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Shehzad I, Banker A, Das B, Humayun A, Wills H, Raju M, Vora N. Successful Weaning From Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) After Initiation of Inhaled Epoprostenol in a Neonate With Refractory Persistent Pulmonary Hypertension of the Newborn (PPHN). Cureus 2023; 15:e45595. [PMID: 37868379 PMCID: PMC10588285 DOI: 10.7759/cureus.45595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Despite improvements in the medical management of persistent pulmonary hypertension of the newborn (PPHN), a significant number of patients persist with inadequate gas exchange and are treated with extracorporeal membrane oxygenation (ECMO). Prolonged time to weaning ECMO can increase mortality risk. Therefore, multiple therapies are utilized for pulmonary hypertension treatment, including pharmacotherapy with pulmonary vasodilators, to improve the prognosis of these critical patients. We report a case of a 37 2/7-week neonate with severe PPHN refractory to triple pulmonary vasodilator therapy (inhaled nitric oxide (iNO), sildenafil, and milrinone) and required veno-venous (VV)-ECMO support to improve oxygenation. Our patient was successfully weaned from ECMO after the addition of inhaled epoprostenol (iEPO) therapy. This report indicates that inhaled prostacyclin therapy effectively helps refractory PPHN patients off extracorporeal life support (ECLS) and should be considered a valuable treatment.
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Affiliation(s)
- Irfan Shehzad
- Neonatology, Baylor Scott & White Health, Austin, USA
| | - Ashish Banker
- Pediatric Cardiology, Baylor Scott & White Health, Temple, USA
| | - Bibhuti Das
- Pediatric Cardiology, Baylor Scott & White Health, Temple, USA
| | - Adil Humayun
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Hale Wills
- Pediatric Surgery, Baylor Scott & White Health, Temple, USA
| | - Muppala Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
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2
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Fletcher KL, Chapman R. Update on pre-ECMO evaluation and treatment for term infants in respiratory failure. Semin Fetal Neonatal Med 2022; 27:101401. [PMID: 36450631 DOI: 10.1016/j.siny.2022.101401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The epidemiology, diagnostic and management approach to severe hypoxemic respiratory failure in the term and near-term neonate has evolved over time, as has the need for extracorporeal membrane oxygenation (ECMO) support in this patient population. Many patients who historically would have required ECMO support now respond to less invasive therapies, with patients requiring ECMO generally representing a higher risk and more heterogenous group of underlying diagnoses. This review will highlight these changes over time and the current available evidence for the diagnosis and management of these infants, as well as the current indications and relative contraindications to ECMO support when oxygen delivery cannot meet demand with less invasive management.
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Affiliation(s)
- Kathryn L Fletcher
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, 333 Cedar Street, LMP, 4085, USA.
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
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3
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Abstract
Inhaled nitric oxide (iNO) therapy had a transformational impact on the management of infants with persistent pulmonary hypertension of the newborn (PPHN). iNO remains the only approved pulmonary vasodilator for PPHN; yet 30% to 40% of patients do not respond or have incomplete response to iNO. Lung recruitment strategies with early surfactant administration and high-frequency ventilation can optimize the response to iNO in the presence of parenchymal lung diseases. Alternate pulmonary vasodilators are used commonly as rescue, life-saving measures, though there is a lack of high-quality evidence supporting their efficacy and safety. This article reviews the available evidence and future directions for research in PPHN.
