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Kausch SL, Lake DE, Di Fiore JM, Weese-Mayer DE, Claure N, Ambalavanan N, Vesoulis ZA, Fairchild KD, Dennery PA, Hibbs AM, Martin RJ, Indic P, Travers CP, Bancalari E, Hamvas A, Kemp JS, Carroll JL, Moorman JR, Sullivan BA. Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Infants Born Extremely Preterm. J Pediatr 2024; 271:114042. [PMID: 38570031 DOI: 10.1016/j.jpeds.2024.114042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The objective of this study was to examine the association of cardiorespiratory events, including apnea, periodic breathing, intermittent hypoxemia (IH), and bradycardia, with late-onset sepsis for extremely preterm infants (<29 weeks of gestational age) on vs off invasive mechanical ventilation. STUDY DESIGN This is a retrospective analysis of data from infants enrolled in Pre-Vent (ClinicalTrials.gov identifier NCT03174301), an observational study in 5 level IV neonatal intensive care units. Clinical data were analyzed for 737 infants (mean gestational age: 26.4 weeks, SD 1.71). Monitoring data were available and analyzed for 719 infants (47 512 patient-days); of whom, 109 had 123 sepsis events. Using continuous monitoring data, we quantified apnea, periodic breathing, bradycardia, and IH. We analyzed the relationships between these daily measures and late-onset sepsis (positive blood culture >72 hours after birth and ≥5-day antibiotics). RESULTS For infants not on a ventilator, apnea, periodic breathing, and bradycardia increased before sepsis diagnosis. During times on a ventilator, increased sepsis risk was associated with longer events with oxygen saturation <80% (IH80) and more bradycardia events before sepsis. IH events were associated with higher sepsis risk but did not dynamically increase before sepsis, regardless of ventilator status. A multivariable model including postmenstrual age, cardiorespiratory variables (apnea, periodic breathing, IH80, and bradycardia), and ventilator status predicted sepsis with an area under the receiver operator characteristic curve of 0.783. CONCLUSION We identified cardiorespiratory signatures of late-onset sepsis. Longer IH events were associated with increased sepsis risk but did not change temporally near diagnosis. Increases in bradycardia, apnea, and periodic breathing preceded the clinical diagnosis of sepsis.
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Affiliation(s)
- Sherry L Kausch
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA.
| | - Douglas E Lake
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Debra E Weese-Mayer
- Division of Autonomic Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Providence, RI
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James S Kemp
- Division of Pediatric Pulmonology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - J Randall Moorman
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
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Hibbs AM, Chen Z, Minich NM, Martin RJ, Raffay TM, MacFarlane PM, Di Fiore JM. Association between Intermittent Hypoxemia and NICU Length of Stay in Preterm Infants. Neonatology 2024:1-9. [PMID: 38437802 DOI: 10.1159/000535264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/14/2023] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Length of hospitalization varies widely in preterm infants and can be affected by multiple maternal and neonatal factors including respiratory instability. Therefore, we aimed to determine the association between postnatal intermittent hypoxemia (IH) and prolonged hospitalization. METHODS This prospective single-center cohort study followed infants born at <31 weeks of gestational age through 2 years corrected age with detailed oxygen saturation data captured from days 7 to 30 of age. RESULTS 51/164 (31%) of infants were discharged after 400/7 weeks of corrected gestational age (CGA). A greater average daily number of IH events (OR per 10 events/day 1.33 [95% CI 1.03-1.72]), duration of events (OR per minute 1.14 [1.07-1.21]), and percent time with oxygen saturation <80% (OR per percent 1.88 [1.25-2.85]) on days 7-30 of age were all significantly associated with prolonged hospitalization past 400/7 weeks CGA. In survival analyses, infants with a greater average daily number of IH events (HR per 10 events/day 0.89 [0.81-0.98]), percent time with oxygen saturation <80% (HR per percent 0.79 [0.67-0.94]), and duration of events (HR per minute 0.93 [0.91-0.95]) on days 7-30 of age all had significantly lower probability of earlier discharge. In addition, there was a significant interaction with gestational age; the association between IH and prolonged hospitalization was stronger in more mature infants (p = 0.024). CONCLUSIONS Physiological instability on days 7-30 of age, as manifested by IH, is significantly associated with prolonged hospitalization. IH likely represents both a marker of initial severity of illness and the beginning of biological cascades, leading to prematurity-associated morbidities.
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Affiliation(s)
- Anna Maria Hibbs
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nori M Minich
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Martin
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas M Raffay
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Peter M MacFarlane
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Juliann M Di Fiore
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kausch SL, Lake DE, Di Fiore JM, Weese-Mayer DE, Claure N, Ambalavanan N, Vesoulis ZA, Fairchild KD, Dennery PA, Hibbs AM, Martin RJ, Indic P, Travers CP, Bancalari E, Hamvas A, Kemp JS, Carroll JL, Moorman JR, Sullivan BA. Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Extremely Preterm Infants. medRxiv 2024:2024.01.26.24301820. [PMID: 38343825 PMCID: PMC10854335 DOI: 10.1101/2024.01.26.24301820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Objectives Detection of changes in cardiorespiratory events, including apnea, periodic breathing, intermittent hypoxemia (IH), and bradycardia, may facilitate earlier detection of sepsis. Our objective was to examine the association of cardiorespiratory events with late-onset sepsis for extremely preterm infants (<29 weeks' gestational age (GA)) on versus off invasive mechanical ventilation. Study Design Retrospective analysis of data from infants enrolled in Pre-Vent (ClinicalTrials.gov identifier NCT03174301), an observational study in five level IV neonatal intensive care units. Clinical data were analyzed for 737 infants (mean GA 26.4w, SD 1.71). Monitoring data were available and analyzed for 719 infants (47,512 patient-days), of whom 109 had 123 sepsis events. Using continuous monitoring data, we quantified apnea, periodic breathing, bradycardia, and IH. We analyzed the relationships between these daily measures and late-onset sepsis (positive blood culture >72h after birth and ≥5d antibiotics). Results For infants not on a ventilator, apnea, periodic breathing, and bradycardia increased before sepsis diagnosis. During times on a ventilator, increased sepsis risk was associated with longer IH80 events and more bradycardia events before sepsis. IH events were associated with higher sepsis risk, but did not dynamically increase before sepsis, regardless of ventilator status. A multivariable model predicted sepsis with an AUC of 0.783. Conclusion We identified cardiorespiratory signatures of late-onset sepsis. Longer IH events were associated with increased sepsis risk but did not change temporally near diagnosis. Increases in bradycardia, apnea, and periodic breathing preceded the clinical diagnosis of sepsis.
