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ARTICLES: Garth D. Meckler and Calvin Lowe To Intubate or Not to Intubate? Transporting Infants on Prostaglandin E1 Pediatrics 2009; 123: e25-e30 [Abstract] [Full text] [PDF]

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Methylxanthine use may affect rate of intubation for infants on prostaglandins

Joshua T Attridge, D. Scott Lim, and Marcia L. Buck   (15 January 2009)

Methylxanthine use may affect rate of intubation for infants on prostaglandins 15 January 2009
Joshua T Attridge, Neonatology University of Virginia, Charlottesville, D. Scott Lim, and Marcia L. Buck Send letter to journal: Re: Methylxanthine use may affect rate of intubation for infants on prostaglandins ja5u{at}virginia.edu Joshua T Attridge, et al.	We would like to compliment Meckler and Lowe on their manuscript describing the complication rates of infants intubated for prostaglandin infusion.[1] Their work is a timely addition to a paucity of recent literature on transport management of the infants with cyanotic heart disease. However, the authors failed to mention any use of prophylactic methylxanthines at the time prostaglandin infusion was initiated. It is unclear whether this class of medications was used in this population and whether their use may have changed the findings noted by Meckler and Lowe. Over the last 5 years, our group has begun to routinely use caffeine as prophylaxis against or treatment for apnea in infants that are started on prostaglandin infusion. This practice was started after examining the data from a randomized controlled trial comparing aminophylline and placebo to prevent apnea infusion in neonates.[2] Caffeine has been used for apnea of prematurity and is known to have a wider therapeutic range than other methylxanthines.[3] Caffeine has also been shown to have few negative short term side effects and no long term side effects (and potential for positive side effects) when used in more premature infants at high risk of developing apnea.[4] We recently reported a retrospective chart review from our institution and found the rate on intubation required for infants on prostaglandin infusion more than halved with caffeine use (from 54% to 20%). [5] The decision to intubate or manage the airway expectantly is a difficult one faced both on transport and in the neonatal intensive care unit when babies are maintained on prostaglandins prior to surgical or transcatheter intervention. As Meckler and Lowe point out, the risks of intubation are not negligible in this population. For clinicians struggling with this decision, prophylactic caffeine may be useful to try and prevent the apnea which can occur with prostaglandins that in many instances is life – saving for these infants. ____________________________________________________________ [1] Meckler GD, Lowe C. To intubate or not to intubate? Transporting infants on prostaglandin E1.Pediatrics. 2009;123:e25-30. [2] Lim DS, Kulik TJ, Kim DW, Charpie JR, Crowley DC, Maher KO. Aminophylline for the prevention of apnea during prostaglandin E1 infusion. Pediatrics. 2003;112:e27-29. [3] Scanlon JEM, Chin KC, Morgan MEI, et al. Caffeine or theophylline for neonatal apnea? Arch Dis Child 1992;67:425-8. [4] Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, Solimano A, Tin W; Caffeine for Apnea of Prematurity Trial Group. Caffeine therapy for apnea of prematurity. N Engl J Med. 2006 354:2112-21. [5] Buck ML, Lim DS, Attridge J. Caffeine for prevention or treatment of alprostadil-induced apnea in infants with congenital heart disease [abstract presented at the American College of Clinical Pharmacy meeting, Louisville, Kentucky, October 2008]. Pharmacotherapy 2008;28:167e. Conflict of Interest: None declared