SNS 2017 - Patent ductus arteriosus - news and views on diagnosis and management
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Lecture on PDA management 11 April 2017, held at the 17th Annual Saudi Neonatology Society Conference, in Riyadh, Saudi Arabia.
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SNS 2017 - Patent ductus arteriosus - news and views on diagnosis and management
- 1. Patent Ductus Arteriosus - news and views on diagnosis and management STEFAN JOHANSSON, MD PhD Sachs Children’s Hospital Karolinska institutet Stockholm, Sweden
- 5. 99nicu Meetup 12-15 June 2017 Stockholm, Sweden EBNEO conference 10-12 Nov 2017 Hyderabad, India
- 7. ”Despite…research and clinical experience with thousands of infants over nearly 6 decades, there is still uncertainty and controversy about the significance, evaluation, and management of patent ductus arteriosus in preterm infants…” AAP Committee on Fetus and Newborn. Pediatrics Dec 2015. doi: 10.1542/peds.2015-3730
- 8. You will still be confused after this lecture
- 9. • What? • Why? • How? • When? • The Stockholm Way!
- 11. PDA – common clinical problem 0 20 40 60 80 100 22 w 23 w 24 w 25 w 26 w PDA rate (%) EXPRESS study (all live-born infants <27 weeks in Sweden 2004-2007) EXPRESS Group. Acta Paediatrica 2010;99:978.
- 12. PDA – what is it? ☞ ”hemodynamically significant PDA” • patophysiological consequences counts!
- 13. PDA – what it is really? Clinical symtoms/signs • murmur • bounding pulses • sBP >> dBP • hypotension • feeding intolerance Echocardiographic signs • patency of the duct • left-right shunt • large left atrium • diastolic ”steal” • diastolic flow in LPA
- 14. PDA – how is it defined? let’s read Methods in papers
- 15. PDA – how is it defined? • ”diastolic flow easily detectable… main pulmonary artery” • ”diastolic backflow in the aorta immediately beneath the ductus” • ”LA-to-Ao-ratio >1.6” van Overmeire. New Engl J Med 2000;343:674
- 16. PDA – how is it defined? • ”left to right ductal shunting” • ”increased LA-to-Ao-ratio” • ”failure to wean from mechanical ventilation” • ”PDA defined as the ICD code for PDA” Richards. Pediatrics 2009;124:e287 Gudmundsdottir. Neonatology 2015:107:87
- 17. PDA – is there a definition? Zonnenberg. Acta Paediatrica 2012;101:247
- 18. So, how should we diagnose PDA?
- 19. • What? • Why? • How? • When? • The Stockholm Way!
- 21. Closing the PDA is rather easy…
- 22. … but what is the point doing it?
- 23. ”PDA increase the risk of…” • mechanical ventilation • pulmonary haemorrhage • NEC • IVH / PVL • ROP • BPD
- 24. Are these associations true? • Conflicting results • Treatment does not seem to reduce risks
- 25. Causality or co-occurence? PDA BPD Short gestational age PDA BPD
- 26. Indomethacin prophylaxis and BPD 999 ELBW infants 49% had PDA after placebo21% had PDA after indo Schmidt. J Pediatr 2006;148:730 41% developed BPD45% developed BPD
- 27. Mandatory closure vs. no Tx • Observational study of two time periods with – mandatory treatment (indomethacin or surgery) – fluid restriction only • In total 178 infants born at 23-26 weeks • BPD rate lower with non-Tx (58 vs. 38%) • No other differences in other morbidities Sung. J Pediatr 2016;177:66
- 28. Should PDAs be treated at all? Benitz. Arch Dis Child FN Ed 2012;97:F80
- 29. I am still a Believer! We have… • plausible associations • a heterogeneous patient population (no clearly defined high-risk group) We need… • larger observational studies • larger randomized trials, also with placebo
- 30. • What? • Why? • How? • When? • The Stockholm Way!
- 31. Medical treatment of PDA • Ibuprofen or indomethacin • Due to lower risk of NEC and transient renal insufficiency, ibuprofen is ”drug of choice” • Enteral and iv ibuprofen ”appears” as effective Cochrane Database Syst Rev. 2015 Feb 18;(2):CD003481
- 32. ”What about paracetamol?” • The jury is still out! • 2 RCT and 14 observational studies • Methodological quality judged as ”poor” • Several studies ongoing / planned. Terrin. Arch Dis Child FN Ed. 2016;101:F127
- 33. • What? • Why? • How? • When? • The Stockholm Way!
- 34. Early ductal shunting • First hours of life: – large shunt volumes – most pronounced hemodynamic impact Kluckow. Early Hum Dev 2005;81:429
- 35. Early targeted treatment • 164 infants <29 weeks, echo within 12 hours • 92 with PDA – indomethacin or placebo • fewer with pulmonary hemorraghe (2 vs 21%) • no effect on mortality or cranial ultrasound but trend towards fewer IVH (4 vs 12%) Kluckow. Arch Dis Child FN Ed. 2014;99:F99
- 36. Early diagnosis • Screening before 3 days compared to indicated echo later – 605 ”paired” infants <29 weeks – lower mortality (14 vs 18%), aOR 0.62 – fewer lung bleedings (6 vs 9%) – no risk differences in NEC, BPD, CNS-lesions Roze. JAMA 2015;313:2441
- 37. • What? • Why? • How? • When? • The Stockholm Way!
- 38. Current protocol in Stockholm Echocardiography day 1-3 • < 27 weeks • all preterm infants on mechanical ventilation Echocardiography upon “clinical suspicion” • preterms > 5-7 days on CPAP and “high” FiO2 • clinical signs
- 39. Our treatment options • Ibuprofen if <14 days of age • Surgery may be considered if: – infant is ”stuck” on invasive ventilation – late relapse – heart failure and/or severe lung disease
- 40. Conservative strategy In well infants on CPAP we wait and see! • Repeated echo’s • Wean CPAP slowly • Fluid restriction at 160 ml/kg/d
- 41. Are you still confused?
- 42. Conclusions • There is no universal PDA definition but… use echocardiography to set your diagnosis • You can close the PDA but… noone knows exactly why you should • Early management might have benefits but… ”more research is needed”