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Affiliation(s)
- Sherry L Kausch
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Karen D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Department of Pediatrics, Providence, RI
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - Colm P Travers
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Department of Pediatrics, Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Brynne A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
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Qiu J, Di Fiore JM, Krishnamurthi N, Indic P, Carroll JL, Claure N, Kemp JS, Dennery PA, Ambalavanan N, Weese-Mayer DE, Hibbs AM, Martin RJ, Bancalari E, Hamvas A, Randall Moorman J, Lake DE. Highly comparative time series analysis of oxygen saturation and heart rate to predict respiratory outcomes in extremely preterm infants. medRxiv 2024:2024.01.24.24301724. [PMID: 38343830 PMCID: PMC10854343 DOI: 10.1101/2024.01.24.24301724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Objective Highly comparative time series analysis (HCTSA) is a novel approach involving massive feature extraction using publicly available code from many disciplines. The Prematurity-Related Ventilatory Control (Pre-Vent) observational multicenter prospective study collected bedside monitor data from > 700 extremely preterm infants to identify physiologic features that predict respiratory outcomes. We calculated a subset of 33 HCTSA features on > 7M 10-minute windows of oxygen saturation (SPO2) and heart rate (HR) from the Pre-Vent cohort to quantify predictive performance. This subset included representatives previously identified using unsupervised clustering on > 3500 HCTSA algorithms. Performance of each feature was measured by individual area under the receiver operating curve (AUC) at various days of life and binary respiratory outcomes. These were compared to optimal PreVent physiologic predictor IH90 DPE, the duration per event of intermittent hypoxemia events with threshold of 90%. Main Results The top HCTSA features were from a cluster of algorithms associated with the autocorrelation of SPO2 time series and identified low frequency patterns of desaturation as high risk. These features had comparable performance to and were highly correlated with IH90_DPE but perhaps measure the physiologic status of an infant in a more robust way that warrants further investigation. The top HR HCTSA features were symbolic transformation measures that had previously been identified as strong predictors of neonatal mortality. HR metrics were only important predictors at early days of life which was likely due to the larger proportion of infants whose outcome was death by any cause. A simple HCTSA model using 3 top features outperformed IH90_DPE at day of life 7 (.778 versus .729) but was essentially equivalent at day of life 28 (.849 versus .850). These results validated the utility of a representative HCTSA approach but also provides additional evidence supporting IH90_DPE as an optimal predictor of respiratory outcomes.
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Affiliation(s)
- Jiaxing Qiu
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Narayanan Krishnamurthi
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO
| | - Phyllis A Dennery
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Department of Pediatrics, Chicago, IL
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
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Raffay TM, Di Fiore JM, Chen Z, Sánchez-Illana Á, Vento M, Piñeiro-Ramos JD, Kuligowski J, Martin RJ, Tatsuoka C, Minich NM, MacFarlane PM, Hibbs AM. Hypoxemia events in preterm neonates are associated with urine oxidative biomarkers. Pediatr Res 2023; 94:1444-1450. [PMID: 37188801 DOI: 10.1038/s41390-023-02646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intermittent hypoxemia (IH) events are common in preterm neonates and are associated with adverse outcomes. Animal IH models can induce oxidative stress. We hypothesized that an association exists between IH and elevated peroxidation products in preterm neonates. METHODS Time in hypoxemia, frequency of IH, and duration of IH events were assessed from a prospective cohort of 170 neonates (<31 weeks gestation). Urine was collected at 1 week and 1 month. Samples were analyzed for lipid, protein, and DNA oxidation biomarkers. RESULTS At 1 week, adjusted multiple quantile regression showed positive associations between several hypoxemia parameters with various individual quantiles of isofurans, neurofurans, dihomo-isoprostanes, dihomo-isofurans, and ortho-tyrosine and a negative correlation with dihomo-isoprostanes and meta-tyrosine. At 1 month, positive associations were found between several hypoxemia parameters with quantiles of isoprostanes, dihomo-isoprostanes and dihomo-isofurans and a negative correlation with isoprostanes, isofurans, neuroprostanes, and meta-tyrosine. CONCLUSIONS Preterm neonates experience oxidative damage to lipids, proteins, and DNA that can be analyzed from urine samples. Our single-center data suggest that specific markers of oxidative stress may be related to IH exposure. Future studies are needed to better understand mechanisms and relationships to morbidities of prematurity. IMPACT Hypoxemia events are frequent in preterm infants and are associated with poor outcomes. The mechanisms by which hypoxemia events result in adverse neural and respiratory outcomes may include oxidative stress to lipids, proteins, and DNA. This study begins to explore associations between hypoxemia parameters and products of oxidative stress in preterm infants. Oxidative stress biomarkers may assist in identifying high-risk neonates.
