapeutic agents to reduce aberrant vasoproliferation and facilitate physiological retinal vascular development.
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Affiliation(s)
- Mariza Fevereiro-Martins
- Laboratório de Genética and Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Investigação Científica Bento da Rocha Cabral, Lisboa, Portugal; Departamento de Oftalmologia, Hospital Cuf Descobertas, Lisboa, Portugal.
| | - Carlos Marques-Neves
- Centro de Estudos das Ci.¼ncias da Visão, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Hercília Guimarães
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
| | - Manuel Bicho
- Laboratório de Genética and Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Investigação Científica Bento da Rocha Cabral, Lisboa, Portugal.
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14
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Bronicki RA, Benitz WE, Buckley JR, Yarlagadda VV, Porta NFM, Agana DO, Kim M, Costello JM. Respiratory Care for Neonates With Congenital Heart Disease. Pediatrics 2022; 150:189881. [PMID: 36317970 DOI: 10.1542/peds.2022-056415h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ronald A Bronicki
- Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Jason R Buckley
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Vamsi V Yarlagadda
- Stanford School of Medicine, Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Nicolas F M Porta
- Northwestern University Feinberg School of Medicine, Division of Neonatology, Pediatric Pulmonary Hypertension Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Devon O Agana
- Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Pediatric Critical Care Medicine, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Minso Kim
- University of California San Francisco School of Medicine, Division of Critical Care, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - John M Costello
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
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15
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House M, Klein S, Parham D, Hysinger EB, Brady JM. Frequent hypoxemia found in infants with bronchopulmonary dysplasia after weaning home oxygen. Pediatr Pulmonol 2022; 57:2638-2645. [PMID: 35832023 DOI: 10.1002/ppul.26076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/29/2022] [Accepted: 07/12/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parental reports and brief clinical examinations are the primary information used to assist clinicians in weaning home supplemental oxygen in infants with bronchopulmonary dysplasia (BPD). Recorded nocturnal oximetry provides an objective assessment of hypoxemia; however, it is unknown if it identifies clinically undetected hypoxemia in the home setting. Our objective was to determine if nocturnal oximetry can identify unreported hypoxemia in infants with BPD who appear ready to wean from supplemental oxygen. STUDY DESIGN We conducted a retrospective chart review of infants born <32 weeks gestation with BPD who were discharged to home receiving supplemental oxygen and completed recorded nocturnal oximetry in room air during an 18-month period. Abnormal oximetry was defined as >5 min with SpO2 < 90% and/or an oxyhemoglobin desaturation index (ODI4) >5. Comparative analysis of patients with normal and abnormal overnight oximetry was performed using Fisher Exact and Wilcoxon signed-rank test. RESULTS Thirty-five former premature infants completed nocturnal oximetry at 5.8 (3.4-8.3) months corrected age. Nocturnal oximetry was abnormal as defined in 67% of the cohort (n = 21). Five percent of patients were hypoxemic, 52% had frequent desaturation events, and 43% had both. No significant differences existed in neonatal characteristics between patients with normal and abnormal studies. CONCLUSIONS Nocturnal oximetry was abnormal in the majority of infants with BPD who were otherwise clinically ready to wean from oxygen support, suggesting that recorded home oximetry could be a feasible and useful tool to evaluate for otherwise clinically unapparent nocturnal hypoxemia in patients with BPD.
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Affiliation(s)
- Melissa House
- Division of Neonatology and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sarah Klein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Danielle Parham
- Division of Neonatology and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Erik B Hysinger
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer M Brady
- Division of Neonatology and Pulmonary Biology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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16
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Estrada MM, Tomlinson LA, Yu Y, Ying GS, Binenbaum G. Daily Oxygen Supplementation and Risk of Retinopathy of Prematurity. Ophthalmic Epidemiol 2022; 30:317-325. [PMID: 36093765 DOI: 10.1080/09286586.2022.2111687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE Excessive oxygen supplementation increases risk of retinopathy of prematurity (ROP). While numerous oxygen parameters could be considered when predicting ROP (saturation targets, actual saturation, fraction of inspired oxygen, etc.), complicated measures are impractical as screening criteria. We sought to develop a simple, clinically useful measure of daily oxygen supplementation during ages 0-28 days to improve prediction of ROP. METHODS Secondary analysis of two Postnatal Growth and ROP (G-ROP) Study cohorts (G-ROP-1 and G-ROP-2) at 45 hospitals. Infants with a known ROP outcome and complete oxygen data were included. Associations between severe ROP and days on supplemental oxygen (FiO2 > 21%), during ages 0-28 days (DSO28) were assessed, controlling for birth weight (BW) and gestational age (GA). New screening criteria incorporating DSO were developed and compared to current guidelines. RESULTS Among 8,949 studied infants, 459 (5.1%) developed type 1 ROP. DSO28 was associated with severe ROP (adjusted-OR 1.05 per day supplemental oxygen, 95%CI 1.03-1.07, p < .0001). The following criteria had 100% sensitivity for type 1 ROP and higher specificity than current guidelines: new BW/GA criteria with DSO (BW<901 g, GA<26 weeks, or DSO >3), 23.4% fewer infants examined; modified G-ROP criteria including DSO, 29.0% fewer infants; original G-ROP criteria, 31.8% fewer infants. CONCLUSION In high-level neonatal-care settings, incorporating DSO (a simple measure of oxygen supplementation) into screening criteria improves sensitivity and specificity for type 1 ROP over current BW-GA criteria, but does not perform as well as the validated G-ROP criteria.
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Affiliation(s)
- Marcela M. Estrada
- Department of Ophthalmology, University of California, Sacramento, California, USA
| | | | - Yinxi Yu
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gui-Shuang Ying
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gil Binenbaum
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Srivatsa B, Hagan JL, Clark RH, Kupke KG. Oxygenation Factors Associated with Retinopathy of Prematurity in Infants of Extremely Low Birth Weight. J Pediatr 2022; 247:46-52.e4. [PMID: 35427689 DOI: 10.1016/j.jpeds.2022.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/06/2022] [Accepted: 03/21/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To study characteristics of oxygenation during the first 2 postnatal months and correlation with the occurrence and severity of retinopathy of prematurity (ROP) among infants of extremely low birth weight. STUDY DESIGN This retrospective study analyzed the incidence and severity of hyperoxemia and hypoxemia while on respiratory support with or without supplemental oxygen among infants of extremely low birth weight (birth weight <1000 g) admitted to the neonatal intensive care unit during 2016-2020. The findings were correlated with the occurrence and severity of ROP after adjusting for baseline covariates. RESULTS After adjusting for differences in baseline demographic and clinical features, the group with severe ROP was exposed to greater fraction of inspired oxygen (FiO2) (P = .001) and experienced more frequent FiO2 titration adjustments (P = .001) compared with the group without ROP. Ambient air hyperoxemia occurred more frequently in the group without ROP (P = .003), and iatrogenic hyperoxemia occurred more frequently in the group with severe ROP (P = .046). There were no differences in the severity of ambient and iatrogenic hyperoxemia in the study population. The group with severe ROP demonstrated more hypoxemic episodes (P = .01) and longer time spent in the severe hypoxemic range (P = .005) compared with the group without ROP. CONCLUSIONS Severe ROP is associated with greater FiO2 exposure, increased iatrogenic hyperoxemia, decreased ambient air hyperoxemia, and increased hypoxemia in infants of extremely low birth weight despite a greater frequency of FiO2 titration. This study illustrates the need for automated closed loop FiO2 delivery systems to further optimize oxygen saturation targeting in this high-risk population.
