Asunto(s)
Hipoxia/tratamiento farmacológico , Óxido Nítrico/administración & dosificación , Administración por Inhalación , Factores de Edad , Ecocardiografía , Edad Gestacional , Humanos , Recién Nacido , Recien Nacido Prematuro , Selección de Paciente , Respiración Artificial , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
We performed serial measurements of plasma endothelin-1 and cytokine levels (interleukin-1, interleukin-6, and tumor necrosis factor-alpha) in 23 children with severe acute respiratory distress syndrome during their first 7 days of disease. We report plasma endothelin-1 and interleukin-6 levels are increased in patients with acute respiratory distress syndrome, and that plasma endothelin-1 levels are significantly greater early in the clinical course of nonsurvivors than survivors. We conclude that plasma endothelin-1 levels are markedly increased in children with severe acute respiratory distress syndrome and speculate that high levels may serve as an early marker of poor outcome.
Asunto(s)
Endotelina-1/sangre , Interleucina-1/sangre , Interleucina-6/sangre , Síndrome de Dificultad Respiratoria del Recién Nacido/sangre , Factor de Necrosis Tumoral alfa/metabolismo , Biomarcadores , Preescolar , Colorado/epidemiología , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Pronóstico , Síndrome de Dificultad Respiratoria del Recién Nacido/diagnóstico , Síndrome de Dificultad Respiratoria del Recién Nacido/mortalidad , Estadísticas no Paramétricas , Análisis de SupervivenciaRESUMEN
OBJECTIVES AND BACKGROUND: To determine whether inhaled nitric oxide (iNO) therapy can attenuate the progression of lung disease in acute hypoxemic respiratory failure, we performed a multicenter, randomized, masked, controlled study of the effects of prolonged iNO therapy on oxygenation. We hypothesized that iNO therapy would improve oxygenation in an acute manner, slow the rate of decline in gas exchange, and decrease the number of patients who meet pre-established oxygenation failure criteria. STUDY DESIGN: A total of 108 children (median age 2.5 years) with severe acute hypoxemic respiratory failure from 7 centers were enrolled. After consent was obtained, patients were randomized to treatment with iNO (10 ppm) or mechanical ventilation alone for at least 72 hours. Patients with an oxygenation index >/=40 for 3 hours or >/=25 for 6 hours were considered treatment failures and exited the study. RESULTS: Patient age, primary diagnosis, pediatric risk of mortality score, mode of ventilation, and median oxygenation index (35 +/- 22 vs 30 +/- 15; iNO vs control; mean +/- SEM) were not different between groups at study entry. Comparisons of oxygenation indexes during the first 12 hours demonstrated an acute improvement in oxygenation in the iNO group at 4 hours (-10.2 vs -2.7, mean values; P <.014) and at 12 hours (-9.2 vs -2.8; P <.007). At 12 hours 36% of the control group met failure criteria in contrast with 16% in the iNO group (P <.05). During prolonged therapy the failure rate was reduced in the iNO group in patients whose entry oxygenation index was >/=25 (P <.04) and in immunocompromised patients (P <.03). CONCLUSIONS: We conclude that iNO causes an acute improvement in oxygenation in children with severe AHRF. Two subgroups (immunocompromised and an entry oxygen index >/=25) appear to have a more sustained improvement in oxygenation, and we speculate that these subgroups may benefit from prolonged therapy.
Asunto(s)
Broncodilatadores/uso terapéutico , Óxido Nítrico/uso terapéutico , Respiración con Presión Positiva , Intercambio Gaseoso Pulmonar/efectos de los fármacos , Insuficiencia Respiratoria/terapia , Administración por Inhalación , Algoritmos , Broncodilatadores/administración & dosificación , Broncodilatadores/farmacología , Niño , Preescolar , Femenino , Humanos , Hipoxia/etiología , Hipoxia/fisiopatología , Hipoxia/terapia , Lactante , Masculino , Óxido Nítrico/administración & dosificación , Óxido Nítrico/farmacología , Oxígeno/sangre , Insuficiencia Respiratoria/complicaciones , Insuficiencia Respiratoria/fisiopatología , Insuficiencia del TratamientoAsunto(s)
Hipoxia/terapia , Surfactantes Pulmonares/administración & dosificación , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Oxigenación por Membrana Extracorpórea , Humanos , Recién Nacido , Síndrome de Dificultad Respiratoria del Recién Nacido/etiología , Resultado del TratamientoRESUMEN
We studied 8 children, ages 8 months to 14 years, during cardiac catheterization in order to determine the acute hemodynamic effects of pulsed nasal cannula delivery of nitric oxide (NO) in children with pulmonary hypertension. NO was administered by continuous mask or pulsed nasal cannula in random order. All patients effectively triggered the NO pulsing device. Pulsed delivery of inhaled NO lowered mean pulmonary artery pressure and pulmonary vascular resistance as effectively as mask delivery of NO. Pulsed inhaled NO delivery may potentially be useful for the long-term domiciliary treatment of pulmonary hypertension in children.
