PDA: To treat or not to treat

Bhombal, Shazia; Bhombal, Shazia; Benitz, William Ε.

doi:10.1111/chd.12708

Cited by 69 publications

(48 citation statements)

References 33 publications

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“…Evidence showed that while treatment was effective in achieving ductal closure, only a single study showed improvement in other outcomes such as pulmonary hemorrhage, BPD, NEC, or death. Correlations between PDA and IVH were and did not support the hypothesis that closure of the ductus improves neurological outcomes [16][17][18][19][20][21][22]. It was concluded that the association of comorbidities with PDA might arise from prematurity itself rather than through prolonged patency of the ductus.…”

Section: Controversy and Practice Variationmentioning

confidence: 91%

“…Although the pathogenesis of BPD is complex, associations between prolonged exposure to a moderate-to-large PDA and BPD have been documented [18,19]. Additional research further established the association of PDA with systemic complications such as NEC, renal impairment, IVH, periventricular leukomalacia (PVL), cerebral palsy, and death [20][21][22].…”

Section: Consequences Of Pda In Elbw Infantsmentioning

confidence: 99%

“…Conservative management without the use of pharmacotherapeutics has become a recent trend in management of the PDA [16,22]. Because many preterm infants will spontaneously close the ductus within the first week, early routine treatment with pharmacological therapy may not offer any benefit.…”

Section: Pharmacologic Therapy Surgical Ligation Transcatheter Closurementioning

confidence: 99%

“…Neonatologists and cardiologists have differing opinions of the consequence of a hsPDA on the eventual outcomes. Certain landmark papers questioning the utility of PDA closure in premature infants may have influenced these opinions [16,22].…”

Section: Controversy and Practice Variationmentioning

confidence: 99%

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PDA Closure in ELBW Infants: If, When, and How to Do It

Whiting¹,

Sathanandam²

2020

Update on Critical Issues on Infant and Neonatal Care

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Patent ductus arteriosus (PDA) is the most common cardiovascular condition afflicting premature neonates especially those born extremely low birth weight (ELBW). Despite five decades of scientific inquiry which has produced thousands of publications including over 65 randomized controlled trials, cardiologists, neonatologists, and surgeons still cannot answer simple questions such as if, when and how to close to the PDA in ELBW infants. This chapter will examine current evidence in order to answer these fundamental questions. The chapter will specifically focus on transcatheter PDA closure (TCPC), which albeit a new therapy, has displayed great potential to be the best therapeutic option in the future. It is about time that physicians from all sub-specialties come together and integrate the evidence to develop a management algorithm for ELBW infants with hemodynamically significant PDA.Update on Critical Issues on Infant and Neonatal Care 2 3. Normal closure of the ductus When a baby takes its first breath, the increased alveolar oxygen content leads to pulmonary vasodilation, resulting in a decreased ratio of pulmonary vascular resistance (R P ) to systemic vascular resistance (R S ). This drop in R P /R S can reverse the flow of blood across the ductus arteriosus from right-to-left to left-to-right (aorta to PA). At this point, the ductus is exposed to high systemic arterial pO 2 , which results in vasoconstriction of the ductus arteriosus through mechanisms not fully elucidated [3][4][5]. A sharp decline in circulating PGE and PGIE along with a rapid increase in pO 2 following birth contributes to constriction, and ultimately functional closure of the ductus. Nearly all healthy, term infants achieve functional closure with 24-72 h [2][3][4][5]. Eventually, hypoxia and fibrosis cause the inner layers of the ductus to permanently close, leaving only a fibrous remnant called the ligamentum arteriosum.

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Section: Controversy and Practice Variationmentioning

confidence: 91%

Section: Consequences Of Pda In Elbw Infantsmentioning

confidence: 99%

Section: Pharmacologic Therapy Surgical Ligation Transcatheter Closurementioning

confidence: 99%

Section: Controversy and Practice Variationmentioning

confidence: 99%

See 2 more Smart Citations

PDA Closure in ELBW Infants: If, When, and How to Do It

Whiting¹,

Sathanandam²

2020

Update on Critical Issues on Infant and Neonatal Care

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show abstract

“…The treatment was withheld if there was identification of gastrointestinal bleeding or oliguria (urine output of less than 1 mL/kg/hour) according to the protocol for PDA management in our NICU. The decision was made by the neonatologists to transfer the ELBWI for surgical ligation if more than two courses of oral ibuprofen were given and the PDA was still significant [11].…”

Section: Methodsmentioning

confidence: 99%

Perinatal risk factors for pulmonary hemorrhage in extremely low-birth-weight infants

et al. 2019

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Background Pulmonary hemorrhage (PH) is a life-threatening respiratory complication of extremely low-birth-weight infants (ELBWIs). However, the risk factors for PH are controversial. Therefore, the purpose of this study was to analyze the perinatal risk factors and short-term outcomes of PH in ELBWIs. Methods This was a retrospective cohort study of live born infants who had birth weights that were less than 1000 g, lived for at least 12 hours, and did not have major congenital anomalies. A logistic regression model was established to analyze the risk factors associated with PH. Results There were 168 ELBWIs born during this period. A total of 160 infants were included, and 30 infants were diagnosed with PH. Risk factors including gestational age, small for gestational age, intubation in the delivery room, surfactant in the delivery room, repeated use of surfactant, higher FiO 2 during the first day, invasive ventilation during the first day and early onset sepsis (EOS) were associated with the occurrence of PH by univariate analysis. In the logistic regression model, EOS was found to be an independent risk factor for PH. The mortality and intraventricular hemorrhage rate of the group of ELBWIs with PH were significantly higher than those of the group of ELBWIs without PH. The rates of periventricular leukomalacia, moderate-to-severe bronchopulmonary dysplasia and severe retinopathy of prematurity, and the duration of the hospital stay were not significantly different between the PH and no-PH groups. Conclusions Although PH did not extend hospital stay or increase the risk of bronchopulmonary dysplasia, it increased the mortality and intraventricular hemorrhage rate in ELBWIs. EOS was the independent risk factor for PH in ELBWIs.

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Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

et al. 2021

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IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019).INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURESThe primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge.Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTSThe study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCEA sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.

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PDA: To treat or not to treat

Cited by 69 publications

References 33 publications

PDA Closure in ELBW Infants: If, When, and How to Do It

PDA Closure in ELBW Infants: If, When, and How to Do It

Perinatal risk factors for pulmonary hemorrhage in extremely low-birth-weight infants

Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

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