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Affiliation(s)
- Bharath Srivatsa
- Neonatology Associates of Atlanta, Atlanta, GA; Northside Hospital, Atlanta, GA; Pediatrix Medical Group, Sunrise, FL.
| | | | | | - Kenneth G Kupke
- Neonatology Associates of Atlanta, Atlanta, GA; Northside Hospital, Atlanta, GA; Pediatrix Medical Group, Sunrise, FL
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18
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Balink S, Onland W, Vrijlandt EJLE, Andrinopoulou ER, Bos AF, Dijk PH, Goossens L, Hulsmann AR, Nuytemans DH, Reiss IKM, Sprij AJ, Kroon AA, van Kaam AH, Pijnenburg M. Supplemental oxygen strategies in infants with bronchopulmonary dysplasia after the neonatal intensive care unit period: study protocol for a randomised controlled trial (SOS BPD study). BMJ Open 2022; 12:e060986. [PMID: 35803625 PMCID: PMC9272124 DOI: 10.1136/bmjopen-2022-060986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Supplemental oxygen is the most important treatment for preterm born infants with established bronchopulmonary dysplasia (BPD). However, it is unknown what oxygen saturation levels are optimal to improve outcomes in infants with established BPD from 36 weeks postmenstrual age (PMA) onwards. The aim of this study is to compare the use of a higher oxygen saturation limit (≥95%) to a lower oxygen saturation limit (≥90%) after 36 weeks PMA in infants diagnosed with moderate or severe BPD. METHODS AND ANALYSIS This non-blinded, multicentre, randomised controlled trial will recruit 198 preterm born infants with moderate or severe BPD between 36 and 38 weeks PMA. Infants will be randomised to either a lower oxygen saturation limit of 95% or to a lower limit of 90%; supplemental oxygen and/or respiratory support will be weaned based on the assigned lower oxygen saturation limit. Adherence to the oxygen saturation limit will be assessed by extracting oxygen saturation profiles from pulse oximeters regularly, until respiratory support is stopped. The primary outcome is the weight SD score at 6 months of corrected age. Secondary outcomes include anthropometrics collected at 6 and 12 months of corrected age, rehospitalisations, respiratory complaints, infant stress, parental quality of life and cost-effectiveness. ETHICS AND DISSEMINATION Ethical approval for the trial was obtained from the Medical Ethics Review Committee of the Erasmus University Medical Centre, Rotterdam, the Netherlands (MEC-2018-1515). Local approval for conducting the trial in the participating hospitals has been or will be obtained from the local institutional review boards. Informed consent will be obtained from the parents or legal guardians of all study participants. TRIAL REGISTRATION NUMBER NL7149/NTR7347.
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Affiliation(s)
- Stephanie Balink
- Department of Paediatrics/Paediatric Respiratory Medicine, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Wes Onland
- Department of Paediatrics, Division of Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Paediatrics, Division of Neonatology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Elianne J L E Vrijlandt
- Department of Paediatrics, Division of Paediatric Pulmonology and Allergology, UMCG, Groningen, The Netherlands
| | | | - Arend F Bos
- Department of Paediatrics, Division of Neonatology, UMCG, Groningen, The Netherlands
| | - Peter H Dijk
- Department of Paediatrics, Division of Neonatology, UMCG, Groningen, The Netherlands
| | - Lucas Goossens
- Erasmus School of Health Policy and Management, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
| | | | - Debbie H Nuytemans
- Department of Paediatrics, Division of Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Paediatrics, Division of Neonatology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Arwen J Sprij
- Department of Paediatrics, Haga Hospital, Den Haag, The Netherlands
| | - André A Kroon
- Department of Paediatrics, Division of Neonatology, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Anton H van Kaam
- Department of Paediatrics, Division of Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Paediatrics, Division of Neonatology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Marielle Pijnenburg
- Department of Paediatrics/Paediatric Respiratory Medicine, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
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Lucchesi M, Marracci S, Amato R, Filippi L, Cammalleri M, Dal Monte M. Neurosensory Alterations in Retinopathy of Prematurity: A Window to Neurological Impairments Associated to Preterm Birth. Biomedicines 2022; 10:biomedicines10071603. [PMID: 35884908 PMCID: PMC9313429 DOI: 10.3390/biomedicines10071603] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/21/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Retinopathy of prematurity (ROP) is one of the main blinding diseases affecting preterm newborns and is classically considered a vascular disorder. The premature exposure to the extrauterine environment, which is hyperoxic in respect to the intrauterine environment, triggers a cascade of events leading to retinal ischemia which, in turn, makes the retina hypoxic thus setting off angiogenic processes. However, many children with a history of ROP show persistent vision impairment, and there is evidence of an association between ROP and neurosensory disabilities. This is not surprising given the strict relationship between neuronal function and an adequate blood supply. In the present work, we revised literature data evidencing to what extent ROP can be considered a neurodegenerative disease, also taking advantage from data obtained in preclinical models of ROP. The involvement of different retinal cell populations in triggering the neuronal damage in ROP was described along with the neurological outcomes associated to ROP. The situation of ROP in Italy was assessed as well.
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Affiliation(s)
- Martina Lucchesi
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Silvia Marracci
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Rosario Amato
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Luca Filippi
- Department of Clinical and Experimental Medicine, Division of Neonatology and NICU, University of Pisa, 56126 Pisa, Italy;
| | - Maurizio Cammalleri
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Massimo Dal Monte
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
- Correspondence: ; Tel.: +39-050-2211426
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20
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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21
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Changes in institutional oxygen saturation targets are associated with an increased rate of severe retinopathy of prematurity. J AAPOS 2022; 26:18.e1-18.e6. [PMID: 35032651 DOI: 10.1016/j.jaapos.2021.10.002] [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: 05/02/2021] [Revised: 09/25/2021] [Accepted: 10/02/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate the effect of changes in institutional peripheral oxygen saturation (SpO2) targets, made in response to recent randomized trials, on risk of developing severe retinopathy of prematurity (ROP). METHODS This study was a secondary analysis of data from 21 North American hospitals during the periods 2006-2012 and 2015-2017. Hospitals were categorized based on whether or not SpO2 targets were increased between the two study periods. Severe ROP (type 1, type 2, or zone III stage 3+) rates were compared within and between groups. Generalized mixed effect models with random intercepts were used to account for within-center clustering and to calculate odds ratios (aOR) adjusted by birth weight (BW) and gestational age (GA), using patient-level data. RESULTS A total of 8,142 infants underwent ROP examinations at 21 hospitals during the two study periods: 5,716 in 2006-2012 (mean BW, 1109 ± 369 g; GA, 28.0 ± 2.6; 11.6% severe ROP); 2,426 in 2015-2017 (mean BW, 1086 ± 347 g; GA, 28.0 ± 2.8; 12.8% severe ROP). Fourteen hospitals increased SpO2 targets, and 7 hospitals did not. Hospitals that increased targets had a 3% increase in severe ROP (from 12% to 15%; aOR = 1.25; 95% CI, 1.01-1.55; P = 0.044); hospitals without SpO2 changes had a 2% decrease (from 11% to 9%; aOR = 0.72; 95% CI, 0.52-1.00; P = 0.049). The difference in change of severe ROP between groups of hospitals was significant (P = 0.005). CONCLUSIONS Increases in institutional SpO2 targets in response to recent randomized trials were associated with increased severe ROP. Hospitals considering increasing their SpO2 targets should anticipate increases in rates of severe ROP and manage screening and treatment resources accordingly.
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22
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Filippi L, Cammalleri M, Amato R, Ciantelli M, Pini A, Bagnoli P, Dal Monte M. Decoupling Oxygen Tension From Retinal Vascularization as a New Perspective for Management of Retinopathy of Prematurity. New Opportunities From β-adrenoceptors. Front Pharmacol 2022; 13:835771. [PMID: 35126166 PMCID: PMC8814365 DOI: 10.3389/fphar.2022.835771] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/05/2022] [Indexed: 12/20/2022] Open
Abstract
Retinopathy of prematurity (ROP) is an evolutive and potentially blinding eye disease that affects preterm newborns. Unfortunately, until now no conservative therapy of active ROP with proven efficacy is available. Although ROP is a multifactorial disease, premature exposition to oxygen concentrations higher than those intrauterine, represents the initial pathogenetic trigger. The increase of oxygenation in a retina still incompletely vascularized promotes the downregulation of proangiogenic factors and finally the interruption of vascularization (ischemic phase). However, the increasing metabolic requirement of the ischemic retina induces, over the following weeks, a progressive hypoxia that specularly increases the levels of proangiogenic factors finally leading to proliferative retinopathy (proliferative phase). Considering non-modifiable the coupling between oxygen levels and vascularization, so far, neonatologists and ophthalmologists have “played defense”, meticulously searching the minimum necessary concentration of oxygen for individual newborns, refining their diagnostic ability, adopting a careful monitoring policy, ready to decisively intervene only in a very advanced stage of disease progression. However, recent advances have demonstrated the possibility to pharmacologically modulate the relationship between oxygen and vascularization, opening thus the perspective for new therapeutic or preventive opportunities. The perspective of a shift from a defensive towards an attack strategy is now at hand.