Asunto(s)
Hemodinámica/efectos de los fármacos , Hipertensión Pulmonar/tratamiento farmacológico , Óxido Nítrico/uso terapéutico , Administración por Inhalación , Adolescente , Función del Atrio Derecho/efectos de los fármacos , Circulación Sanguínea/efectos de los fármacos , Presión Sanguínea/efectos de los fármacos , Cateterismo Cardíaco , Gasto Cardíaco/efectos de los fármacos , Cateterismo/instrumentación , Niño , Preescolar , Esquema de Medicación , Servicios de Atención de Salud a Domicilio , Humanos , Lactante , Cuidados a Largo Plazo , Máscaras , Óxido Nítrico/administración & dosificación , Nariz , Estudios Prospectivos , Arteria Pulmonar , Presión Esfenoidal Pulmonar/efectos de los fármacos , Resistencia Vascular/efectos de los fármacosRESUMEN
BACKGROUND: Although inhaled nitric oxide (iNO) causes selective pulmonary vasodilation and improves oxygenation in newborn infants with persistent pulmonary hypertension, its effects are variable. We hypothesized (1) that the response to iNO therapy is dependent on the primary disease associated with persistent pulmonary hypertension of the newborn (PPHN) and (2) that the combination of high-frequency oscillatory ventilation (HFOV) with iNO would be efficacious in patients for whom either therapy alone had failed. METHODS: To determine the relative roles of iNO and HFOV in the treatment of severe PPHN, we enrolled 205 neonates in a randomized, multicenter clinical trial. Patients were stratified by predominant disease category: respiratory distress syndrome (n = 70), meconium aspiration syndrome (n = 58), idiopathic PPHN or pulmonary hypoplasia (excluding congenital diaphragmatic hernia) ("other": n = 43), and congenital diaphragmatic hernia (n = 34); they were then randomly assigned to treatment with iNO and conventional ventilation or to HFOV without iNO. Treatment failure (partial pressure of arterial oxygen [PaO2] < 60 mm Hg) resulted in crossover to the alternative treatment; treatment failure after crossover led to combination treatment with HFOV plus iNO. Treatment response with the assigned therapy was defined as sustained PaO2 of 60 mm Hg or greater. RESULTS: Baseline oxygenation index and PaO2 were 48 +/- 2 and 41 +/- 1 mm Hg, respectively, during treatment with conventional ventilation. Ninety-eight patients were randomly assigned to initial treatment with HFOV, and 107 patients to iNO. Fifty-three patients (26%) recovered with the initially assigned therapy without crossover (30 with iNO [28%] and 23 with HFOV [23%]; p = 0.33). Within this group, survival was 100% and there were no differences in days of mechanical ventilation, air leak, or supplemental oxygen requirement at 28 days. Of patients whose initial treatment failed, crossover treatment with the alternate therapy was successful in 21% and 14% for iNO and HFOV, respectively (p = not significant). Of 125 patients in whom both treatment strategies failed, 32% responded to combination treatment with HFOV plus iNO. Overall, 123 patients (60%) responded to either treatment alone or combination therapy. By disease category, response rates for HFOV plus iNO in the group with respiratory syndrome and the group with meconium aspiration syndrome were better than for HFOV alone or iNO with conventional ventilation (p < 0.05). Marked differences in outcomes were noted among centers (percent death or treatment with extracorporeal membrane oxygenation = 29% to 75%). CONCLUSIONS: We conclude that treatment with HFOV plus iNO is often more successful than treatment with HFOV or iNO alone in severe PPHN. Differences in responses are partly related to the specific disease associated with PPHN.
