Download PDF
Am J Perinatol 2012; 29(07): 519-526
DOI: 10.1055/s-0032-1310523
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Variation in the Management of Persistent Pulmonary Hypertension of the Newborn: A Survey of Physicians in Canada, Australia, and New Zealand

Sandesh Shivananda
1   Department of Pediatrics, McMaster University, Ontario, Canada
,
Lucia Ahliwahlia
3   Department of Pediatrics, University of Toronto, Ontario, Canada
,
Martin Kluckow
2   Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, Australia
,
Jenny Luc
3   Department of Pediatrics, University of Toronto, Ontario, Canada
,
Robert Jankov
3   Department of Pediatrics, University of Toronto, Ontario, Canada
,
Patrick McNamara
3   Department of Pediatrics, University of Toronto, Ontario, Canada
› Author Affiliations
Further Information

Publication History

29 October 2011

21 December 2011

Publication Date:
11 April 2012 (online)

    Permissions and Reprints

Abstract

Background Despite advances in management of persistent pulmonary hypertension of the newborn (PPHN), the risk of mortality and adverse neurological sequelae remains high. Characterizing variation in practices is a crucial step toward improved patient outcome.

Objective Evaluate intensive care practices in Canada and the Australia–New Zealand region (AUS-NZ).

Methods A prospective cross-sectional online survey of neonatologists was conducted. A 35-item questionnaire was developed, validated, and piloted to collect information on diagnosis, inhaled nitric oxide (iNO) practices, alternative vasodilators or cardiotropes, and echocardiography. Variation among survey respondents as well as intergroup comparison was performed.

Results Data were collected from 217 respondents. Echocardiography and arterial blood gas were the most common diagnostic tests to assess the severity of PPHN. iNO administration is more frequently scrutinized in Canada (36% versus 10% [AUS-NZ], p < 0.001). Canadian physicians reported higher use of intravenous milrinone (p < 0.001), vasopressin (p = 0.02), and inhaled prostacyclin (p = 0.02), but lower use of sildenafil (p = 0.01) for refractory pulmonary hypertension. A greater proportion of neonatologists in AUS-NZ were trained to perform echocardiography (p < 0.001) to optimize treatment decisions.

Conclusion Wide variation exists in the management of PPHN. There is a need to provide more guidance regarding principles of management in PPHN, while recognizing the dynamic nature of cardiopulmonary physiology in individual patients.

Keywords

persistent pulmonary hypertension of the newborn - oxygenation failure - cardiotropes - vasodilator therapy - targeted neonatal echocardiography
 