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Bearl DW, Dodd DA, Thurm C, Hall M, Soslow JH, Feingold B, Godown J. Practice Variation, Costs and Outcomes Associated with the Use of Inhaled Nitric Oxide in Pediatric Heart Transplant Recipients. Pediatr Cardiol 2019; 40:650-657. [PMID: 30547294 PMCID: PMC6855671 DOI: 10.1007/s00246-018-2042-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/08/2018] [Indexed: 01/06/2023]
Abstract
Right ventricular (RV) failure is a potentially fatal complication following heart transplantation (HTx). Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that is used to decrease pulmonary vascular resistance immediately post-HTx to reduce the risk of RV failure. The aim of this study was to describe utilization patterns, costs, and outcomes associated with post-transplant iNO use in children. All pediatric HTx recipients (2002-2016) were identified from a unique linked PHIS/SRTR dataset. Post-HTx iNO use was determined based on hospital billing data. Utilization patterns and associated costs were described. The association of iNO support with post-HTx survival was assessed using the Kaplan-Meier method and a multivariable Cox proportional hazards model was used to adjust for risk factors. A total of 2833 pediatric HTx recipients from 28 centers were identified with 1057 (36.5%) receiving iNO post-HTx. Post-HTx iNO use showed significant increase overall (17.2-54.7%, p < 0.001) and wide variation among centers (9-100%, p < 0.001). Patients with congenital heart disease (aOR 1.4, 95% CI 1.2, 1.6), requiring mechanical ventilation at HTx (aOR 1.3, 95% CI 1.1, 1.6), and pre-transplant iNO (aOR 9.3, 95% CI 5.4, 16) were more likely to receive iNO post-HTx. The median daily cost of iNO was $2617 (IQR $1843-$3646). Patients who required > 5 days of iNO post-HTx demonstrated inferior 1-year post-HTx survival (p < 0.001) and iNO use > 5 days was independently associated with worse post-HTx survival (AHR 1.6, 95% CI 1.2, 2.1; p < 0.001). There is wide variation in iNO use among centers following pediatric HTx with use increasing over time despite significant incremental cost. Prolonged iNO use post-HTx is associated with worse survival, likely serving as a marker of residual illness severity. Further research is needed to define the populations that derive the greatest benefit from this costly therapy.
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Affiliation(s)
- David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA.
| | - Debra A Dodd
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, KS, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Jonathan H Soslow
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA
| | - Brian Feingold
- Pediatrics and Clinical and Translational Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Godown
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, 37232-9119, USA
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Intravenous epoprostenol improves oxygenation index in patients with persistent pulmonary hypertension of the newborn refractory to nitric oxide. J Perinatol 2018; 38:1212-1219. [PMID: 30046179 DOI: 10.1038/s41372-018-0179-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/19/2018] [Accepted: 06/26/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Evaluate the short-term effects of IV epoprostenol in neonates with persistent pulmonary hypertension (PPHN) of the newborn. STUDY DESIGN We reviewed 36 patients with inhaled nitric oxide (iNO) refractory PPHN placed on IV epoprostenol from 2010 to 2015. Patients were categorized as responders or non-responders (who either died or required extracorporeal membranous oxygenation). RESULTS There were 15 responders and 21 non-responders. Pulmonary hypoplasia was the etiology of PPHN for 57% of non-responders vs. 13% of responders. Median oxygenation index (OI) was similar at baseline (41.8 non-responders vs. 36.5 responders, p = 0.41) with responders having a significantly lower OI by 4 h of treatment (42.3 vs. 23.1, p = 0.002). Epoprostenol responders had a median OI decrease of 11.6 within 4 h (p = 0.017) with a significant response persisting through 24 h. CONCLUSION In infants with iNO-refractory PPHN, initiation of IV epoprostenol was associated with a significant and rapid OI reduction among responders.
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Davis MD, Donn SM, Ward RM. Administration of Inhaled Pulmonary Vasodilators to the Mechanically Ventilated Neonatal Patient. Paediatr Drugs 2017; 19:183-192. [PMID: 28374138 DOI: 10.1007/s40272-017-0221-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension is a life-threatening condition that affects people of all ages that can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and infectious disorders. It is commonly treated with inhaled pulmonary vasodilators such as nitric oxide and less frequently using formulations and analogs of prostacyclin. To minimize systemic effects and preserve pulmonary vasodilation, vasodilators are often administered directly into the airway. Nitric oxide is the only USA Food and Drug Administration-approved inhaled pulmonary vasodilator that can be used during mechanical ventilation. Over the past two decades, interest has grown in the use of aerosolized prostacyclin and prostacyclin analogs for the treatment of pulmonary hypertension during mechanical ventilation. Clinicians who administer inhaled prostacyclin may not have a clear understanding of its risks because of the lack of data from large clinical trials examining safety and efficacy; moreover, its safe use remains poorly documented. The off-label use of drugs is legitimate, but prescribers must recognize the potential complications and liability in doing so. This manuscript aims to address potential problems related to the aerosol administration of pulmonary vasodilators in the mechanically ventilated neonatal patient.
