Changes in ventilator strategies and outcomes in preterm infants

Vendettuoli, Valentina; Bellù, Roberto; Zanini, Rinaldo; Mosca, Fabio; Gagliardi, Luigi

doi:10.1136/archdischild-2013-305165

Cited by 45 publications

(33 citation statements)

References 23 publications

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“…However, the number of days on mechanical ventilation ranged up to 50 days and 60 days in the low-and high-dose vitamin D group, respectively, which was within the time period of documented increased serum 25(OH)D levels. A decreased need of mechanical ventilation is an important finding, as even modern invasive ventilator treatment for preterm neonates is associated with an increased risk of complications including BPD (67,99). One other RCT has reported on a lower risk of preterm birth in mothers with resultant higher 25(OH)D, adjusted for race, but gave no lung disease data (100), whereas another smaller RCT of smaller size with later gestational age at enrollment found no difference in gestational age at delivery (43).…”

Section: Discussionmentioning

confidence: 99%

The impact of vitamin D on fetal and neonatal lung maturation. A systematic review

Lykkedegn

Sørensen

Beck-Nielsen

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

116

104

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-Respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) are major complications to preterm birth. Hypovitaminosis D is prevalent in pregnancy. We systematically reviewed the evidence of the impact of vitamin D on lung development, surfactant synthesis, RDS, and BPD searching PubMed, Embase, and Cochrane databases with the terms vitamin D AND (surfactant OR lung maturation OR lung development OR respiratory distress syndrome OR fetal lung OR prematurity OR bronchopulmonary dysplasia). Three human studies, ten animal studies, two laboratory studies, and one combined animal and laboratory study were included. Human evidence was sparse, allowing no conclusions. BPD was not associated with vitamin D receptor polymorphism in a fully adjusted analysis. Animal and laboratory studies showed substantial positive effects of vitamin D on the alveolar type II cell, fibroblast proliferation, surfactant synthesis, and alveolarization. These data support the hypothesis of hypovitaminosis D as a frequent, modifiable risk factor of RDS and BPD, which should be tested in randomized controlled trials on pregnant women, those with threatening preterm delivery, or in the preterm neonates. Future experimental and human studies should aim to identify optimal time windows, vitamin D doses, and cut-off levels for 25-hydroxyvitamin D in interventions against RDS, BPD, and later adverse respiratory outcomes. vitamin D; fetus; lung; surfactant; preterm; neonate THE IMPORTANCE OF VITAMIN D in nonskeletal fetal and childhood health has become increasingly recognized in the last decades (19,65). The impact of vitamin D on early lung development and maturation and lung diseases of early life is an emerging field of research. Hypovitaminosis D during pregnancy is associated with reduced placental development and weight, leading to a presumed risk of preterm birth (24,25), which per se may lead to respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). Moreover, vitamin D is suggested to play a role in the embryogenesis and in cellular growth and differentiation, including lung development and regulation of lung maturation in the fetus (23,29,38,70,71,108), whereby hypovitaminosis D could be hypothesized to aggravate premature neonatal lung diseases.Vitamin D is involved in the development of the innate and adaptive immune system, and, because of its unique capacity to bind to the vitamin D receptor (VDR) and thereby to serve as a transcriptional factor, vitamin D can regulate gene expression and exert widespread immunomodulatory effects including proliferation, differentiation, and complex regulation (19, 56, 58 -61, 64, 65, 68, 69, 105). Evidence suggests that vitamin D may stimulate regulatory T cell development and T cell function to suppress inappropriate Th1 and Th2 responses to environmental exposure (i.e., allergens, infection load), leading to a more balanced immune response inhibiting autoimmune diseases (with Th1 dominance) and allergic diseases (Th2 dominance) (55). Vitamin D could therefore be inv...

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Section: Discussionmentioning

confidence: 99%

The impact of vitamin D on fetal and neonatal lung maturation. A systematic review

Lykkedegn

Sørensen

Beck-Nielsen

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

116

104

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“…Some of these perceived changes include better uptake of antenatal steroids, improved thermoregulation and oxygen titration at resuscitation, changes in respiratory management, and improved nutrition management. Reports from other networks or collaborative efforts have compared outcomes over time and showed mixed results some showing improved outcomes while others showing worsening outcomes …”

