Strategies for the prevention of bronchopulmonary dysplasia

Risk factors of bronchopulmonary dysplasia depending on the severity of the disease in very preterm infants

OBJECTIVE

Bronchopulmonary dysplasia (BPD) remains a common pathology in very preterm infants. The risk of complications increases with the severity of the disease.The study aimed to determine the factors affecting the formation of moderate/severe BPD in the modern population of very preterm infants.

METHODS

Data from 201 very low birth weight infants < 32 weeks of gestation were used in a retrospective cohort study. Infants were retrospectively divided into two groups based on the type of respiratory support at 36 weeks of postmenstrual age (PMA) - mild BPD (133 infants) and moderate/severe BPD (68 infants). The influence of major perinatal risk factors, neonatal morbidity, and medical interventions on the development of moderate/severe BPD was assessed.

RESULTS

The groups were different in the incidence of intrauterine growth restriction (5% vs. 15%; p = 0.02), maternal hypertension (5% vs. 18%; p = 0.004), cesarean section (29% vs. 43%; p = 0.04), severe intraventricular hemorrhage (9% vs. 19%; p = 0.04), and retinopathy of prematurity (5% vs. 18%; p = 0.002), as well as in need for chest compressions during resuscitation at birth (2% vs. 9%; p = 0.01) for mild and moderate/severe BPD, respectively. Infants in the moderate/severe BPD group had lower Apgar scores at 1 and 5 min, required longer mechanical ventilation (220 (10-1904) hours vs. 72 (1-614) hours; p < 0.0001), CPAP duration (456 (16-1320) hours vs. 278 (10-1200) hours; p = 0.0002), oxygen supply (50 (3-146) days vs. 29 (2-68) days; p < 0.0001), as well as antibacterial therapy (61 (16-177) days vs. 52 (9-121) days; p = 0.0001) and hospital stay (109 (59-321) days vs. 85 (45-205) days; p < 0.0001). Infants with more severe BPD were also significantly more likely to die after reaching the PMA of 36 weeks (12% vs. 1%; p = 0.0003).According to the multivariable logistic regression analysis, the moderate/severe BPD was reliably and independently determined by maternal hypertension (aOR 4.53, 95% CI 1.48-13.91) and genitourinary infections (aOR 4.41, 95% CI 1.41-13.78), as well as the duration of CPAP (aOR 1.002, 95% CI 1.001-1.004) and mechanical ventilation (aOR 1.006, 95% CI 1.004-1.009).

CONCLUSIONS

Duration of respiratory support is the main risk factor that determines the development of moderate/severe BPD in the modern population of very preterm infants. Maternal hypertension and genitourinary infections may influence the severity of lung injury.

How to personalise ventilation of infants with congenital diaphragmatic hernia? A simulation study

BACKGROUND

We aim to develop a non-invasive, bed-side method for supporting personalised ventilation of neonates with congenital diaphragmatic hernia (CDH). Currently, there are no CDH severity measures to do it. As ventilation inhomogeneity (VI) resulting from lung hypoplasia is highly variable in CDH patients, mechanical ventilation is a real challenge and the risk of lung injury is high.

METHODS

We conducted 250 simulations of conventional ventilation of CDH cases using the infant hybrid (numerical-physical) respiratory simulator and a ventilator. Utilising simulation results, we searched for a regression model describing patient ventilation parameters as a function of the respiratory system parameters, ventilator settings and two new CDH severity measures: VI-degree defined as a ratio of time constants ratio of the contralateral and ipsilateral lung (T1/T2) and chest-wall-to-lung compliance ratio (CW/CL). The regression model aimed to find the T1/T2 and CW/CL values for real CDH cases and estimate optimal, matched to VI-degree, peak inspiratory and mean airway pressure (PIP, MAP).

RESULTS

The developed regression models (R2 = 0.78 ÷ 0.98; P < 0.001) enabled to find clinically hard-to-measure values of T1/T2 and CW/CL ratios for three patients, respectively: 9 and 6.52 (P1), 3.5 and 4.96 (P2), and 4 and 5.02 (P3). The T1/T2 and CW/CL correlated with defect size (gamma coefficient: 1; P < 0.05), duration of mechanical ventilation and hospitalization (Spearmen's coefficient: 0.99; P < 0.01). The clinical and estimated PIP and MAP didn't differ statistically.

CONCLUSION

The T1/T2 and CW/CL indices can help to personalize CDH infants' ventilation and might be used for prognostication.

Can the Oxygen Saturation Index Predict Severe Bronchopulmonary Dysplasia?

