Early Use of Inhaled Nitric Oxide in Preterm Infants: Is there a Rationale for Selective Approach?

Chandrasekharan, Praveen; Kozielski, Rafał; Kumar, Vasantha H.S.; Rawat, Munmun; Manja, Veena; Ma, Changxing; Lakshminrusimha, Satyanarayana

doi:10.1055/s-0036-1592346

Cited by 31 publications

(27 citation statements)

References 53 publications

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“…An inverse relationship exists between birth weight and cardiopulmonary disease in adults including pulmonary hypertension [ 20 ]. Small for gestational age (SGA), oligohydramnios, sepsis, perinatal stress, and prolonged mechanical ventilation are additional risk factors for development for PH in infants [ 21 , 22 , 23 , 24 ] ( Figure 2 ). Elevated pulmonary vascular resistance (PVR) in preterm infants with hypoplastic lungs [ 25 ] may be related to maldevelopment from a decrease in cross-sectional area and an abnormal muscularization of the pulmonary vasculature [ 26 ], exacerbated by the physiologic immaturity of the nitric oxide (NO) signaling pathways [ 27 ].…”

Section: Bronchopulmonary Dysplasia and Pulmonary Hypertensionmentioning

confidence: 99%

“…Prolonged rupture of membranes and pulmonary hypertension of the newborn (PPHN) worsened the histological changes in these infants [ 48 ]. We have shown that preterm infants who died of severe respiratory failure also exhibit muscularized arteries on smooth muscle actin staining [ 21 ]; and that the smooth muscle area ratio is directly related to severity of respiratory disease in these infants [ 21 ]. As the pulmonary vasculature of the premature neonate has the capacity to remodel over time, a potential exists for the development of PH later on in life, especially so in infants with mild to moderate BPD.…”

Section: Bronchopulmonary Dysplasia and Pulmonary Hypertensionmentioning

confidence: 99%

“…Premature infants fall under either one of the two indications for initiation of iNO: moderate HRF with echocardiographic evidence of PH prior to initiation of iNO or severe HRF wherein iNO was initiated, as a desperate measure without a prior echocardiogram. Premature infants treated with iNO had a higher incidence of prolonged preterm rupture of membranes (pPROM) and oligohydramnios [ 21 ]. Preterm infants with HRF exposed to antenatal steroids and pPROM had improved oxygenation response to iNO and survival [ 21 ].…”

Section: Management Of Infants With Phmentioning

confidence: 99%

“…Premature infants treated with iNO had a higher incidence of prolonged preterm rupture of membranes (pPROM) and oligohydramnios [ 21 ]. Preterm infants with HRF exposed to antenatal steroids and pPROM had improved oxygenation response to iNO and survival [ 21 ]. Antenatal betamethasone reduces oxidative stress and improves response of pulmonary arteries to vasodilators in lambs with PPHN [ 98 ].…”

Section: Management Of Infants With Phmentioning

confidence: 99%

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Diagnostic Approach to Pulmonary Hypertension in Premature Neonates

Kumar

2017

Children

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Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease in premature infants following respiratory distress at birth. With increasing survival of extremely low birth weight infants, alveolar simplification is the defining lung characteristic of infants with BPD, and along with pulmonary hypertension, increasingly contributes to both respiratory morbidity and mortality in these infants. Growth restricted infants, infants born to mothers with oligohydramnios or following prolonged preterm rupture of membranes are at particular risk for early onset pulmonary hypertension. Altered vascular and alveolar growth particularly in canalicular and early saccular stages of lung development following mechanical ventilation and oxygen therapy, results in developmental lung arrest leading to BPD with pulmonary hypertension (PH). Early recognition of PH in infants with risk factors is important for optimal management of these infants. Screening tools for early diagnosis of PH are evolving; however, echocardiography is the mainstay for non-invasive diagnosis of PH in infants. Cardiac computed tomography (CT) and magnetic resonance are being used as imaging modalities, however their role in improving outcomes in these patients is uncertain. Follow-up of infants at risk for PH will help not only in early diagnosis, but also in appropriate management of these infants. Aggressive management of lung disease, avoidance of hypoxemic episodes, and optimal nutrition determine the progression of PH, as epigenetic factors may have significant effects, particularly in growth-restricted infants. Infants with diagnosis of PH are managed with pulmonary vasodilators and those resistant to therapy need to be worked up for the presence of cardio-vascular anomalies. The management of infants and toddlers with PH, especially following premature birth is an emerging field. Nonetheless, combination therapies in a multi-disciplinary setting improves outcomes for these infants.

