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Abdel-Latif ME, Walker E, Osborn DA. Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2024; 1:CD008309. [PMID: 38270182 PMCID: PMC10809312 DOI: 10.1002/14651858.cd008309.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Laryngeal mask airway surfactant administration (S-LMA) has the potential benefit of surfactant administration whilst avoiding endotracheal intubation and ventilation, ventilator-induced lung injury and bronchopulmonary dysplasia (BPD). OBJECTIVES To evaluate the benefits and harms of S-LMA either as prophylaxis or treatment (rescue) compared to placebo, no treatment, or intratracheal surfactant administration via an endotracheal tube (ETT) with the intent to rapidly extubate (InSurE) or extubate at standard criteria (S-ETT) or via other less-invasive surfactant administration (LISA) methods on morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome (RDS). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and three trial registries in December 2022. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster- or quasi-RCTs of S-LMA compared to placebo, no treatment, or other routes of administration (nebulised, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and extracted data. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included eight trials (seven new to this update) recruiting 510 newborns. Five trials (333 infants) compared S-LMA with surfactant administration via ETT with InSurE. One trial (48 infants) compared S-LMA with surfactant administration via ETT with S-ETT, and two trials (129 infants) compared S-LMA with no surfactant administration. We found no studies comparing S-LMA with LISA techniques or prophylactic or early S-LMA. S-LMA versus surfactant administration via InSurE S-LMA may have little or no effect on the composite outcome of death or BPD at 36 weeks' postmenstrual age (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.27 to 8.34, I 2 = not applicable (NA) as 1 study had 0 events; risk difference (RD) 0.02, 95% CI -0.07 to 0.10; I 2 = 0%; 2 studies, 110 infants; low-certainty evidence). There may be a reduction in the need for mechanical ventilation at any time (RR 0.53, 95% CI 0.36 to 0.78; I 2 = 27%; RD -0.14, 95% CI -0.22 to -0.06, I 2 = 89%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 17; 5 studies, 333 infants; low-certainty evidence). However, this was limited to four studies (236 infants) using analgesia or sedation for the InSurE group. There was little or no difference for air leak during first hospitalisation (RR 1.39, 95% CI 0.65 to 2.98; I 2 = 0%; 5 studies, 333 infants (based on 3 studies as 2 studies had 0 events); low-certainty evidence); BPD among survivors to 36 weeks' PMA (RR 1.28, 95% CI 0.47 to 3.52; I 2 = 0%; 4 studies, 264 infants (based on 3 studies as 1 study had 0 events); low-certainty evidence); or death (all causes) during the first hospitalisation (RR 0.28, 95% CI 0.01 to 6.60; I 2 = NA as 2 studies had 0 events; 3 studies, 203 infants; low-certainty evidence). Neurosensory disability was not reported. Intraventricular haemorrhage ( IVH) grades III and IV were reported among the study groups (1 study, 50 infants). S-LMA versus surfactant administration via S-ETT No study reported death or BPD at 36 weeks' PMA. S-LMA may reduce the use of mechanical ventilation at any time compared with S-ETT (RR 0.47, 95% CI 0.31 to 0.71; RD -0.54, 95% CI -0.74 to -0.34; NNTB 2, 95% CI 2 to 3; 1 study, 48 infants; low-certainty evidence). We are very uncertain whether S-LMA compared with S-ETT reduces air leak during first hospitalisation (RR 2.56, 95% CI 0.11 to 59.75), IVH grade III or IV (RR 2.56, 95% CI 0.11 to 59.75) and death (all causes) during the first hospitalisation (RR 0.17, 95% CI 0.01 to 3.37) (1 study, 48 infants; very low-certainty evidence). No study reported BPD to 36 weeks' PMA or neurosensory disability. S-LMA versus no surfactant administration Rescue surfactant could be used in both groups. There may be little or no difference in death or BPD at 36 weeks (RR 1.65, 95% CI 0.85 to 3.22; I 2 = 58%; RD 0.08, 95% CI -0.03 to 0.19; I 2 = 0%; 2 studies, 129 infants; low-certainty evidence). There was probably a reduction in the need for mechanical ventilation at any time with S-LMA compared with nasal continuous positive airway pressure without surfactant (RR 0.57, 95% CI 0.38 to 0.85; I 2 = 0%; RD -0.24, 95% CI -0.40 to -0.08; I 2 = 0%; NNTB 4, 95% CI 3 to 13; 2 studies, 129 infants; moderate-certainty evidence). There was little or no difference in air leak during first hospitalisation (RR 0.65, 95% CI 0.23 to 1.88; I 2 = 0%; 2 studies, 129 infants; low-certainty evidence) or BPD to 36 weeks' PMA (RR 1.65, 95% CI 0.85 to 3.22; I 2 = 58%; 2 studies, 129 infants; low-certainty evidence). There were no events in either group for death during the first hospitalisation (1 study, 103 infants) or IVH grade III and IV (1 study, 103 infants). No study reported neurosensory disability. AUTHORS' CONCLUSIONS In preterm infants less than 36 weeks' PMA, rescue S-LMA may have little or no effect on the composite outcome of death or BPD at 36 weeks' PMA. However, it may reduce the need for mechanical ventilation at any time. This benefit is limited to trials reporting the use of analgesia or sedation in the InSurE and S-ETT groups. There is low- to very-low certainty evidence for no or little difference in neonatal morbidities and mortality. Long-term outcomes are largely unreported. In preterm infants less than 32 weeks' PMA or less than 1500 g, there are insufficient data to support or refute the use of S-LMA in clinical practice. Adequately powered trials are required to determine the effect of S-LMA for prevention or early treatment of RDS in extremely preterm infants. S-LMA use should be limited to clinical trials in this group of infants.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Discipline of Neonatology, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, ACT, Australia
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
- Department of Public Health, College of Science Health and Engineering, La Trobe University, Bundoora, VIC, Australia
| | - Elizabeth Walker
- Canberra Health Services Library and Multimedia, Canberra Health Services, Canberra, ACT, Australia
| | - David A Osborn
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
- Department of Neonatology, Royal Prince Alfred Hospital, Camperdown, Australia
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Malibary H, Nasief H, Tamur S, Ashfaq M, Iftikhar M, Naqoosh A, Khadawardi K, Bahauddin AA, Alzahrani A, Hassan A. Effect of Nasal Continuous Airway Pressure With and Without Surfactant Administration for the Treatment of Respiratory Distress Syndrome in Preterm Neonates. Cureus 2023; 15:e46974. [PMID: 38021697 PMCID: PMC10640871 DOI: 10.7759/cureus.46974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background Neonatal respiratory distress syndrome is a common cause of respiratory distress in newborns, often resulting from a lack of surfactant production or premature lung breakdown. The objective of this study was to compare the effect of nasal continuous airway pressure with and without surfactant administration for the treatment of respiratory distress syndrome in preterm neonates. Methodology A comparative analytical study was conducted on 100 neonates (group A continuous positive airway pressure (CPAP) with surfactant = 50 vs. group B CPAP only= 50 ). The group was allocated to the patient according to sequence. In group A, the neonates were given surfactant by the INSURE (intubation, surfactant, extubation) technique via an endotracheal tube with a single dose of 100 mg/kg/dose within the first hours of life followed by CPAP. In group B, the neonates were given only CPAP after birth. At follow-up after 24 hours, pH, pCO2, pO2, positive end-expiratory pressure (PEEP), and FiO2 were documented. All information was recorded on a predesigned questionnaire and results were subjected to statistical analysis to determine the significance of observed differences. Collected data were entered and analyzed using SPSS version 22 (IBM Corp., Armonk, NY, USA). Both groups were compared for mean pH, pCO2, pO2, PEEP, and FiO2 using an independent-sample t-test and effectiveness using a chi-square test. A significant difference was considered when the p-value was ≤0.05. Results Group A had a mean age of 4.84 ± 0.95 hours, while group B had a mean age of 5.5 ± 1.26 hours (p = 0.04). Gender distribution was similar in both groups, with 46.0% males and 54.0% females in group A, and 48.0% males and 52.0% females in group B (p = 0.841). Regarding post-treatment blood gas analysis, group A had a mean pH of 7.30 ± 0.05, and group B had a mean pH of 7.302 ± 0.07. While there was no significant difference in pO2 levels (p = 0.38), there was a substantial difference in pCO2 levels, with group A at 38.26 ± 4.35 and group B at 35.45 ± 4.36 (p = 0.02).CPAP parameters also showed a statistically significant difference in PEEP pCO2, with group A at 4.5 ± 0.73 and group B at 4.16 ± 0.37 (p = 0.004). After treatment, group A exhibited significant improvements in blood gas analysis and CPAP parameters compared to group B. Conclusions The study revealed that both CPAP with and without surfactant treatment effectively treat respiratory distress syndrome in preterm infants, with both being safe, effective, secure, and reducing side effects. However, CPAP treatment without surfactant is a non-invasive and cost-effective option.
