Alexandria Egypt Bpd 04-09

2nd International Neonatology Conference April 2 - 4, 2009 Alexandria, Egypt

Pre- and postnatal risk factors in the pathogenesis of BPD: The role of infections

Prof. Christian P. Speer, MD, FRCPE Director and Chairman University Children’s Hospital Würzburg, Germany

BPD (3/89 - 3/91)

60

„Low Risk“ (n=48) „High Risk“ (n=26)

% FiO2

50

40

30 20

0

5

10

15

20

Postnatal age (days) Gerhardt, 1994

25

30

100% 80% 60% 40% 20% 0%

500-599

600-699

700-799

800-899

900-1000 1001-1250 1251-1500

Birth weight (g) BPD

Alive at 28 days

Died < 28 days

Neonatal survival and incidence of BPD defined as ≥ 28 days' duration of oxygen dependency during hospitalization at the UM/JMC during the period 1995 - 2000 (n = 1266 inborn infants; birthweight, 500 - 1000 g). Bancalari E et al, Semin Neonatol, 2003

Inflammatory Cells in TAF

CELL NUMBER

107

106

105

Infants at risk for BPD Infants with RDS Non-pulmonary disorders

104 Birth 1 2 3 4 5 6 7 8 9 10 14 DAYS Merritt et al, J Clin Invest 1983

TAF= tracheal aspirate fluid

Chorioamnionitis Microorganisms, LPS Hyperoxia Baro-/ Volutrauma

PMN

Capillary

Airway TNF- α IL-1 Type IIPneumozyt

Mo

IL-8

Fibroblast Speer Biol Neon 2001; Shimotake et al Pediatr Res 2004 Speer, Drug Discovery Today 2007

Interstitium

Al

Vascular Space

bu m

tic c ta o em ctors h C Fa

in

Elastase O2 , OH

Pe rm

e

ab In ili M fla ed m ty ia ma to to rs ry Alveolar Space

Mo

Aveolar Macrophage

Type II Pneumocyte Speer Biol Neon 2001; Speer, Drug Discovery Today 2007

Surfactant

% Change In Enyzme Activity

Albumin in lung effluent 10 8 BPD 6

Controls

4 p<0.01 2 0

3

5

7

postnatal age (days) Groneck et al, Pediatrics, 1994

10

15

26 weeks of gestation, day 10 of life

Histologic Chorioamnionitis Histological chorioamnionitis %

70 60

n= 261

n= 139

50

n= 200 n= 164 n= 236

40 30

n= 284

n= 375

n= 380

n= 539

20

n= 580

n= 770

10 0

20-24 25

26 27 28 29 30 31 32 Gestational Age (completed weeks)

Lahra and Jeffrey, AJOBGYN, 190:147, 2004

33

34

Frequency of a positive amniotic fluid (AF) culture and intraamniotic inflammation 80 60 % 40 20 0

20-27

27-30 30-33 Gestational age (weeks)

intra-amniotic inflammation (P< .001) Shim et al, Am J Obstet Gynecol, 2004

33-35

positive AF culture (P< .05)

Detection of bacteria in placental tissues obtained from extremely low gestational age neonates Study design: A sample of the chorionic parenchyma from neonates delivered between 23 – 27 weeks was cultured and tested by PCR , n = 1365 Results: Culture positive 68% of vaginal deliveries 41% of caesarean sections 30% had only aerobic bacteria 21% had only anaerobic bacteria 9% had Mycoplasma / Ureaplasma Conclusion: Approximately half of second – trimester placentas harbour organisms within the chorionic plate Onderdonk et al AJ0G 2008

Intrauterine Cytokine Exposure TNFα IL-1 IL-8

Systemic Fetal Inflammatory Response

Elevated IL-6 concentrations in umbilical cord blood Yoon et al, Am J Obstet Gynecol, 1999