Asunto(s)
Ventilación de Alta Frecuencia , Óxido Nítrico/uso terapéutico , Síndrome de Circulación Fetal Persistente/terapia , Administración por Inhalación , Terapia Combinada , Estudios Cruzados , Oxigenación por Membrana Extracorpórea , Femenino , Hernias Diafragmáticas Congénitas , Humanos , Recién Nacido , Pulmón/anomalías , Masculino , Síndrome de Aspiración de Meconio/tratamiento farmacológico , Síndrome de Aspiración de Meconio/terapia , Óxido Nítrico/administración & dosificación , Oxígeno/sangre , Síndrome de Circulación Fetal Persistente/tratamiento farmacológico , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológico , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Tasa de Supervivencia , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
OBJECTIVE: To describe the outcome of a group of term newborn infants treated with inhaled nitric oxide for severe persistent pulmonary hypertension. STUDY DESIGN: We performed a prospective longitudinal medical and neurodevelopmental follow-up of 51 infants treated as neonates for persistent pulmonary hypertension of the newborn with inhaled nitric oxide. The original number of treated infants was 87, of whom 25 died in the neonatal period; of 62 infants who survived, 51 were seen at 1 year of age and 33 completed a 2-year evaluation. Statistical analysis used population medians, means, and standard deviations for parameters assessed. Paired t tests and chi-square analysis were used to compare outcomes measured at 1 year with assessment at 2 years for the 32 infants seen at both 1- and 2-year visits. RESULTS: At 1-year follow-up median growth percentiles were 20%, 72.5%, and 50% for weight, length, and occipitofrontal circumference, respectively. Thirteen of 51 infants (25.5%) were < 5th percentile in weight. Nine of 51 infants (17.6%) had feeding problems (need for gastrostomy feeding or gastroesophageal reflux), and 14 (27.5%) had a clinical diagnosis of reactive airways disease. Infant development as measured by the Bayley Scales of Infant Development was 104 +/- 16 for the mental development index and 97 +/- 20 for the psychomotor index. Six of 51 infants (11.8%) were found to have severe neurologic handicaps, defined as a Bayley score on either the mental development or psychomotor index of < 68, abnormal findings on neurologic examination, or both. Fewer children (6.1% vs 15.7%) required supplemental oxygen at 2 years compared with 1 year, and performance on the psychomotor index of the Bayley Scales improved significantly. CONCLUSIONS: One- and 2-year follow-up of a cohort of infants with persistent pulmonary hypertension of the newborn who were treated with inhaled nitric oxide had an 11.8% (1 year) and 12.1% (2-year) rate of severe neurodevelopmental disability. There are ongoing medical problems in these infants including reactive airways disease and slow growth that merit continued close longitudinal follow-up.
Asunto(s)
Óxido Nítrico/uso terapéutico , Síndrome de Circulación Fetal Persistente/tratamiento farmacológico , Administración por Inhalación , Estatura , Peso Corporal , Encéfalo/crecimiento & desarrollo , Cefalometría , Desarrollo Infantil , Preescolar , Estudios de Cohortes , Nutrición Enteral , Femenino , Estudios de Seguimiento , Hueso Frontal/crecimiento & desarrollo , Reflujo Gastroesofágico/fisiopatología , Gastrostomía , Crecimiento , Humanos , Lactante , Recién Nacido , Estudios Longitudinales , Enfermedades Pulmonares/fisiopatología , Masculino , Óxido Nítrico/administración & dosificación , Hueso Occipital/crecimiento & desarrollo , Terapia por Inhalación de Oxígeno , Síndrome de Circulación Fetal Persistente/fisiopatología , Estudios Prospectivos , Desempeño Psicomotor , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Successful management of severe PPHN depends on the application of appropriate strategies to manage the cardiopulmonary interactions that characterize this syndrome. Manifestations of PPHN often involve dysfunctional pulmonary vasoregulation, with suprasystemic pulmonary vascular resistance causing extrapulmonary shunting, pulmonary parenchymal disease causing intrapulmonary shunting, and systemic hemodynamic deterioration. Inhaled NO can cause marked improvement in oxygenation when optimal lung inflation is achieved and systemic blood volume and vascular resistance are adequate. Although concern has been expressed regarding potential increases in costs associated with this new therapy, we have found that the successful application of inhaled NO in PPHN has reduced costs of hospitalization and duration of hospital stay by approximately 50% and 40%, respectively. However, inhaled NO alone is unlikely to cause sustained improvement in oxygenation in neonatal hypoxemic respiratory failure associated with severe parenchymal lung disease without extrapulmonary shunting. Inhaled NO may be an important tool in the management of severe PPHN when its application is limited to patients with severe extrapulmonary shunting and vigilant attention is given to changes in the clinical course.
