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)
50
„High Risk“ (n=26)
% FiO2

40

30

20
0 5 10 15 20 25 30
Postnatal age (days)
Gerhardt, 1994
 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

107
CELL NUMBER

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
TAF= tracheal aspirate fluid
Merritt et al, J Clin Invest 1983
 Chorioamnionitis
Microorganisms, LPS PMN
Hyperoxia
Baro-/ Volutrauma
Capillary
Airway

TNF- α Mo
IL-1
Type II-
Pneumozyt

IL-8

Fibroblast Interstitium
Speer Biol Neon 2001; Shimotake et al Pediatr Res 2004
Speer, Drug Discovery Today 2007
 Al Vascular
bu Space
m
in
ctic
o ta Elastase
h em ctors Pe
C Fa O2 , OH rm
e
ab
In
M fla ili
ed m
ia ma
ty
to to
rs ry
Alveolar
Space
Mo
Aveolar
Macrophage
Type II Surfactant
Pneumocyte

Speer Biol Neon 2001; Speer, Drug Discovery Today 2007

 Albumin in lung effluent
10
% Change In Enyzme Activity

8
BPD
6 Controls

4
p<0.01
2

0
3 5 7 10 15
postnatal age (days)

Groneck et al, Pediatrics, 1994

26 weeks of gestation, day 10 of life
 Histologic Chorioamnionitis

70 n=
261 n=
n=
Histological chorioamnionitis %

200
60 139
n=
164
50
n= n=
236 284
40 n=
375 n=
380
30 n=
n=
539
580 n=
20 770

10

0
20-24 25 26 27 28 29 30 31 32 33 34
Gestational Age (completed weeks)

Lahra and Jeffrey, AJOBGYN, 190:147, 2004
 Frequency of a positive amniotic fluid (AF) culture
and intraamniotic inflammation

80

60

% 40

20

0
20-27 27-30 30-33 33-35
Gestational age (weeks)

intra-amniotic inflammation (P< .001) positive AF culture (P< .05)

Shim et al, Am J Obstet Gynecol, 2004

 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
TNF-
α
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 Amnionitis negative

Schmidt, Speer. Am J Obstet Gynecol 2001

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

Amnionitis positive Amnionitis positive

Schmidt, Speer. Am J Obstet Gynecol 2001
 ICAM-expression in
endothelium of an umbilical artery

Chorioamnionitis, funisitis, No chorioamnionitis,

GA 26 weeks 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
700 p = 0.004
ICAM – 1 (ng/ml)

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

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
80 Ureaplasma urealyticum (n=19)
Prenatal infection (n=7)
Interleukin-1 (pg/µg SC)

70 RDS, no infection, no BPD

(n=9) *
60
*
50 *
40 * *

30

20 * *p<0.01
10

0
1 3 5 7
postnatal age (days)
Groneck, Schmale, Soditt, Stützer, Götze-Speer, Speer,
Pediatr Pulmonol 2001 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

1.000.000
CFU`s

100.000
10.000

1.000

100

10
1
AF 24 hr 72 hr 144 hr 240 hr 336 hr
(amniotic fluid)

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 Uu - negative Uu - positive

animals ventilated animals at 14 animals at 14
for 14 days days of age days of age
Yoder, Coalson et al, Pediatr Res 2004
 Imbalance between Proinflammatory
and Antiinflammatory Cytokines
Neonatal Lung Lavage

Immature Macrophage Mature Macrophage

TNF-α TNF-α
IL-10
IL-1β IL-1β
IL-10 IL-8 IL-8

Endothelium
Leukocyte
Jones et al.Pediatr Res, 1996
CD 68 and
TNF-a positive cells 24 hours
 700 TNF-α+ cells
Interstitial density (mm2)

600 Sulphated GAGs

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
Age at death

Murch et al, Pediatr Res, 1996

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

TNF - α IL-6 MCP-1

3.0 * ** 1000 **** 12

2.5 800 10
Fold change 3RA

Fold change 3RA

Fold change 3RA

2.0 8
600 ****
1.5 6
400
1.0 4 **
200 **** ***
0.5 2
***
0.0 0 0
1 3 6 10 1 3 6 10 1 3 6 10
Neonatal age (days) Neonatal age (days) Neonatal age (days)

100% oxygen * p<.05 *** p<.001

controls ** p<.01 **** p<.0001
Wagenaar et al, Free Radic Biol Med, 2004
 Ventilation Strategy on BALF
Cytokine Concentrations
-Isolated Rat Lung Model-

1400 TNF-α 1400 IL-1β

C: Control
1200 1200 MVHP: moderate volume
high PEEP
200 200 MVZP: moderate volume
0 PEEP
100 100
HVZP: high volume
0 0 0 PEEP
MVHP
MVZP
HVZP
C
MVHP
MVZP
HVZP
C

Tremblay et al, JCI 1997

 Continuous Positive Airway Pressure causes Lung
Injury in a Rat Model of Sepsis
1000 1000
†
800 800

TNF-α(pg/mL)
IL-1β (pg/mL)

600 600

400 400

200 200

0 0
SALINE SALINE LPS LPS SALINE SALINE LPS LPS
-CPAP +CPAP -CPAP +CPAP -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 Postnatal events
+ Resuscitation
Chorioamnionitis
- Cytokine + Oxygen toxicity
exposure of the + Mechanical ventilation
fetus- + Pulmonary and / or
Sequential
lung injury
systemic infection
+ 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