Transcript Colic, Reflux and Allergy

Chronic Lung Disease
SpR Training Day, 5/10/06
Dr Russell Peek
Objectives
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By the end of this session, you will:
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have evaluated the use of systemic corticosteroids
in the ventilated preterm infant;
be able to discuss the role of other treatments in
prevention and management of chronic lung
disease;
appreciate important issues in discharge planning
for the infant with chronic lung disease;
understand long term outcomes for infants with
chronic lung disease.
Systemic Corticosteroids
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Chronic lung disease is an inflammatory
process
Corticosteroids are potent anti-inflammatory
agents
Why not try corticosteroids to prevent or treat
chronic lung disease?
Scenario
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Peter, born after spontaneous preterm labour at 26
weeks, is now 15 days old. He has been ventilated
since birth. A patent arterial duct was successfully
treated with a single course of ibuprofen.
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SIMV 28/6 FiO2 0.45. Not tolerant of weaning.
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Chest xray: evolving CLD.
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Should he receive steroids?
Task
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In 3 groups discuss the Cochrane reviews of
early, moderately early and late use of
corticosteroids.
Task
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Prepare a brief presentation to give to the
rest of the group considering the following
issues:
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effectiveness in preventing chronic lung disease
short term side effects
long term outcomes
clinical ‘bottom line’
Cochrane Conclusions
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Methodological quality of long term studies limited
Assessment before school age in most
Insufficient power to detect adverse long term
outcomes.
Benefits may not outweigh potential adverse effects
Use as rescue therapy
Minimise dose and duration.
Recent evidence: The DART study
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Low dose dexamethasone
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facilitates extubation, (OR 11.2)
shortens duration of intubation, (14 vs. 21 days)
reduces oxygen requirements
no significant effect on
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blood glucose or BP
mortality or oxygen requirement at 36 weeks
Low-dose dexamethasone facilitates extubation among chronically ventilator dependent
infants: a multicenter, international, randomised controlled trial. Doyle et al. Pediatrics
(2006): 117; 75-83
Kaplan-Meier Plot
Counselling parents
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Having discussed the Cochrane reviews and
the DART study, how would you counsel
parents if you were considering
corticosteroids for their child?
Other Treatment Strategies
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Other prophylaxis or treatment strategies:
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anti-inflammatory
bronchodilation
specific nutritients
antibiotic
etc
Inhaled Corticosteroids
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No difference in effectiveness or side-effect
profiles for inhaled versus systemic steroids
No long term outcome data
Not recommended based on current
evidence
Sodium Cromoglycate
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A mast cell stabiliser that inhibits neutrophil
activation and neutrophil chemotaxis.
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No evidence from RCTs of a role in
prevention of CLD.
Inhaled Bronchodilators
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Insufficient data to reliably assess use of
salbutamol for prevention of CLD.
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Further clinical trials are necessary to
assess bronchodilators for prophylaxis or
treatment.
Vitamin A
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Vitamin A is necessary for normal lung
growth and integrity of respiratory tract
epithelial cells
Studies involved repeat im. doses
Modest reduction in death or oxygen
dependence at 1 month (RR 0.93, NNT 20)
Modest reduction in oxygen dependence at
36 weeks postnatal age (RR 0.87, NNT 14)
Vitamin E
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An antioxidant
Deficiency worsens oxygen toxicity
No evidence that routine supplementation
prevents CLD
Inositol
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component of phospholipids
critical role in surfactant synthesis
supplementation reduced risk of CLD or
death in 1 small study
further evidence required
Selenium
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a part of glutathione peroxidase
acts synergistically with vitamin E
supplementation produced no reduction in
CLD or days of oxygen therapy
Glutamine
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essential for rapidly dividing cells
not present in routine TPN
supplementation produced no reduction in
BPD in one study
Superoxide Dismutase
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Free oxygen radicals implicated in the
pathogenesis of chronic lung disease in
preterm infants
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Currently insufficient evidence about efficacy
in preventing chronic lung disease
Diuretics - systemic
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Lung disease in preterm infants is often
complicated with lung oedema
Administration of diuretics improves
pulmonary mechanics in CLD
Little evidence to support any benefit on
need for ventilatory support, length of
hospital stay or long-term outcome
Diuretics - inhaled
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A single dose of aerosolized furosemide
improves pulmonary mechanics
Lack of data concerning effects on important
clinical outcomes
Not currently recommended
Antibiotics
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Ureaplasma urealyticum postulated as a
cause of CLD (not proven)
Erythromycin has been investigated in 2
small studies
No statistically significant effect on CLD,
death or combined outcome of CLD or death
Alpha 1 Proteinase inhibitor
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Aim to counteract enzymatic damage to lung
tissues with prophylactic proteinase inhibitor
No reduction in risk of CLD at 36 weeks
No reduction in adverse neurodevelopmental outcomes
No significant difference in other respiratory
parameters.
Nutrition
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Babies with CLD
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feed less well than other preterm infants
have lower fluid intakes
have increased energy expenditure
often have abnormal growth patterns
are at risk of ongoing faltering growth
The Energy Balance Equation
Nutrition
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No evidence base for nutrition in CLD
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ideal energy intake
optimum mix of protein/CHO/fat
rates of growth
In general, supplemented feeds are used
Nutrition
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Monitor weight, height and OFC
Height ‘catch up’ can continue to age 10
Weight gain is often more problematic
Discharge Planning
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Peter is now 1 week past term and has
stable saturations in 50cc low flow oxygen.
He is fully bottle fed.
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What issues should be considered before
discharge and at the discharge planning
meeting?
Discharge Planning
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Home oxygen therapy
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oximeter? apnoea alarm?
Resuscitation training
Vaccination
Risks of smoking and infection
Nutrition and growth
Medication
Follow up
Oxygen therapy
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In adults, pulmonary hypertension occurs
<90% saturation
Normal babies have saturations >95%
Growth is poorer with saturations <92%
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Aim for >94% at home; minimise time <90%
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O2 Saturation Study
Long term outlook
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Pulmonary function
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Reduced lung volumes (VC, FEV1)
Decreased lung compliance
Decreased airway conductance
Improvement occurs to age 8
Generally fail to achieve normal values
Long term outlook
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Functional outcome - illness
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More respiratory morbidity in early life
Cough and wheeze with respiratory viruses
Functional outcome - exercise
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Similar endurance in mid childhood
Similar maximal oxygen consumption
More desaturation
Faster, shallower breathing
Objectives
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By the end of this session, you will:
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have evaluated the use of systemic corticosteroids
in the ventilated preterm infant;
be able to discuss the role of other treatments in
prevention and management of chronic lung
disease;
appreciate important issues in discharge planning
for the infant with chronic lung disease;
understand long term outcomes for infants with
chronic lung disease.
Any Questions?
Summary
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Chronic lung disease is associated with
morbidity into childhood and adolescence
Few pharmacological approaches to
treatment or prevention have proven useful
Attention should be given to optimising
oxygen saturations and nutrition
Discharge planning is essential