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Affiliation(s)
- Luca Filippi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Luca Filippi,
| | | | - Rosario Amato
- Department of Biology, University of Pisa, Pisa, Italy
| | | | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paola Bagnoli
- Department of Biology, University of Pisa, Pisa, Italy
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Cudjoe GA, Ameley A, Ohemeng-Dapaah J, Bhatt P, Donda K, Dapaah-Siakwan F. National trends in the incidence and management of retinopathy of prematurity in the United States, 2009 -2018. J Neonatal Perinatal Med 2022; 15:553-557. [PMID: 35491807 DOI: 10.3233/npm-210826] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Retinopathy of prematurity is a major cause of morbidity in preterm infants but population-based studies to evaluate recent trends in incidence in the United States (US) are lacking. Moreover, previous studies did not include the use of anti-Vascular Endothelial Growth Factor medications. The objective was to examine the recent secular trends in the incidence and treatment of severe retinopathy of prematurity (sROP) in the United States (US) from 2009 to 2018. METHODS This was a population-based, serial cross-sectional study that utilized data from the National Inpatient Sample. The inclusion criteria were preterm infants with gestational age (GA) ≤30 weeks and length of stay > 28 days. The primary outcomes were trends in ROP surgery (photocoagulation, cryotherapy, scleral buckling, vitrectomy) and intravitreal injection of therapeutic (anti-VEGF) medications. The Cochrane-Armitage test was used to evaluate trends and P-value < 0.05 was considered significant. RESULTS Out of 279,664 hospitalizations that met the inclusion criteria, 12,942 (4.6%) had sROP. Those with sROP were more likely to have severe intraventricular hemorrhage (12.5% vs 6.1%), bronchopulmonary dysplasia (48.2% vs 25.9%), and pulmonary hypertension (10.7% vs 4.7%). From 2009-2018, sROP significantly increased from 3.4% to 5.3% (P < 0.001), ROP surgery decreased from 36.8% to 11.9% (P < 0.001) while intra-vitreal administration of therapeutic drugs increased from 2% to 7.6% (P < 0.001). CONCLUSION Surgery for sROP decreased while intra-vitreal administration of therapeutic drugs increased in the setting of increasing incidence of sROP in the US. Taken together, these findings suggest a gradual practice change and the long-term outcomes of intra-vitreal agents warrants future study.
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Affiliation(s)
- G A Cudjoe
- Korle Bu Teaching Hospital, Accra, Ghana
| | - A Ameley
- Greater Accra Regional Hospital, Pediatrics, Accra, Ghana
| | | | - P Bhatt
- Department of Pediatrics, United Hospital Center, Bridgeport, WV, USA
| | - K Donda
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - F Dapaah-Siakwan
- Neonatal Intensive Care Unit, Valley Children's Hospital, Madera, CA, USA
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Jhaveri Sanghvi U, Wright CJ, Hernandez TL. Pulmonary Resilience: Moderating the Association between Oxygen Exposure and Pulmonary Outcomes in Extremely Preterm Newborns. Neonatology 2022; 119:433-442. [PMID: 35551136 PMCID: PMC9296587 DOI: 10.1159/000524438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/29/2022] [Indexed: 11/19/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease of infancy associated with high morbidity and mortality. Although most prevalent following extremely preterm birth, BPD is diagnosed at 36 weeks post-menstrual age, when the disease trajectory is underway, and long-term physiological implications may be irreversible. There is an urgent and unmet need to identify how early exposures can be modified to decrease the risk of developing BPD before disease progression becomes irreversible. Extremely preterm newborns encounter a paradox at birth: oxygen is a life-sustaining component of ex utero life yet is undeniably toxic. Attempts at minimizing supplemental oxygen exposure by targeting lower oxygen saturations appear to decrease BPD but may increase mortality. Given the potential association between lower oxygen saturations and increased mortality, practice guidelines favor targeting higher saturations. This uniformly increases oxygen exposure, prompting a cascade of pathogenic mechanisms implicated in BPD development. In this review, we introduce the concept of pulmonary resilience: a homeostatic process driven by the autonomic nervous system (ANS) as a moderator of physiologic stress that when functional, could inform successful environmental adaptation following extremely preterm birth. We hypothesize that infants with early-life ANS dysfunction require a higher oxygen dose for survival; conversely, oxygen exposure could be safely limited in infants with more robust early-life ANS function, an indicator of pulmonary resilience. Characterizing the pulmonary resilience continuum to guide individualized supplemental oxygen dosing may reduce morbidity and mortality in this growing population of extremely preterm infants at risk for BPD.
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Affiliation(s)
- Urvi Jhaveri Sanghvi
- College of Nursing, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Teri L Hernandez
- College of Nursing, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA.,Division of Endocrinology, Department of Medicine, Metabolism, and Diabetes, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA.,Department of Research, Innovation, and Clinical Practice, Children's Hospital Colorado, Aurora, Colorado, USA
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25
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Nair V, Loganathan P, Lal MK, Bachman T. Automated Oxygen Delivery in Neonatal Intensive Care. Front Pediatr 2022; 10:915312. [PMID: 35813378 PMCID: PMC9257066 DOI: 10.3389/fped.2022.915312] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/20/2022] [Indexed: 11/20/2022] Open
Abstract
Oxygen is the most common drug used in the neonatal intensive care. It has a narrow therapeutic range in preterm infants. Too high (hyperoxemia) or low oxygen (hypoxemia) is associated with adverse neonatal outcomes. It is not only prudent to maintain oxygen saturations in the target range, but also to avoid extremes of oxygen saturations. In routine practice when done manually by the staff, it is challenging to maintain oxygen saturations within the target range. Automatic control of oxygen delivery is now feasible and has shown to improve the time spent with in the target range of oxygen saturations. In addition, it also helps to avoid extremes of oxygen saturation. However, there are no studies that evaluated the clinical outcomes with automatic control of oxygen delivery. In this narrative review article, we aim to present the current evidence on automatic oxygen control and the future directions.
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Affiliation(s)
- Vrinda Nair
- Neonatal Intensive Care Unit, South Tees Hospitals National Health Service (NHS) Foundation Trust, James Cook University Hospital, Middlesbrough, United Kingdom.,Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Prakash Loganathan
- Neonatal Intensive Care Unit, South Tees Hospitals National Health Service (NHS) Foundation Trust, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Mithilesh Kumar Lal
- Neonatal Intensive Care Unit, South Tees Hospitals National Health Service (NHS) Foundation Trust, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Thomas Bachman
- School of Biomedical Engineering, Czech Technical University in Prague, Prague, Czechia
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26
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Dargaville PA, Marshall AP, McLeod L, Salverda HH, Te Pas AB, Gale TJ. Automation of oxygen titration in preterm infants: Current evidence and future challenges. Early Hum Dev 2021; 162:105462. [PMID: 34511288 DOI: 10.1016/j.earlhumdev.2021.105462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
For the preterm infant with respiratory insufficiency requiring supplemental oxygen, tight control of oxygen saturation (SpO2) is advocated, but difficult to achieve in practice. Automated control of oxygen delivery has emerged as a potential solution, with six control algorithms currently embedded in commercially-available respiratory support devices. To date, most clinical evaluations of these algorithms have been short-lived crossover studies, in which a benefit of automated over manual control of oxygen titration has been uniformly noted, along with a reduction in severe SpO2 deviations and need for manual FiO2 adjustments. A single non-randomised study has examined the effect of implementation of automated oxygen control with the CLiO2 algorithm as standard care for preterm infants; no clear benefits in relation to clinical outcomes were noted, although duration of mechanical ventilation was lessened. The results of randomised controlled trials are awaited. Beyond the gathering of evidence regarding a treatment effect, we contend that there is a need for a better understanding of the function of contemporary control algorithms under a range of clinical conditions, further exploration of techniques of adaptation to individualise algorithm performance, and a concerted effort to apply this technology in low resource settings in which the majority of preterm infants receive care. Attainment of these goals will be paramount in optimisation of oxygen therapy for preterm infants globally.
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Affiliation(s)
- Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Andrew P Marshall
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Lachlann McLeod
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Hylke H Salverda
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Timothy J Gale
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in infants and is associated with increased mortality, respiratory morbidity, neurodevelopmental impairment, and increased healthcare costs. In parallel with advances made in the field of neonatal intensive care, the phenotype of BPD has evolved from a fibrocystic disease affecting late preterm infants to one of impaired parenchymal development and dysregulated vascular growth predominantly affecting infants born before 29 weeks' gestational age. BPD has been shown to have significant lifelong consequences. Adults with BPD have been found to have abnormal lung function tests, reduced exercise tolerance, and may be at increased risk for developing chronic obstructive pulmonary disease. Evidence shows that BPD occurs secondary to genetic-environmental interactions in an immature lung. In this review, we evaluate the various clinical definitions, imaging modalities, and biomarker data that are helpful in making an early diagnosis of BPD. In addition, we evaluate recent evidence about the prevention and treatment of BPD. We discuss the invasive and non-invasive ventilation strategies and pharmacological agents used in the early, evolving, and established phases of BPD.