Asunto(s)
Óxido Nítrico/administración & dosificación , Síndrome de Circulación Fetal Persistente/tratamiento farmacológico , Síndrome de Circulación Fetal Persistente/fisiopatología , Administración por Inhalación , Humanos , Recién Nacido , Óxido Nítrico/toxicidad , Circulación PulmonarRESUMEN
To determine the physiologic effects of inhaled nitric oxide (NO) on oxygenation and hemodynamics in children with severe hypoxemic respiratory failure, we studied the acute response to inhaled NO during mechanical ventilation in 17 pediatric patients. Diagnoses included adult respiratory distress syndrome (ARDS) (10 patients), bronchopulmonary dysplasia with viral pneumonitis (6 patients), and acute pneumonitis, caused by respiratory syncytial virus, without chronic lung disease (1 patient). Gas exchange and hemodynamic measurements were compared before and during exposure to inhaled NO (20 ppm) without changing ventilator settings for 30 minutes. Hemodynamic variables, including pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index, were measured in 10 patients with ARDS. Inhaled NO acutely improved oxygenation in 15 of 17 patients; mean arterial oxygen tension increased from 58 +/- 13 mm Hg (baseline) to 86 +/- 25 mm Hg after 30 minutes (p < 0.01). Inhaled NO lowered mean pulmonary artery pressure (42 +/- 6 mm Hg at baseline to 31 +/- 6 mm Hg; p < 0.01) and intrapulmonary shunt (39% +/- 7% vs 32% +/- 7%; p < 0.01) without changing systemic arterial pressure or pulmonary capillary wedge pressure. Cardiac index increased by 14% (p < 0.01). Fifteen patients were subsequently treated with low-dose inhaled NO (3 to 10 ppm) for 1 to 24 days; 5 (50%) of 10 patients with ARDS and 7 (100%) of the 7 non-ARDS patients survived. We conclude that inhaled NO acutely improves oxygenation and lowers pulmonary vascular resistance without causing adverse hemodynamic effects in severe hypoxemic respiratory failure in pediatric patients. Inhaled NO may be a useful adjuvant therapy in children with acute hypoxemic respiratory failure, including infants with bronchopulmonary dysplasia, but whether prolonged low-dose inhalational NO therapy can reduce morbidity or improve survival rates remains unknown.
Asunto(s)
Hipoxia/terapia , Óxido Nítrico/uso terapéutico , Síndrome de Dificultad Respiratoria/terapia , Insuficiencia Respiratoria/terapia , Terapia Respiratoria , Adolescente , Niño , Preescolar , Hemodinámica , Humanos , Hipoxia/fisiopatología , Lactante , Intercambio Gaseoso Pulmonar , Síndrome de Dificultad Respiratoria/fisiopatología , Insuficiencia Respiratoria/fisiopatologíaRESUMEN
We studied the efficacy of low-dose nitric oxide inhalation in nine consecutive patients with severe persistent pulmonary hypertension of the newborn (PPHN) who were candidates for extracorporeal membrane oxygenation (ECMO). All patients had marked hypoxemia despite aggressive ventilator management and echocardiographic evidence of pulmonary hypertension. Associated diagnoses included meconium aspiration syndrome (3 patients), sepsis (3 patients), and congenital diaphragmatic hernia (2 patients). Infants were initially treated with inhaled nitric oxide at 20 ppm for 4 hours and then at 6 ppm for 20 hours. In all infants, oxygenation promptly improved (arterial/alveolar oxygen ratio, 0.077 +/- 0.016 at baseline vs 0.193 +/- 0.030 at 4 hours; p < 0.001) without a decrease in systemic blood pressure. Sustained improvement in oxygenation was achieved in eight patients treated with inhaled nitric oxide for 24 hours at 6 ppm (arterial/alveolar oxygen ratio, 0.270 +/- 0.053 at 24 hours; p < 0.001 vs baseline). One patient with overwhelming sepsis had an initial improvement of oxygenation with nitric oxide but required ECMO for multiorgan and cardiac dysfunction. We conclude that low doses of nitric oxide cause sustained clinical improvement in severe PPHN and may reduce the need for ECMO. However, immediate availability of ECMO is important in selected cases of PPHN complicated by severe systemic hemodynamic collapse.
