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PEDIATRICS Vol. 105 No. 1 January 2000, pp. 14-20

Persistent Pulmonary Hypertension of the Newborn in the Era Before Nitric Oxide: Practice Variation and Outcomes

Received May 21, 1997; accepted Feb 24, 1998.

Michele C. Walsh-Sukys*, Jon E. TysonDagger , Linda L. Wright§, Charles R. Bauerparallel , Sheldon B. Korones, David K. Stevenson#, Joel Verter**, Barbara J. StollDagger Dagger , James A. Lemons§§, Lu-Ann Papile||, Seetha Shankaran¶¶, Edward F. Donovan##, William Oh***, Richard A. EhrenkranzDagger Dagger Dagger , and Avroy A. Fanaroff*

From the * Case Western Reserve University, Cleveland, Ohio; Dagger  University of Texas Southwestern Medical Center, Dallas, Texas; § National Institute of Child Health and Human Development, Bethesda, Maryland; parallel  University of Miami, Miami, Florida;  University of Tennessee, Memphis, Tennessee; # Stanford University, Stanford, California; ** Biostatistics Center, George Washington University, Washington DC; Dagger Dagger  Emory University, Atlanta, Georgia; §§ Indiana University, Indianapolis, Indiana; || University of New Mexico, Albuquerque, New Mexico; ¶¶ Wayne State University, Detroit, Michigan; ## University of Cincinnati, Cincinnati, Ohio; *** Women & Infants Hospital, Providence, Rhode Island; and Dagger Dagger Dagger  Yale University, New Haven, Connecticut.

Objectives.  In the era before widespread use of inhaled nitric oxide, to determine the prevalence of persistent pulmonary hypertension (PPHN) in a multicenter cohort, demographic descriptors of the population, treatments used, the outcomes of those treatments, and variation in practice among centers.

Study Design.  A total of 385 neonates who received >= 50% inspired oxygen and/or mechanical ventilation and had documented evidence of PPHN (2D echocardiogram or preductal or postductal oxygen difference) were tracked from admission at 12 Level III neonatal intensive care units. Demographics, treatments, and outcomes were documented.

Results.  The prevalence of PPHN was 1.9 per 1000 live births (based on 71 558 inborns) with a wide variation observed among centers (.43-6.82 per 1000 live births). Neonates with PPHN were admitted to the Level III neonatal intensive care units at a mean of 12 hours of age (standard deviation: 19 hours). Wide variations in the use of all treatments studied were found at the centers. Hyperventilation was used in 65% overall but centers ranged from 33% to 92%, and continuous infusion of alkali was used in 75% overall, with a range of 27% to 93% of neonates. Other frequently used treatments included sedation (94%; range: 77%-100%), paralysis (73%; range: 33%-98%), and inotrope administration (84%; range: 46%-100%). Vasodilator drugs, primarily tolazoline, were used in 39% (range: 13%-81%) of neonates. Despite the wide variation in practice, there was no significant difference in mortality among centers. Mortality was 11% (range: 4%-33%). No specific therapy was clearly associated with a reduction in mortality. To determine whether the therapies were equivalent, neonates treated with hyperventilation were compared with those treated with alkali infusion. Hyperventilation reduced the risk of extracorporeal membrane oxygenation without increasing the use of oxygen at 28 days of age. In contrast, the use of alkali infusion was associated with increased use of extracorporeal membrane oxygenation (odds ratio: 5.03, compared with those treated with hyperventilation) and an increased use of oxygen at 28 days of age.

Conclusions.  Hyperventilation and alkali infusion are not equivalent in their outcomes in neonates with PPHN. Randomized trials are needed to evaluate the role of these common therapies.  Key words:  pulmonary hypertension of the newborn, newborn, treatments, outcomes, practice variation.




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