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Affiliation(s)
- Husam Malibary
- Internal Medicine, King Abdulaziz University, Jeddah, SAU
| | - Hisham Nasief
- Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Shadi Tamur
- Department of Pediatrics, College of Medicine, Taif University, Taif, SAU
| | - Muhammad Ashfaq
- Pediatrics, National Institute of Child Health, Karachi, PAK
| | | | - Ayesha Naqoosh
- Social and Preventive Pediatrics, Sir Ganga Ram Hospital, Lahore, PAK
| | | | - Ammar A Bahauddin
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Madinah, SAU
| | - Ahmad Alzahrani
- Department of Pediatrics, College of Medicine, Taif University, Taif, SAU
| | - Amber Hassan
- European School of Molecular Medicine, University of Milan, Milan, ITA
- Translational Neuroscience Lab, CEINGE-Biotecnologie Avanzate, Naples, ITA
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Reid E, Kamlin OF, Orsini F, De Paoli AG, Clark HW, Soll RF, Carlin JB, Davis PG, Dargaville PA. Success of blinding a procedural intervention in a randomised controlled trial in preterm infants receiving respiratory support. Clin Trials 2023; 20:479-485. [PMID: 37144610 DOI: 10.1177/17407745231171647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Blinding of treatment allocation from treating clinicians in neonatal randomised controlled trials can minimise performance bias, but its effectiveness is rarely assessed. METHODS To examine the effectiveness of blinding a procedural intervention from treating clinicians in a multicentre randomised controlled trial of minimally invasive surfactant therapy versus sham treatment in preterm infants of gestation 25-28 weeks with respiratory distress syndrome. The intervention (minimally invasive surfactant therapy or sham) was performed behind a screen within the first 6 h of life by a 'study team' uninvolved in clinical care including decision-making. Procedure duration and the study team's words and actions during the sham treatment mimicked those of the minimally invasive surfactant therapy procedure. Post-intervention, three clinicians completed a questionnaire regarding perceived group allocation, with the responses matched against actual intervention and categorised as correct, incorrect, or unsure. Success of blinding was calculated using validated blinding indices applied to the data overall (James index, successful blinding defined as > 0.50), or to the two treatment allocation groups (Bang index, successful blinding: -0.30 to 0.30). Blinding success was measured within staff role, and the associations between blinding success and procedural duration and oxygenation improvement post-procedure were estimated. RESULTS From 1345 questionnaires in relation to a procedural intervention in 485 participants, responses were categorised as correct in 441 (33%), incorrect in 142 (11%), and unsure in 762 (57%), with similar proportions for each of the response categories in the two treatment arms. The James index indicated successful blinding overall 0.67 (95% confidence interval (CI) 0.65-0.70). The Bang index was 0.28 (95% CI 0.23-0.32) in the minimally invasive surfactant therapy group and 0.17 (95% CI 0.12-0.21) in the sham arm. Neonatologists more frequently guessed the correct intervention (47%) than bedside nurses (36%), neonatal trainees (31%), and other nurses (24%). For the minimally invasive surfactant therapy intervention, the Bang index was linearly related to procedural duration and oxygenation improvement post-procedure. No evidence of such relationships was seen in the sham arm. CONCLUSION Blinding of a procedural intervention from clinicians is both achievable and measurable in neonatal randomised controlled trials.
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Affiliation(s)
- Elizabeth Reid
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Omar F Kamlin
- Newborn Research, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Francesca Orsini
- Clinical Epidemiology & Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Antonio G De Paoli
- Department of Paediatrics, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Howard W Clark
- Department of Neonatal Research, University College London, London, UK
| | - Roger F Soll
- Pediatrics, The University of Vermont, Burlington, VT, USA
| | - John B Carlin
- Clinical Epidemiology & Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Peter G Davis
- Newborn Research, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
- Department of Paediatrics, Royal Hobart Hospital, Hobart, TAS, Australia
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Ramaswamy VV, Bandyopadhyay T, Abiramalatha T, Pullattayil S AK, Szczapa T, Wright CJ, Roehr CC. Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis. EClinicalMedicine 2023; 62:102097. [PMID: 37538537 PMCID: PMC10393620 DOI: 10.1016/j.eclinm.2023.102097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 08/05/2023] Open
Abstract
Background The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS. Methods The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life. Findings 58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) <0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low. Interpretation Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound. Funding None.
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Affiliation(s)
| | | | - Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
| | | | - Tomasz Szczapa
- II Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Newborn Services, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
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Shin SH, Shin SH, Kim SH, Song IG, Jung YH, Kim EK, Kim HS. Noninvasive Neurally Adjusted Ventilation in Postextubation Stabilization of Preterm Infants: A Randomized Controlled Study. J Pediatr 2022; 247:53-59.e1. [PMID: 35460702 DOI: 10.1016/j.jpeds.2022.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/07/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the effects of noninvasive neurally adjusted ventilatory assist (NIV-NAVA) to nasal continuous positive airway pressure (NCPAP) in achieving successful extubation in preterm infants. STUDY DESIGN This prospective, single-center, randomized controlled trial enrolled preterm infants born at <30 weeks of gestation who received invasive ventilation. Participants were assigned at random to either NIV-NAVA or NCPAP after their first extubation from invasive ventilation. The primary outcome of the study was extubation failure within 72 hours of extubation. Electrical activity of the diaphragm (Edi) values were collected before extubation and at 1, 4, 12, and 24 hours after extubation. RESULTS A total of 78 infants were enrolled, including 35 infants in the NIV-NAVA group and 35 infants in the NCPAP group. Extubation failure within 72 hours of extubation was higher in the NCPAP group than in the NIV-NAVA group (28.6% vs 8.6%; P = .031). The duration of respiratory support and incidence of severe bronchopulmonary dysplasia were similar in the 2 groups. Peak and swing Edi values were comparable before and at 1 hour after extubation, but values at 4, 12, and 24 hours after extubation were lower in the NIV-NAVA group compared with the NCPAP group. CONCLUSIONS In the present trial, NIV-NAVA was more effective than NCPAP in preventing extubation failure in preterm infants. TRIAL REGISTRATION ClinicalTrials.gov: NCT02590757.