Asunto(s)
Óxido Nítrico/administración & dosificación , Síndrome de Circulación Fetal Persistente/tratamiento farmacológico , Vasodilatadores/administración & dosificación , Enfermedad Aguda , Administración por Inhalación , Evaluación de Medicamentos , Ecocardiografía , Oxigenación por Membrana Extracorpórea , Humanos , Recién Nacido , Oxígeno/sangre , Síndrome de Circulación Fetal Persistente/sangre , Síndrome de Circulación Fetal Persistente/diagnóstico por imagen , Insuficiencia Respiratoria/sangre , Insuficiencia Respiratoria/diagnóstico por imagen , Insuficiencia Respiratoria/tratamiento farmacológico , Factores de TiempoRESUMEN
To study the potential role of endothelin-1, a potent endothelium-derived vasoconstrictor peptide, in the pathophysiology of persistent pulmonary hypertension of the newborn (PPHN), we measured arterial concentrations of immunoreactive endothelin-1 (irET-1) in 24 neonates with PPHN. Secondary diagnoses included meconium aspiration syndrome (13 patients), sepsis (2), congenital diaphragmatic hernia (1), asphyxia (1), pulmonary hemorrhage (1), aspiration of blood (1), and respiratory distress syndrome (1). Compared with irET-1 levels in umbilical cord blood in normal infants (15.1 +/- 4.1 pg/ml; mean +/- SEM) and in newborn infants with hyaline membrane disease who were supported by mechanical ventilation (11.8 +/- 1.2 pg/ml), infants with PPHN had markedly elevated circulating irET-1 levels (27.6 +/- 3.6 pg/ml; p < 0.01 vs cord blood, hyaline membrane disease). Infants with severe PPHN requiring extracorporeal membrane oxygenation (ECMO) therapy had higher irET-1 levels than infants with milder disease (31.0 +/- 4.7 for ECMO-treated infants vs 21.2 +/- 2.0 for non-ECMO-treated infants; p < 0.05). In patients treated without ECMO, irET-1 progressively decreased during the following 3 to 5 days, paralleling clinical improvement. In contrast, irET-1 concentrations remained elevated in infants with severe PPHN during ECMO therapy. We conclude that circulating irET-1 levels are elevated in newborn infants with PPHN, are positively correlated with disease severity, and decline with resolution of disease in patients who do not require ECMO therapy. Whether endothelin-1 contributes directly to the pathophysiology of PPHN or is simply a marker of disease activity remains speculative.
Asunto(s)
Anticuerpos/sangre , Endotelinas/inmunología , Síndrome de Circulación Fetal Persistente/sangre , Análisis de Varianza , Oxigenación por Membrana Extracorpórea , Femenino , Sangre Fetal/química , Humanos , Enfermedad de la Membrana Hialina/sangre , Enfermedad de la Membrana Hialina/epidemiología , Recién Nacido , Masculino , Síndrome de Circulación Fetal Persistente/epidemiología , Síndrome de Circulación Fetal Persistente/terapia , Radioinmunoensayo , Factores de TiempoRESUMEN
Low doses of inhaled nitric oxide caused selective and sustained pulmonary vasodilation in an infant with pulmonary hypertension without causing systemic hypotension, despite the failure of treatment with other vasodilators.
Asunto(s)
Hipertensión Pulmonar/tratamiento farmacológico , Óxido Nítrico/uso terapéutico , Arteria Pulmonar/efectos de los fármacos , Administración por Inhalación , Presión Sanguínea/efectos de los fármacos , Femenino , Humanos , Hipertensión Pulmonar/fisiopatología , Lactante , Óxido Nítrico/administración & dosificación , Óxido Nítrico/farmacología , Arteria Pulmonar/fisiopatología , Resistencia Vascular/efectos de los fármacos , Vasodilatación/efectos de los fármacosRESUMEN
To determine whether pulmonary function in infants with asymptomatic cystic fibrosis is related to genotype, we studied 18 infants with cystic fibrosis identified through neonatal screening and 18 healthy control infants. Infants with cystic fibrosis (mean age, 2.0 months; range, 1.0 to 4.6 months) were identified from June 1990 to September 1991 through a statewide screening program based on elevated immunoreactive trypsinogen concentrations. Pulmonary function testing was done before and after inhalation of albuterol. There were no differences in pulmonary function between the cystic fibrosis group and the control infants (mean age, 2.7 months; range, 0.9 to 4.5 months). However, infants homozygous for the delta F508 deletion (n = 10) differed from infants with other genotypic variants of cystic fibrosis and control infants with respect to respiratory system resistance (79.4 +/- 11.5 vs 52.0 +/- 3.8 vs 55.5 +/- 5.0 cm H2O/L per second, respectively; p = 0.04) and specific conductance (0.15 +/- 0.02 vs 0.21 +/- 0.02 vs 0.21 +/- 0.02 cm H2O-1 sec-1, respectively; p = 0.02). Infants homozygous for the delta F508 deletion, but not other infants, responded to albuterol with a decrease in respiratory system resistance. We conclude that infants with asymptomatic cystic fibrosis homozygous for the delta F508 deletion have early evidence of airways obstruction and may need early respiratory treatment.