Neutrophil Influx in Pulmonary Tissue Following Chorioamnionitis

Amnionitis positive Schmidt, Speer. Am J Obstet Gynecol 2001

Amnionitis negative

In-Situ Hybridization Expression of IL-8 in Lung Tissue Following Chorioamnionitis

Amnionitis positive Schmidt, Speer. Am J Obstet Gynecol 2001

Amnionitis positive

ICAM-expression in endothelium of an umbilical artery

Chorioamnionitis, funisitis, GA 26 weeks

No chorioamnionitis, GA 26 weeks

Heinrich, Kramer, Seidenspinner, Marx, Berg, Groneck, Speer Pediatr Res 2005

Soluble ICAM-1 levels in preterm infants exposed to chorioamnioitis p = 0.0006 p = 0.004

ICAM – 1 (ng/ml)

700 500 300

100 70

Control

Chorioamn.

Chorioamn. & Funisitis

Heinrich, Kramer, Seidenspinner, Marx, Berg, Groneck, Speer, Pediatr Res 2005

Apoptotic indices in lungs of stillborn fetuses ***

20 15

AI

*p<0.05 10

*

***p<0.001 vs. stillborn fetuses

5 0 N=

12

10 13 stillborn stillborn stillborn +maternal +maternal chorioamnionitis chorioamnionitis +pneumonia

May, Marx, Seidenspinner, Speer, Histopathology 2004

May, Marx, Seidenspinner, Speer, Histopathology 2004

50 µm

Chorioamnionitis, mechanical ventilation, and postnatal sepsis as modulators of CLD

Greatest risk for CLD •exposure to chorioamnionitis and / either •mechanical ventilation > 7 days or •postnatal infection Conclusion: These 2 postnatal factors interact with antenatal infection to further increase the risk of CLD Van Marter et al, Pediatrics 2002

TAF-Interleukin-1 and Microbial Colonization of the Airways

Interleukin-1 (pg/µg SC)

80 70 60

Ureaplasma urealyticum (n=19) Prenatal infection (n=7) RDS, no infection, no BPD (n=9) *

40

*

*

50

*

*

30 20

*

*p<0.01

10 0

1

3

5

postnatal age (days)

Groneck, Schmale, Soditt, Stützer, Götze-Speer, Speer, Pediatr Pulmonol 2001

7

TAF = tracheal aspirate fluid

The Alabama Preterm Birth Study: Umbilical cord blood Ureaplasma urealyticum and Mycoplasma hominis cultures in very preterm newborn infants Study 351 mother / infant dyads with deliveries between 23 and 32 weeks’ gestational age Results U. urealyticum an for M. hominis were present in 23% of cord blood cultures Intrauterine infection and inflammation were more common among infants with positive U. urealyticum and M. hominis cultures Infants with positive cord blood U. urealyticum and M. hominis cultures were more likely to have neonatal systemic inflammatory response syndrome (SIRS) and probably bronchopulmonary dysplasia (BPD). Goldenberg et al, AJOG 2008

Twenty percent of very preterm neonates (23-32 weeks of gestation) are born with bacteremia caused by genital Mycoplasmas

Romero, Garite, AJOG, 2008

Colony forming units for Ureaplasma urealyticum at delivery and postnatal tracheal aspirates in premature baboons 10.000.000

CFU`s

1.000.000 100.000 10.000 1.000 100 10 1

AF 24 hr (amniotic fluid)

72 hr

144 hr

240 hr

336 hr

Animals with negative culture at 14 days of postnatal age (Uu -), n=5 Animals with persistently positive cultures (Uu+), n=4 Yoder, Coalson et al, Pediatr Res 2004

Effects of antenatal colonization with Ureaplasma urealyticum on pulmonary disease in the immature baboon

Uninfected animals ventilated for 14 days Yoder, Coalson et al, Pediatr Res 2004

Uu - negative animals at 14 days of age

Uu - positive animals at 14 days of age

Imbalance between Proinflammatory and Antiinflammatory Cytokines Neonatal Lung Lavage

