First name
David
Middle name
A
Last name
Munson

Title

Inhaled Nitric Oxide Is Associated with Improved Oxygenation in a Subpopulation of Infants with Congenital Diaphragmatic Hernia and Pulmonary Hypertension.

Year of Publication

2020

Number of Pages

167-172

Date Published

2020 04

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVES: </strong>To determine which patients with congenital diaphragmatic hernia (CDH) and pulmonary hypertension (PH) benefit from inhaled nitric oxide (iNO) treatment by comparing characteristics and outcomes of iNO responders to nonresponders.</p>

<p><strong>STUDY DESIGN: </strong>We performed a retrospective chart review of infants with CDH treated at our center between 2011 and 2016. In a subset of patients, iNO was initiated for hypoxemia or echocardiographic evidence of extrapulmonary right to left shunting. Initial post-treatment blood gases were reviewed, and patients were classified as responders (increased PaO &gt;20&nbsp;mm Hg) or nonresponders. Baseline characteristics, echocardiograms and outcomes were compared between groups with Fisher exact tests and Mann-Whitney t tests, as appropriate.</p>

<p><strong>RESULTS: </strong>During the study period, 95 of 131 patients with CDH (73%) were treated with iNO. All patients with pretreatment echocardiograms (n&nbsp;=&nbsp;90) had echocardiographic evidence of PH. Thirty-eight (40%) patients met treatment response criteria. Responders had significant improvements in PaO (51&nbsp;±&nbsp;3 vs 123&nbsp;±&nbsp;7&nbsp;mm Hg, P &lt; .01), alveolar-arterial gradient (422&nbsp;±&nbsp;30 vs 327&nbsp;±&nbsp;27&nbsp;mm Hg, P &lt; .01), and PaO to FiO ratio (82&nbsp;±&nbsp;10 vs 199&nbsp;±&nbsp;15&nbsp;mm Hg, P &lt; .01). Nonresponders were more likely to have left ventricular systolic dysfunction (27% vs 8%, P&nbsp;=&nbsp;.03) on echocardiogram. Responders were less likely to require extracorporeal membrane support (50 vs 24%, P&nbsp;=&nbsp;.02).</p>

<p><strong>CONCLUSIONS: </strong>iNO treatment is associated with improved oxygenation and reduced need for ECMO in a subpopulation of patients with CDH with PH and normal left ventricular systolic function.</p>

DOI

10.1016/j.jpeds.2019.09.052

Alternate Title

J Pediatr

PMID

31706636

Title

Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding.

Year of Publication

2019

Date Published

2019 Nov 04

ISSN Number

1468-2052

Abstract

<p><strong>OBJECTIVE: </strong>Compare rates of hypoxaemia during transpyloric and gastric feedings in very preterm infants with severe bronchopulmonary dysplasia.</p>

<p><strong>DESIGN: </strong>N-of-1 multiple crossover trials with individual patient and pooled data analyses.</p>

<p><strong>SETTING: </strong>Level IV intensive care nursery.</p>

<p><strong>PATIENTS: </strong>Infants receiving positive airway pressure between 36 and 55 weeks postmenstrual age were enrolled between December 2014-July 2016.</p>

<p><strong>INTERVENTION: </strong>N-of-1 trial consisting of two blocks, each with a 4-day gastric and 4-day transpyloric feeding period assigned in random order.</p>

<p><strong>MAIN OUTCOME MEASURES: </strong>The primary outcome was the frequency of daily intermittent hypoxaemic events (SpO ≤80% lasting 10-180 s). Secondary outcomes included the daily proportion of time with an SpO ≤80% and mean daily fraction of inspired oxygen.</p>

<p><strong>RESULTS: </strong>Of 15 infants, 13 completed the trial and 2 stopped early for transient worsening in respiratory status during gastric feedings. In the intention-to-treat analyses, transpyloric feedings resulted in increased rates of intermittent hypoxaemia in five infants, greater time per day in hypoxaemia in three infants and more supplemental oxygen use in three infants. One infant received more supplemental oxygen during gastric feedings. The remaining study outcomes were similar between the feeding routes in all other infants. Pooling all data, transpyloric feedings resulted in a higher frequency of intermittent hypoxaemic events (median 7.5/day (IQR 1-23.5) vs 3/day (1-11); adjusted incidence rate ratio 1.8, 95% CI 1.3 to 2.5) and a greater proportion of daily hypoxaemia time (median 0.8% (IQR 0.1-2.3) vs 0.4% (0.07-1.8); adjusted mean difference 1.6, 95% CI 1.1 to 2.5).</p>

<p><strong>CONCLUSIONS: </strong>Transpyloric compared with gastric feedings modestly increased rates of hypoxaemia among study participants.</p>

<p><strong>TRIAL REGISTRATION NUMBER: </strong>NCT02142621.</p>

DOI

10.1136/archdischild-2019-317148

Alternate Title

Arch. Dis. Child. Fetal Neonatal Ed.

PMID

31685527

Title

Trends in transcatheter and operative closure of patent ductus arteriosus in neonatal intensive care units: Analysis of data from the Pediatric Health Information Systems Database.

Year of Publication

2019

Number of Pages

121-130

Date Published

2019 Aug 17

ISSN Number

1097-6744

Abstract

<p><strong>BACKGROUND: </strong>The risks and benefits of pharmacologic treatment and operative closure of patent ductus arteriosus (O-PDA) in premature infants remain controversial. Recent series have demonstrated the feasibility of transcatheter PDA closure (TC-PDA) in increasingly small infants. The effect of this change on practice has not been evaluated.</p>

<p><strong>METHODS: </strong>A multicenter observational study of infants treated in neonatal intensive care units in hospitals contributing data to the Pediatric Health Information Systems Database from January 2007 to December 2017 was performed to study trends in the propensities for (1) mechanical closure of PDA and (2) TC-PDA versus O-PDA, as well as interhospital variation in practice.</p>

<p><strong>RESULTS: </strong>A total of 6,214 subjects at 44 hospitals were studied (5% TC-PDA). Subject median gestational age was 25 weeks (interquartile range: 24-27 weeks). Median age at closure was 24 days (interquartile range: 14-36 days). The proportion of all neonatal intensive care unit patients undergoing either O-PDA or TC-PDA decreased (3.1% in 2007 and 0.7% in 2017, P &lt; .001), whereas the proportion in which TC-PDA was used increased significantly (0.1% in 2007 to 29.0% in 2017). Case-mix-adjusted multivariable models similarly demonstrated increasing propensity to pursue TC-PDA (odds ratio [OR] 1.66 per year, P &lt; .001) with acceleration of the trend after 2014 (OR 2.46 per year, P &lt; .001) as well as significant practice variation (P &lt; .001, median OR 4.6) across the study period.</p>

<p><strong>CONCLUSIONS: </strong>In the face of decreasing closure of PDA, the use of TC-PDA increased dramatically with significant practice variability. This demonstrates that there is equipoise for potential clinical trials.</p>

DOI

10.1016/j.ahj.2019.08.009

Alternate Title

Am. Heart J.

PMID

31654942

WATCH THIS PAGE

Subscription is not available for this page.