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confidence: 99%

Preterm infant outcomes in New South Wales and the Australian Capital Territory

Bolisetty

Legge

Bajuk³

et al. 2015

J Paediatrics Child Health

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Aim: This study aimed to provide updated information on gestation-specific hospital outcomes of extreme to very preterm infants admitted to neonatal intensive care units. Methods: A population-based retrospective cohort study of infants born between 23 +0 and 31 +6 weeks gestation and admitted to a network of neonatal intensive care units between 2007 and 2011 in a well-defined geographic area of New South Wales and the Australian Capital Territory. Main outcome measures were survival and major morbidities prior to hospital discharge. Results: Of 4454 infants included, hospital survival rates based on gestational age alone were 27%, 59%, 76%, 85%, 91% and over 95% at 23, 24, 25, 26, 27 and 28-31 weeks, respectively. Survival rates for each week up to 29 weeks gestation differed by at least 5% when perinatal risk factors including birthweight percentile, exposure to antenatal steroids, birth outside a tertiary hospital and gender were included in the survival estimation. All the major outcome figures were then simplified and displayed in a simple, easy-to-understand preterm outcome table for counselling purposes. Conclusion: We report the latest hospital outcomes of extreme to very preterm infants in New South Wales and the Australian Capital Territory. Survival rates based on gestational age alone may not provide the true estimate as the survival for these infants can vary based on the presence or absence of other relevant perinatal factors.Key words: counselling; hospital survival; infant; outcome; preterm. What is already known on this topic1 Clinical outcomes of extreme to very preterm infants can vary among regions. 2 Clinicians require up-to-date information from within their regions to provide accurate counselling, assist in benchmarking and facilitate review of local policies to improve outcomes. What this paper adds1 We demonstrated that survival rates of these infants are dependent on many perinatal factors, and these factors can vary for each week. 2 We created gestational age-specific survival figures based on various clinical scenarios and risk factors at each week.Periodic evaluation of the outcomes of preterm infants within a well-defined region that shares similar health settings and practices provides vital information to the clinicians for counselling the parents and families at risk of preterm delivery. Gestational age-specific estimates are more easily estimated than birthweight prior to delivery and therefore more relevant when attempting to determine the approximate survival of a given infant for the purpose of pre-birth counselling. 1 However, each pregnancy is unique and may have different combinations of risk factors that may influence the outcomes for in their infants. Therefore, survival outcomes are better estimated by inclusion of other factors such as gender, antenatal steroid exposure and weight for gestational age besides gestational age.2,3 These riskadjusted outcomes provide more meaningful information to clinicians and families caring for these infants.We previously published ...

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“…Studies have shown that restricting the use of IMV is feasible in clinical practice and is associated with a reduction in the incidence of BPD [6,7]. Interestingly, none of these studies reported the impact of restricted use of IMV on NDI [5].…”

Section: Introductionmentioning

confidence: 99%

Restricted Ventilation Associated with Reduced Neurodevelopmental Impairment in Preterm Infants

Vliegenthart

Onland²,

Wassenaer-Leemhuis³

et al. 2017

Neonatology

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Background and Objective: Restrictive use of invasive mechanical ventilation (IMV) in preterm infants reduces the risk of bronchopulmonary dysplasia (BPD). Our objective was to determine its effect on neurodevelopmental impairment (NDI) at 24 months' corrected age (CA). Methods: This retrospective single-center cohort study included all patients with a gestational age <30 weeks born in 2004/2005 (epoch 1) and 2010/2011 (epoch 2). In epoch 2, we introduced a policy of restriction on IMV and liberalized the use of respiratory stimulants in the delivery room and neonatal intensive care. Data on patient characteristics, respiratory management, short-term outcomes, mortality, BPD, and NDI at 24 months' CA were collected. Results: Four hundred and four preterm infants were included. Compared to those in epoch 1, infants in epoch 2 were less likely to be intubated and the duration of IMV was shorter. Other noninvasive adjuvant therapies such as caffeine, doxapram, and nasal ventilation were more often used during epoch 2. There was a trend to less BPD in epoch 2 compared to epoch 1 (17 vs. 23%, adjusted OR = 0.75, 95% CI: 0.48, 1.16). Mortality did not change over time. The combined outcome death or NDI at 24 months' CA was significantly lower in epoch 2 compared to epoch 1 (24.7 vs. 33.9%, adjusted OR = 0.71, 95% CI: 0.53, 0.97). Conclusions: Restricted use of IMV is feasible in preterm infants and might be associated with a reduced risk of the combined outcome death or NDI at 24 months' CA. Larger studies are needed to confirm these findings.

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Changes in ventilator strategies and outcomes in preterm infants

Abstract: Despite a stable baseline risk, from 2006 to 2010, we observed a lower level of invasiveness, a reduction of mechanical ventilation and an increase of NIV use, and this was accompanied by a decrease in risk-adjusted mortality and BPD.

Cited by 45 publications

References 23 publications

The impact of vitamin D on fetal and neonatal lung maturation. A systematic review

The impact of vitamin D on fetal and neonatal lung maturation. A systematic review

Preterm infant outcomes in New South Wales and the Australian Capital Territory

Restricted Ventilation Associated with Reduced Neurodevelopmental Impairment in Preterm Infants

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