Asunto(s)
Fibrosis Quística/genética , Pulmón/fisiopatología , Tamizaje Neonatal , Fibrosis Quística/epidemiología , Fibrosis Quística/fisiopatología , Femenino , Genotipo , Humanos , Lactante , Recién Nacido , Masculino , Pruebas de Función Respiratoria , Factores de RiesgoRESUMEN
To evaluate the impact of early pancreatic insufficiency on growth and nutritional status in cystic fibrosis, we studied 49 infants identified by a newborn screening program. Pancreatic insufficiency, determined by increased 72-hour fecal fat excretion, was present in 59% (23/39) of infants at diagnosis (7.0 +/- 0.8 weeks; mean +/- SEM). Before initiation of pancreatic enzyme replacement, growth and nutritional status of pancreatic-insufficient (n = 16) and pancreatic-sufficient (n = 13) infants were compared. Pancreatic-insufficient infants gained less weight from birth to diagnosis (13.4 +/- 3.4 vs 22.3 +/- 4.0 gm/day; p = 0.05), had decreased triceps skin-fold thicknesses (4.5 +/- 0.3 vs 6.1 +/- 0.4 mm; p less than 0.005), and had lower blood urea nitrogen (3.07 +/- 0.42 vs 4.62 +/- 0.65 mg/dl; p = 0.02) and albumin (2.99 +/- 0.14 vs 3.54 +/- 0.14 gm/dl; p less than 0.01) levels despite higher gross calorie (154 +/- 8 vs 116 +/- 13 kcal/kg per day; p less than 0.01) and protein intakes (2.81 +/- 0.21 vs 2.14 +/- 0.33 gm/kg per day; p = 0.03). Fecal nitrogen loss was correlated with fat loss (r = 0.79; p less than 0.001). Fat malabsorption was present in 79% (30/38) and 92% (33/36) of infants tested at 6 months and 12 months of age, respectively, indicating that pancreatic insufficiency persists and increases in frequency throughout infancy. We conclude that pancreatic insufficiency is prevalent in young infants with cystic fibrosis and has a significant impact on growth and nutrition.
Asunto(s)
Fibrosis Quística/fisiopatología , Insuficiencia Pancreática Exocrina/fisiopatología , Crecimiento/fisiología , Tamizaje Neonatal , Estado Nutricional/fisiología , Antropometría , Peso al Nacer , Nitrógeno de la Urea Sanguínea , Lactancia Materna , Fibrosis Quística/diagnóstico , Grasas de la Dieta/administración & dosificación , Proteínas en la Dieta/administración & dosificación , Ingestión de Energía , Insuficiencia Pancreática Exocrina/epidemiología , Femenino , Humanos , Incidencia , Recién Nacido , Masculino , Albúmina Sérica/análisisRESUMEN
To understand better the events associated with the initiation of lung disease in young children with cystic fibrosis (CF), we prospectively performed a longitudinal study examining the early bacteriologic, immunologic, and clinical courses of 42 children with CF diagnosed after identification by neonatal screening. Serial evaluations included history and physical examination, chest radiographs, throat cultures for bacteria, and determinations of serum immunoglobulin levels and circulating immune complexes. At a mean follow-up age of 27 months, 19% of the children had serial throat cultures positive for Pseudomonas aeruginosa; the first positive culture was found at a mean age of 21 months. In three infants the initial P. aeruginosa isolates were mucoid. As determined by typing with a DNA probe, serial P. aeruginosa isolates from each patient were identical over time but were genetically distinct from isolates recovered from other patients. Of 11 infants with P. aeruginosa, nine (82%) had previous isolates of Staphylococcus aureus or Haemophilus influenzae; all had received prior antibiotic therapy. In comparison with other infants with CF, children with P. aeruginosa grown on serial throat cultures more frequently had daily cough (p less than 0.01), lower chest radiograph scores (p less than 0.05), and elevated levels of circulating immune complexes (p less than 0.01). None of the study infants had persistent hypogammaglobulinemia or hypergammaglobulinemia. We conclude that (1) S. aureus and H. influenzae remain the isolates most frequently recovered from infants with CF; (2) initial recovery of P. aeruginosa by throat culture is often preceded by the onset of chronic respiratory signs; (3) elevations of circulating immune complexes can occur early, often after the initial recovery of P. aeruginosa; and (4) early P. aeruginosa isolates are genetically distinct, demonstrating the lack of cross-colonization in this newborn population.