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Affiliation(s)
- Margaret Gilfillan
- Division of Neonatology, St Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anita Bhandari
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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28
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Behnke J, Dippel CM, Choi Y, Rekers L, Schmidt A, Lauer T, Dong Y, Behnke J, Zimmer KP, Bellusci S, Ehrhardt H. Oxygen Toxicity to the Immature Lung-Part II: The Unmet Clinical Need for Causal Therapy. Int J Mol Sci 2021; 22:10694. [PMID: 34639034 PMCID: PMC8508961 DOI: 10.3390/ijms221910694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022] Open
Abstract
Oxygen toxicity continues to be one of the inevitable injuries to the immature lung. Reactive oxygen species (ROS) production is the initial step leading to lung injury and, subsequently, the development of bronchopulmonary dysplasia (BPD). Today, BPD remains the most important disease burden following preterm delivery and results in life-long restrictions in lung function and further important health sequelae. Despite the tremendous progress in the pathomechanistic understanding derived from preclinical models, the clinical needs for preventive or curative therapies remain unmet. This review summarizes the clinical progress on guiding oxygen delivery to the preterm infant and elaborates future directions of research that need to take into account both hyperoxia and hypoxia as ROS sources and BPD drivers. Many strategies have been tested within clinical trials based on the mechanistic understanding of ROS actions, but most have failed to prove efficacy. The majority of these studies were tested in an era before the latest modes of non-invasive respiratory support and surfactant application were introduced or were not appropriately powered. A comprehensive re-evaluation of enzymatic, antioxidant, and anti-inflammatory therapies to prevent ROS injury is therefore indispensable. Strategies will only succeed if they are applied in a timely and vigorous manner and with the appropriate outcome measures.
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Affiliation(s)
- Judith Behnke
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Constanze M. Dippel
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Yesi Choi
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Lisa Rekers
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Annesuse Schmidt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Tina Lauer
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Ying Dong
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Jonas Behnke
- Department of Internal Medicine V, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Klinikstrasse 33, 35392 Giessen, Germany;
| | - Klaus-Peter Zimmer
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
| | - Saverio Bellusci
- Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center (UGMLC), Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Aulweg 130, 35392 Giessen, Germany;
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Lung Research Center (DZL), Feulgenstrasse 12, 35392 Giessen, Germany; (J.B.); (C.M.D.); (Y.C.); (L.R.); (A.S.); (T.L.); (Y.D.); (K.-P.Z.)
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Wickramasinghe LC, van Wijngaarden P, Tsantikos E, Hibbs ML. The immunological link between neonatal lung and eye disease. Clin Transl Immunology 2021; 10:e1322. [PMID: 34466225 PMCID: PMC8387470 DOI: 10.1002/cti2.1322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/02/2021] [Accepted: 07/13/2021] [Indexed: 01/02/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) are two neonatal diseases of major clinical importance, arising in large part as a consequence of supplemental oxygen therapy used to promote the survival of preterm infants. The presence of coincident inflammation in the lungs and eyes of neonates receiving oxygen therapy indicates that a dysregulated immune response serves as a potential common pathogenic factor for both diseases. This review examines the current state of knowledge of immunological dysregulation in BPD and ROP, identifying similarities in the cellular subsets and inflammatory cytokines that are found in the alveoli and retina during the active phase of these diseases, indicating possible mechanistic overlap. In addition, we highlight gaps in the understanding of whether these responses emerge independently in the lung and retina as a consequence of oxygen exposure or arise because of inflammatory spill‐over from the lung. As BPD and ROP are anatomically distinct, they are often considered discreet disease entities and are therefore treated separately. We propose that an improved understanding of the relationship between BPD and ROP is key to the identification of novel therapeutic targets to treat or prevent both conditions simultaneously.
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Affiliation(s)
- Lakshanie C Wickramasinghe
- Leukocyte Signalling LaboratoryDepartment of Immunology and PathologyCentral Clinical SchoolMonash UniversityMelbourneVICAustralia
| | - Peter van Wijngaarden
- OphthalmologyDepartment of SurgeryUniversity of MelbourneMelbourneVICAustralia
- Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalEast MelbourneVICAustralia
| | - Evelyn Tsantikos
- Leukocyte Signalling LaboratoryDepartment of Immunology and PathologyCentral Clinical SchoolMonash UniversityMelbourneVICAustralia
| | - Margaret L Hibbs
- Leukocyte Signalling LaboratoryDepartment of Immunology and PathologyCentral Clinical SchoolMonash UniversityMelbourneVICAustralia
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30
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Chaves-Samaniego MJ, Chaves-Samaniego MC, Muñoz Hoyos A, García Serrano JL. Nuevas evidencias sobre el efecto protector de la ganancia de peso en la retinopatía del prematuro. An Pediatr (Barc) 2021. [DOI: 10.1016/j.anpedi.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Arima M, Inoue H, Nakao S, Misumi A, Suzuki M, Matsushita I, Araki S, Yamashiro C, Takahashi K, Ochiai M, Yoshida N, Hirose M, Kishimoto J, Todaka K, Hasegawa S, Kimura K, Kusuhara K, Kondo H, Ohga S, Sonoda KH. Study protocol for a multicentre, open-label, single-arm phase I/II trial to evaluate the safety and efficacy of ripasudil 0.4% eye drops for retinopathy of prematurity. BMJ Open 2021; 11:e047003. [PMID: 34315793 PMCID: PMC8317081 DOI: 10.1136/bmjopen-2020-047003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Retinopathy of prematurity (ROP) is a vascular proliferative disorder that occurs in preterm infants. Existing treatments are only indicated in severe ROP cases due to the high invasiveness and the potential risk of irreversible side effects. We previously elucidated that ripasudil, a selective inhibitor of the Rho-associated protein kinase, has the ability to inhibit abnormal retinal neovascularisation in animal models. In addition, ripasudil eye drops (Glanatec ophthalmic solution 0.4%) have been already used for the treatment of glaucoma. Since eye drop therapy is less invasive, early intervention for ROP is possible. The purpose of this phase I/II trial is to evaluate the safety and efficacy of ripasudil eye drops for preterm infants with ROP. METHODS AND ANALYSIS This is a multicentre, open-label, single-arm phase I/II trial. To evaluate the safety and efficacy of ripasudil as much as possible, ripasudil will be administered to all enrolled preterm infants with zone I/II, stage 1, or worse ROP. The safety and efficacy of ripasudil in treated patients will be assessed in comparison to a historical control group. Because this is the first trial of ripasudil in preterm infants, a dose-escalation study (once daily for 1 week, then two times per day for 2 weeks) will be conducted in phase I. After obtaining approval from the independent data and safety monitoring board to continue the trial after the completion of phase I, phase II will be conducted. In phase II, ripasudil eye drops will be administered two times per day for 12 weeks. The primary endpoint in phase II is also safety. Efficacy and pharmacokinetics will be evaluated as secondary endpoints. ETHICS AND DISSEMINATION This study protocol was approved by the institutional review board at each of the participating centres. Data will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT04621136 and jRCT2071200047.
