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Glaser K, Bamat NA, Wright CJ. Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature. Arch Dis Child Fetal Neonatal Ed 2023; 108:554-560. [PMID: 36600473 PMCID: PMC10246486 DOI: 10.1136/archdischild-2022-324530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today's neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicolas A Bamat
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Bhandari V, Black R, Gandhi B, Hogue S, Kakkilaya V, Mikhael M, Moya F, Pezzano C, Read P, Roberts KD, Ryan RM, Stanford RH, Wright CJ. RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS. J Perinatol 2023; 43:982-990. [PMID: 37188774 PMCID: PMC10400415 DOI: 10.1038/s41372-023-01690-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To provide the best clinical practice guidance for surfactant use in preterm neonates with respiratory distress syndrome (RDS). The RDS-Neonatal Expert Taskforce (RDS-NExT) initiative was intended to add to existing evidence and clinical guidelines, where evidence is lacking, with input from an expert panel. STUDY DESIGN An expert panel of healthcare providers specializing in neonatal intensive care was convened and administered a survey questionnaire, followed by 3 virtual workshops. A modified Delphi method was used to obtain consensus around topics in surfactant use in neonatal RDS. RESULT Statements focused on establishing RDS diagnosis and indicators for surfactant administration, surfactant administration methods and techniques, and other considerations. After discussion and voting, consensus was achieved on 20 statements. CONCLUSION These consensus statements provide practical guidance for surfactant administration in preterm neonates with RDS, with a goal to contribute to improving the care of neonates and providing a stimulus for further investigation to bridge existing knowledge gaps.
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Affiliation(s)
- Vineet Bhandari
- The Children's Regional Hospital at Cooper/Cooper Medical School of Rowan University, Camden, NJ, USA.
| | | | - Bheru Gandhi
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Fernando Moya
- Division of Wilmington Pediatric Subspecialists, Department of Pediatrics, UNC School of Medicine, Wilmington, NC, USA
| | - Chad Pezzano
- Department of Cardio-Respiratory Services Pediatric -Albany Medical Center, Albany, NY, USA
| | - Pam Read
- AESARA Inc., Chapel Hill, NC, USA
| | | | - Rita M Ryan
- UH Rainbow Babies and Children's Hospital -Case Western Reserve University, Cleveland, OH, USA
| | | | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
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Wright CJ, Glaser K, Speer CP, Härtel C, Roehr CC. Reply. J Pediatr 2023; 257:113363. [PMID: 36828344 DOI: 10.1016/j.jpeds.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Charles C Roehr
- Medical Sciences, Division, Nuffield Department of Population Health, University of Oxford, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, United Kingdom
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Balázs G, Balajthy A, Seri I, Hegyi T, Ertl T, Szabó T, Röszer T, Papp Á, Balla J, Gáll T, Balla G. Prevention of Chronic Morbidities in Extremely Premature Newborns with LISA-nCPAP Respiratory Therapy and Adjuvant Perinatal Strategies. Antioxidants (Basel) 2023; 12:1149. [PMID: 37371878 DOI: 10.3390/antiox12061149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Less invasive surfactant administration techniques, together with nasal continuous airway pressure (LISA-nCPAP) ventilation, an emerging noninvasive ventilation (NIV) technique in neonatology, are gaining more significance, even in extremely premature newborns (ELBW), under 27 weeks of gestational age. In this review, studies on LISA-nCPAP are compiled with an emphasis on short- and long-term morbidities associated with prematurity. Several perinatal preventative and therapeutic investigations are also discussed in order to start integrated therapies as numerous organ-saving techniques in addition to lung-protective ventilations. Two thirds of immature newborns can start their lives on NIV, and one third of them never need mechanical ventilation. With adjuvant intervention, these ratios are expected to be increased, resulting in better outcomes. Optimized cardiopulmonary transition, especially physiologic cord clamping, could have an additively beneficial effect on patient outcomes gained from NIV. Organ development and angiogenesis are strictly linked not only in the immature lung and retina, but also possibly in the kidney, and optimized interventions using angiogenic growth factors could lead to better morbidity-free survival. Corticosteroids, caffeine, insulin, thyroid hormones, antioxidants, N-acetylcysteine, and, moreover, the immunomodulatory components of mother's milk are also discussed as adjuvant treatments, since immature newborns deserve more complex neonatal interventions.