Immature Macrophage

IL-10

Mature Macrophage TNF-α IL-1β IL-8

TNF-α IL-1β IL-8 Endothelium Leukocyte

Jones et al.Pediatr Res, 1996

IL-10

CD 68 and

TNF-a positive cells

24 hours

Interstitial density (mm2)

700

TNF-α+ cells Sulphated GAGs

600 500 400 300 200 100 0

Stillborn <12 h 12-23 h 24-47 h 48-72 h 3-7 days 7-14 days n=5 n=5 n=6 n=6 n=4 n=6 n=8

Murch et al, Pediatr Res, 1996

Age at death

Relative mRNA expression of genes to inflammation (TNF-α, IL-6, MCP-1) in rat pups exposed to 100% oxygen or control pups

**

2.5 2.0 1.5 1.0 0.5 0.0

1 6 10 3 Neonatal age (days)

MCP-1

IL-6

1000 800 600 400 200 0

12

****

**** ***

1 6 10 3 Neonatal age (days)

Wagenaar et al, Free Radic Biol Med, 2004

Fold change 3RA

*

Fold change 3RA

Fold change 3RA

3.0

TNF - α

10 8

****

6 4 2 0

** ***

1 6 10 3 Neonatal age (days)

100% oxygen * p<.05 *** p<.001 ** p<.01 **** p<.0001 controls

Ventilation Strategy on BALF Cytokine Concentrations -Isolated Rat Lung Model1400

TNF-α

1400

IL-1β

C:

Control

1200

1200

MVHP: moderate volume high PEEP

200

200

100

100

MVZP: moderate volume 0 PEEP

Tremblay et al, JCI 1997

C MVHP MVZP HVZP

0 C MVHP MVZP HVZP

0

HVZP: high volume 0 PEEP

Continuous Positive Airway Pressure causes Lung Injury in a Rat Model of Sepsis 1000

1000

† 800

TNF-α(pg/mL)

IL-1β (pg/mL)

800 600 400 200 0

SALINE SALINE LPS LPS -CPAP +CPAP -CPAP +CPAP

600 400 200 0

SALINE SALINE LPS LPS -CPAP +CPAP -CPAP +CPAP

i.v. LPS was given prior to initiation of experiments. Animals were observed for 3 hours Tsuchida, Post et al , Am J Physiol Lung Cell, 2005

+CPAP: 4cm H2O

Continuous Positive Airway Pressure causes Lung Injury in a Rat Model of Sepsis

Intravenous saline with CPAP (4cm H2O)

Intravenous LPS with CPAP

i.v. LPS was given prior to initiation of experiments. Animals were observed for 3 hours Tsuchida, Post et al , Am J Physiol Lung Cell, 2005

Prenatal events Chorioamnionitis - Cytokine exposure of the fetus-

Postnatal events + + + +

Resuscitation Oxygen toxicity Mechanical ventilation Pulmonary and / or Sequential systemic infection lung injury + PDA

Pulmonary inflammatory response Aberrant wound healing Inhibition of alveolarization and vascular development

“New“ BPD

Strategies how to reduce inflammation in the airways and pulmonary tissue ● Use lower SaO2 , FiO2 ● Reduce mechanical ventilation, reduce suctioning, extubate early ● Use surfactant as early as possible ● Close PDA: Prolonged PDA and late closure are associated with an increased risk of BPD Thomas, Speer, J Perinatol 2007, Neonatology 2008; Aly, Pediatrics 2007; Geary et al, Pediatrics 2008

Strategies how to reduce inflammation in the airways and pulmonary tissue ● Treat sepsis and pulmonary infections properly ● Early nutrition, early amino acid administration ● Caffeine ● Vitamin A ● Dexamethasone and other glucocorticoids cannot currently be recommended for prevention of BPD Thomas, Speer, J Perinatol 2007 , Neonatology 2008; Aly, Pediatrics 2007; Geary et al, Pediatrics 2008