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Affiliation(s)
- Mitsuru Arima
- Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Hirosuke Inoue
- Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shintaro Nakao
- Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Ophthalmology, National Kyushu Medical Center, Fukuoka, Japan
| | - Akiko Misumi
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Maya Suzuki
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Itsuka Matsushita
- Ophthalmology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shunsuke Araki
- Pediatrics, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Chiemi Yamashiro
- Ophthalmology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kazumasa Takahashi
- Pediatrics, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Masayuki Ochiai
- Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Masayuki Hirose
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Junji Kishimoto
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Koji Todaka
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Shunji Hasegawa
- Pediatrics, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kazuhiro Kimura
- Ophthalmology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Koichi Kusuhara
- Pediatrics, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroyuki Kondo
- Ophthalmology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shouichi Ohga
- Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koh-Hei Sonoda
- Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Dani C, Pratesi S, Luzzati M, Petrolini C, Montano S, Remaschi G, Coviello C. Cerebral and splanchnic oxygenation during automated control of inspired oxygen (FiO 2 ) in preterm infants. Pediatr Pulmonol 2021; 56:2067-2072. [PMID: 33773084 DOI: 10.1002/ppul.25379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/17/2021] [Accepted: 03/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Our aim in this study was to assess the effect of the Predictive Intelligent Control of Oxygenation (PRICO® ) system on cerebral (rSO2 C) and splanchnic (rSO2 S) oxygenation in a cohort of preterm infants with frequent desaturations. METHODS Twenty infants with gestational age <32 weeks (n = 20) were assigned in random sequence to 12 h of automated or manual adjustment of FiO2 . Over this period, they were studied continuously by near-infrared spectroscopy (NIRS). RESULTS We found that rSO2 C [68.0% (60.5%-74.7%) vs. 68.5% (62%-72%); p = .824] and rSO2 S [27.0% (17.3%-45.7%) vs. 27.0% (15%-53%); p = .878] were similar during automatic and manual control of FiO2 . Time spent with SpO2 90%-95% was higher during the automatic than manual control of FiO2 , while time spent with SpO2 <80% or >95% was lower. CONCLUSIONS Automated control of FiO2 with PRICO® system did not improve brain and splanchnic oxygenation in comparison with manual control in a cohort of preterm infants, but it significantly decreased SpO2 fluctuations and limited the duration of both hypoxemia and hyperoxemia.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital of Florence, Florence, Italy
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Michele Luzzati
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Chiara Petrolini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Simona Montano
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Giulia Remaschi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Caterina Coviello
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
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New evidence on the protector effect of weight gain in retinopathy of prematurity. An Pediatr (Barc) 2021; 95:78-85. [PMID: 34172428 DOI: 10.1016/j.anpede.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/25/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Retinopathy of prematurity (ROP) is characterised by insufficient vascular development in the retina, and requires early treatment to avoid visual disability in severe cases. ROP is currently the second leading cause of preventable child blindness in the world. PATIENTS AND METHODS This was an observational, retrospective, case-control study including 233 preterm infants examined between 1999 and 2019. RESULTS Postnatal weight gain in the first 4 weeks of life, birth weight, gestational age, mechanical ventilation, transfusion, presence of sepsis, persistence of arterial ductus, necrotising enterocolitis, intraventricular haemorrhage, or periventricular leukomalacia were found to be significantly different between the ROP groups requiring and not requiring treatment. The mean postnatal weight gain in the ROP group not requiring treatment was 12.75 ± 5.99 g/day, whereas it was 9.50 ± 5.45 g/day in the ROP group requiring treatment. The risk of developing ROP that required treatment decreased with an increase in weight gain. The risk reduction was 2.76%-8.35% in preterm infants gaining 10 g/day, and 7.17%-12.76% in infants gaining 20 g/day. CONCLUSIONS The risk of developing ROP requiring treatment decreased with increasing weight gain in the first 4 weeks of life. This was applicable in infants with postnatal weight gain ≥14 g/day. However, gestational age, birth weight, time of mechanical ventilation, and comorbidity should be taken into account when evaluating the risk of ROP requiring treatment.
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Pulmonary hypertension in a neonatologist-performed echocardiographic follow-up of bronchopulmonary dysplasia. Eur J Pediatr 2021; 180:1711-1720. [PMID: 33474582 DOI: 10.1007/s00431-021-03954-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/22/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Neonatologist-performed echocardiography (NPE) is an established tool for bedside hemodynamic evaluation, including pulmonary hypertension (PH). PH may complicate bronchopulmonary dysplasia (BPD) course. Aims of this retrospective study were to assess the feasibility of NPE follow-up of infants with BPD and to describe the course of PH of infants with moderate/severe BPD. Preterm infants <32 gestational weeks or birthweight ≤1500 g with moderate/severe BPD underwent NPE follow-up, from 36 weeks postmenstrual age up to 8 months postnatal age. Twenty-three preemies were included (birth weight 840 (213) g, gestational age 26.8 (2.3) weeks); 12/23 developed mild PH, 2/12 after discharge. PH resolved at 8.9 (3.9) months. Clinical and echocardiographic variables did not differ between infants with and without PH, except pulmonary artery acceleration time (PAAT) and PAAT/right ventricle ejection time (RVET) ratio (PAAT: 36 weeks, 68.9 (11.9) vs 52.0 (19.1), p = 0.0443; 6 months: 83.9 (38.9) vs 74.8 (16.9), p = 0.0372). No deaths or admissions for PH were reported. Neonatologist's Image Quality Assessment score attributed by the cardiologist assumed as gold standard was adequate or optimal (9.5/14 total score); inter-rater agreement was excellent (ICC 0.974).Conclusions: NPE follow-up seems to be feasible and safe in both intensive care and outpatient clinic. Mild PH is frequently detected in moderate/severe BPD, with good prognosis. What is Known: • Preterm infants with bronchopulmonary dysplasia (BPD) may develop pulmonary hypertension (PH) and have a late diagnosis. • Neonatologist-performed echocardiography (NPE) is an established tool for bedside hemodynamic evaluation of the neonate. What is New: • To our knowledge this is the first study of NPE follow-up of moderate/severe BPD, describing the course of mild PH from diagnosis to its resolution. • NPE follow-up of BPD seems to be safe and practicable, in both intensive care and outpatient clinic, as long as neonatologists maintain a sound collaboration with pediatric cardiologists.
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Fitri N, Efendi D. Factors that impact the accuracy with which nurses place preterm infants with respiratory distress syndrome in the prone position. LA PEDIATRIA MEDICA E CHIRURGICA 2021; 43. [PMID: 37184323 DOI: 10.4081/pmc.2021.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Indexed: 11/23/2022] Open
Abstract
Prone positioning is an important treatment procedure for preterm infants with Respiratory Distress Syndrome (RDS). However, the accuracy with which preterm infants in the Neonatal Intensive Care Unit (NICU) are placed in the prone position is impacted by several factors. The current study aimed to identify these factors. One hundred and twenty-eight nurses were included in this cross-sectional study. Direct observations of the research subjects were used to collect the research data. The participants completed a research questionnaire that included their demographic data and three others to obtain information on their clinical experience, knowledge of positioning, caring behaviors, and efficacy. Independent factors likely to affect preterm infant positioning were evaluated using multivariate logistic regression. The alpha level was set at 5%. Knowledge (p=0.002) and caring behavior (p=0.009) significantly influenced the accuracy with which nurses placed preterm infants with RDS in the prone position. Nursing efficacy, infant’s bodyweight, gestational age, the institution, and DNR decisions did not significantly impact accuracy. NICU nursing staff require interventions to increase their knowledge of the accurate positioning of preterm infants with RDS.
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Concurrent Physiological and Pathological Angiogenesis in Retinopathy of Prematurity and Emerging Therapies. Int J Mol Sci 2021; 22:ijms22094809. [PMID: 34062733 PMCID: PMC8124946 DOI: 10.3390/ijms22094809] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022] Open
Abstract
Retinopathy of prematurity (ROP) is an ocular vascular disease affecting premature infants, characterized by pathological retinal neovascularization (RNV), dilated and tortuous retinal blood vessels, and retinal or vitreous hemorrhages that may lead to retinal detachment, vision impairment and blindness. Compared with other neovascular diseases, ROP is unique because of ongoing and concurrent physiological and pathological angiogenesis in the developing retina. While the disease is currently treated by laser or cryotherapy, anti-vascular endothelial growth factor (VEGF) agents have been extensively investigated but are not approved in the U.S. because of safety concerns that they negatively interfere with physiological angiogenesis of the developing retina. An ideal therapeutic strategy would selectively inhibit pathological but not physiological angiogenesis. Our group recently described a novel strategy that selectively and safely alleviates pathological RNV in animal models of ROP by targeting secretogranin III (Scg3), a disease-restricted angiogenic factor. The preclinical profile of anti-Scg3 therapy presents a high potential for next-generation disease-targeted anti-angiogenic therapy for the ROP indication. This review focuses on retinal vessel development in neonates, the pathogenesis of ROP and its underlying molecular mechanisms, including different animal models, and provides a summary of current and emerging therapies.
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Varisco G, Mortel H, Cabrera‐Quiros L, Atallah L, Hueske‐Kraus D, Long X, Cottaar EJE, Zhan Z, Andriessen P, Pul C. Optimisation of clinical workflow and monitor settings safely reduces alarms in the NICU. Acta Paediatr 2021; 110:1141-1150. [PMID: 33048364 PMCID: PMC7983880 DOI: 10.1111/apa.15615] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/16/2020] [Accepted: 10/07/2020] [Indexed: 11/29/2022]
Abstract
Aim To address alarm fatigue, a new alarm management system which ensures a quicker delivery of alarms together with waveform information on nurses' handheld devices was implemented and settings optimised. The effects of this clinical implementation on alarm rates and nurses' responsiveness were measured in an 18‐bed single family rooms neonatal intensive care unit (NICU). Methods The technical implementation of the alarm management system was followed by clinical workflow optimisation. Alarms and vital parameters from October 2017 to December 2019 were analysed. Measures included monitoring alarms, nurses' response to alarms and time spent by patients in different saturation ranges. A survey among nurses was performed to evaluate changes in alarm rate and use of protocols. Results A significant reduction of monitoring alarms per patient days was detected after the optimisation phase (in particular for SpO2 ≤ 80%, P < .001). More time was spent by infants within the optimal peripheral oxygen saturation range (88% < SpO2 < 95%, P < .001). Results from the surveys showed that false alarms are less likely to cause an inappropriate response after the optimisation phase. Conclusion The implementation of an alarm management solution and an optimisation programme can safely reduce the alarm burden inside of the NICU environment.