Asunto(s)
Fibrosis Quística/microbiología , Tamizaje Neonatal , Complejo Antígeno-Anticuerpo/sangre , Fibrosis Quística/epidemiología , Fibrosis Quística/inmunología , Haemophilus influenzae/aislamiento & purificación , Humanos , Inmunoglobulinas/análisis , Lactante , Recién Nacido , Estudios Longitudinales , Faringe/microbiología , Estudios Prospectivos , Infecciones por Pseudomonas/epidemiología , Infecciones por Pseudomonas/inmunología , Infecciones por Pseudomonas/microbiología , Pseudomonas aeruginosa/aislamiento & purificación , Estudios Seroepidemiológicos , Staphylococcus aureus/aislamiento & purificaciónRESUMEN
To determine the frequency of respiratory syncytial virus (RSV) as the cause of hospitalization for acute pulmonary exacerbations in young infants with cystic fibrosis (CF), and to assess the clinical effects of RSV infections, we prospectively followed 48 children with a diagnosis of CF after identification by newborn screening. At a mean follow-up age of 28.8 months (range 5 to 59), 18 infants (38%) had been hospitalized a total of 30 times for acute respiratory distress. At the time of admission, 18 infants (60%) were less than 12 months, 8 (27%) between 12 and 24 months, and 4 more than 2 years of age. The RSV was identified in seven hospitalized infants, as determined by fluorescent antibody, immunoassay, or culture. Before admission with RSV infection, one of the seven infants had chronic respiratory signs, none had Brasfield chest x-ray scores below 20, and a previous throat culture was positive for Staphylococcus aureus in one infant. Hospitalizations were prolonged (mean duration 22 days), and were characterized by significant morbidity, with three infants (43%) requiring mechanical ventilation and five infants (71%) requiring home oxygen therapy for persistent hypoxemia at discharge. At a mean follow-up age of 26 months, these infants more frequently have chronic respiratory signs (p less than 0.01) and lower chest radiograph scores (p less than 0.05) than other CF infants. These findings demonstrate that RSV is an important cause of early acute respiratory tract morbidity in young infants with CF, and suggest the need for studying new strategies to implement early and aggressive antiviral therapy in young infants with CF.
Asunto(s)
Fibrosis Quística/complicaciones , Trastornos Respiratorios/etiología , Infecciones por Respirovirus/complicaciones , Preescolar , Hospitalización , Humanos , Lactante , Recién Nacido , Oxígeno/uso terapéutico , Estudios Prospectivos , Trastornos Respiratorios/terapia , Virus Sincitiales RespiratoriosAsunto(s)
Fibrosis Quística/sangre , Enfermedades Respiratorias/prevención & control , Albúmina Sérica/deficiencia , Fibrosis Quística/tratamiento farmacológico , Fibrosis Quística/epidemiología , Femenino , Humanos , Lactante , Recién Nacido , Lipasa/uso terapéutico , Masculino , Tamizaje Masivo , Extractos Pancreáticos/uso terapéutico , Pancreatina/uso terapéutico , Pancrelipasa , Riesgo , Comprimidos RecubiertosRESUMEN
Thirteen of 30 infants with bronchopulmonary dysplasia demonstrated systolic blood pressure readings above 113 mm Hg on at least three separate occasions. In contrast, only one of 22 infants without BPD developed hypertension. The onset of hypertension often followed discharge from the nursery, was transient, and responded well to antihypertensive medication. Its significance is exemplified by the presence of left ventricular hypertrophy in three infants and a cerebrovascular accident in one child. We conclude that systemic hypertension is a significant problem in infants with BPD, and recommend close monitoring of blood pressure during their follow-up care.