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Affiliation(s)
- Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Seung Hyun Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seh Hyun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - In Gyu Song
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Bundang Hospital, Sungnam-si, Republic of Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
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Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
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Pareek P, Deshpande S, Suryawanshi P, Sah LK, Chetan C, Maheshwari R, More K. Less Invasive Surfactant Administration (LISA) vs. Intubation Surfactant Extubation (InSurE) in Preterm Infants with Respiratory Distress Syndrome: A Pilot Randomized Controlled Trial. J Trop Pediatr 2021; 67:6378622. [PMID: 34595526 DOI: 10.1093/tropej/fmab086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE There has been an endeavor in recent years, to administer surfactant by minimally invasive techniques to neonates with surfactant deficiency. The objective of this study was to compare the need for intubation and mechanical ventilation after surfactant delivery, using Less Invasive Surfactant Administration (LISA) technique and Intubation SURfactant Extubation (InSurE), in preterm infants with respiratory distress syndrome (RDS). METHODS We conducted a pilot randomized control trial (RCT) at a tertiary care center over a period of 18 months. Preterm neonates with RDS (gestational age 28-36 weeks) were randomized to receive surfactant within 6 h of birth by InSurE or LISA. The primary outcome was need for intubation and mechanical ventilation within 72 h of birth. Infants were followed until discharge for adverse events and complications. RESULTS A total of 40 infants were analyzed (20 in each group). There was no difference in the need for intubation and mechanical ventilation within 72 h of birth between the two groups [InSurE, 6 (30%) and LISA, 6 (30%), relative risk 1.0, 95% confidence interval 0.51-1.97]. About 15% of infants in both groups had adverse events during the procedure. There was no statistically significant difference in the rates of major complications or duration of respiratory support, hospital stay and mortality. CONCLUSION We found LISA to be feasible and equally effective as InSurE for surfactant administration in the treatment of RDS in preterm infants. Future larger RCTs are required to compare the efficacy and long-term outcomes of LISA with the standard invasive methods of surfactant administration.
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Affiliation(s)
- Prince Pareek
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra 411043, India
| | - Sujata Deshpande
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra 411043, India
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra 411043, India
| | - Love Kumar Sah
- Department of Pediatrics, Janaki Medical College and Teaching Hospital Pvt. Ltd, Janakpur 45600, Nepal
| | - Chinmay Chetan
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra 411043, India
| | - Rajesh Maheshwari
- Department of Neonatology, Westmead Hospital, Westmead 2145, Australia
| | - Kiran More
- Department of Neonatology, Sidra Medicine, Doha 44074000, Qatar
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Abdel-Latif ME, Davis PG, Wheeler KI, De Paoli AG, Dargaville PA. Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2021; 5:CD011672. [PMID: 33970483 PMCID: PMC8109227 DOI: 10.1002/14651858.cd011672.pub2] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Non-invasive respiratory support is increasingly used for the management of respiratory dysfunction in preterm infants. This approach runs the risk of under-treating those with respiratory distress syndrome (RDS), for whom surfactant administration is of paramount importance. Several techniques of minimally invasive surfactant therapy have been described. This review focuses on surfactant administration to spontaneously breathing infants via a thin catheter briefly inserted into the trachea. OBJECTIVES Primary objectives In non-intubated preterm infants with established RDS or at risk of developing RDS to compare surfactant administration via thin catheter with: 1. intubation and surfactant administration through an endotracheal tube (ETT); or 2. continuation of non-invasive respiratory support without surfactant administration or intubation. Secondary objective 1. To compare different methods of surfactant administration via thin catheter Planned subgroup analyses included gestational age, timing of intervention, and use of sedating pre-medication during the intervention. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 30 September 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. SELECTION CRITERIA We included randomised trials comparing surfactant administration via thin catheter (S-TC) with (1) surfactant administration through an ETT (S-ETT), or (2) continuation of non-invasive respiratory support without surfactant administration or intubation. We also included trials comparing different methods/strategies of surfactant administration via thin catheter. We included preterm infants (at < 37 weeks' gestation) with or at risk of RDS. DATA COLLECTION AND ANALYSIS Review authors independently assessed study quality and risk of bias and extracted data. Authors of all studies were contacted regarding study design and/or missing or unpublished data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 studies (18 publications; 2164 neonates) in this review. These studies compared surfactant administration via thin catheter with surfactant administration through an ETT with early extubation (Intubate, Surfactant, Extubate technique - InSurE) (12 studies) or with delayed extubation (2 studies), or with continuation of continuous positive airway pressure (CPAP) and rescue surfactant administration at pre-specified criteria (1 study), or compared different strategies of surfactant administration via thin catheter (1 study). Two trials reported neurosensory outcomes of of surviving participants at two years of age. Eight studies were of moderate certainty with low risk of bias, and eight studies were of lower certainty with unclear risk of bias. S-TC versus S-ETT in preterm infants with or at risk of RDS Meta-analyses of 14 studies in which S-TC was compared with S-ETT as a control demonstrated a significant decrease in risk of the composite outcome of death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.48 to 0.73; risk difference (RD) -0.11, 95% CI -0.15 to -0.07; number needed to treat for an additional beneficial outcome (NNTB) 9, 95% CI 7 to 16; 10 studies; 1324 infants; moderate-certainty evidence); the need for intubation within 72 hours (RR 0.63, 95% CI 0.54 to 0.74; RD -0.14, 95% CI -0.18 to -0.09; NNTB 8, 95% CI; 6 to 12; 12 studies, 1422 infants; moderate-certainty evidence); severe intraventricular haemorrhage (RR 0.63, 95% CI 0.42 to 0.96; RD -0.04, 95% CI -0.08 to -0.00; NNTB 22, 95% CI 12 to 193; 5 studies, 857 infants; low-certainty evidence); death during first hospitalisation (RR 0.63, 95% CI 0.47 to 0.84; RD -0.02, 95% CI -0.10 to 0.06; NNTB 20, 95% CI 12 to 58; 11 studies, 1424 infants; low-certainty evidence); and BPD among survivors (RR 0.57, 95% CI 0.45 to 0.74; RD -0.08, 95% CI -0.11 to -0.04; NNTB 13, 95% CI 9 to 24; 11 studies, 1567 infants; moderate-certainty evidence). There was no significant difference in risk of air leak requiring drainage (RR 0.58, 95% CI 0.33 to 1.02; RD -0.03, 95% CI -0.05 to 0.00; 6 studies, 1036 infants; low-certainty evidence). None of the studies reported on the outcome of death or survival with neurosensory disability. Only one trial compared surfactant delivery via thin catheter with continuation of CPAP, and one trial compared different strategies of surfactant delivery via thin catheter, precluding meta-analysis. AUTHORS' CONCLUSIONS Administration of surfactant via thin catheter compared with administration via an ETT is associated with reduced risk of death or BPD, less intubation in the first 72 hours, and reduced incidence of major complications and in-hospital mortality. This procedure had a similar rate of adverse effects as surfactant administration through an ETT. Data suggest that treatment with surfactant via thin catheter may be preferable to surfactant therapy by ETT. Further well-designed studies of adequate size and power, as well as ongoing studies, will help confirm and refine these findings, clarify whether surfactant therapy via thin tracheal catheter provides benefits over continuation of non-invasive respiratory support without surfactant, address uncertainties within important subgroups, and clarify the role of sedation.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Discipline of Neonatology, The Medical School, College of Medicine and Health, Australian National University, Acton, Canberra, Australia
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, Australia
- Department of Public Health, School of Psychology and Public Health, College of Science, Health & Engineering, La Trobe University, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| | - Kevin I Wheeler
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Neonatology, The Royal Children's Hospital Melbourne, Parkville, Australia
- The University of Melbourne, Melbourne, Australia
| | | | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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9
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Patel P, Houck A, Fuentes D. Examining Variations in Surfactant Administration (ENVISION): A Neonatology Insights Pilot Project. CHILDREN-BASEL 2021; 8:children8040261. [PMID: 33800603 PMCID: PMC8065748 DOI: 10.3390/children8040261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/01/2022]
Abstract
Variability in neonatal clinical practice is well recognized. Respiratory management involves interdisciplinary care and often is protocol driven. The most recent published guidelines for management of respiratory distress syndrome and surfactant administration were published in 2014 and may not reflect current clinical practice in the United States. The goal of this project was to better understand variability in surfactant administration through conduct of health care provider (HCP) interviews. Questions focused on known practice variations included: use of premedication, decisions to treat, technique of surfactant administration and use of guidelines. Data were analyzed for trends and results were communicated with participants. A total of 54 HCPs participated from June to September 2020. In almost all settings, neonatologists or nurse practitioners intubated the infant and respiratory therapists administered surfactant. The INSURE (INtubation-SURrfactant-Extubation) technique was practiced by 83% of participants. Premedication prior to intubation was used by 76% of HCPs. An FiO2 ≥ 30% was the most common threshold for surfactant administration (48%). In conclusion, clinical practice variations exist in respiratory management and surfactant administration and do not seem to be specific to NICU level or institution type. It is unknown what effects the variability in clinical practice might have on clinical outcomes.