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Affiliation(s)
- Michael D Davis
- Physiology and Biophysics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street, Hermes A. Kontos Medical Sciences Building Room 215, Richmond, VA, 23298, USA.
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert M Ward
- Professor Emeritus, Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Greenough A, Papalexopoulou N. The roles of drug therapy given via the endotracheal tube to neonates. Arch Dis Child Fetal Neonatal Ed 2017; 102:F277-F281. [PMID: 28270430 DOI: 10.1136/archdischild-2016-311711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 11/04/2022]
Abstract
Many drugs are given to intubated neonates by the inhalation route. The optimum aerosol delivery system, however, has not been identified and there are many challenges in delivering drugs effectively to the lower airways of intubated neonates. The effectiveness of surfactant in prematurely born infants and nitric oxide has been robustly investigated. Other drugs are being used on very limited evidence.
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Affiliation(s)
- Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Niovi Papalexopoulou
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
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Hilgendorff A, Apitz C, Bonnet D, Hansmann G. Pulmonary hypertension associated with acute or chronic lung diseases in the preterm and term neonate and infant. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart 2016; 102 Suppl 2:ii49-56. [PMID: 27053698 DOI: 10.1136/heartjnl-2015-308591] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 10/14/2015] [Indexed: 11/04/2022] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is the most common neonatal form and mostly reversible after a few days with improvement of the underlying pulmonary condition. When pulmonary hypertension (PH) persists despite adequate treatment, the severity of parenchymal lung disease should be assessed by chest CT. Pulmonary vein stenosis may need to be ruled out by cardiac catheterisation and lung biopsy, and genetic workup is necessary when alveolar capillary dysplasia is suspected. In PPHN, optimisation of the cardiopulmonary situation including surfactant therapy should aim for preductal SpO2between 91% and 95% and severe cases without post-tricuspid-unrestrictive shunt may receive prostaglandin E1 to maintain ductal patency in right heart failure. Inhaled nitric oxide is indicated in mechanically ventilated infants to reduce the need for extracorporal membrane oxygenation (ECMO), and sildenafil can be considered when this therapy is not available. ECMO may be indicated according to the ELSO guidelines. In older preterm infant, where PH is mainly associated with bronchopulmonary dysplasia (BPD) or in term infants with developmental lung anomalies such as congenital diaphragmatic hernia or cardiac anomalies, left ventricular diastolic dysfunction/left atrial hypertension or pulmonary vein stenosis, can add to the complexity of the disease. Here, oral or intravenous sildenafil should be considered for PH treatment in BPD, the latter for critically ill patients. Furthermore, prostanoids, mineralcorticoid receptor antagonists, and diuretics can be beneficial. Infants with proven or suspected PH should receive close follow-up, including preductal/postductal SpO2measurements, echocardiography and laboratory work-up including NT-proBNP, guided by clinical improvement or lack thereof.