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Affiliation(s)
- Gergely Balázs
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - András Balajthy
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - István Seri
- First Department of Pediatrics, School of Medicine, Semmelweis University, 1083 Budapest, Hungary
- Keck School of Medicine of USC, Children's Hospital of Los Angeles, Los Angeles, CA 90033, USA
| | - Thomas Hegyi
- Department of Pediatrics, Division of Neonatology, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ 08903, USA
| | - Tibor Ertl
- Departments of Neonatology and Obstetrics & Gynecology, University of Pécs Medical School, 7624 Pécs, Hungary
- MTA-PTE Human Reproduction Scientific Research Group, University of Pécs, 7624 Pécs, Hungary
| | - Tamás Szabó
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Röszer
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Ágnes Papp
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - József Balla
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- ELKH-UD Vascular Pathophysiology Research Group, Hungarian Academy of Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Gáll
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - György Balla
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- ELKH-UD Vascular Pathophysiology Research Group, Hungarian Academy of Sciences, University of Debrecen, 4032 Debrecen, Hungary
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Viscardi RM, Magder LS, Terrin ML, Davis NL. Predicting the likelihood of lower respiratory tract Ureaplasma infection in preterms. Arch Dis Child Fetal Neonatal Ed 2023; 108:250-255. [PMID: 36261143 PMCID: PMC10113605 DOI: 10.1136/archdischild-2022-324192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/06/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop predictive models of Ureaplasma spp lower airway tract infection in preterm infants. METHODS A dataset was assembled from five cohorts of infants born <33 weeks gestational age (GA) enrolled over 17 years (1999-2016) with culture and/or PCR-confirmed tracheal aspirate Ureaplasma status in the first week of life (n=415). Seventeen demographic, obstetric and neonatal factors were analysed including admission white blood cell (WBC) counts. Best subset regression was used to develop three risk scores for lower airway Ureaplasma infection: (1) including admission laboratory values, (2) excluding admission laboratory values and (3) using only data known prenatally. RESULTS GA and rupture of membranes >72 hours were significant predictors in all 3 models. When all variables including admission laboratory values were included in the regression, WBC count was also predictive in the resulting model. When laboratory values were excluded, delivery route was found to be an additional predictive factor. The area under the curve for the receiver operating characteristic indicated high predictive ability of each model to identify infants with lower airway Ureaplasma infection (range 0.73-0.77). CONCLUSION We developed predictive models based on clinical and limited laboratory information available in the perinatal period that can distinguish between low risk (<10%) and high risk (>40%) of lower airway Ureaplasma infection. These may be useful in the design of phase III trials of therapeutic interventions to prevent Ureaplasma-mediated lung disease in preterm infants and in clinical management of at-risk infants.
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Affiliation(s)
- Rose Marie Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael L Terrin
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalie L Davis
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Härtel C, Herting E, Humberg A, Hanke K, Mehler K, Keller T, Mauer I, Frieauff E, Meyer S, Thome UH, Wieg C, Schmidtke S, Kribs A, Göpel W. Association of Administration of Surfactant Using Less Invasive Methods With Outcomes in Extremely Preterm Infants Less Than 27 Weeks of Gestation. JAMA Netw Open 2022; 5:e2225810. [PMID: 35943742 PMCID: PMC9364126 DOI: 10.1001/jamanetworkopen.2022.25810] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE The inclusion of less invasive surfactant administration (LISA) in the care of preterm infants has been found to be beneficial for respiratory outcomes. Recently, the OPTIMIST trial found higher mortality rates in the subgroup of infants born at 25 to 26 weeks' gestational age (GA) who received surfactant treatment while spontaneously breathing. OBJECTIVE To analyze outcomes among LISA-exposed, highly vulnerable babies born at less than 27 weeks' GA within the large-scale observational cohort of the German Neonatal Network. DESIGN, SETTING, AND PARTICIPANTS In this cohort study of data from 68 tertiary level neonatal intensive care units in Germany of infants born between 22 weeks 0 days to 26 weeks 6 days of gestation between April 1, 2009, and December 31, 2020, short-term outcomes among infants receiving LISA vs infants not receiving LISA were compared. EXPOSURE Use of LISA within the first 72 hours of life. MAIN OUTCOMES AND MEASURES The main outcomes were rates of LISA use, use of mechanical ventilation within the first 72 hours (considered failure of LISA), and association of LISA with outcomes, including death from all causes, bronchopulmonary dysplasia (BPD), death and BPD combined, pneumothorax, retinopathy of prematurity, intracerebral hemorrhage, and periventricular leukomalacia. To address potential confounding factors, multivariate logistic regression models were used. RESULTS A total of 6542 infants (3030 [46.3%] female and 3512 [53.7%] male; mean [SD] GA, 25.3 (1.1) weeks; mean [SD] birth weight, 715 [180] g) were analyzed; 2534 infants (38.7%) received LISA, which was most frequently given quasi-prophylactically during delivery room management. Among the infants who received LISA, 1357 (53.6%) did not require mechanical ventilation in the first 72 hours compared with 331 infants (8.3%) of 4008 who did not receive LISA. In a multivariate logistic regression model that adjusted for GA, small-for-GA status, sex, multiple birth, inborn status, antenatal steroid use, and maximum fraction of inspired oxygen in the first 12 hours of life, LISA was associated with reduced risks of all-cause death (odds ratio [OR], 0.74; 95% CI, 0.61-0.90; P = .002), BPD (OR, 0.69; 95% CI, 0.62-0.78; P < .001), and BPD or death (OR, 0.64; 95% CI, 0.57-0.72; P < .001) compared with infants without LISA exposure. CONCLUSIONS AND RELEVANCE The results of this long-term multicenter cohort study suggest that LISA may be associated with reduced risks of adverse outcomes in extremely preterm infants.
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Affiliation(s)
- Christoph Härtel
- Department of Paediatrics, University of Würzburg, Würzburg, Germany
| | - Egbert Herting
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Alexander Humberg
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Kathrin Hanke
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Katrin Mehler
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Titus Keller
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Isabell Mauer
- Department of Paediatrics, University of Würzburg, Würzburg, Germany
| | - Eric Frieauff
- Department of Paediatrics, University of Würzburg, Würzburg, Germany
| | - Sascha Meyer
- Department of General Pediatrics and Neonatology, University Children’s Hospital of Saarland, Homburg, Germany
| | - Ulrich H. Thome
- Division of Neonatology, Department of Women’s and Children’s Health, University Children’s Hospital Leipzig, Leipzig, Germany
| | - Christian Wieg
- Neonatology and Pediatric Intensive Care, Children’s Hospital Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Susanne Schmidtke
- Division of Neonatology, Asklepios Hospital Hamburg-Barmbek, Hamburg, Germany
| | - Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Wolfgang Göpel
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
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