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10
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Silahli M, Tekin M. The Comparison of LISA and INSURE techniques in term of neonatal morbidities and mortality among premature infants. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020189. [PMID: 33525282 PMCID: PMC7927556 DOI: 10.23750/abm.v91i4.8845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Respiratory distress syndrome (RDS) is the most common cause of respiratory failure among premature infants. The most important choice for the treatment of RDS is still exogenous surfactant replacement therapy and respiratory support. Today, there are some different surfactant applying techniques. In this study, we aimed to evaluate the effects of the surfactant administration techniques in premature infants less than 33 weeks of gestational age. METHODS The medical data were collected retrospectively from the medical records of Baskent University, Konya Training and Research Hospital between 2010 and 2016. The patient divided into two subgroups as Less Invasive Surfactant Administration (LISA) group (n: 35) and Intubation- Surfactant administration and rapid Extubation (INSURE) group (n: 30). Two surfactant administration techniques were evaluated on the neonatal morbidities and mortality among premature infants. RESULTS There were no significant differences in maternal and neonatal characteristics between the two groups. Duration on the nasal continues positive airway pressure (nCPAP) is significantly higher in the LISA group as compared with the INSURE group (p<0.001). And also between two groups, there were no significant differences in term of neonatal mortality and morbidities. CONCLUSION The technique of the surfactant administration has no effect on the postnatal morbidities. LISA method is safe and effective as much as INSURE method, which is still a good alternative in centers with lack of experience about LISA. We need to perform studies that have larger sample size and prospective randomized controlled trials.
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Affiliation(s)
- Musa Silahli
- Neonatal Intensive Care Unit, Baskent University Konya Training and Research Hospital, Konya, Turkey..
| | - Mehmet Tekin
- Department of Pediatrics, Baskent University Konya Training and Research Hospital, Konya, Turkey..
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11
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Nanda D, Nangia S, Thukral A, Yadav CP. A new clinical respiratory distress score for surfactant therapy in preterm infants with respiratory distress. Eur J Pediatr 2020; 179:603-610. [PMID: 31853688 DOI: 10.1007/s00431-019-03530-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022]
Abstract
The guidelines for surfactant therapy are largely based on studies done in developed coun1tries wherein the facility infrastructure, patient profile, and clinical practices are different from low- and middle-income countries (LMICs). Though SRT is widely practiced in developing countries, there exists variability in clinical practice. Our objective was to identify the factors which would predict the need of surfactant administration and develop a "clinical respiratory distress (RD) score" for surfactant administration in preterm neonates with respiratory distress. A prospective observational study was conducted in 153 preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress who were managed with CPAP and/or surfactant where indicated. Gestation < 32 weeks, no antenatal corticosteroid (ANS), hypothermia at admission, Apgar score < 3 at 1 minute, and Silverman score > 2 at 2 hours were found to be the significant factors in predicting surfactant requirement in multivariate regression analysis. A seven point scale was developed and categorized into two categories as < 4 and ≥ 4. The sensitivity, specificity, PPV, and NPV were 67%, 87%, 86%, and 68%, respectively, with a cutoff score ≥ 4. The positive likelihood ratio was 5.07 (95% CI 2.71-9.48), and negative likelihood ratio was 0.38 (95% CI 0.28-0.52). The observed rate of surfactant administration was found to be around 32% when the composite score was below four, and the rate increased to almost 86% when the composite score was ≥ 4. The predictive accuracy of the model was subsequently evaluated in a cohort of 56 preterm infants with respiratory distress.. Sensitivity, specificity and positive and negative predictive value during the validation phase were 97%, 73%, 85%, and 94%, respectively. With a composite score less than 4, the observed rate of surfactant administration was 6% (95% CI 1%-28%) as against the model predicted rate of 24%, while with composite score ≥ 4, the observed rate was 85% (95% CI 69%-94%) as against the model predicted rate of 90%.Conclusion: "Clinical RD score" is a simple score, which can be utilized for decision-making for early surfactant administration for preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress.Trial Registration: NCT03273764What is Known:• Both CPAP and surfactant therapy are effective in management of preterm infants with RDS.• The efficacy of surfactant replacement therapy is better when it is administered early in the course of disease.What is New:• Many of the known risk factors for RDS do not predict surfactant requirement.• "Composite RD score" comprising of five independent predictors of surfactant requirement with a numeric cutoff may help decide which preterm neonates with respiratory distress need early surfactant administration in low- and middle-income countries.
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Affiliation(s)
- Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan University, Bhubaneswar, Odisha, India
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital and Smt. Sucheta Kriplani Hospital, New Delhi, India.
| | - Anu Thukral
- Newborn Health Knowledge Centre, WHO Collaborating Centre for Training and Research in Neonatal Care, ICMR Centre for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - C P Yadav
- Epidemiology and Clinical Research Division, National Institute of Malaria Research (NIMR), Indian Council of Medical Research, New Delhi, India
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12
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Awaysheh F, Alhmaiedeen N, Al-Ghananim R, Bsharat A, Al-Hasan M. Criteria for Using INSURE in Management of Premature Babies with Respiratory Distress Syndrome. Med Arch 2019; 73:240-243. [PMID: 31762557 PMCID: PMC6853746 DOI: 10.5455/medarh.2019.73.240-243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction Respiratory distress syndrome (RDS) is defined as acute respiratory distress caused by surfactant deficiency that disturbs gas exchange in preterm infants. It is one of the most common neonatal problems and has been considered to be the most common cause of mortality and morbidity in preterm babies. Aim In this study, different variables were studied to predict factors for INSURE failure that might help in choosing infants for this procedure early. Methods Sixty three (63) patients were enrolled in this study as they met the inclusion criteria. All neonates were intubated briefly less than 2 hours, given natural surfactant in the dose of 3 ml/kg. As soon as it was appropriate and the neonate was stable in the form of normal heart rate and oxygenation, extubation was done and the baby connected to NCPAP at a pressure of 6 cmH2O. INSURE failure was considered if the patient needed mechanical ventilation for more than 72 hours while INSURE success was considered if we were able to wean the patient from CPAP or if the patient didn't need mechanical ventilation in the first 72 hours after surfactant administration. The indications for mechanical ventilation after INSURE procedure were respiratory distress with desaturation (02 sat less than 90%), recurrent apnea, Pco2 more than 60 mmHg. Results Since INSURE procedure is being largely applied in the neonatal intensive care units, it is important to determine the candidate neonate for this procedure with the minimum failure rate. Although the sample of our study is small, but we can suggest that neonate with gestational age less than 28, birth weight less than 1000 gm, umbilical PH of less than 7, low Apgar score and anemic patients are at high risk for INSURE failure. Conclusion Early diagnosis of PDA and IVH is essential to avoid INSURE method in these patients.