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Affiliation(s)
- Anne Hilgendorff
- Department of Neonatology, Dr von Haunersche Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Christian Apitz
- Department of Paediatric Cardiology, Children's Hospital, University of Ulm, Ulm, Germany
| | - Damien Bonnet
- Unité Médico-Chirurgicale de Cardiologie Congénitale et Pédiatrique, Centre de référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Necker Enfants Malades, APHP, Université Paris Descartes, Sorbonne Paris, Paris, France
| | - Georg Hansmann
- Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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9
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DiBlasi RM, Crotwell DN, Shen S, Zheng J, Fink JB, Yung D. Iloprost drug delivery during infant conventional and high-frequency oscillatory ventilation. Pulm Circ 2016; 6:63-9. [PMID: 27162615 PMCID: PMC4860545 DOI: 10.1086/685080] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Iloprost is a selective pulmonary vasodilator approved for inhalation by the Food and Drug Administration. Iloprost has been increasingly used in the management of critically ill neonates with hypoxic lung disease. This in vitro study was designed to test the hypothesis that aerosol drug delivery could be effectively administered to infants with both conventional ventilation and high-frequency oscillatory ventilation (HFOV). A neonatal test lung model configured with newborn lung mechanics was ventilated with a conventional ventilator and an HFOV with standard settings. A vibrating-mesh nebulizer was placed (1) proximal to the patient airway in the inspiratory limb between the humidifier probe and patient wye (conventional) as well as between the vent circuit and the endotracheal tube (ETT) for HFOV and (2) between the ventilator and humidifier (distal). Iloprost was nebulized in three separate runs using three new nebulizers in each of the circuit locations. A collecting filter was placed at the distal end of the ETT for each trial. Iloprost was quantified using high-performance liquid chromatography. The percentage of nominal dose delivered was greater with the nebulizer placed proximal to the airway for conventional ventilation (10.74% ± 2%) and HFOV (29% ± 2%) than with it placed in the distal position (2.96% ± 0.2% vs. 0.96% ± 0.8%, respectively; P < 0.05). Drug delivery in proximal position was nearly threefold greater during HFOV than during conventional ventilation. In conclusion, iloprost drug delivery was best achieved when the nebulizer was placed proximal to the patient airway during neonatal mechanical ventilation. Drug delivery appears to be more efficient during HFOV than during conventional ventilation.
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Affiliation(s)
- Robert M DiBlasi
- Respiratory Therapy Department, Seattle Children's Hospital, Seattle, Washington, USA; Seattle Children's Hospital Research Institute, Seattle, Washington, USA
| | - Dave N Crotwell
- Respiratory Therapy Department, Seattle Children's Hospital, Seattle, Washington, USA
| | - Shuijie Shen
- Seattle Children's Hospital Research Institute, Seattle, Washington, USA
| | - Jiang Zheng
- Seattle Children's Hospital Research Institute, Seattle, Washington, USA
| | | | - Delphine Yung
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
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10
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Cosa N, Costa E. Inhaled pulmonary vasodilators for persistent pulmonary hypertension of the newborn: safety issues relating to drug administration and delivery devices. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:45-51. [PMID: 27110141 PMCID: PMC4835137 DOI: 10.2147/mder.s99601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Treatment for persistent pulmonary hypertension of the newborn (PPHN) aims to reduce pulmonary vascular resistance while maintaining systemic vascular resistance. Selective pulmonary vasodilation may be achieved by targeting pulmonary-specific pathways or by delivering vasodilators directly to the lungs. Abrupt withdrawal of a pulmonary vasodilator can cause rebound pulmonary hypertension. Therefore, use of consistent delivery systems that allow for careful monitoring of drug delivery is important. This manuscript reviews published studies of inhaled vasodilators used for treatment of PPHN and provides an overview of safety issues associated with drug delivery and delivery devices as they relate to the risk of rebound pulmonary hypertension. Off-label use of aerosolized prostacyclins and an aerosolized prostaglandin in neonates with PPHN has been reported; however, evidence from large randomized clinical trials is lacking. The amount of a given dose of aerosolized drug that is actually delivered to the lungs is often unknown, and the actual amount of drug deposited in the lungs can be affected by several factors, including patient size, nebulizer used, and placement of the nebulizer within the breathing circuit. Inhaled nitric oxide (iNO) is the only pulmonary vasodilator approved by the US Food and Drug Administration for the treatment of PPHN. The iNO delivery device, INOmax DSIR®IR, is designed to constantly monitor NO, NO2, and O2 deliveries and is equipped with audible and visual alarms to alert providers of abrupt discontinuation and incorrect drug concentration. Other safety features of this device include two independent backup delivery systems, a backup drug cylinder, a battery that provides up to 6 hours of uninterrupted medication delivery, and 27 alarms that monitor delivery, dosage, and system functions. The ability of the drug delivery device to provide safe, consistent dosing is important to consider when selecting a pulmonary vasodilator.
