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Pulmonary Resilience: Moderating the Association between Oxygen Exposure and Pulmonary Outcomes in Extremely Preterm
Urvi Jhaveri Sanghvi1, Clyde J Wright2, Teri L Hernandez1,3,4
1College of Nursing, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA.
Insights
Bronchopulmonary dysplasia (BPD) risk in preterm infants may be reduced by assessing autonomic nervous system (ANS) function. Tailoring oxygen therapy based on pulmonary resilience could improve outcomes and decrease mortality.
Area of Science:
- Neonatal Medicine
- Respiratory Physiology
- Developmental Pediatrics
Background:
- Bronchopulmonary dysplasia (BPD) is a severe chronic lung disease in infants, particularly those born extremely preterm.
- Current BPD management involves supplemental oxygen, but balancing its benefits against toxicity and mortality risks is challenging.
- Early identification of factors influencing BPD development is crucial to prevent irreversible lung damage.
Purpose of the Study:
- To introduce the concept of pulmonary resilience as a potential moderator of physiological stress in extremely preterm infants.
- To hypothesize that autonomic nervous system (ANS) function indicates pulmonary resilience and can guide individualized oxygen therapy.
- To explore how modifying early exposures, specifically oxygen, can reduce BPD risk before irreversible progression.
Main Methods:
- This review synthesizes current knowledge on BPD pathogenesis and the role of the autonomic nervous system (ANS).
- It proposes a novel framework of 'pulmonary resilience' linked to ANS function.
- The concept is explored in the context of supplemental oxygen management in extremely preterm neonates.
Main Results:
- Extremely preterm infants face a paradox with oxygen: essential for survival yet toxic.
- Current guidelines favoring higher oxygen saturations may increase BPD risk due to prolonged oxygen exposure.
- Pulmonary resilience, mediated by the ANS, is hypothesized to influence an infant's tolerance to oxygen therapy.
Conclusions:
- Infants with ANS dysfunction may need higher oxygen levels, while those with robust ANS function might tolerate lower levels.
- Individualizing supplemental oxygen based on pulmonary resilience could mitigate BPD-related morbidity and mortality.
- Further research into characterizing the pulmonary resilience continuum is needed to optimize care for preterm infants.
Abstract:
Bronchopulmonary dysplasia (BPD) is a chronic lung disease of infancy associated with high morbidity and mortality. Although most prevalent following extremely preterm birth, BPD is diagnosed at 36 weeks post-menstrual age, when the disease trajectory is underway, and long-term physiological implications may be irreversible. There is an urgent and unmet need to identify how early exposures can be modified to decrease the risk of developing BPD before disease progression becomes irreversible. Extremely preterm newborns encounter a paradox at birth: oxygen is a life-sustaining component of ex utero life yet is undeniably toxic. Attempts at minimizing supplemental oxygen exposure by targeting lower oxygen saturations appear to decrease BPD but may increase mortality. Given the potential association between lower oxygen saturations and increased mortality, practice guidelines favor targeting higher saturations. This uniformly increases oxygen exposure, prompting a cascade of pathogenic mechanisms implicated in BPD development. In this review, we introduce the concept of pulmonary resilience: a homeostatic process driven by the autonomic nervous system (ANS) as a moderator of physiologic stress that when functional, could inform successful environmental adaptation following extremely preterm birth. We hypothesize that infants with early-life ANS dysfunction require a higher oxygen dose for survival; conversely, oxygen exposure could be safely limited in infants with more robust early-life ANS function, an indicator of pulmonary resilience. Characterizing the pulmonary resilience continuum to guide individualized supplemental oxygen dosing may reduce morbidity and mortality in this growing population of extremely preterm infants at risk for BPD.
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