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Affiliation(s)
- Faten Awaysheh
- Department of Pediatrics, King Hussein Medical Center, Amman, Jordan
| | | | - Raeda Al-Ghananim
- Department of Pediatrics, King Hussein Medical Center, Amman, Jordan
| | - Areej Bsharat
- Department of Pediatrics, King Hussein Medical Center, Amman, Jordan
| | - Mohammad Al-Hasan
- Department of Emergency Medicine, King Hussein Medical Center, Amman, Jordan
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13
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Lee BK, Shin SH, Jung YH, Kim EK, Kim HS. Comparison of NIV-NAVA and NCPAP in facilitating extubation for very preterm infants. BMC Pediatr 2019; 19:298. [PMID: 31462232 PMCID: PMC6712684 DOI: 10.1186/s12887-019-1683-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/21/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Various types of noninvasive respiratory modalities that lead to successful extubation in preterm infants have been explored. We aimed to compare noninvasive neurally adjusted ventilatory assist (NIV-NAVA) and nasal continuous positive airway pressure (NCPAP) for the postextubation stabilization of preterm infants. METHODS This retrospective study was divided into two distinct periods, between July 2012 and June 2013 and between July 2013 and June 2014, because NIV-NAVA was applied beginning in July 2013. Preterm infants of less than 30 weeks GA who had been intubated with mechanical ventilation for longer than 24 h and were weaned to NCPAP or NIV-NAVA after extubation were enrolled. Ventilatory variables and extubation failure were compared after weaning to NCPAP or NIV-NAVA. Extubation failure was defined when infants were reintubated within 72 h of extubation. RESULTS There were 14 infants who were weaned to NCPAP during Period I, and 2 infants and 16 infants were weaned to NCPAP and NIV-NAVA, respectively, during Period II. At the time of extubation, there were no differences in the respiratory severity score (NIV-NAVA 1.65 vs. NCPAP 1.95), oxygen saturation index (1.70 vs. 2.09) and steroid use before extubation. Several ventilation parameters at extubation, such as the mean airway pressure, positive end-expiratory pressure, peak inspiratory pressure, and FiO2, were similar between the two groups. SpO2 and pCO2 preceding extubation were comparable. Extubation failure within 72 h after extubation was observed in 6.3% of the NIV-NAVA group and 37.5% of the NCPAP group (P = 0.041). CONCLUSIONS The data in the present showed promising implications for using NIV-NAVA over NCPAP to facilitate extubation.
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Affiliation(s)
- Byoung Kook Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
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14
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Taylor G, Jackson W, Hornik CP, Koss A, Mantena S, Homsley K, Gattis B, Kudumu-Clavell M, Clark R, Smith PB, Laughon MM. Surfactant Administration in Preterm Infants: Drug Development Opportunities. J Pediatr 2019; 208:163-168. [PMID: 30580975 PMCID: PMC6486873 DOI: 10.1016/j.jpeds.2018.11.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/26/2018] [Accepted: 11/26/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate how frequently surfactant is used off-label in preterm infants. STUDY DESIGN We conducted a retrospective cohort analysis of prospectively collected administrative data for 2005-2015 from 348 neonatal intensive care units in the US. We quantified off-label administration of poractant alfa, calfactant, or beractant in inborn infants born at <37 weeks of gestational age (GA). Off-label surfactant administration was defined according to the Food and Drug Administration (FDA) label. RESULTS Of a total of 110 822 preterm infants who received surfactant, 68 226 (62%) received the surfactant off-label. The majority of infants who received surfactant off-label had a higher birth weight than those who received surfactant on-label (40 716 [37%]), had an older GA than those who received surfactant on-label (35 191 [32%]), or were treated with intubation and surfactant administration followed by immediate extubation (INSURE) (32 310 [29%]). Poractant alfa was administered via INSURE more frequently than beractant or calfactant (16 688 [38%], 7137 [20%], and 8485 [27%], respectively). An increasing number of infants received surfactant via INSURE from 2005 to 2015 (from 1697 [19%] to 3368 [36%]). CONCLUSIONS The majority of surfactant given to preterm infants is administered off-label. The uptrend in administration via INSURE coincides with increased supporting evidence. The gap between FDA labeling and current clinic practice exemplifies an opportunity for label expansion, which may require additional prospective or retrospective safety and/or effectiveness data for infants of older GA and higher birth weight.
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Affiliation(s)
- Genevieve Taylor
- Department of Pediatrics, The University of North Carolina, Chapel Hill, NC.
| | - Wesley Jackson
- Department of Pediatrics, The University of North Carolina, Chapel Hill, NC
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Alec Koss
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Sreekar Mantena
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kenya Homsley
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Blair Gattis
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina, Chapel Hill, NC
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15
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Minocchieri S, Berry CA, Pillow JJ. Nebulised surfactant to reduce severity of respiratory distress: a blinded, parallel, randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2019; 104:F313-F319. [PMID: 30049729 PMCID: PMC6764249 DOI: 10.1136/archdischild-2018-315051] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 06/09/2018] [Accepted: 06/27/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate if nebulised surfactant reduces intubation requirement in preterm infants with respiratory distress treated with nasal continuous positive airway pressure (nCPAP). DESIGN Double blind, parallel, stratified, randomised control trial. SETTING Sole tertiary neonatal unit in West Australia. PATIENTS Preterm infants (290-336 weeks' gestational age, GA) less than 4 hours of age requiring 22%-30% supplemental oxygen, with informed parental written consent. INTERVENTIONS Infants were randomised within strata (290-316 and 320-336 weeks' GA) to bubble nCPAP or bubble nCPAP and nebulised surfactant (200 mg/kg: poractant alfa) using a customised vibrating membrane nebuliser (eFlow neonatal). Surfactant nebulisation (100 mg/kg) was repeated after 12 hours for persistent supplemental oxygen requirement. MAIN OUTCOME MEASURES The primary outcomes were requirement for intubation and duration of mechanical ventilation at 72 hours. Data analysis followed the intention-to-treat principle. RESULTS 360 of 606 assessed infants were eligible; 64 of 360 infants were enrolled and randomised (n=32/group). Surfactant nebulisation reduced the requirement for intubation within 72 hours: 11 of 32 infants were intubated after continuous positive airway pressure (CPAP) and nebulised surfactant compared with 22 of 32 infants receiving CPAP alone (relative risk (95% CI)=0.526 (0.292 to 0.950)). The reduced requirement for intubation was limited to the 320-336 weeks' GA stratum. The median (range) duration of ventilation in the first 72 hours was not different between the intervention (0 (0-62) hours) and control (9 (0-64) hours; p=0.220) groups. There were no major adverse events. CONCLUSIONS Early postnatal nebulised surfactant may reduce the need for intubation in the first 3 days of life compared with nCPAP alone in infants born at 290-336 weeks' GA with mild respiratory distress syndrome. Confirmation requires further adequately powered studies. TRIAL REGISTRATION NUMBER ACTRN12610000857000.
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Affiliation(s)
- Stefan Minocchieri
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Perth, Western Australia, Australia,Neonatal Clinical Care Unit, Women and Newborn Health Service, Perth, Western Australia, Australia,Neonatologie, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Clare A Berry
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - J Jane Pillow
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Perth, Western Australia, Australia,Neonatal Clinical Care Unit, Women and Newborn Health Service, Perth, Western Australia, Australia,School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia
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16
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Miyahara J, Sugiura H, Ohki S. The evaluation of the efficacy and safety of non-invasive neurally adjusted ventilatory assist in combination with INtubation-SURfactant-Extubation technique for infants at 28 to 33 weeks of gestation with respiratory distress syndrome. SAGE Open Med 2019; 7:2050312119838417. [PMID: 30906554 PMCID: PMC6421598 DOI: 10.1177/2050312119838417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/26/2019] [Indexed: 11/10/2022] Open
Abstract
Objectives: The aim of this study is to evaluate the efficacy and safety of non-invasive neurally adjusted ventilatory assist used after INtubation-SURfactant-Extubation in preterm infants with respiratory distress syndrome. Methods: We conducted a prospective observational study that included 15 inborn preterm infants at 28 (0/7) to 33 (6/7) weeks of gestation with respiratory distress syndrome in the period from April 2017 to October 2018. After INtubation-SURfactant-Extubation, infants underwent non-invasive neurally adjusted ventilatory assist. INtubation-SURfactant-Extubation failure was defined as follows: fraction of inspired oxygen requirement >0.4, respiratory acidosis, and severe apnea within 5 days after surfactant administration. Results: Two of the 15 (13.3%) infants showed INtubation-SURfactant-Extubation failure and required mechanical ventilation. No infants experienced any major complications such as pneumothorax, patent ductus arteriosus ligation, severe intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, or death. Conclusion: The rate of INtubation-SURfactant-Extubation failure when non-invasive neurally adjusted ventilatory assist was used after INtubation-SURfactant-Extubation for preterm infants with respiratory distress syndrome was 13.3%. Non-invasive neurally adjusted ventilatory assist can be safely performed without severe complications for preterm infants soon after birth.