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Affiliation(s)
- Thomas M Raffay
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Ángel Sánchez-Illana
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Analytical Chemistry, Universtitat de València, Burjassot, Spain
| | - Maximo Vento
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Division of Neonatology, University & Polytechnic Hospital La Fe (HULAFE), Valencia, Spain
| | | | - Julia Kuligowski
- Neonatal Research Unit, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Richard J Martin
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Nori M Minich
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Peter M MacFarlane
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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7
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Ambalavanan N, Weese-Mayer DE, Hibbs AM, Claure N, Carroll JL, Moorman JR, Bancalari E, Hamvas A, Martin RJ, Di Fiore JM, Indic P, Kemp JS, Dormishian A, Krahn KN, Qiu J, Dennery PA, Ratcliffe SJ, Troendle JF, Lake DE. Cardiorespiratory Monitoring Data to Predict Respiratory Outcomes in Extremely Preterm Infants. Am J Respir Crit Care Med 2023; 208:79-97. [PMID: 37219236 PMCID: PMC10870840 DOI: 10.1164/rccm.202210-1971oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/01/2023] [Indexed: 05/24/2023] Open
Abstract
Rationale: Immature control of breathing is associated with apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants. However, it is not clear if such events independently predict worse respiratory outcome. Objectives: To determine if analysis of cardiorespiratory monitoring data can predict unfavorable respiratory outcomes at 40 weeks postmenstrual age (PMA) and other outcomes, such as bronchopulmonary dysplasia at 36 weeks PMA. Methods: The Prematurity-related Ventilatory Control (Pre-Vent) study was an observational multicenter prospective cohort study including infants born at <29 weeks of gestation with continuous cardiorespiratory monitoring. The primary outcome was either "favorable" (alive and previously discharged or inpatient and off respiratory medications/O2/support at 40 wk PMA) or "unfavorable" (either deceased or inpatient/previously discharged on respiratory medications/O2/support at 40 wk PMA). Measurements and Main Results: A total of 717 infants were evaluated (median birth weight, 850 g; gestation, 26.4 wk), 53.7% of whom had a favorable outcome and 46.3% of whom had an unfavorable outcome. Physiologic data predicted unfavorable outcome, with accuracy improving with advancing age (area under the curve, 0.79 at Day 7, 0.85 at Day 28 and 32 wk PMA). The physiologic variable that contributed most to prediction was intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <90%. Models with clinical data alone or combining physiologic and clinical data also had good accuracy, with areas under the curve of 0.84-0.85 at Days 7 and 14 and 0.86-0.88 at Day 28 and 32 weeks PMA. Intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <80% was the major physiologic predictor of severe bronchopulmonary dysplasia and death or mechanical ventilation at 40 weeks PMA. Conclusions: Physiologic data are independently associated with unfavorable respiratory outcome in extremely preterm infants.
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Affiliation(s)
| | - Debra E. Weese-Mayer
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anna Maria Hibbs
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - John L. Carroll
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Aaron Hamvas
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard J. Martin
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Juliann M. Di Fiore
- University Hospitals Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - James S. Kemp
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | | | - Jiaxing Qiu
- University of Virginia, Charlottesville, Virginia
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8
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Di Fiore JM, Martin RJ, Raffay TM. Intermittent Hypoxemia and Bronchopulmonary Dysplasia: Manifestations of Immature Respiratory Control and the Preterm Lung. Am J Respir Crit Care Med 2021; 204:1126-1127. [PMID: 34634221 PMCID: PMC8759306 DOI: 10.1164/rccm.202109-2077ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology Rainbow Babies and Children's Hospital Cleveland, Ohio.,Department of Pediatrics Case Western Reserve University Cleveland, Ohio
| | - Richard J Martin
- Division of Neonatology Rainbow Babies and Children's Hospital Cleveland, Ohio.,Department of Pediatrics Case Western Reserve University Cleveland, Ohio
| | - Thomas M Raffay
- Division of Neonatology Rainbow Babies and Children's Hospital Cleveland, Ohio.,Department of Pediatrics Case Western Reserve University Cleveland, Ohio
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9
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Abstract
A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.
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Affiliation(s)
- Steven Conlon
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Juliann M Di Fiore
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
| | - Richard J Martin
- Rainbow Babies & Children's Hospital, Case Western Reserve Univ School of Medicine, Cleveland, OH, USA.
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10
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Di Fiore JM, Raffay TM. The relationship between intermittent hypoxemia events and neural outcomes in neonates. Exp Neurol 2021; 342:113753. [PMID: 33984336 DOI: 10.1016/j.expneurol.2021.113753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 04/06/2021] [Accepted: 05/07/2021] [Indexed: 12/20/2022]
Abstract
This brief review examines 1) patterns of intermittent hypoxemia in extremely preterm infants during early postnatal life, 2) the relationship between neonatal intermittent hypoxemia exposure and outcomes in both human and animal models, 3) potential mechanistic pathways, and 4) future alterations in clinical care that may reduce morbidity. Intermittent hypoxemia events are pervasive in extremely preterm infants (<28 weeks gestation at birth) during early postnatal life. An increased frequency of intermittent hypoxemia events has been associated with a range of poor neural outcomes including language and cognitive delays, motor impairment, retinopathy of prematurity, impaired control of breathing, and intraventricular hemorrhage. Neonatal rodent models have shown that exposure to short repetitive cycles of hypoxia induce a pathophysiological cascade. However, not all patterns of intermittent hypoxia are deleterious and some may even improve neurodevelopmental outcomes. Therapeutic interventions include supplemental oxygen, pressure support and pharmacologic drugs but prolonged hyperoxia and pressure exposure have been associated with cardiopulmonary morbidity. Therefore, it becomes imperative to distinguish high risk from neutral and/or even beneficial patterns of intermittent hypoxemia during early postnatal life. Identification of such patterns could improve clinical care with targeted interventions for high-risk patterns and minimal or no exposure to treatment modalities for low-risk patterns.