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Affiliation(s)
- Gabriele Varisco
- Applied Physics Eindhoven University of Technology Eindhoven The Netherlands
- Clinical Physics Máxima Medical Center Veldhoven The Netherlands
| | - Heidi Mortel
- Pediatrics Máxima Medical Center Veldhoven The Netherlands
| | - Laura Cabrera‐Quiros
- Applied Physics Eindhoven University of Technology Eindhoven The Netherlands
- Clinical Physics Máxima Medical Center Veldhoven The Netherlands
| | | | | | - Xi Long
- Philips Research Eindhoven The Netherlands
- Electrical Engineering Eindhoven University of Technology Eindhoven The Netherlands
| | - Eduardus JE Cottaar
- Applied Physics Eindhoven University of Technology Eindhoven The Netherlands
| | - Zhuozhao Zhan
- Mathematics and Computer Science Eindhoven University of Technology Eindhoven The Netherlands
| | - Peter Andriessen
- Applied Physics Eindhoven University of Technology Eindhoven The Netherlands
- Pediatrics Máxima Medical Center Veldhoven The Netherlands
| | - Carola Pul
- Applied Physics Eindhoven University of Technology Eindhoven The Netherlands
- Clinical Physics Máxima Medical Center Veldhoven The Netherlands
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Hamza W, AbdElaal N, Awad H, Tawfik S, Elsayed Y. The impact of targeted oxygen reduction test in preterm infants on reducing the oxygen exposure. J Neonatal Perinatal Med 2021; 14:61-65. [PMID: 32538878 DOI: 10.3233/npm-200459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Caring for infants on respiratory support is a challenge in the middle-income countries, applying a protocol of targeted oxygen reduction test (tORT) guided by daily assessment of oxygen histograms is novel and practical approach. OBJECTIVE To study the impact of tORT guided by daily assessment of oxygen histograms as a quality improvement project aiming to decrease days on oxygen support, and duration of hospital admission in preterm infants. STUDY DESIGN A quality project conducted in neonatal intensive care units (NICU) of two hospitals, from 2017- 2018 (Epochs II). After a period of observation of a cohort of preterm Infants, 2016-2017 (Epoch I). The main aims were to reduce days on oxygen and hospital admission days. All infants in Epoch II underwent daily assessment of oxygen histograms and a trial of oxygen reduction if applicable as per a predefined protocol. Comparison was made between these two Epochs, and the primary outcome was the time to successful discontinuation of oxygen support. RESULTS Fifty-nine infants were included; 30 underwent the protocolized tORT (Epoch II) with a median (IQR) of 4 (2-6) tORC per infant. Postanal age at presentation (time of initial tORT assessment was performed at the postnatal age of 8 (5, 13) days. Days on oxygen and total numbers of hospital days were significantly less in Epoch II. Oxygen histograms significantly improved after tORT. CONCLUSIONS Applying tORT guided by oxygen histograms may have a significant impact on oxygen exposure and hospitalization days of patients admitted to the NICU.
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Affiliation(s)
| | | | - H Awad
- Ain Shams University, Egypt
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Arima M, Fujii Y, Sonoda KH. Translational Research in Retinopathy of Prematurity: From Bedside to Bench and Back Again. J Clin Med 2021; 10:jcm10020331. [PMID: 33477419 PMCID: PMC7830975 DOI: 10.3390/jcm10020331] [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] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 12/11/2022] Open
Abstract
Retinopathy of prematurity (ROP), a vascular proliferative disease affecting preterm infants, is a leading cause of childhood blindness. Various studies have investigated the pathogenesis of ROP. Clinical experience indicates that oxygen levels are strongly correlated with ROP development, which led to the development of oxygen-induced retinopathy (OIR) as an animal model of ROP. OIR has been used extensively to investigate the molecular mechanisms underlying ROP and to evaluate the efficacy of new drug candidates. Large clinical trials have demonstrated the efficacy of anti-vascular endothelial growth factor (VEGF) agents to treat ROP, and anti-VEGF therapy is presently becoming the first-line treatment worldwide. Anti-VEGF therapy has advantages over conventional treatments, including being minimally invasive with a low risk of refractive error. However, long-term safety concerns and the risk of late recurrence limit this treatment. There is an unmet medical need for novel ROP therapies, which need to be addressed by safe and minimally invasive therapies. The recent progress in biotechnology has contributed greatly to translational research. In this review, we outline how basic ROP research has evolved with clinical experience and the subsequent emergence of new drugs. We discuss previous and ongoing trials and present the candidate molecules expected to become novel targets.
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Affiliation(s)
- Mitsuru Arima
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 8128582, Japan; (Y.F.); (K.-H.S.)
- Center for Clinical and Translational Research, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 8128582, Japan
- Correspondence: ; Tel.: +81-92-642-5648
| | - Yuya Fujii
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 8128582, Japan; (Y.F.); (K.-H.S.)
| | - Koh-Hei Sonoda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 8128582, Japan; (Y.F.); (K.-H.S.)
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Raghuveer TS, Zackula R. Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 Update and Meta-analysis. Neoreviews 2021; 21:e249-e263. [PMID: 32238487 DOI: 10.1542/neo.21-4-e249] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The incidence of retinopathy of prematurity (ROP) is showing an increasing trend in the United States. This may be because of increasing survival rates among extremely preterm infants (<25 weeks' gestation) and targeting higher oxygen saturation. Five randomized clinical trials of low versus high oxygen saturation target ranges found increased mortality in the low oxygen saturation target group and an increased incidence of ROP in the high oxygen saturation target group. The American Academy of Pediatrics recommends using an oxygen saturation target range of 90% to 95% in extremely low-birthweight infants. The change of practice to target this higher oxygen saturation range, from admission until discharge, may be contributing to the increasing incidence of ROP in extremely preterm infants. To decrease the incidence of ROP without increasing mortality, 2 new cohort trials suggest gradually increasing oxygen saturation targets as preterm infants mature. There is evidence that human milk, vitamin A, and omega-3 fatty acids can help, in addition to continuous oxygen saturation monitoring, to decrease the risk of ROP. We review this literature and provide a meta-analysis to evaluate the evidence.
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Affiliation(s)
| | - R Zackula
- Research, University of Kansas School of Medicine at Wichita, Wichita, KS
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Rantakari K, Rinta-Koski OP, Metsäranta M, Hollmén J, Särkkä S, Rahkonen P, Lano A, Lauronen L, Nevalainen P, Leskinen MJ, Andersson S. Early oxygen levels contribute to brain injury in extremely preterm infants. Pediatr Res 2021; 90:131-139. [PMID: 33753894 PMCID: PMC7984503 DOI: 10.1038/s41390-021-01460-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extremely low gestational age newborns (ELGANs) are at risk of neurodevelopmental impairments that may originate in early NICU care. We hypothesized that early oxygen saturations (SpO2), arterial pO2 levels, and supplemental oxygen (FiO2) would associate with later neuroanatomic changes. METHODS SpO2, arterial blood gases, and FiO2 from 73 ELGANs (GA 26.4 ± 1.2; BW 867 ± 179 g) during the first 3 postnatal days were correlated with later white matter injury (WM, MRI, n = 69), secondary cortical somatosensory processing in magnetoencephalography (MEG-SII, n = 39), Hempel neurological examination (n = 66), and developmental quotients of Griffiths Mental Developmental Scales (GMDS, n = 58). RESULTS The ELGANs with later WM abnormalities exhibited lower SpO2 and pO2 levels, and higher FiO2 need during the first 3 days than those with normal WM. They also had higher pCO2 values. The infants with abnormal MEG-SII showed opposite findings, i.e., displayed higher SpO2 and pO2 levels and lower FiO2 need, than those with better outcomes. Severe WM changes and abnormal MEG-SII were correlated with adverse neurodevelopment. CONCLUSIONS Low oxygen levels and high FiO2 need during the NICU care associate with WM abnormalities, whereas higher oxygen levels correlate with abnormal MEG-SII. The results may indicate certain brain structures being more vulnerable to hypoxia and others to hyperoxia, thus emphasizing the role of strict saturation targets. IMPACT This study indicates that both abnormally low and high oxygen levels during early NICU care are harmful for later neurodevelopmental outcomes in preterm neonates. Specific brain structures seem to be vulnerable to low and others to high oxygen levels. The findings may have clinical implications as oxygen is one of the most common therapies given in NICUs. The results emphasize the role of strict saturation targets during the early postnatal period in preterm infants.