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Affiliation(s)
- Jun Miyahara
- Department of Neonatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Hiroshi Sugiura
- Department of Neonatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Shigeru Ohki
- Department of Neonatology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
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17
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Malakian A, Bashirnezhadkhabaz S, Aramesh MR, Dehdashtian M. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: a randomized controlled trial. J Matern Fetal Neonatal Med 2019; 33:2601-2607. [PMID: 30513030 DOI: 10.1080/14767058.2018.1555810] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Respiratory distress syndrome (RDS) is one of the main causes of mortality in premature neonates. Treatment of these neonates with invasive mechanical ventilation has side effects such as chronic pulmonary diseases. Noninvasive ventilation, such as nasal continuous positive airway pressure (NCPAP) and nasal high-frequency oscillation ventilation (NHFOV), has shown to reduce the burden of chronic lung disease. NHFOV is a promising new mode of noninvasive ventilation and may reduce the need for mechanical ventilation and reduce possible complications. In this study, we hypothesized that early NHFOV would reduce the need for invasive respiratory support in comparison to NCPAP in preterm neonates with RDS.Methods: One hundred twenty-four neonates between 28 to 34 weeks of gestational age (GA) with RDS hospitalized at Imam Khomeini Hospital, Ahvaz in 2016 were included in this randomized controlled study. The primary outcomes were the failure of NHFOV and NCPAP within 72 h after birth. The secondary outcomes were the duration of invasive ventilation and possible side effects.Results: Out of 124 neonates in this study, 63 and 61 neonates were studied in the NHFOV and NCPAP groups, respectively. There were no significant differences between NHFOV (6.5%) and NCPAP (14.1%) groups in terms of rates of primary consequences (p = .13). However, the duration of noninvasive ventilation in NHFOV was significantly less than that of NCPAP group (p = .01).Conclusion: In our study group, preterm infants from 28 to 34 weeks of GA, NHFOV did not reduce the need for mechanical ventilation during the first 72 h after birth compared to NCPAP; however, the duration of noninvasive ventilation in the NHFOV group was significantly shorter.
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Affiliation(s)
- Arash Malakian
- Department of Pediatrics, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shiva Bashirnezhadkhabaz
- Department of Pediatrics, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad-Reza Aramesh
- Department of Pediatrics, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Masoud Dehdashtian
- Department of Pediatrics, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Vento M, Bohlin K, Herting E, Roehr CC, Dargaville PA. Surfactant Administration via Thin Catheter: A Practical Guide. Neonatology 2019; 116:211-226. [PMID: 31461712 DOI: 10.1159/000502610] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/06/2019] [Indexed: 11/19/2022]
Abstract
Exogenous surfactant replacement is the most effective evidence-based therapy for respiratory distress syndrome in preterm infants. The mode of administration has evolved in the last decade towards less invasive techniques that aim to effectively provide an adequate dose of surfactant, while allowing spontaneous respiration to continue, and with the support of continuous positive airway pressure. Surfactant delivery via aerosolisation, pharyngeal instillation, and laryngeal mask are being actively pursued in research, but have not yet been adopted to any significant degree in clinical practice. Surfactant administration via thin catheter, on the other hand, is becoming more widely used in neonatal intensive care units worldwide and is now an acknowledged alternative to the standard mode of surfactant delivery. Different devices, including nasogastric tubes, vascular catheters, and purpose-built surfactant instillation catheters are used. We present here a contemporary review of surfactant administration via thin catheter, in a practical guide format that reflects the individual and collective scientific opinions of the clinicians who participated in formulating the guide.
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Affiliation(s)
- Maximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain, .,Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain,
| | - Kajsa Bohlin
- Department of Neonatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Egbert Herting
- Department of Paediatrics, University of Luebeck, Luebeck, Germany
| | - Charles Christoph Roehr
- Newborn Services, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Medical Sciences Division, University of Oxford, Department of Paediatrics, Oxford, United Kingdom
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Abstract
BACKGROUND Ureaplasma spp. is a known risk factor for bronchopulmonary dysplasia in premature infants. Emerging research suggests treatment with azithromycin or clarithromycin in the first days of life (DOLs) reduces bronchopulmonary dysplasia in Ureaplasma spp. positive infants. Side effects of these antibiotics make it imperative to optimize reliable noninvasive screening procedures to identify infants who would benefit from treatment. METHODS The aim of this study was to determine the best site and time to screen for Ureaplasma spp. in 24- to 34-week premature infants. Oral, nasal, gastric and tracheal cultures were collected and placed immediately in 10B broth media. Polymerase chain reaction verified culture results and identified the Ureaplasma spp. RESULTS Cultures yielded a Ureaplasma spp. incidence of 80/168 = 47.6% [95% confidence interval (CI): 40-56]. Nasal cultures had greater sensitivity to detect Ureaplasma spp. than oral cultures (P = 0.008): however, a significant proportion of infants with Ureaplasma spp. would have been missed (12/79 = 15.2%, 95% CI: 8%-25%, P < 0.001) if oral cultures were not obtained. For all sites, the collection at DOL 7-10 were more likely to be positive than the collection at DOL 1-2: however, a significant proportion (5/77 = 6.5%, 95% CI: 2-15, P < 0.001) of infants with Ureaplasma spp. would have been missed if the DOL 1-2 cultures were not obtained. CONCLUSIONS For optimal Ureaplasma spp. detection in 24- to 34-week premature infants, cultures need to be taken both early and late in the first 10 DOLs both from nasal and oral secretions.
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Koh JW, Kim JW, Chang YP. Transient intubation for surfactant administration in the treatment of respiratory distress syndrome in extremely premature infants. KOREAN JOURNAL OF PEDIATRICS 2018; 61:315-321. [PMID: 30304909 PMCID: PMC6212708 DOI: 10.3345/kjp.2018.06296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/11/2018] [Indexed: 12/02/2022]
Abstract
Purpose To investigate the effectiveness of transient intubation for surfactant administration and extubated to nasal continuous positive pressure (INSURE) for treatment of respiratory distress syndrome (RDS) and to identify the factors associated with INSURE failure in extremely premature infants. Methods Eighty-four infants with gestational age less than 28 weeks treated with surfactant administration for RDS for 8 years were included. Perinatal and neonatal characteristics were retrospectively reviewed, and major pulmonary outcomes such as duration of mechanical ventilation (MV) and bronchopulmonary dysplasia (BPD) plus death at 36-week postmenstrual age (PMA) were compared between INSURE (n=48) and prolonged MV groups (n=36). The factors associated with INSURE failure were determined. Results Duration of MV and the occurrence of BPD at 36-week PMA were significantly lower in INSURE group than in prolonged MV group (P<0.05), but BPD plus death at 36-week PMA was not significantly different between the 2 groups. In a multivariate analysis, a reduced duration of MV was only significantly associated with INSURE (P=0.001). During the study period, duration of MV significantly decreased over time with an increasing rate of INSURE application (P<0.05), and BPD plus death at 36-week PMA also tended to decrease over time. A low arterial-alveolar oxygen tension ratio (a/APO2 ratio) was a significant predictor for INSURE failure (P=0.001). Conclusion INSURE was the noninvasive ventilation strategy in the treatment of RDS to reduce MV duration in extremely premature infants with gestational age less than 28 weeks.