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Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America
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11
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Shah VP, Raffay TM, Martin RJ, Vento M, Sánchez-Illana Á, Piñeiro-Ramos JD, Kuligowski J, Di Fiore JM. The Relationship between Oxidative Stress, Intermittent Hypoxemia, and Hospital Duration in Moderate Preterm Infants. Neonatology 2020; 117:577-583. [PMID: 32799210 PMCID: PMC7854776 DOI: 10.1159/000509038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/27/2020] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Lipid peroxidation products are present following oxidation of polyunsaturated fatty acids in the eye, brain, and various cell membranes. Elevated levels of lipid peroxidation products and increased intermittent hypoxemia (IH) events have been associated with adverse outcomes in extremely preterm infants. The moderate preterm newborn has a still-developing oxidant defense system and immature respiratory control, but little is known about lipid peroxidation levels and IH in this larger and more common preterm population. OBJECTIVE To determine the association between oxidative stress and IH in moderate preterm infants. METHOD Oxygen saturation was continuously monitored in 51 moderate preterm infants (i.e., 31 + 0/7 to 33 + 6/7 weeks' gestation). Urine samples were collected at the end of the first and second weeks of life. Samples were analyzed for total lipid peroxidation products (neurofurans, isofurans, neuroprostanes, isoprostanes, and di-homo-isofurans). RESULT At week 1, there was a correlation between increased IH frequency and neurofurans (p < 0.04) and di-homo-isofurans (p < 0.003). At week 2, there was no correlation between IH and lipid peroxidation markers. Ele-vations in neurofurans, isofurans, neuroprostanes, and di-homo-isofurans in the first and/or second week of life were associated with a longer stay in hospital. CONCLUSION Elevations in lipid peroxidation biomarkers in moderate preterm infants during their first weeks of life are associated with a higher frequency of IH and prolonged hospitalization.
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Affiliation(s)
- Vidhi P Shah
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Martin
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Máximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | | | | | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | - Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA,
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA,
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Sánchez-Illana Á, Shah V, Piñeiro-Ramos JD, Di Fiore JM, Quintás G, Raffay TM, MacFarlane PM, Martin RJ, Kuligowski J. Adrenic acid non-enzymatic peroxidation products in biofluids of moderate preterm infants. Free Radic Biol Med 2019; 142:107-112. [PMID: 30818053 PMCID: PMC6800232 DOI: 10.1016/j.freeradbiomed.2019.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/11/2019] [Accepted: 02/19/2019] [Indexed: 10/27/2022]
Abstract
Oxidative stress plays an essential role in processes of signaling and damage to biomolecules during early perinatal life. Isoprostanoids and isofuranoids from the free radical-catalyzed peroxidation of polyunsaturated fatty acids (PUFAs) are widely recognized as reliable biomarkers of oxidative stress. However, their quantification is not straightforward due to high structural similarity of the compounds formed. In this work, a semiquantitative method for the analysis of adrenic acid (AdA, C22:4 n-6) non-enzymatic peroxidation products (i.e. dihomo-isoprostanes and dihomo-isofurans) was developed. The proposed ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) method was applied to the analysis of blood plasma and urine from preterm infants providing information about AdA peroxidation.
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Affiliation(s)
- Ángel Sánchez-Illana
- Neonatal Research Unit, Health Research Institute La Fe, Avda Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Vidhi Shah
- Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - José David Piñeiro-Ramos
- Neonatal Research Unit, Health Research Institute La Fe, Avda Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Juliann M Di Fiore
- Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA; Case Western Reserve University, Cleveland, OH, USA
| | - Guillermo Quintás
- Health and Biomedicine, Leitat Technological Center, Avda Fernando Abril Martorell 106, 46026, Valencia, Spain; Analytical Unit, Health Research Institute Hospital La Fe, Avda Fernando Abril Martorell 106, 46026, Valencia, Spain
| | - Thomas M Raffay
- Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA; Case Western Reserve University, Cleveland, OH, USA
| | - Peter M MacFarlane
- Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA; Case Western Reserve University, Cleveland, OH, USA
| | - Richard J Martin
- Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA; Case Western Reserve University, Cleveland, OH, USA
| | - Julia Kuligowski
- Neonatal Research Unit, Health Research Institute La Fe, Avda Fernando Abril Martorell 106, 46026, Valencia, Spain.
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14
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Abstract
Intermittent hypoxemia (IH) events are common during early postnatal life, particularly in preterm infants. These events have been associated with multiple morbidities, including retinopathy of prematurity, sleep disordered breathing, neurodevelopmental impairment, and mortality. The relationship between IH and poor outcomes may depend on the patterns (frequency, duration, and timing) of the IH events. Current treatment modalities used in the clinical setting have been only partially successful in reducing the incidence of apnea and accompanying IH, but the risks and benefits of more aggressive interventions should include knowledge of the relationship between IH and morbidity.
