Timing of PDA Closure and Respiratory Outcome in Premature Infants

The investigators propose the present study with the following aims:

• to determine whether early patent ductus arteriosus {PDA} treatment with ibuprofen (specifically treatment at the onset of clinical symptoms) is superior to late ibuprofen treatment (specifically treatment only when symptoms of a hemodynamically significant PDA are present) in the evolution of bronchopulmonary dysplasia {BPD} (defined as duration of supplemental oxygen exposure during the first 28 days), and
• to determine whether early PDA treatment with ibuprofen will be superior to late treatment with ibuprofen in efficacy of PDA closure, need for rescue therapy, need for PDA ligation and incidence of major complications of prematurity.

Hypothesis: Early pharmacologic closure of PDA with ibuprofen will improve respiratory course and reduce BPD as reflected by a reduction in duration of supplemental oxygen during the first 28 days of age vs. late pharmacologic treatment with ibuprofen.

Outcome variables: The primary outcome of this study is the number of days spent on supplemental oxygen by each infant during the first 28 days.

Other outcomes to be determined between groups include:

• Mortality
• Other respiratory variables: total days on supplemental oxygen, days on mechanical ventilation, oxygen dependence at 36 weeks post menstrual age, age at final extubation.
• Other respiratory complications: pneumothorax, pulmonary interstitial emphysema, need for high frequency ventilation, pulmonary hypertension
• Efficacy of PDA closure: number of courses of medication required, need for ligation
• Other neonatal complications: intraventricular hemorrhage {IVH}, periventricular leukomalacia {PVL}, retinopathy of prematurity {ROP}, necrotizing enterocolitis {NEC}, intestinal perforation, sepsis, renal dysfunction (oliguria, elevated creatinine)
• Time to achieving full enteral feedings, time to regain birth weight, weight at discharge.
• Length of hospital stay

Study terminated when iv ibuprofen withdrawn for both clinical and research use.

• Drug: Early ibuprofen
  IBUPROFEN DOSING SCHEDULE: initial dose 10 mg/kg, then two doses 5 mg/kg each, after 24 and 48 h, slow IV infusion. Initial therapy will be blinded. At the diagnosis of PDA, infants randomized to "early treatment" will receive blinded ibuprofen. Infants randomized to "late treatment" will receive blinded placebo. The criteria for a hemodynamically significant PDA include: SIGNS OF PDA + Presence of significant pulmonary hemorrhage ALONE OR SIGNS OF PDA +: Pulmonary edema, plus a large heart on CXR + one of the following: Hypotension, Respiratory failure (not due to something other than PDA) defined as at least two of the following respirator settings: Need for supplemental O2 > 50%; need IMV >40; need for PIP > 20; or need for HFOV. Once hemodynamically significant PDA criteria met, if echo is positive, infants from both groups can receive open label ibuprofen; infants who had received placebo will be have ibuprofen for the first time (thus, "late" ibuprofen).
• Other: Late ibuprofen expectant group

  Other: Late Ibuprofen expectant group

  Drug: Late ibuprofen expectant group

  IBUPROFEN DOSING SCHEDULE: At the diagnosis of PDA, infants randomized to "late ibuprofen expectant group" will receive blinded placebo. If criteria of a hemodynamically significant PDA develop, infants from this group can now receive open label ibuprofen at an initial dose of 10 mg/kg, then two doses 5 mg/kg each, after 24 and 48 h, slow IV infusion. Signs of a hemodynamically significant PDA include: SIGNS OF PDA + Presence of significant pulmonary hemorrhage ALONE OR SIGNS OF PDA +: Pulmonary edema, plus a large heart on CXR + one of the following: Hypotension, Respiratory failure (not due to something other than PDA) defined as at least two of the following respirator settings: Need for supplemental O2 > 50%; need IMV >40; need for PIP > 20; or need for HFOV. Infants who had received placebo will be have ibuprofen for the first time (thus, "late" ibuprofen or expectant).

• Experimental: early ibuprofen

  Drug: Early ibuprofen

  IBUPROFEN DOSING SCHEDULE: At the diagnosis of PDA, infants randomized to "early treatment" will receive blinded ibuprofen initial dose 10 mg/kg, then two doses 5 mg/kg each, after 24 and 48 h, slow IV infusion. Initial therapy will be blinded. This group will then be eligible to receive unblended, open label ibuprofen for a hemodynamically significant PDA include: SIGNS OF PDA + Presence of significant pulmonary hemorrhage ALONE OR SIGNS OF PDA +: Pulmonary edema, plus a large heart on CXR + one of the following: Hypotension, Respiratory failure (not due to something other than PDA) defined as at least two of the following respirator settings: Need for supplemental O2 > 50%; need IMV >40; need for PIP > 20; or need for HFOV.

  Intervention: Drug: Early ibuprofen
• Late Ibuprofen expectant group

  Drug: Late ibuprofen expectant group

  IBUPROFEN DOSING SCHEDULE: At the diagnosis of PDA, infants randomized to "late ibuprofen expectant group" will receive blinded placebo. If criteria of a hemodynamically significant PDA develop, infants from this group can now receive open label ibuprofen at an initial dose of 10 mg/kg, then two doses 5 mg/kg each, after 24 and 48 h, slow IV infusion. Signs of a hemodynamically significant PDA include: SIGNS OF PDA + Presence of significant pulmonary hemorrhage ALONE OR SIGNS OF PDA +: Pulmonary edema, plus a large heart on CXR + one of the following: Hypotension, Respiratory failure (not due to something other than PDA) defined as at least two of the following respirator settings: Need for supplemental O2 > 50%; need IMV >40; need for PIP > 20; or need for HFOV. Infants who had received placebo will be have ibuprofen for the first time (thus, "late" ibuprofen or expectant).

  Intervention: Other: Late ibuprofen expectant group

Inclusion Criteria:

• Inborn patients at JHS hospitals (admitted to the NICU at JMH within the first 72 hrs of age
• BW 500-1250 grams
• 23-32 wks gestational age
• > 1d but < 14d of age.

Exclusion Criteria:

• Major congenital malformations
• Proven sepsis (positive blood culture)
• Contraindications to the use of Ibuprofen or Indomethacin
• Terminal condition, not expected to survive beyond 48 h
• Infants born excessively SGA(3 S.D. below the mean for GA)
• Infants with initial PDA presentation that is hemodynamically significant