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Affiliation(s)
- Ji Won Koh
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
| | - Jong-Wan Kim
- Institute of Tissue Regeneration Engineering (ITREN), Dankook University, Cheonan, Korea
| | - Young Pyo Chang
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
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21
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Shim GH. Update of minimally invasive surfactant therapy. KOREAN JOURNAL OF PEDIATRICS 2017; 60:273-281. [PMID: 29042870 PMCID: PMC5638833 DOI: 10.3345/kjp.2017.60.9.273] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/10/2017] [Accepted: 08/18/2017] [Indexed: 11/27/2022]
Abstract
To date, preterm infants with respiratory distress syndrome (RDS) after birth have been managed with a combination of endotracheal intubation, surfactant instillation, and mechanical ventilation. It is now recognized that noninvasive ventilation (NIV) such as nasal continuous positive airway pressure (CPAP) in preterm infants is a reasonable alternative to elective intubation after birth. Recently, a meta-analysis of large controlled trials comparing conventional methods and nasal CPAP suggested that CPAP decreased the risk of the combined outcome of bronchopulmonary dysplasia or death. Since then, the use of NIV as primary therapy for preterm infants has increased, but when and how to give exogenous surfactant remains unclear. Overcoming this problem, minimally invasive surfactant therapy (MIST) allows spontaneously breathing neonates to remain on CPAP in the first week after birth. MIST has included administration of exogenous surfactant by intrapharyngeal instillation, nebulization, a laryngeal mask, and a thin catheter. In recent clinical trials, surfactant delivery via a thin catheter was found to reduce the need for subsequent endotracheal intubation and mechanical ventilation, and improves short-term respiratory outcomes. There is also growing evidence for MIST as an alternative to the INSURE (intubation-surfactant-extubation) procedure in spontaneously breathing preterm infants with RDS. In conclusion, MIST is gentle, safe, feasible, and effective in preterm infants, and is widely used for surfactant administration with noninvasive respiratory support by neonatologists. However, further studies are needed to resolve uncertainties in the MIST method, including infant selection, optimal surfactant dosage and administration method, and need for sedation.
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Affiliation(s)
- Gyu-Hong Shim
- Department of Pediatrics, Inje University Busan Paik Hospital, Busan, Korea
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22
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Venkataraman R, Kamaluddeen M, Hasan SU, Robertson HL, Lodha A. Intratracheal Administration of Budesonide-Surfactant in Prevention of Bronchopulmonary Dysplasia in Very Low Birth Weight Infants: A Systematic Review and Meta-Analysis. Pediatr Pulmonol 2017; 52:968-975. [PMID: 28165675 DOI: 10.1002/ppul.23680] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/16/2017] [Accepted: 01/20/2017] [Indexed: 11/05/2022]
Abstract
Despite the near universal adaptation of gentle mechanical ventilation, surfactant use and non-invasive respiratory support, bronchopulmonary dysplasia (BPD) remains one of the most common respiratory morbidities in very low birth weight (VLBW) infants. Thus, the objective of this review was to evaluate the efficacy of intra-tracheal administration of budesonide-surfactant mixture in preventing bronchopulmonary dysplasia (BPD) in very low birth weight (VLBW) infants. MEDLINE, EMBASE, and PubMed were searched for randomized clinical trials in which intra-tracheal administration of budesonide-surfactant was used to prevent BPD in infants. The primary outcomes were BPD and composite outcome of death or BPD. Meta-analysis of the two clinical trials revealed that infants who received intra-tracheal instillation of budesonide-surfactant mixture demonstrated 43% reduction in the risk of BPD (RR: 0.57; 95%CI: 0.43-0.76, NNT = 5). Although mortality was not different between the groups (OR: 0.61; 95%CI: 0.34-1.04), a 40% reduction was observed in the composite outcome of death or BPD in the budesonide-surfactant group (RR: 0.60; 95%CI: 0.49-0.74, NNT = 3). Thus, this review concludes that intra-tracheal administration of budesonide-surfactant combination was associated with decreased incidence of BPD alone or composite outcome of death or BPD in VLBW infants though there is a need for larger trials before it can be recommended as a standard of care.
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Affiliation(s)
| | | | - Shabih U Hasan
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Abhay Lodha
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, Peter Lougheed Centre, Calgary, Alberta, Canada
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Esmaeilnia T, Nayeri F, Taheritafti R, Shariat M, Moghimpour-Bijani F. Comparison of Complications and Efficacy of NIPPV and Nasal CPAP in Preterm Infants With RDS. IRANIAN JOURNAL OF PEDIATRICS 2016; 26:e2352. [PMID: 27307960 PMCID: PMC4904342 DOI: 10.5812/ijp.2352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 11/08/2015] [Accepted: 12/09/2015] [Indexed: 11/27/2022]
Abstract
Background: Respiratory distress syndrome (RDS) is one of the most common diseases in neonates admitted to NICU. For this important cause of morbidity and mortality in preterm neonates, several treatment methods have been used. To date, non-invasive methods are preferred due to fewer complications. Objectives: Herein, two non-invasive methods of ventilation support are compared: NCPAP vs. NIPPV. Patients and Methods: This is a randomized clinical trial. Premature neonates with less than 34 weeks gestation, suffering from RDS entered the study, including 151 newborns admitted to Vali-Asr NICU during 2012-2013. Most of these patients received surfactant as early rescue via INSURE method and then randomly divided into two NCPAP (73 neonates) and NIPPV (78 neonates) groups. Both early and late complications are compared including extubation failure, hospital length of stay, GI perforation, apnea, intraventricular hemorrhage (IVH) and mortality rate. Results: The need for re-intubation was 6% in NIPPV vs. 17.6% in NCPAP group, which was statistically significant (P = 0.031). The length of hospital stay was 23.92 ± 13.5 vs. 32.61 ± 21.07 days in NIPPV and NCPAP groups, respectively (P = 0.002). Chronic lung disease (CLD) was reported to be 4% in NCPAP and 0% in NIPPV groups (P = 0.035). The most common complication occurred in both groups was traumatization of nasal skin and mucosa, all of which fully recovered. Gastrointestinal perforation was not reported in either group. Conclusions: This study reveals the hospital length of stay, re-intubation and BPD rates are significantly declined in neonates receiving NIPPV as the treatment for RDS.
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Affiliation(s)
- Tahereh Esmaeilnia
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Fatemeh Nayeri
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Roya Taheritafti
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Roya Taheritafti, Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9126188148, Fax: +98-2188484577, E-mail:
| | - Mamak Shariat
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Faezeh Moghimpour-Bijani
- Department of Pediatrics, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
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Recomendaciones para la asistencia respiratoria en el recién nacido ( iii ). Surfactante y óxido nítrico. An Pediatr (Barc) 2015; 83:354.e1-6. [DOI: 10.1016/j.anpedi.2015.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/18/2015] [Indexed: 11/18/2022] Open
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Castillo Salinas F, Elorza Fernández D, Gutiérrez Laso A, Moreno Hernando J, Bustos Lozano G, Gresa Muñoz M, López de Heredia Goya J, Aguar Carrascosa M, Miracle Echegoyen X, Fernández Lorenzo J, Serrano M, Concheiro Guisan A, Carrasco Carrasco C, Comuñas Gómez J, Moral Pumarega M, Sánchez Torres A, Franco M. Recommendations for respiratory support in the newborn (III). Surfactant and nitric oxide. An Pediatr (Barc) 2015. [DOI: 10.1016/j.anpede.2015.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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26
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Continuous positive airway pressure in preterm neonates: An update of current evidence and implications for developing countries. Indian Pediatr 2015; 52:319-28. [DOI: 10.1007/s13312-015-0632-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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27
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Narasaraju T, Shukla D, More S, Huang C, Zhang L, Xiao X, Liu L. Role of microRNA-150 and glycoprotein nonmetastatic melanoma protein B in angiogenesis during hyperoxia-induced neonatal lung injury. Am J Respir Cell Mol Biol 2015; 52:253-61. [PMID: 25054912 DOI: 10.1165/rcmb.2013-0021oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Glycoprotein nonmetastatic melanoma protein B (GPNMB), a transmembrane protein, has been reported to have an important role in tissue repair and angiogenesis. Recently, we have demonstrated that hyperoxia exposure down-regulates microRNA (miR)-150 expression and concurrent induction of its target gene, GPNMB, in neonatal rat lungs. This study aimed to test the hypothesis that soluble GPNMB (sGPNMB) promotes angiogenesis in the hyperoxic neonatal lungs. Wild-type (WT) or miR-150 knockout (KO) neonates, exposed to 95% O2 for 3, 6, and 10 days, were evaluated for lung phenotypes, GPNMB protein expression in the lungs, and sGPNMB levels in the bronchoalveolar lavage. Angiogenic effects of sGPNMB were examined both in vitro and in vivo. After a 6-day exposure, similar analyses were performed in WT and miR-150 KO neonates during recovery at 7, 14, and 21 days. miR-150 KO neonates displayed an increased capillary network, decreased inflammation, and less alveolar damage compared with WT neonates after hyperoxia exposure. The early induction of GPNMB and sGPNMB were found in miR-150 KO neonates. The recombinant GPNMB, which contained a soluble portion of GPNMB, promoted endothelial tube formation in vitro and enhanced angiogenesis in vivo. The increased capillaries in the hyperoxic lungs of miR-150 KO neonates appeared dysmorphic. They were abnormally enlarged in size and occasionally laid at subepithelial regions in the alveoli. However, the lung architecture returned to normal during recovery, suggesting that abnormal vascularity during hyperoxia does not affect postnatal lung development. GPNMB plays an important role in angiogenesis during hyperoxia injury. Treatment with GPNMB may offer a novel therapeutic approach in reducing pathologic complications in bronchopulmonary dysplasia.