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Affiliation(s)
- Juliann M. Di Fiore
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, Division of Neonatology, Suite RBC 3100, Cleveland, OH 44106-6010
| | - Peter M MacFarlane
- Case Western Reserve University, Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, USA
| | - Richard J Martin
- Case Western Reserve University, Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, USA
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15
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Dennery PA, Di Fiore JM, Ambalavanan N, Bancalari E, Carroll JL, Claure N, Hamvas A, Hibbs AM, Indic P, Kemp J, Krahn KN, Lake D, Laposky A, Martin RJ, Natarajan A, Rand C, Schau M, Weese-Mayer DE, Zimmet AM, Moorman JR. Pre-Vent: the prematurity-related ventilatory control study. Pediatr Res 2019; 85:769-776. [PMID: 30733614 PMCID: PMC6503843 DOI: 10.1038/s41390-019-0317-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The increasing incidence of bronchopulmonary dysplasia in premature babies may be due in part to immature ventilatory control, contributing to hypoxemia. The latter responds to ventilation and/or oxygen therapy, treatments associated with adverse sequelae. This is an overview of the Prematurity-Related Ventilatory Control Study which aims to analyze the under-utilized cardiorespiratory continuous waveform monitoring data to delineate mechanisms of immature ventilatory control in preterm infants and identify predictive markers. METHODS Continuous ECG, heart rate, respiratory, and oxygen saturation data will be collected throughout the NICU stay in 500 infants < 29 wks gestation across 5 centers. Mild permissive hypercapnia, and hyperoxia and/or hypoxia assessments will be conducted in a subcohort of infants along with inpatient questionnaires, urine, serum, and DNA samples. RESULTS Primary outcomes will be respiratory status at 40 wks and quantitative measures of immature breathing plotted on a standard curve for infants matched at 36-37 wks. Physiologic and/or biologic determinants will be collected to enhance the predictive model linking ventilatory control to outcomes. CONCLUSIONS By incorporating bedside monitoring variables along with biomarkers that predict respiratory outcomes we aim to elucidate individualized cardiopulmonary phenotypes and mechanisms of ventilatory control contributing to adverse respiratory outcomes in premature infants.
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Affiliation(s)
- Phyllis A. Dennery
- Brown University, Warren Alpert School of Medicine, Hasbro Children’s Hospital, Providence, RI,Address for Correspondence Phyllis A. Dennery, MD, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Office of the Chair, Hasbro Children’s Hospital, 593 Eddy Street, Suite 125 / Providence, RI 02903, (401) 444-5648,
| | - Juliann M. Di Fiore
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Namasivayam Ambalavanan
- University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics Molecular and Cellular Pathology, and Cell, Developmental, and Integrative Biology, Birmingham, AL
| | - Eduardo Bancalari
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - John L. Carroll
- University of Arkansas for Medical Science, Department of Pediatrics, Little Rock, AR
| | - Nelson Claure
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - Aaron Hamvas
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Anna Maria Hibbs
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Premananda Indic
- University of Texas Tyler, Department of Electrical Engineering, University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics, Tyler, TX
| | - James Kemp
- Washington University School of Medicine in St. Louis, Department of Pediatrics, St. Louis, MO
| | - Katy N. Krahn
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Douglas Lake
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Aaron Laposky
- National Institute of Health, National Center of Sleep Disorders Research, Bethesda, MD
| | - Richard J. Martin
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Aruna Natarajan
- Division of Lung Diseases, National Heart Lung and Blood Institute, National Institute of Health, Bethesda, MD
| | - Casey Rand
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Molly Schau
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Debra E. Weese-Mayer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Amanda M. Zimmet
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - J. Randall Moorman
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
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Raffay TM, Dylag AM, Sattar A, Abu Jawdeh EG, Cao S, Pax BM, Loparo KA, Martin RJ, Di Fiore JM. Neonatal intermittent hypoxemia events are associated with diagnosis of bronchopulmonary dysplasia at 36 weeks postmenstrual age. Pediatr Res 2019; 85:318-323. [PMID: 30538265 PMCID: PMC6377834 DOI: 10.1038/s41390-018-0253-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is a chronic lung disease and major pulmonary complication after premature birth. We have previously shown that increased intermittent hypoxemia (IH) events have been correlated to adverse outcomes and mortality in extremely premature infants. We hypothesize that early IH patterns are associated with the development of BPD. METHODS IH frequency, duration, and nadirs were assessed using oxygen saturation (SpO2) waveforms in a retrospective cohort of 137 extremely premature newborns (<28 weeks gestation). Daily levels of inspired oxygen and mean airway pressure exposures were also recorded. RESULTS Diagnosis of BPD at 36 weeks postmenstrual age was associated with increased daily IH, longer IH duration, and a higher IH nadir. Significant differences were detected through day 7 to day 26 of life. Infants who developed BPD had lower mean SpO2 despite their exposure to increased inspired oxygen and increased mean airway pressure. CONCLUSIONS BPD was associated with more frequent, longer, and less severe IH events in addition to increased oxygen and pressure exposure within the first 26 days of life. Early IH patterns may contribute to the development of BPD or aid in identification of neonates at high risk.
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Affiliation(s)
- Thomas M Raffay
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Andrew M Dylag
- Division of Neonatology, Golisano Children’s Hospital, Department of Pediatrics, University of Rochester, Rochester, NY
| | - Abdus Sattar
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Elie G Abu Jawdeh
- Division of Neonatology, Kentucky Children’s Hospital, Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Shufen Cao
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH
| | - Benjamin M Pax
- Department of Electrical Engineering and Computer Science & Institute for Smart, Secure and Connected Systems, Case Western Reserve University, Cleveland, OH
| | - Kenneth A Loparo
- Department of Electrical Engineering and Computer Science & Institute for Smart, Secure and Connected Systems, Case Western Reserve University, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies & Children's Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA.