Background/Objectives: Even with improvements in perinatal care, bronchopulmonary dysplasia (BPD) continues to be a major challenge, especially in smaller and more premature infants. Early detection of severe BPD can improve treatment outcomes. This study aims to evaluate the correlation between the oxygen saturation index (OSI) and severe BPD/death in preterm infants, with a focus on the OSI's predictive value. Methods: In this retrospective observational study, infants with a gestational age of less than 32 weeks who required either invasive or non-invasive mechanical ventilation were included. Ventilator settings and OSI values were collected on days 3, 7, 14, 21, and 28 of life. The correlations between postnatal OSIs and outcomes such as death or severe BPD were analyzed using logistic regression. Results: Out of the 210 eligible infants, 54 (25.7%) either died or were diagnosed with severe BPD. In our study, OSI values on postnatal days 14, 21, and 28 were significantly higher in preterm infants who developed severe BPD or died, with mean OSI-14, OSI-21, and OSI-28 values of 4.9, 3.5, and 2.8, respectively. The OSI showed the highest sensitivity and specificity on postnatal days 14 and 21, with cut-off points of 3.6 and 3.1, respectively. We built a basic chart to predict severe BPD/death with OSI-14 and OSI-21 and delivery room intubation with 86% sensitivity and 84.5% specificity (increasing up to 98.8% specificity). Conclusions: This study showed that the diagnostic power of the OSI in predicting severe BPD or death was highest for OSI-14 and OSI-21. We demonstrated that calculating the OSI, a non-invasive clinical tool, can predict severe BPD/death in infants born before 32 weeks as early as the 14th day of life.

Meta-analysis of budesonide and surfactant combination for the prevention of bronchopulmonary dysplasia in preterm neonates based on gestational age

Background

Budesonide, an inhaled corticosteroid, and surfactant, a substance that lowers surface tension in the lungs, are both used to prevent Bronchopulmonary Dysplasia (BPD). This meta-analysis evaluates the effectiveness of combining budesonide and surfactant in preventing BPD in preterm neonates compared to surfactant alone.

Method

A comprehensive search of electronic databases, including PubMed, Scopus, Google Scholar, CNKI, and Embase, was conducted from their inception up to August 30, 2024. The focus was on evaluating the combination of Budesonide and surfactant for the prevention of BPD in preterm neonates. This assessment involved calculating ORs and their 95% CIs to determine the treatment's effectiveness. The primary outcomes measured were the incidence of BPD and mortality rates, while secondary outcomes included the rates of intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), patent ductus arteriosus (PDA), sepsis, neonatal necrotizing enterocolitis (NEC), and pneumothorax.

Results

This research, combining a meta-analysis and observational data, indicates that Budesonide-Surfactant therapy significantly reduces BPD in preterm neonates with NRDS, regardless of gestational age. Additional benefits, including decreased mortality (in ≥27 gestational weeks), NEC, PDA, ROP, and Sepsis, were observed in the observational study, though pneumothorax increased in the ≥27 gestational weeks group. The meta-analysis corroborated reductions in BPD, PDA, and mortality (in ≥27 gestational weeks), supporting the potential of Budesonide-Surfactant to improve outcomes in preterm infants.

Conclusions

The intratracheal administration of pulmonary surfactants combined with budesonide was associated with a reduction in the incidence of BPD, mortality, and PDA. Although the prevalence of ROP, NEC, IVH, and sepsis was lower in the test group compared to the control group, these differences did not reach statistical significance. These findings suggest that the combined use of budesonide and surfactant is effective in preventing BPD and mortality, as well as in reducing certain secondary outcomes.

Expanding diversity in developmental profiles of very-low-birth-weight infants during 6 years after birth

Very-low-birth-weight infants (VLBWIs) are at high risk for neurodevelopmental problems after age 3 years. We investigated the association between the developmental quotient (DQ) of VLBWIs and their growth profiles during 6 years after birth. Participants were VLBWIs born at Kokura Medical Center (the first cohort) and Kyushu University Hospital (the second cohort) between 2012 and 2017. Recorded charts were used to collect growth profiles and developmental quotients (DQ) of the participants until age 6 years. In the first cohort (n = 64), the DQ values at age 6 years were correlated with those at age 3 years. VLBWIs with DQ ≥ 85 at age 6 years had a higher body weight and height at age 3 years than those with DQ < 85. The second cohort (n = 69) validated these findings. A comparative analysis of the two cohorts revealed that the DQ of VLBWIs was dissociated from their growth profiles after age 3 years. Clustering analyses indicated that DQ values at age 3 years predicted better the prognosis of VLBWIs with DQ ≥ 85 at age 6 years than their growth profiles. This study demonstrates that VLBWIs gain divergent profiles in growth, development, and growth-and-development correlation during postnatal 6 years.

AI models in clinical neonatology: a review of modeling approaches and a consensus proposal for standardized reporting of model performance

Artificial intelligence (AI) is a rapidly advancing area with growing clinical applications in healthcare. The neonatal intensive care unit (NICU) produces large amounts of multidimensional data allowing AI and machine learning (ML) new avenues to improve early diagnosis, enhance monitoring, and provide highly-targeted treatment approaches. In this article, we review recent clinical applications of AI to important neonatal problems, including sepsis, retinopathy of prematurity, bronchopulmonary dysplasia, and others. For each clinical area, we highlight a variety of ML models published in the literature and examine the future role they may play at the bedside. While the development of these models is rapidly expanding, a fundamental understanding of model selection, development, and performance evaluation is crucial for researchers and healthcare providers alike. As AI plays an increasing role in daily practice, understanding the implications of AI design and performance will enable more effective implementation. We provide a comprehensive explanation of the AI development process and recommendations for a standardized performance metric framework. Additionally, we address critical challenges, including model generalizability, ethical considerations, and the need for rigorous performance monitoring to avoid model drift. Finally, we outline future directions, emphasizing the importance of collaborative efforts and equitable access to AI innovations.