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Affiliation(s)
- Nathan Cosa
- Department of Respiratory Care, Banner Desert Medical Center, Cardon Children's Medical Center, Mesa, AZ, USA
| | - Edward Costa
- Department of Medical Affairs, Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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11
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Searcy RJ, Morales JR, Ferreira JA, Johnson DW. The role of inhaled prostacyclin in treating acute respiratory distress syndrome. Ther Adv Respir Dis 2015; 9:302-12. [PMID: 26294418 DOI: 10.1177/1753465815599345] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome of acute lung injury that is characterized by noncardiogenic pulmonary edema and severe hypoxemia second to a pathogenic impairment of gas exchange. Despite significant advances in the area, mortality remains high among ARDS patients. High mortality and a limited spectrum of therapeutic options have left clinicians searching for alternatives, spiking interest in selective pulmonary vasodilators (SPVs). Despite the lack of robust evidence, SPVs are commonly employed for their therapeutic role in improving oxygenation in patients who have developed refractory hypoxemia in ARDS. While inhaled epoprostenol (iEPO) also impacts arterial oxygenation by decreasing ventilation-perfusion (V/Q) mismatching and pulmonary shunt flow, this effect is not different from inhaled nitric oxide (iNO). The most effective and safest dose for yielding a clinically significant increase in PaO2 and reduction in pulmonary artery pressure (PAP) appears to be 20-30 ng/kg/min in adults and 30 ng/kg/min in pediatric patients. iEPO appears to have a ceiling effect above these doses in which no additional benefit may be derived. iNO and iEPO have shown similar efficacy profiles; however, they differ with respect to cost and ease of therapeutic administration. The most beneficial effects of iEPO have been seen in adult patients with secondary ARDS as compared with primary ARDS, most likely due to the difference in etiology of the two disease states, and in patients suffering from baseline right ventricular heart failure. Although iEPO has demonstrated improvements in hemodynamic parameters and oxygenation in ARDS patients, due to the limited number of randomized clinical trials and the lack of studies investigating mortality, the use of iEPO cannot be recommended as standard of care in ARDS. iEPO should be reserved for those refractory to traditional therapies.
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Affiliation(s)
- Randi J Searcy
- Department of Pharmacy, University of Florida Health Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - James R Morales
- University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Jason A Ferreira
- University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Donald W Johnson
- University of Florida Health Jacksonville, Jacksonville, Florida, USA
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12
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Brunner N, de Jesus Perez VA, Richter A, Haddad F, Denault A, Rojas V, Yuan K, Orcholski M, Liao X. Perioperative pharmacological management of pulmonary hypertensive crisis during congenital heart surgery. Pulm Circ 2014; 4:10-24. [PMID: 25006417 DOI: 10.1086/674885] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 09/12/2013] [Indexed: 01/12/2023] Open
Abstract
Pulmonary hypertensive crisis is an important cause of morbidity and mortality in patients with pulmonary arterial hypertension secondary to congenital heart disease (PAH-CHD) who require cardiac surgery. At present, prevention and management of perioperative pulmonary hypertensive crisis is aimed at optimizing cardiopulmonary interactions by targeting prostacyclin, endothelin, and nitric oxide signaling pathways within the pulmonary circulation with various pharmacological agents. This review is aimed at familiarizing the practitioner with the current pharmacological treatment for dealing with perioperative pulmonary hypertensive crisis in PAH-CHD patients. Given the life-threatening complications associated with pulmonary hypertensive crisis, proper perioperative planning can help anticipate cardiopulmonary complications and optimize surgical outcomes in this patient population.
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Affiliation(s)
- Nathan Brunner
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Vinicio A de Jesus Perez
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Alice Richter
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - François Haddad
- Division of Cardiology, Stanford School of Medicine, Stanford, California, USA
| | - André Denault
- Division of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Vanessa Rojas
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Ke Yuan
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Mark Orcholski
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Xiaobo Liao
- Division of Pulmonary and Critical Care Medicine, Stanford School of Medicine, Stanford, California, USA ; Division of Cardiothoracic Surgery, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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13
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Baker CD, Abman SH, Mourani PM. Pulmonary Hypertension in Preterm Infants with Bronchopulmonary Dysplasia. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2014; 27:8-16. [PMID: 24669351 DOI: 10.1089/ped.2013.0323] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/16/2014] [Indexed: 01/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD), the chronic lung disease of prematurity, is a significant contributor to perinatal morbidity and mortality. Premature birth disrupts pulmonary vascular growth and initiates a cascade of events that result in impaired gas exchange, abnormal vasoreactivity, and pulmonary vascular remodeling that may ultimately lead to pulmonary hypertension (PH). Even infants who appear to have mild BPD suffer from varying degrees of pulmonary vascular disease (PVD). Although recent studies have enhanced our understanding of the pathobiology of PVD and PH in BPD, much remains unknown with respect to how PH should be properly defined, as well as the most accurate methods for the diagnosis and treatment of PH in infants with BPD. This article will provide neonatologists and primary care providers, as well as pediatric cardiologists and pulmonologists, with a review of the pathophysiology of PH in preterm infants with BPD and a summary of current clinical recommendations for managing PH in this population.