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Section: Bronchopulmonary Dysplasia and Pulmonary Hypertensionmentioning

confidence: 99%

Section: Bronchopulmonary Dysplasia and Pulmonary Hypertensionmentioning

confidence: 99%

Section: Management Of Infants With Phmentioning

confidence: 99%

Section: Management Of Infants With Phmentioning

confidence: 99%

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Diagnostic Approach to Pulmonary Hypertension in Premature Neonates

Kumar

2017

Children

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“… Intravascular obstruction due to hyperviscosity—polycythemia. Pulmonary hypertension (PH) in preterm infants in the initial phase of RDS [ 10 ]. Pulmonary venous hypertension [ 11 ].…”

Section: Etiology Of Persistent Pulmonary Hypertension Of the Newbmentioning

confidence: 99%

Persistent Pulmonary Hypertension in the Newborn

Mathew

Lakshminrusimha

2017

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Persistent pulmonary hypertension of the newborn (PPHN) is a syndrome of failed circulatory adaptation at birth due to delay or impairment in the normal fall in pulmonary vascular resistance (PVR) that occurs following birth. The fetus is in a state of physiological pulmonary hypertension. In utero, the fetus receives oxygenated blood from the placenta through the umbilical vein. At birth, following initiation of respiration, there is a sudden precipitous fall in the PVR and an increase of systemic vascular resistance (SVR) due to the removal of the placenta from circulation. There is dramatic increase in pulmonary blood flow with a decrease in, and later reversal of shunts at the foramen ovale and ductus arteriosus. The failure of this normal physiological pulmonary transition leads to the syndrome of PPHN. PPHN presents with varying degrees of hypoxemic respiratory failure. Survival of infants with PPHN has significantly improved with the use of gentle ventilation, surfactant and inhaled nitric oxide (iNO). PPHN is associated with significant mortality and morbidity among survivors. Newer agents that target different enzymatic pathways in the vascular smooth muscle are in different stages of development and testing. Further research using these agents is likely to further reduce morbidity and mortality associated with PPHN.

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Risk factors and bronchopulmonary dysplasia severity: data from the Spanish Bronchopulmonary Dysplasia Research Network

et al. 2021

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GEIDIS is a national based research-net registry of patients with bronchopulmonary dysplasia (BPD) from public and private Spanish hospitals. It was created to provide data on the clinical characterization and follow up of infants with BPD until adulthood. The purpose of this observational study was to analyze the characteristics and the impact of perinatal risk factors on BPD severity. The study included 1,780 patients diagnosed with BPD. Of the total sample, 98.6% were premature (less than 37 weeks) and 89,4% less than 30 weeks of gestation. The median gestational age was 27.1 weeks (25.8-28.5) and median birth weight 890 g (740-1,090 g). 52.3% (n=931) were classi ed as mild (type 1), 25.1% (n=447) were moderate (type 2), and 22.6% (n=402) severe BPD (type 3).Most pre-and postnatal risk factors for type 2/3 BPD were associated with the length of exposure to mechanical ventilation (MV). Independent prenatal risk factors were male gender, oligohydramnios, and intrauterine growth restriction. Postnatal risk factors included the need for FiO 2 of > 0.30 in the delivery room, two or more doses of surfactant administration, nosocomial pneumonia, and the length of exposure to MV.Conclusions: In this national based research-net registry of BPD patients the length of MV is the most important risk factor associated with type 2/3 BPD. Among type 3 BPD patients, those who required an FiO 2 > .30 at 36 weeks' postmenstrual age had a higher morbidity, during hospitalization and at discharge, compared to those with nasal positive pressure but FiO 2 < .30.

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Early Use of Inhaled Nitric Oxide in Preterm Infants: Is there a Rationale for Selective Approach?

Cited by 31 publications

References 53 publications

Diagnostic Approach to Pulmonary Hypertension in Premature Neonates

Diagnostic Approach to Pulmonary Hypertension in Premature Neonates

Persistent Pulmonary Hypertension in the Newborn

Risk factors and bronchopulmonary dysplasia severity: data from the Spanish Bronchopulmonary Dysplasia Research Network

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