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Affiliation(s)
- Krista Rantakari
- Children's Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Olli-Pekka Rinta-Koski
- grid.5373.20000000108389418Department of Computer Science, Aalto University School of Science, Espoo, Finland
| | - Marjo Metsäranta
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jaakko Hollmén
- grid.5373.20000000108389418Department of Computer Science, Aalto University School of Science, Espoo, Finland ,grid.10548.380000 0004 1936 9377Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
| | - Simo Särkkä
- grid.5373.20000000108389418Department of Computer Science, Aalto University School of Science, Espoo, Finland
| | - Petri Rahkonen
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Aulikki Lano
- grid.7737.40000 0004 0410 2071Pediatric Neurology, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Leena Lauronen
- grid.7737.40000 0004 0410 2071Clinical Neurophysiology, HUS Medical Imaging Center, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Päivi Nevalainen
- grid.7737.40000 0004 0410 2071Clinical Neurophysiology, HUS Medical Imaging Center, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland ,grid.7737.40000 0004 0410 2071BioMag Laboratory, HUS Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Markus J. Leskinen
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sture Andersson
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Park JH, Hwang JH, Chang YS, Lee MH, Park WS. Survival rate dependent variations in retinopathy of prematurity treatment rates in very low birth weight infants. Sci Rep 2020; 10:19401. [PMID: 33173128 PMCID: PMC7656246 DOI: 10.1038/s41598-020-76472-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 10/26/2020] [Indexed: 11/09/2022] Open
Abstract
As increased oxidative stress causes increased mortality and morbidities like bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) in very low birth weight infants (VLBWIs), the conundrum of improved survival but increased ROP observed with the high oxygen saturation target range of 91–95% is difficult to explain. To determine the survival rate-dependent variation in ROP treatment rate, 6292 surviving eligible VLBWIs registered in the Korean Neonatal Network were arbitrarily grouped according to the survival rate of infants at 23–24 weeks’ gestation as group I (> 70%, n = 1626), group II (40–70%, n = 2984) and group III (< 40%, n = 1682). Despite significantly higher survival and lower BPD rates in group I than in groups II and III, the ROP treatment rate was higher in group I than in groups II and III. However, the adjusted odds ratios for ROP treatment were not significantly different between the study groups, and the ROP treatment rate in the infants at 23–24 weeks’ gestation was 21-fold higher than the infants at ≥ 27 weeks’ gestation. The controversial association between improved survival and reduced BPD reflecting quality improvement of neonatal intensive care but increased ROP treatment rate might be primarily attributed to the improved survival of the most immature infants.
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Affiliation(s)
- Jae Hyun Park
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Republic of Korea
| | - Jong Hee Hwang
- Department of Pediatrics, Ilsan Paik Hospital, InJe University College of Medicine, Goyang, Republic of Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Myung Hee Lee
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Filippi L, Dal Monte M. A safety review of drugs used for the treatment of retinopathy of prematurity. Expert Opin Drug Saf 2020; 19:1409-1418. [PMID: 32954858 DOI: 10.1080/14740338.2020.1826927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Retinopathy of Prematurity (ROP) is a sight-threatening disease representing one of the main disabling diseases affecting premature newborns. Presently, ROP is treated by surgical interventions and drug therapies are limited to the off-label use of a little amount of molecules approved for other pathologies. AREAS COVERED Many drugs that may potentially be used in treating ROP are recently proposed, in many cases after the demonstration of their effectiveness in preclinical studies. In this review, the authors discuss safety and effectiveness of the main proposed approaches in the pharmacologic treatment of the disease, including approaches based on oxygen therapy and nutritional interventions. EXPERT OPINION Surgical approaches to ROP are not without side effects. However, most of the proposed pharmacologic interventions can also raise specific concerns. In particular, these approaches follow a curative paradigm and are proposed in patients once the disease has progressed, with an effectiveness that is often smaller than expected. A goal in the treatment of ROP would be moving the paradigm toward a preventive approach that could be potentially effective in treating extremely low birth weight preterm infants before ROP becomes manifest.
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Affiliation(s)
- Luca Filippi
- Neonatal Intensive Care Unit, Medical Surgical Fetal-Neonatal Department, "A. Meyer" University Children's Hospital , Florence, Italy
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Gisondo CM, Donn SM. <p>Bronchopulmonary Dysplasia: An Overview</p>. RESEARCH AND REPORTS IN NEONATOLOGY 2020. [DOI: 10.2147/rrn.s271255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Nitzan M, Nitzan I, Arieli Y. The Various Oximetric Techniques Used for the Evaluation of Blood Oxygenation. SENSORS 2020; 20:s20174844. [PMID: 32867184 PMCID: PMC7506757 DOI: 10.3390/s20174844] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 12/12/2022]
Abstract
Adequate oxygen delivery to a tissue depends on sufficient oxygen content in arterial blood and blood flow to the tissue. Oximetry is a technique for the assessment of blood oxygenation by measurements of light transmission through the blood, which is based on the different absorption spectra of oxygenated and deoxygenated hemoglobin. Oxygen saturation in arterial blood provides information on the adequacy of respiration and is routinely measured in clinical settings, utilizing pulse oximetry. Oxygen saturation, in venous blood (SvO2) and in the entire blood in a tissue (StO2), is related to the blood supply to the tissue, and several oximetric techniques have been developed for their assessment. SvO2 can be measured non-invasively in the fingers, making use of modified pulse oximetry, and in the retina, using the modified Beer–Lambert Law. StO2 is measured in peripheral muscle and cerebral tissue by means of various modes of near infrared spectroscopy (NIRS), utilizing the relative transparency of infrared light in muscle and cerebral tissue. The primary problem of oximetry is the discrimination between absorption by hemoglobin and scattering by tissue elements in the attenuation measurement, and the various techniques developed for isolating the absorption effect are presented in the current review, with their limitations.
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Affiliation(s)
- Meir Nitzan
- Department of Physics/Electro-Optics Engineering, Jerusalem College of Technology, 21 Havaad Haleumi St., Jerusalem 91160, Israel;
- Correspondence:
| | - Itamar Nitzan
- Monash Newborn, Monash Children’s Hospital, Melbourne 3168, Australia;
- Department of Neonatology, Shaare Zedek Medical Center, Shmuel Bait St 12, Jerusalem 9103102, Israel
| | - Yoel Arieli
- Department of Physics/Electro-Optics Engineering, Jerusalem College of Technology, 21 Havaad Haleumi St., Jerusalem 91160, Israel;
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Kovatis KZ, Di Fiore JM, Martin RJ, Abbasi S, Chaundhary AS, Hoover S, Zhang Z, Kirpalani H. Effect of Blood Transfusions on Intermittent Hypoxic Episodes in a Prospective Study of Very Low Birth Weight Infants. J Pediatr 2020; 222:65-70. [PMID: 32423683 DOI: 10.1016/j.jpeds.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/18/2020] [Accepted: 03/09/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To compare the number of intermittent hypoxia events before and after packed red blood cell (pRBC) and non-pRBC transfusions in very low birth weight infants, and to compare the time spent with saturations of ≤85% before and after transfusions in the same population. STUDY DESIGN This prospective observational study was conducted from April 2014 to August 2017. It included 92 transfusions (81 pRBC, 11 non-pRBC) from 41 very low birth weight infants between 230/7 and 286/7 weeks of gestation. The primary outcome was number of intermittent hypoxia events. Secondary outcomes included the percent time of Peripheral capillary oxygen saturation (SpO2)of ≤85%, ≤80%, and ≤75%. A mixed ANOVA model was used to examine the relationship between event rate and covariates. RESULTS The mean number of intermittent hypoxia events per hour decreased from 5.27 ± 5.02 events per hour before pRBC transfusion to 3.61 ± 3.17 per hour after pRBC transfusions (P < .01) and intermittent hypoxia did not change after non-RBC transfusions (before, 4.45 ± 3.19 vs after, 4.47 ± 2.78; P = NS). The percent time with saturations of ≤80% and ≤75% significantly decreased after pRBC transfusions (P = .01). The time with saturations of ≤85% did not significantly change after non-pRBC transfusion. CONCLUSIONS In very low birth weight infants with a hematocrit of 20%-42%, pRBC transfusions are associated with decreased frequency of intermittent hypoxia. No such diminution of intermittent hypoxia events was observed in infants who had received a non-pRBC transfusion. This finding suggests that the observed beneficial effects of RBC transfusions on apnea and its clinical manifestations of intermittent hypoxia are mediated through an enhanced oxygen carrying capacity.
