PDF Abstract Chronic respiratory morbidity is a common complication of premature birth, generally defined by the presence of bronchopulmonary dysplasia, both clinically and in trials of respiratory therapies.
PDF Abstract Chronic respiratory morbidity is a common complication of premature birth, generally defined by the presence of bronchopulmonary dysplasia, both clinically and in trials of respiratory therapies. However, recent data have highlighted that bronchopulmonary dysplasia does not correlate with chronic respiratory morbidity in older children born preterm.
Longitudinally evaluating pulmonary morbidity from early life through to childhood provides a more rational method of defining the continuum of chronic respiratory morbidity of prematurity, and offers new insights into the efficacy of neonatal respiratory interventions. The changing nature of preterm lung disease suggests that a multimodal approach using dynamic lung function assessment will be needed to assess the efficacy of a neonatal respiratory therapy and predict the long-term respiratory consequences of premature birth.
Our aim is to review the literature regarding the long-term respiratory outcomes of neonatal respiratory strategies, the difficulties of assessing dynamic lung function in infants, and potential new solutions. Abstract Better measures are needed to predict chronic respiratory morbidity in survivors born prematurely http: The most frequently used clinical predictor of long-term respiratory risk is the presence of bronchopulmonary dysplasia BPD.
The definition of BPD has changed considerably since the first histopathological definition of Northway et al. In the post-surfactant and gentle ventilation era, these processes were rarely seen and chronic respiratory morbidity better reflected a disruption of lung growth, resulting in a combination of structural airways damage, failure of alveolarisation and vascular development, with resultant impairment of gas exchange .
Following broad international consensus, BPD was redefined to reflect the need for oxygen therapy beyond 28 days after birth . As neonatal respiratory care become more refined, this BPD definition also failed to reflect the physiological consequences of preterm birth.
In order to develop more interinstitutional consistency, in Walsh et al. In , Quine et al. Despite the evolution of BPD from a histological to physiological clinical entity, common to all these definitions is a single resultant dichotomous diagnosis made near term-corrected gestation. Over the past 50 years BPD has been used as a surrogate for identifying infants at risk of later respiratory morbidity. Consequently, BPD has become the primary respiratory outcome in the assessment of respiratory strategies adopted in neonatal intensive care units NICUs.
While medical advances, including artificial surfactant, antenatal corticosteroids, lung protective strategies of mechanical ventilation and noninvasive respiratory support techniques improve survival of extremely premature infants, BPD remains a major clinical problem with little change in prevalence over the past 20 years, suggesting that it may lack the precision to delineate the true differences in the long-term implications of modern NICU respiratory therapies .
Recently, a high incidence of respiratory morbidity in children born preterm, even in the absence of BPD, has been described . Irrespective of BPD diagnosis, children born prematurely have altered lung function with at least partially reversible airflow obstruction high airways resistance and gas trapping and increased airway reactivity, but with little evidence of eosinophilic inflammation. Lung parenchymal abnormalities on thoracic imaging, hospital readmissions for respiratory problems and increased respiratory symptoms are common in preterm survivors .
The high incidence of later pulmonary morbidity among children born preterm, independent of a diagnosis of BPD, highlights the shortcomings of BPD as a surrogate for long-term pulmonary morbidity. The dichotomous nature of modern BPD definitions lacks the ability to describe the evolution of the functional and pathophysiological multifactorial continuous disease processes that increasingly clinicians are aware extend into childhood.
We contend that preterm lung disease represents a pathophysiological continuum requiring repeated evaluation throughout life. As such, BPD, a single time-based dichotomous measure of defining the long-term impact of preterm birth is inadequate. Sensitive and repeatable early-life measures of lung function and structure should inform outcomes of clinical interventions, allow identification of those at risk and follow lung development through childhood.
This review aims to provide a perspective from a literature review of 1 the long-term outcomes of neonatal respiratory therapies; and 2 the current state of neonatal respiratory assessment tools as outcome measures of chronic respiratory morbidity of prematurity. Articles relating to the specific aims of the review and relevant references cited in those articles were reviewed.
All authors repeatedly reviewed the entire manuscript until a consensus was reached.
Articles published in English, French and Italian were included. Long-term outcomes of neonatal respiratory therapies: This section summarises some of the major advances and controversies in the respiratory support of the preterm lung and describes whether the trial data allow interpretation of the long-term respiratory implications. Oxygen and mechanical ventilation: It is well known that higher oxygen needs are associated with ventilator-induced lung injury, as well as directly inducing acute lung injury .
Prolonged neonatal oxygen exposure has been identified as a prognostic indicator for subsequent long-term airway obstruction . Duration of oxygen exposure in neonatal life was found to be predictive of later pulmonary abnormalities on high-resolution computed tomography HRCT imaging . Oxygen exposure requires consideration of dose as well as duration. This suggests that the dose of early-life oxygen supplementation, rather than its duration, may be a stronger and earlier prognostic respiratory predictor.
A reproducible and simple to use oxygen cumulative score to indicate magnitude of injury, correlated to later respiratory function is needed. Mechanical ventilation has an important role in early lung injury. In later childhood, duration of mechanical ventilation is associated with reduced forced vital capacity, increased functional residual capacity and bronchial hyperresponsiveness . Both oxygen supplementation and ventilator support have a strong link to long-term respiratory outcomes.
However, current BPD definitions are limited to the duration of oxygen supplementation and mechanical ventilation, rather than oxygen dose or type mechanical ventilation.
The investigation of first-intention HFOV serves as an example of the complexity of neonatal respiratory trial interpretation. Throughout this period CMV strategies, such as the availability of synchronisation and volume targeting, have improved, and it has become evident that mode of support is of lesser importance than how clinicians apply it. Long-term respiratory outcomes have been reported from some trials table 1.
There was no subsequent difference in respiratory morbidity and function or morbidity at 9 months, 2 years and 8—9 years in survivors . A similar longitudinal finding was reported by Lista and colleagues in a more recent small cohort of infants followed-up to 7 years, in whom antenatal steroid exposure, prophylactic surfactant therapy and high lung volume HFOV were used. It is possible that HFOV preserves small airway function better than CMV once long-term injury is established, with higher maximal flow at functional residual capacity observed at 12 months in a small series of infants with BPD .
There is a strong physiological rationale to limit excessive tidal volume exposure, and VTV achieves this by dynamically adapting to changing disease state . Whether this benefit is a result of shorter duration of mechanical ventilation or a reduction in volutrauma exposure is unclear.
Further studies are needed to confirm whether the physiological rationale of VTV in early life confers long-term respiratory benefits.
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