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Sildenafil untuk hipertensi pulmonari dalam neonat

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Abstract

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Background

Persistent pulmonary hypertension in neonates (PPHN) is associated with high mortality. Currently, the therapeutic mainstay for PPHN is assisted ventilation and administration of inhaled nitric oxide (iNO). However, nitric oxide is costly and may not be appropriate in resource‐poor settings. Approximately 30% of patients fail to respond to iNO. High concentrations of phosphodiesterases in the pulmonary vasculature has led to the use of phosphodiesterase inhibitors such as sildenafil or milrinone.

Objectives

To assess the efficacy and safety of sildenafil in the treatment of persistent pulmonary hypertension in neonates.

Search methods

The Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL databases were searched from their inception until December 2010; Clinicaltrials.gov web site, the reference lists of identified trials, and abstracts of meetings were searched without any language restriction.

Selection criteria

Randomised or quasi‐randomised controlled trials of sildenafil compared with placebo or other pulmonary vasodilators, irrespective of dose, route and duration of administration in neonates with PPHN, were included if the trial reported any of the pre‐specified outcomes.

Data collection and analysis

The methodological quality of the trials was assessed regarding how bias was minimized at study entry, during study intervention and at outcomes measurement. Data on relevant outcomes were extracted and the effect size was estimated and reported as relative risk (RR), risk difference (RD) and weighted mean difference (MD) as appropriate. The I‐squared (I2) test of heterogeneity was applied.

Main results

Three eligible trials that enrolled 77 infants were identified. The methodological quality of the studies indicated low‐moderate risk of bias. All studies were performed in resource‐limited settings where iNO and high frequency ventilation were not available at the time of study. There was significant reduction in mortality in the sildenafil group (typical RR 0.20, 95% CI 0.07 to 0.57; typical RD ‐0.38, 95% CI ‐0.60 to ‐0.16; Number needed to treat to benefit 3, 95% CI 2 to 6). Physiological parameters of oxygenation (oxygenation index, PaO2) suggested a steady improvement after the first dose of sildenafil. No clinically important side effects were identified.

Authors' conclusions

Sildenafil in the treatment of PPHN has significant potential especially in resource limited settings. However, a large scale randomised trial comparing sildenafil with the currently used vasodilator, inhaled nitric oxide, is needed to assess efficacy and safety.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Ringkasan bahasa mudah

Sildenafil untuk hipertensi pulmonari dalam neonat

Sesetengah bayi mengalami hipertensi pulmonari neonatal yang berterusan (PPHN), satu keadaan yang mana tekanan dalam saluran darah yang membekalkan darah ke paru paru menjadi terlalu tinggi. Tekanan tinggi yang berterusan dalam saluran‐saluran ini menyebabkan kurang darah mengalir ke paru‐paru dan, oleh itu, kurang oksigen sampai ke darah dan organ‐organ badan. Sildenafil boleh menyebabkan otot saluran‐saluran ini merehat dan menjadikan aliran darah yang lebih baik dan penghantaran oksigen yang lebih baik kepada semua organ. Rawatan ini amat berguna apabila pendekatan rawatan lain tiada. Namun demikian, dalam persekitaran yang mempunyai banyak sumber, kajian lanjut adalah diperlukan untuk membandingkan sildenafil dengan rawatan yang sedia ada dari segi kesan dan keselamatan.