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Affiliation(s)
- Christopher D Baker
- Section of Pulmonary Medicine, University of Colorado School of Medicine , Aurora, Colarado. ; Pediatric Heart Lung Center, University of Colorado School of Medicine , Aurora, Colarado
| | - Steven H Abman
- Section of Pulmonary Medicine, University of Colorado School of Medicine , Aurora, Colarado. ; Pediatric Heart Lung Center, University of Colorado School of Medicine , Aurora, Colarado
| | - Peter M Mourani
- Pediatric Heart Lung Center, University of Colorado School of Medicine , Aurora, Colarado. ; Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine , Aurora, Colarado
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14
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Inhaled Epoprostenol to Support the Severely Hypoxemic Patient With Acute Respiratory Distress Syndrome. Dimens Crit Care Nurs 2013; 32:229-36. [DOI: 10.1097/dcc.0b013e3182a076f6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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15
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Collaco JM, Romer LH, Stuart BD, Coulson JD, Everett AD, Lawson EE, Brenner JI, Brown AT, Nies MK, Sekar P, Nogee LM, McGrath-Morrow SA. Frontiers in pulmonary hypertension in infants and children with bronchopulmonary dysplasia. Pediatr Pulmonol 2012; 47:1042-53. [PMID: 22777709 PMCID: PMC3963167 DOI: 10.1002/ppul.22609] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 05/19/2012] [Indexed: 12/23/2022]
Abstract
Pulmonary hypertension (PH) is an increasingly recognized complication of premature birth and bronchopulmonary dysplasia (BPD), and is associated with increased morbidity and mortality. Extreme phenotypic variability exists among preterm infants of similar gestational ages, making it difficult to predict which infants are at increased risk for developing PH. Intrauterine growth retardation or drug exposures, postnatal therapy with prolonged positive pressure ventilation, cardiovascular shunts, poor postnatal lung and somatic growth, and genetic or epigenetic factors may all contribute to the development of PH in preterm infants with BPD. In addition to the variability of severity of PH, there is also qualitative variability seen in PH, such as the variable responses to vasoactive medications. To reduce the morbidity and mortality associated with PH, a multi-pronged approach is needed. First, improved screening for and increased recognition of PH may allow for earlier treatment and better clinical outcomes. Second, identification of both prenatal and postnatal risk factors for the development of PH may allow targeting of therapy and resources for those at highest risk. Third, understanding the pathophysiology of the preterm pulmonary vascular bed may help improve outcomes through recognizing pathways that are dysregulated in PH, identifying novel biomarkers, and testing novel treatments. Finally, the recognition of conditions and exposures that may exacerbate or lead to recurrent PH is needed to help with developing treatment guidelines and preventative strategies that can be used to reduce the burden of disease.
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Affiliation(s)
- Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-2533, USA
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Sharma M, Callan E, Konduri GG. Pulmonary vasodilator therapy in persistent pulmonary hypertension of the newborn. Clin Perinatol 1984; 11:693-701. [PMID: 6488673 PMCID: PMC8885147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A review of the physiology of persistent pulmonary hypertension of the newborn is provided, followed by a critical review of many of the agents that have been employed to treat this condition. In addition, the authors speculate on what type of pharmacologic therapy may prove useful in the future.
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Affiliation(s)
- Megha Sharma
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Emily Callan
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI
| | - G. Ganesh Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI
- Corresponding author: G. Ganesh Konduri, MD., 999 N 92 St, CCC Ste C410, Wauwatosa, WI, 53226.
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