  • References

  • 1 Walsh-Sukys MC, Tyson JE, Wright LL , et al. Persistent pulmonary hypertension of the newborn in the era before nitric oxide: practice variation and outcomes. Pediatrics 2000; 105 (1 Pt 1) 14-20
    CrossrefPubMedGoogle Scholar
  • 2 The Neonatal Inhaled Nitric Oxide Study Group. Inhaled nitric oxide in full-term and nearly full-term infants with hypoxic respiratory failure. N Engl J Med 1997; 336: 597-604
    CrossrefPubMedGoogle Scholar
  • 3 Lipkin PH, Davidson D, Spivak L, Straube R, Rhines J, Chang CT. Neurodevelopmental and medical outcomes of persistent pulmonary hypertension in term newborns treated with nitric oxide. J Pediatr 2002; 140: 306-310
    CrossrefPubMedGoogle Scholar
  • 4 Roberts Jr JD, Fineman JR, Morin III FC , et al; The Inhaled Nitric Oxide Study Group. Inhaled nitric oxide and persistent pulmonary hypertension of the newborn. N Engl J Med 1997; 336: 605-610
    CrossrefPubMedGoogle Scholar
  • 5 Evans N. Echocardiographic assessment of the newborn infant with suspected persistent pulmonary hypertension. Semin Neonatol 1997; 2: 37-48
    CrossrefPubMedGoogle Scholar
  • 6 Statistics Canada, Catalogue No. 84F0210X. Births 2006. 2008 ; Available at: http://www.statcan.gc.ca/daily-quotidien/080926/dq080926a-eng.htm . Accessed August 27, 2009
    PubMedGoogle Scholar
  • 7 Statistics New Zealand (2012). Demographic trends: 2011. Wellington: Statistics New Zealand. Available at: www.stats.govt.nz/browse_for_stats/population/estimates_and_projections/demographic-trends-2011.aspx . Accessed on March 29, 2012
    PubMedGoogle Scholar
  • 8 Australian Bureau of Statistics. 3301.0-Births, Australia, 2007. 2008 ; Available at: http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3301.0 . Accessed August 27, 2009
    PubMedGoogle Scholar
  • 9 Canadian pediatric Society. Levels of neonatal care. Position statement (FN 2006–02). Paediatr Child Health (Oxford) 2006; 11: 303-306
    PubMedGoogle Scholar
  • 10 Bryman A, Cramer D. Bivariate analysis. Exploring differences between scores on two variables. In: Bryman A, Cramer D, eds. Quantitative Data Analysis with SPSS Release 10 for Windows. Philadelphia: Taylor & Francis Inc.; 2001
    Google Scholar
  • 11 Vehovar V, Lozar K, Batagelj Z, Zaletel M. Nonresponse in Web surveys. In: Groves RM, Dillman DA, Eltinge JL, Little JA, eds. Survey Nonresponse. Hoboken, NJ: John Wiley & Sons; 2001
    Google Scholar
  • 12 Finer NN, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. Cochrane Database Syst Rev 2006; (4) CD000399
    PubMedGoogle Scholar
  • 13 Barrington KJ, Finer NN. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev 2007; (3) CD000509
    PubMedGoogle Scholar
  • 14 Macrae DJ, Field D, Mercier JC , et al. Inhaled nitric oxide therapy in neonates and children: reaching a European consensus. Intensive Care Med 2004; 30: 372-380
    CrossrefPubMedGoogle Scholar
  • 15 American Academy of Pediatrics. American Academy of Pediatrics. Committee on Fetus and Newborn. Use of inhaled nitric oxide. Pediatrics 2000; 106 (2 Pt 1) 344-345
    CrossrefPubMedGoogle Scholar
  • 16 Adams JM, Stark AR. Persistent pulmonary hypertension of the newborn. In: UptoDate, Garcia-Prats JA, Kim MS. eds. 2009. Available at: www.uptodate.com/home/index.html . Accessed on March 29, 2012
    Google Scholar
  • 17 Konduri GG, Kim UO. Advances in the diagnosis and management of persistent pulmonary hypertension of the newborn. Pediatr Clin North Am 2009; 56: 579-600
    CrossrefPubMedGoogle Scholar
  • 18 Barefield ES, Karle VA, Phillips III JB, Carlo WA. Inhaled nitric oxide in term infants with hypoxemic respiratory failure. J Pediatr 1996; 129: 279-286
    CrossrefPubMedGoogle Scholar
  • 19 Clark RH, Kueser TJ, Walker MW , et al; Clinical Inhaled Nitric Oxide Research Group. Low-dose nitric oxide therapy for persistent pulmonary hypertension of the newborn. N Engl J Med 2000; 342: 469-474
    CrossrefPubMedGoogle Scholar
  • 20 Day RW, Lynch JM, White KS, Ward RM. Acute response to inhaled nitric oxide in newborns with respiratory failure and pulmonary hypertension. Pediatrics 1996; 98 (4 Pt 1) 698-705
    PubMedGoogle Scholar
