Neonatology ; Noninvasive ventilation with vs without early surfactant to prevent chronic lung disease in preterm infants. A systematic review and meta-analysis. JAMA Pediatrics. Impact of minimally invasive surfactant therapy in preterm infants at weeks gestation. Less invasive surfactant administration and complications of preterm birth.
Nature Scientific reports DOI Date last published: 25 March This document is only valid for the day on which it is accessed. Please read our disclaimer. Newborn intensive care. Background The administration of exogenous surfactant to newborn infants with or at risk of Respiratory Distress Syndrome RDS is established practice.
Surfactant is indicated for the treatment of RDS in premature infants. Precautions Transient bradycardia or oxygen desaturation may occur. Adverse reactions Endotracheal tube blockage and pulmonary haemorrhage are potential complications of surfactant administration. Administration See Poractant alpha protocol. LISA Selected infants may be considered for thin catheter administration of surfactant.
Infants should have good respiratory effort. One-to-one nursing is recommended for the duration of the administration and observations. Inform the level 3 specialist and staff in case the infant requires intubation.
INSURE In general infants requiring intubation will be moved to Level 3 as intubation drugs may be required when performing INSURE technique, acknowledging that this may prolong recovery time and some infants will therefore require ongoing ventilation.
Position the baby supine with head in a neutral position. Extubate to CPAP as soon as clinically able. Suctioning should be avoided for 4 hours unless absolutely indicated for a blocked ETT. Etiology of surfactant inactivation or dysfunction: pulmonary hemorrhage, sepsis, pneumonia, meconium aspiration, and post surfactant slump. Ideally the dose should be given within 1 hr of birth but definitely before 2 hours of age. The technical details of administration are discussed in the package insert and in the NICU Nursing Protocols on administration.
Ventilator Management: A blood gas should be checked within 15 - 20 minutes of the dose and the ventilator settings should be weaned appropriately to minimize the risk of a pneumothorax. Subsequent to this review, several large trials have included CPAP use in the delivery room. Trial results have demonstrated that the latter strategy is safe and that it may reduce the number of infants intubated and given surfactant [ 18 ] [ 19 ] [ 24 ].
These studies suggest that use of nasal CPAP shortly after birth as the primary mode of respiratory support is an acceptable alternative to elective intubation and administration of prophylactic surfactant. However, the criteria for surfactant administration in infants initially supported by CPAP are less clear Level 1a evidence. One potential issue with INSURE is the perceived difficulty with extubation for selected infants, even without the influence of premedication.
Concerns about lung injury remain, however, even with brief mechanical ventilation [ 27 ]. Therefore, alternative modes of surfactant administration are needed and some of these are discussed below. The timing of surfactant administration for preterm infants intubated for RDS was examined in one systematic review [ 8 ] that compared early within the first 2 h of age to late surfactant administration delayed until RDS was established, usually 2 h or beyond.
Meta-analyses of six randomized trials showed that early surfactant was associated with a significant decrease in mortality, BPD at 36 weeks, BPD or death at 36 weeks, and reduction in the risk of air leak, with no increase in the risk for pulmonary hemorrhage or severe IVH.
A number of studies comparing early to late surfactant, as defined by oxygen requirement thresholds, suggest that low FiO 2 0. This finding held especially in infants born to mothers who received two doses of antenatal corticosteroids. Further, two large randomized trials that did not allow infants initially managed with CPAP to receive surfactant until an FiO 2 threshold of 0.
Use of surfactant before inter-facility transport of preterm infants was found to be associated with lower oxygen requirement during transport and shorter duration of ventilation support, compared with controls [ 33 ] Level 4 evidence.
Surfactant, no matter which form, has been shown to be efficacious in the treatment of RDS. A plethora of systematic reviews since the late s have summarized the vast literature on the many clinical trials comparing effects of different types of surfactant. First-generation synthetic surfactants are composed of DPPC without surfactant proteins, and they are less effective in reducing ventilation support, pneumothorax, and mortality compared with animal-derived surfactants [ 4 ].
The only second-generation synthetic surfactant ever tested in infants is lucinactant Surfaxin , which contains two phospholipids, a fatty acid, and a hydrophobic synthetic peptide to mimic SP-B KL4. Lucinactant was withdrawn from the market in preceding trials of its aerosolized form [ 34 ]. A wide variety of animal-derived or natural surfactants are available for use, and many clinical trials have been conducted to compare the efficacy of different preparations.
One systematic review of 13 RCTs associated administering animal-derived surfactant to infants with established RDS with significant improvement in oxygenation, ventilation requirements, and reduction of air leak, mortality before hospital discharge, and in death or BPD at 28 days, compared with placebo [ 6 ]. Another systematic review included 16 trials comparing different animal-derived surfactants [ 7 ].
While the two types of bovine surfactant preparations were comparable in reducing death or BPD, meta-analysis showed that porcine surfactant was more effective than bovine surfactant in reducing mortality before discharge, death or BPD at 36 weeks, and need for re-dosing.
However, a trend toward increased mortality associated with the use of poractant was also noted, although these deaths were not respiratory-related. In summary, animal-derived and the newer generation synthetic surfactants are both effective for treating RDS and improving survival without BPD. When comparing different animal-derived surfactants, emerging evidence suggests that porcine minced lung extract, especially in higher dose, may be superior to bovine surfactant for improving acute respiratory status and reducing mortality or BPD in infants with RDS Level 1a evidence.
Generally accepted practice at the present time is to repeat doses of surfactant only when there is evidence of ongoing RDS based on ventilation and oxygen requirements.
Their results suggested that delaying re-dosing of surfactant until the infant requires escalated respiratory support is acceptable, except when RDS is complicated by sepsis or perinatal hypoxic-ischemic injury.
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