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Affiliation(s)
- Kelley Z Kovatis
- Department of Neonatology, Christiana Care Health System, Newark, DE.
| | - Juliann M Di Fiore
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Soraya Abbasi
- Division of Neonatology, Pennsylvania Hospital, Philadelphia, PA; Division of Neonatology, University of Pennsylvania, Philadelphia, PA
| | | | - Stephen Hoover
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Zugui Zhang
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
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Bachman TE, Iyer NP, Newth CJL, Ross PA, Khemani RG. Thresholds for oximetry alarms and target range in the NICU: an observational assessment based on likely oxygen tension and maturity. BMC Pediatr 2020; 20:317. [PMID: 32593300 PMCID: PMC7320542 DOI: 10.1186/s12887-020-02225-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Continuous monitoring of SpO2 in the neonatal ICU is the standard of care. Changes in SpO2 exposure have been shown to markedly impact outcome, but limiting extreme episodes is an arduous task. Much more complicated than setting alarm policy, it is fraught with balancing alarm fatigue and compliance. Information on optimum strategies is limited. METHODS This is a retrospective observational study intended to describe the relative chance of normoxemia, and risks of hypoxemia and hyperoxemia at relevant SpO2 levels in the neonatal ICU. The data, paired SpO2-PaO2 and post-menstrual age, are from a single tertiary care unit. They reflect all infants receiving supplemental oxygen and mechanical ventilation during a 3-year period. The primary measures were the chance of normoxemia (PaO2 50-80 mmHg), risks of severe hypoxemia (PaO2 ≤ 40 mmHg), and of severe hyperoxemia (PaO2 ≥ 100 mmHg) at relevant SpO2 levels. RESULTS Neonates were categorized by postmenstrual age: < 33 (n = 155), 33-36 (n = 192) and > 36 (n = 1031) weeks. From these infants, 26,162 SpO2-PaO2 pairs were evaluated. The post-menstrual weeks (median and IQR) of the three groups were: 26 (24-28) n = 2603; 34 (33-35) n = 2501; and 38 (37-39) n = 21,058. The chance of normoxemia (65, 95%-CI 64-67%) was similar across the SpO2 range of 88-95%, and independent of PMA. The increasing risk of severe hypoxemia became marked at a SpO2 of 85% (25, 95%-CI 21-29%), and was independent of PMA. The risk of severe hyperoxemia was dependent on PMA. For infants < 33 weeks it was marked at 98% SpO2 (25, 95%-CI 18-33%), for infants 33-36 weeks at 97% SpO2 (24, 95%-CI 14-25%) and for those > 36 weeks at 96% SpO2 (20, 95%-CI 17-22%). CONCLUSIONS The risk of hyperoxemia and hypoxemia increases exponentially as SpO2 moves towards extremes. Postmenstrual age influences the threshold at which the risk of hyperoxemia became pronounced, but not the thresholds of hypoxemia or normoxemia. The thresholds at which a marked change in the risk of hyperoxemia and hypoxemia occur can be used to guide the setting of alarm thresholds. Optimal management of neonatal oxygen saturation must take into account concerns of alarm fatigue, staffing levels, and FiO2 titration practices.
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Affiliation(s)
- Thomas E Bachman
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic. .,, Lake Arrowhead, USA.
| | - Narayan P Iyer
- Fetal and Neonatal Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Patrick A Ross
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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48
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Abstract
The premature infant is to some extent protected from hypoxia, however defense against hyperoxia is poorly developed. The optimal assessment of oxygenation is to measure oxygen delivery and extraction. At the bedside PaO2 and SpO2 are approximations of oxygenation at the tissue level. After birth asphyxia it is crucial to know whether or not to give oxygen supplementation, when, how much, and for how long. Oxygen saturation targets in the delivery room have been studied, but the optimal targets might still be unknown because factors like gender and delayed cord clamping influence saturation levels. However, SpO2 > 80% at 5 min of age is associated with favorable long term outcome in preterm babies. Immature infants most often need oxygen supplementation beyond the delivery room. Predefined saturation levels, and narrow alarm limits together with the total oxygen exposure may impact on development of oxygen related diseases like ROP and BPD. Hyperoxia is a strong trigger for genetic and epigenetic changes, contributing to the development of these conditions and perhaps lifelong changes.
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Affiliation(s)
| | - Ola Didrik Saugstad
- Department of Pediatric Research, University of Oslo & Ann and Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Norway.
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49
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Gantz MG, Carlo WA, Finer NN, Rich W, Faix RG, Yoder BA, Walsh MC, Newman N, Laptook A, Schibler K, Das A, Higgins RD. Achieved oxygen saturations and retinopathy of prematurity in extreme preterms. Arch Dis Child Fetal Neonatal Ed 2020; 105:138-144. [PMID: 31229956 PMCID: PMC6925651 DOI: 10.1136/archdischild-2018-316464] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 05/06/2019] [Accepted: 05/13/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To identify achieved oxygen saturations (SpO2) associated with increased risk of severe retinopathy of prematurity (ROP). DESIGN This is a secondary analysis of the Surfactant Positive Airway Pressure and Pulse Oximetry Trial (SUPPORT)randomised controlled trial. SpO2 was recorded up to 36 weeks' postmenstrual age. Saturations through 9 postnatal weeks were explored graphically, and logistic regression models were created to predict severe ROP. SETTING 20 centres of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. PATIENTS 984 surviving infants of 24-27 weeks' gestational age born in 2005-2009. INTERVENTIONS SUPPORT targeted SpO2 to a lower (85%-89%) or higher (91%-95%) range through 36 weeks' postmenstrual age or off respiratory support. MAIN OUTCOME MEASURES Severe ROP defined as threshold ROP, ophthalmological surgery or bevacizumab treatment. RESULTS There were statistically significant interactions between duration of oxygen supplementation and percentage of time in certain achieved saturation ranges. Specifically, for infants who spent at least 2 weeks on oxygen in postnatal weeks 1-5, a higher percentage of time at 91%-96% SpO2 was associated with increased odds of severe ROP. For infants who spent at least 3 weeks on oxygen in postnatal weeks 6-9, a higher percentage of time at 97%-100% SpO2 was associated with increased odds of severe ROP. Other significant risk factors were lower gestational age and birth weight, non-Hispanic white versus black race, prospectively defined severe illness, late-onset sepsis or meningitis, and clinical centre. CONCLUSIONS Among extremely preterm survivors to discharge, the association between SpO2 and severe ROP depended on the timing and duration of oxygen supplementation.
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Affiliation(s)
- Marie G. Gantz
- RTI International, Research Triangle Park, North Carolina, USA
| | | | - Neil N. Finer
- University of California, San Diego, San Diego, California, USA
| | - Wade Rich
- University of California, San Diego, San Diego, California, USA
| | | | | | | | - Nancy Newman
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Abbot Laptook
- Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Kurt Schibler
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Abhik Das
- RTI International, Rockville, Maryland, USA
| | - Rosemary D. Higgins
- College of Health and Human Services, George Mason University, Fairfax, Virginia, USA
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50
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Tarnow-Mordi W, Kirby A. Current Recommendations and Practice of Oxygen Therapy in Preterm Infants. Clin Perinatol 2019; 46:621-636. [PMID: 31345552 DOI: 10.1016/j.clp.2019.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This narrative review identified 23 publications in 2011 to 2019 discussing randomized trials of oxygen saturation targets of 85% to 89% versus 91% to 95% in infants below 28 weeks' gestation. Of 18 commentaries or consensus statements, 17 recommended saturation targets above 89%. Five systematic reviews reported that the 85% to 89% target increased mortality but not the composite of death or disability. The evidence for increased mortality was assessed as of "high", "moderate," or "low," quality, reflecting substantial differences in interpreting the GRADE guidelines. Systematic reviews and guidelines without biostatisticians or epidemiologists as co-authors should be considered potentially problematic.
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Affiliation(s)
- William Tarnow-Mordi
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
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