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17
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Di Fiore JM, Dylag AM, Honomichl RD, Hibbs AM, Martin RJ, Tatsuoka C, Raffay TM. Early inspired oxygen and intermittent hypoxemic events in extremely premature infants are associated with asthma medication use at 2 years of age. J Perinatol 2019; 39:203-211. [PMID: 30367103 PMCID: PMC6351157 DOI: 10.1038/s41372-018-0264-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/07/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Extremely premature infants are at risk for childhood wheezing. Early respiratory support and intermittent hypoxemia (IH) events may be associated with adverse breathing outcomes. STUDY DESIGN A single-center retrospective cohort study of 137 premature infants <28 weeks gestational age characterized the associations of cumulative oxygen, cumulative mean airway pressure, IH, and oxygen saturation (SpO2) on the primary outcome of prescription asthma medication use at 2-year follow-up. Relative risk was calculated by generalized estimating equations. RESULTS Reported asthma medication use was 46%. At 1-3 days of age, elevated cumulative oxygen exposure, increased daily IH, and lower mean SpO2 (adjusted for gestational age and sex) and increased cumulative mean airway pressure exposure (unadjusted) were associated with asthma medication use. CONCLUSION Increased oxygen and frequent IH events during just the first 3 days of age may help identify extremely premature newborns at risk for symptomatic childhood wheezing requiring prescription asthma medications.
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Affiliation(s)
- Juliann M. Di Fiore
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Andrew M. Dylag
- Division of Neonatology, Golisano Children’s Hospital, University of Rochester, Rochester, NY
| | - Ryan D. Honomichl
- Division of Neurology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH
| | - Anna Maria Hibbs
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Richard J. Martin
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Curtis Tatsuoka
- Division of Neurology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH
| | - Thomas M. Raffay
- Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
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Abstract
Myo-inositol is a highly abundant stereoisomer of the inositol family of sugar alcohols and forms the structural basis for a variety of polyphosphate derivatives including second messengers and membrane phospholipids. These derivatives regulate numerous cell processes including gene transcription, membrane excitability, vesicular trafficking, intracellular calcium signaling, and neuronal growth and development. Myo-inositol can be formed endogenously from the breakdown of glucose, is found in a variety of foods including breastmilk and is commercially available as a nutritional supplement. Abnormal myo-inositol metabolism has been shown to underlie the pathophysiology of a variety of clinical conditions including Down Syndrome, traumatic brain injury, bronchopulmonary dysplasia (BPD), and respiratory distress syndrome (RDS). Several animal studies have shown that myo-inositol may play a critical role in development of both the central and peripheral respiratory neural control system; a notable example is the neonatal apnea and respiratory insufficiency that manifests in a mouse model of myo-inositol depletion, an effect that is also postnatally lethal. This review focuses on myo-inositol (and some of its derivatives) and how it may play a role in respiratory neural control; we also discuss clinical evidence demonstrating a link between serum myo-inositol levels and the incidence of intermittent hypoxemia (IH) events (a surrogate measure of apnea of prematurity (AOP)) in preterm infants. Further, there are both animal and human infant studies that have demonstrated respiratory benefits following supplementation with myo-inositol, which highlights the prospects that nutritional requirements are important for appropriate development and maturation of the respiratory system.
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Affiliation(s)
- Peter M MacFarlane
- Case Western Reserve University, Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
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Raffay TM, Dylag AM, Di Fiore JM, Smith LA, Einisman HJ, Li Y, Lakner MM, Khalil AM, MacFarlane PM, Martin RJ, Gaston B. S-Nitrosoglutathione Attenuates Airway Hyperresponsiveness in Murine Bronchopulmonary Dysplasia. Mol Pharmacol 2016; 90:418-26. [PMID: 27484068 PMCID: PMC5034690 DOI: 10.1124/mol.116.104125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 07/28/2016] [Indexed: 12/20/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is characterized by lifelong obstructive lung disease and profound, refractory bronchospasm. It is observed among survivors of premature birth who have been treated with prolonged supplemental oxygen. Therapeutic options are limited. Using a neonatal mouse model of BPD, we show that hyperoxia increases activity and expression of a mediator of endogenous bronchoconstriction, S-nitrosoglutathione (GSNO) reductase. MicroRNA-342-3p, predicted in silico and shown in this study in vitro to suppress expression of GSNO reductase, was decreased in hyperoxia-exposed pups. Both pretreatment with aerosolized GSNO and inhibition of GSNO reductase attenuated airway hyperresponsiveness in vivo among juvenile and adult mice exposed to neonatal hyperoxia. Our data suggest that neonatal hyperoxia exposure causes detrimental effects on airway hyperreactivity through microRNA-342-3p–mediated upregulation of GSNO reductase expression. Furthermore, our data demonstrate that this adverse effect can be overcome by supplementing its substrate, GSNO, or by inhibiting the enzyme itself. Rates of BPD have not improved over the past two decades; nor have new therapies been developed. GSNO-based therapies are a novel treatment of the respiratory problems that patients with BPD experience.