  • 21 The Neonatal Inhaled Nitric Oxide Study Group (NINOS). Inhaled nitric oxide and hypoxic respiratory failure in infants with congenital diaphragmatic hernia. Pediatrics 1997; 99: 838-845
    CrossrefPubMedGoogle Scholar
  • 22 Guthrie SO, Walsh WF, Auten K, Clark RH. Initial dosing of inhaled nitric oxide in infants with hypoxic respiratory failure. J Perinatol 2004; 24: 290-294
    CrossrefPubMedGoogle Scholar
  • 23 Shah PS, Ohlsson A. Sildenafil for pulmonary hypertension in neonates. Cochrane Database Syst Rev 2007; (3) CD005494
    PubMedGoogle Scholar
  • 24 Ho JJ, Rasa G. Magnesium sulfate for persistent pulmonary hypertension of the newborn. Cochrane Database Syst Rev 2007; (3) CD005588
    PubMedGoogle Scholar
  • 25 Paramothayan NS, Lasserson TJ, Wells AU, Walters EH. Prostacyclin for pulmonary hypertension. Cochrane Database Syst Rev 2003; (2) CD002994
    PubMedGoogle Scholar
  • 26 Lorch SA, Cnaan A, Barnhart K. Cost-effectiveness of inhaled nitric oxide for the management of persistent pulmonary hypertension of the newborn. Pediatrics 2004; 114: 417-426
    CrossrefPubMedGoogle Scholar
  • 27 Goldman AP, Tasker RC, Haworth SG, Sigston PE, Macrae DJ. Four patterns of response to inhaled nitric oxide for persistent pulmonary hypertension of the newborn. Pediatrics 1996; 98 (4 Pt 1) 706-713
    PubMedGoogle Scholar
  • 28 Abman SH, Kinsella JP. Inhaled nitric oxide for persistent pulmonary hypertension of the newborn: the physiology matters!. Pediatrics 1995; 96: 1153-1155
    PubMedGoogle Scholar
  • 29 Thébaud B, Petit T, De Lagausie P, Dall'Ava-Santucci J, Mercier JC, Dinh-Xuan AT. Altered guanylyl-cyclase activity in vitro of pulmonary arteries from fetal lambs with congenital diaphragmatic hernia. Am J Respir Cell Mol Biol 2002; 27: 42-47
    CrossrefPubMedGoogle Scholar
  • 30 Baquero H, Soliz A, Neira F, Venegas ME, Sola A. Oral sildenafil in infants with persistent pulmonary hypertension of the newborn: a pilot randomized blinded study. Pediatrics 2006; 117: 1077-1083
    CrossrefPubMedGoogle Scholar
  • 31 Cole FS, Alleyne C, Barks JD , et al. NIH Consensus Development Conference statement: inhaled nitric-oxide therapy for premature infants. Pediatrics 2011; 127: 363-369
    CrossrefPubMedGoogle Scholar
  • 32 INOmax® (nitric oxide) for inhalation. 2007 Available at: http://www.inomax.com/pdf/prescribing_information.pdf . Accessed August 27, 2009
    PubMedGoogle Scholar
  • 33 Williams LJ, Shaffer TH, Greenspan JS. Inhaled nitric oxide therapy in the near-term or term neonate with hypoxic respiratory failure. Neonatal Netw 2004; 23: 5-13
    PubMedGoogle Scholar
  • 34 Aly H, Sahni R, Wung JT. Weaning strategy with inhaled nitric oxide treatment in persistent pulmonary hypertension of the newborn. Arch Dis Child Fetal Neonatal Ed 1997; 76: F118-F122
    CrossrefPubMedGoogle Scholar
  • 35 Sokol GM, Fineberg NS, Wright LL, Ehrenkranz RA. Changes in arterial oxygen tension when weaning neonates from inhaled nitric oxide. Pediatr Pulmonol 2001; 32: 14-19
    Google Scholar
  • 36 Noori S, Friedlich P, Seri I. Pharmacology review: the use of dobutamine in the treatment of neonatal cardiovascular compromise. NeoReviews 2004; 5: e22-e26
    CrossrefPubMedGoogle Scholar
  • 37 Evans N. Which inotrope for which baby?. Arch Dis Child Fetal Neonatal Ed 2006; 91: F213-F220
    PubMedGoogle Scholar
  • 38 Evans N, Kluckow M, Currie A. Range of echocardiographic findings in term neonates with high oxygen requirements. Arch Dis Child Fetal Neonatal Ed 1998; 78: F105-F111
    CrossrefPubMedGoogle Scholar
  • 39 Kluckow M, Seri I, Evans N. Functional echocardiography: an emerging clinical tool for the neonatologist. J Pediatr 2007; 150: 125-130
    CrossrefPubMedGoogle Scholar
  • 40 Shah DM, Kluckow M. Early functional echocardiogram and inhaled nitric oxide: usefulness in managing neonates born following extreme preterm premature rupture of membranes (PPROM). J Paediatr Child Health 2011; 47: 340-345
    CrossrefPubMedGoogle Scholar
  • 41 Eysenbach G, Wyatt J. Using the Internet for surveys and health research. J Med Internet Res 2002; 4: E13
    CrossrefPubMedGoogle Scholar
  • 42 Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative?. Fam Pract 2003; 20: 545-551
    CrossrefPubMedGoogle Scholar