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Affiliation(s)
- Thomas M Raffay
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Andrew M Dylag
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Juliann M Di Fiore
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura A Smith
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Helly J Einisman
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Yuejin Li
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mitchell M Lakner
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ahmad M Khalil
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter M MacFarlane
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Richard J Martin
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Benjamin Gaston
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
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Walsh MC, Di Fiore JM, Martin RJ. Interaction of Target Oxygen Saturation, Bronchopulmonary Dysplasia, and Pulmonary Hypertension in Small for Gestational Age Preterm Neonates-Reply. JAMA Pediatr 2016; 170:808. [PMID: 27271028 DOI: 10.1001/jamapediatrics.2016.0998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michele C Walsh
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Juliann M Di Fiore
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Walsh MC, Di Fiore JM, Martin RJ, Gantz M, Carlo WA, Finer N. Association of Oxygen Target and Growth Status With Increased Mortality in Small for Gestational Age Infants: Further Analysis of the Surfactant, Positive Pressure and Pulse Oximetry Randomized Trial. JAMA Pediatr 2016; 170:292-4. [PMID: 26746140 PMCID: PMC5292772 DOI: 10.1001/jamapediatrics.2015.3794] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michele C. Walsh
- Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland Ohio
| | - Juliann M. Di Fiore
- Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland Ohio
| | - Richard J. Martin
- Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland Ohio
| | - Marie Gantz
- RTI International, Research Triangle Park, North Carolina
| | | | - Neil Finer
- Department of Pediatrics, University of California, San Diego
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Reyburn B, Di Fiore JM, Raffay T, Martin RJ, Prakash YS, Jafri A, MacFarlane PM. The Effect of Continuous Positive Airway Pressure in a Mouse Model of Hyperoxic Neonatal Lung Injury. Neonatology 2016; 109:6-13. [PMID: 26394387 PMCID: PMC4654984 DOI: 10.1159/000438818] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/16/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) and supplemental oxygen have become the mainstay of neonatal respiratory support in preterm infants. Although oxygen therapy is associated with respiratory morbidities including bronchopulmonary dysplasia (BPD), the long-term effects of CPAP on lung function are largely unknown. We used a hyperoxia-induced mouse model of BPD to explore the effects of daily CPAP in the first week of life on later respiratory system mechanics. OBJECTIVE We wanted to test the hypothesis that daily CPAP in a newborn-mouse model of BPD improves longer-term respiratory mechanics. METHODS Mouse pups from C57BL/6 pregnant dams were exposed to room air (RA) or hyperoxia (50% O2, 24 h/day) for the first postnatal week with or without exposure to daily CPAP (6 cm H2O, 3 h/day). Respiratory system resistance (Rrs) and compliance (Crs) were measured following a subsequent 2-week period of RA recovery. Additional measurements included radial alveolar and macrophage counts. RESULTS Mice exposed to hyperoxia had significantly elevated Rrs, decreased Crs, reduced alveolarization and increased macrophage counts at 3 weeks when compared to RA-treated mice. Daily CPAP treatment significantly improved Rrs, Crs and alveolarization and decreased lung macrophage infiltration in the hyperoxia-exposed pups. CONCLUSIONS We have demonstrated that daily CPAP had a longer-term benefit on baseline respiratory system mechanics in a neonatal mouse model of BPD. We speculate that this beneficial effect of CPAP was the consequence of a decrease in the inflammatory response and resultant alveolar injury associated with hyperoxic lung injury in newborns.
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Affiliation(s)
- Brent Reyburn
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
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Abstract
Hypoxic episodes are troublesome components of bronchopulmonary dysplasia (BPD) in preterm infants. Immature respiratory control seems to be the major contributor, superimposed on abnormal respiratory function. Relatively short respiratory pauses may precipitate desaturation and bradycardia. This population is predisposed to pulmonary hypertension; it is likely that pulmonary vasoconstriction also plays a role. The natural history has been well-characterized in the preterm population at risk for BPD; however, the consequences are less clear. Proposed associations of intermittent hypoxia include retinopathy of prematurity, sleep disordered breathing, and neurodevelopmental delay. Future study should address whether these associations are causal relationships.
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Affiliation(s)
- Richard J. Martin
- Case Western Reserve University School of Medicine, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, Ohio 44106-6010, Ph: 216-844-3387/Fax: 216-844-3380
| | - Juliann M. Di Fiore
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, Ohio 44106-6010, Ph: 216-368-1245/Fax: 216-844-3380
| | - Michele C. Walsh
- Case Western Reserve University School of Medicine, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, Ohio 44106-6010, Ph: 216-844-3759/Fax: 216-844-3380
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Di Fiore JM, Walsh M, Wrage L, Rich W, Finer N, Carlo WA, Martin RJ. Low oxygen saturation target range is associated with increased incidence of intermittent hypoxemia. J Pediatr 2012; 161:1047-52. [PMID: 22738947 PMCID: PMC3730286 DOI: 10.1016/j.jpeds.2012.05.046] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 04/27/2012] [Accepted: 05/21/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To test the hypothesis that preterm infants randomized to a low vs high O(2) saturation target range have a higher incidence of intermittent hypoxemia. STUDY DESIGN A subcohort of 115 preterm infants with high resolution pulse oximetry enrolled in the Surfactant, Positive Pressure, and Oxygenation Randomized Trial were randomized to low (85%-89%) or high (91%-95%) O(2) saturation target ranges. Oxygen saturation was monitored until 36 weeks postmenstrual age or until the infant was breathing room air without respiratory support for ≥72 hours. RESULTS The low target O(2) saturation group had a higher rate of intermittent hypoxemia (≤80% for ≥10 seconds and ≤3 minutes) prior to 12 days and beyond 57 days of life (P < .05). The duration shortened (P < .0001) and the severity increased (P < .0001) with increasing postnatal age with no differences between target saturation groups. The higher rate of intermittent hypoxemia events in the low target group was associated with a time interval between events of <1 minute. CONCLUSION A low O(2) saturation target was associated with an increased rate of intermittent hypoxemia events that was dependent on postnatal age. The duration and severity of events was comparable between target groups. Further investigation is needed to assess the role of intermittent hypoxemia and their timing on neonatal morbidity.
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MESH Headings
- Age Factors
- Female
- Humans
- Hypoxia/blood
- Hypoxia/epidemiology
- Hypoxia/etiology
- Incidence
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/etiology
- Male
- Models, Statistical
- Monitoring, Physiologic
- Oximetry
- Oxygen/blood
- Prospective Studies
- Regression Analysis
- Respiration, Artificial/adverse effects
- Respiration, Artificial/methods
- Severity of Illness Index
- Single-Blind Method
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Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH 44106, USA.
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Abstract
OBJECTIVE Characterize the incidence and possible etiologies of acid reflux events detected by pH and not identified by multiple intraluminal impedance (MII) monitoring. MATERIALS AND METHODS Acid reflux events detected by pH but not identified by MII (pH-only) were documented in 80 preterm and 39 term infants. Reasons for failure of MII to detect these events were classified as failure to meet MII scoring criteria, presence of an air bolus, technical artifact, and no change in impedance. Events with no change in impedance were stratified to low impedance throughout the study (possible esophageal inflammation), transient decrease in pre-event impedance (presence of refluxate), occurrence <30 seconds of a preceding event, and no explanation. RESULTS A total of 2572 events were detected by pH, with 59% of events not identified by MII. A higher incidence of pH-only events occurred in preterm versus term infants (54 +/- 27% versus 42 +/- 23%, P = .025, respectively). Thirteen percent of pH-only events were missed due to MII scoring criteria, 12% due to technical artifact, 11% due to an air bolus, and 64% had no change in impedance. Of the 978 events with no change in impedance, 154 were associated with low impedance throughout the study, 430 with a transient decrease in pre-event impedance, and 175 were preceded by a reflux episode within 30 seconds. CONCLUSIONS There was a high incidence of acid reflux events detected by pH but not identified by MII. This occurred more often in the least mature infants, and we speculate that delayed esophageal fluid clearance is the major underlying mechanism.
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Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH 44106, USA.
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Martin RJ, Di Fiore JM, Hibbs AM. Gastroesophageal reflux in preterm infants: is positioning the answer? J Pediatr 2007; 151:560-1. [PMID: 18035128 DOI: 10.1016/j.jpeds.2007.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Accepted: 07/02/2007] [Indexed: 10/22/2022]
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Abstract
OBJECTIVE To examine the temporal relationship between apnea and gastroesophageal reflux (GER) and to assess the effect of GER on apnea duration. METHODS A total of 119 preterm infants underwent 12-hour cardiorespiratory monitoring studies using respiratory inductance plethysmography, heart rate, oxygen saturation (SaO2), and esophageal pH. The studies were scored for GER (pH <4 for > or =5 seconds) and apnea > or =15 seconds or > or =10 seconds that occurred within 30 seconds of GER. Apnea > or =10 seconds was used to assess whether GER would prolong apnea duration. RESULTS There were 6255 episodes of GER. Only 1% of GER episodes were associated with apnea > or =15 seconds, and there was no difference in apnea rate before, during, or after GER. There was also no difference in rate of apnea > or =10 seconds before versus during GER; however, there was a decrease in apnea rate immediately after GER. The presence of GER during apnea did not prolong apnea duration, and GER had no effect on the lowest SaO2 or heart rate during apnea. CONCLUSION There is no evidence of a temporal relationship between acid-based GER and apnea in preterm infants. In addition, GER does not prolong apnea duration and does not exacerbate the resultant decrease in heart rate and SaO2.
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Affiliation(s)
- Juliann M Di Fiore
- Department of Pediatrics, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA.
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Abstract
Gastroesophageal reflux (GER) and apnea are both common occurrences in premature infants but their relationship is controversial. We present the evidence for and against an association between GER and apnea and discuss the merits and limitations of the various methodologies employed in characterizing such a relationship. Overall, GER and apnea do not appear temporally related in preterm infants, despite strong physiologic evidence that stimulation of laryngeal afferents elicits central apnea and laryngeal adduction. In a subpopulation of infants with neurodevelopmental compromise, there may be an increased incidence of both apnea and GER, although the direct association between GER and apnea in this population is unclear. Therefore, we believe there is no evidence to support widespread use of anti-reflux medications in the treatment of apnea in preterm infants. Further studies are needed to clarify the existence of a small subpopulation of infants who may have GER-induced apnea, to identify potential triggering mechanisms, and to document benefit from newer pharmacological approaches.
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Affiliation(s)
- Eleanor J Molloy
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH 44106, USA
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Abstract
Episodes of apnoea, desaturation and bradycardia are a common occurrence in preterm infants and are known to persist after hospital discharge. These events are typically detected by clinical bedside monitoring, but the type and number of events depend on alarm settings, the inclusion of continuous pulse oximetry and the mode of respiratory monitoring used. The long term effects of cardiorespiratory events remain controversial; however, some studies have suggested an association between prolonged apnoea and morbidity such as impaired neurodevelopmental outcome. Common clinical practice requires an event-free period before hospital discharge, although the specific length of time varies between institutions. Therefore, with the current demand to shorten hospital stay, the possible persistence of cardiorespiratory events after hospital discharge and the potential consequences of these events, cardiorespiratory monitoring remains a subject of considerable interest. Since cardiorespiratory event detection is dependent on the mode of monitoring used, this chapter will focus on both the respiratory patterns and types of cardiorespiratory events that occur in the infant population and the modalities of cardiorespiratory monitoring currently available to detect these events.
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Affiliation(s)
- Juliann M Di Fiore
- Department of Pediatrics, Rainbow Babies & Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA.
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