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Affiliation(s)
- Telugu Narasaraju
- The Lundberg-Kienlen Lung Biology and Toxicology Laboratory, Department of Physiological Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, Oklahoma
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Nakhshab M, Tajbakhsh M, Khani S, Farhadi R. Comparison of the effect of surfactant administration during nasal continuous positive airway pressure with that of nasal continuous positive airway pressure alone on complications of respiratory distress syndrome: a randomized controlled study. Pediatr Neonatol 2015; 56:88-94. [PMID: 25264154 DOI: 10.1016/j.pedneo.2014.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 04/23/2014] [Accepted: 05/22/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Studies on early surfactant administration during nasal continuous positive airway pressure (NCPAP) [intubate-surfactant-extubate (INSURE)] have used continuous positive airway pressure and INSURE in the first hours after birth, but in many centers patients are transported from far away hospitals, reaching the center at a later time. The aim of this study was to compare the effect of INSURE with only NCPAP in the management of respiratory distress syndrome (RDS) in an outborn hospital. METHODS This study was a controlled randomized clinical trial on 60 neonates who were transported to the neonatal intensive care unit of Boo-Ali Sina Hospital. Neonates born at 27(0)/7 to 34(6)/7 weeks of gestation, aged ≤12 hours, and diagnosed with RDS were placed on NCPAP and then randomly assigned to INSURE or NCPAP alone. The primary outcome was the need for intubation and mechanical ventilation on the basis of the criteria defined by us, and the secondary outcomes were neonatal mortality and other complications of RDS. RESULTS In 13 months, 60 eligible neonates were enrolled. Our participants in INSURE group received surfactant at the mean age of 5.1 hours. The relative risk of need for mechanical ventilation was 0.55 (95% confidence interval: 0.15-1.9, p = 0.53), and the rate of mortality or other complications of RDS was statistically similar between the two groups. CONCLUSION After the first few hours of life (mean age of 5.1 hours), the rate of mortality and chronic lung disease and the need for mechanical ventilation were not statistically different between patients receiving INSURE and those in receipt of NCPAP alone.
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Affiliation(s)
- Maryam Nakhshab
- Department of Pediatrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
| | - Mehdi Tajbakhsh
- Department of Pediatrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Soghra Khani
- Faculty of Nursing, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Roya Farhadi
- Department of Pediatrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
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Li W, Long C, Zhangxue H, Jinning Z, Shifang T, Juan M, Renjun L, Yuan S. Nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure for preterm infants with respiratory distress syndrome: a meta-analysis and up-date. Pediatr Pulmonol 2015; 50:402-9. [PMID: 25418007 DOI: 10.1002/ppul.23130] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 07/31/2014] [Accepted: 08/11/2014] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate whether nasal intermittent positive pressure ventilation (NIPPV) would decrease the requirement for endotracheal ventilation compared with nasal continuous positive airway pressure(NCPAP) for preterm infants with respiratory distress syndrome (RDS) and compare the related complications between these two noninvasive variations of respiratory support METHODS A search of major electronic databases, including Medline (1980-2013) and the Cochrane Central Register of Controlled Trials, for randomized controlled trials that compared NIPPV versus NCPAP for preterm infants with RDS was performed. MAIN RESULTS Six randomized controlled trials met selection criteria (n = 1,527). The meta-analyses demonstrated significant decrease in the need for invasive ventilation in the NIPPV group (RR:0.53; 95% CI, 0.33-0.85). In the subgroup of infants who received surfactant also demonstrated a significant rate of failure of nasal support in the NIPPV group (RR:0.57; 95% CI 0.42-0.78). However, the subgroup of infants whose gestational age (GA) ≤ 30 weeks or birth weight (BW) < 1,500 g showed no difference between the two groups (RR:0.59; 95% CI 0.27-1.26); and the subgroup of infants whose GA > 30 weeks or BW > 1,500 g also showed no difference between the two groups (RR:0.63; 95% CI 0.29-1.39). No differences in other outcome variables were observed between the two groups. CONCLUSIONS Among preterm infants with RDS, there was a significant decrease in the need for invasive ventilation in the NIPPV group as compared with NCPAP group, especially for the infants who received surfactant. However, NIPPV could not decrease the need for invasive ventilation both in the subgroup of infants whose GA ≤ 30 weeks or BW < 1,500 g and the subgroup of infants with BW of >30 weeks or BW > 1,500 g. It is limited to analysis the primary outcome generally. Larger trials of this intervention are needed to assess the difference in this primary outcome and the related complications between both forms of noninvasive respiratory support.
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Affiliation(s)
- Wang Li
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
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Priyadarshi A, Quek WS, Luig M, Lui K. Is it feasible to identify preterm infants with respiratory distress syndrome for early extubation to continuous positive airway pressure post-surfactant treatment during retrieval? J Paediatr Child Health 2015; 51:321-7. [PMID: 25196918 DOI: 10.1111/jpc.12724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2014] [Indexed: 11/27/2022]
Abstract
AIM Preterm infants with respiratory distress syndrome (RDS) requiring surfactant treatment are often retrieved mechanically ventilated to the receiving hospital. INSURE (INtubate, SURfactant, Extubate) technique is not routinely performed by Newborn and Pediatric Emergency Transport Services NSW (NETS) during retrieval. This study aims to evaluate the likelihood of using INSURE technique during retrieval. We attempted to study the clinical characteristics of preterm infants with RDS who were favourably extubated (FE) shortly after admission to the receiving hospital. METHODS Retrospective study of preterm infants, gestational age (GA) > 28 weeks with RDS requiring retrieval by NETS. RESULTS Two hundred twenty-three infants, median GA of 33 weeks (range 29-36), median birthweight 2200 g (1000-4080) were examined. A percentage of 49.7 received CPAP, and 50.3% required MV. Eighteen (16%) infants were FE (<6 h) at receiving hospital. FiO2 on stabilisation (FiO2 (st)) by NETS correlated with FiO2 on admission to receiving hospital (r = 0.863). A percentage of 81 of ventilated infants received premedications including morphine. No significant differences were noted for GA, stabilisation ventilator settings, surfactant dose (mean 155 mg/kg) and mode of transport between FE and non-FE groups. FiO2 (st) post-surfactant treatment was significantly lower in FE compared with non-FE group (mean 0.28 vs. 0.41 respectively). The area under the curve from receiver operating characteristic based on FiO2 (st) was 0.646 (P = 0.050), the sensitivity and specificity of FiO2 (st) cut-off points (between 0.25 and 0.30) was low. CONCLUSION FiO2 on stabilisation post-surfactant treatment has a weak predictive value and may not be adequate to be used as sole criteria to extubate to CPAP prior to transport. FiO2 at stabilisation should be included as an eligibility criteria for a randomised trial of INSURE during retrieval, but other clinical assessments are needed.
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Affiliation(s)
- Archana Priyadarshi
- New Born Care Centre, Royal Hospital for Women, Sydney, New South Wales, Australia
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Early versus late extubation after surfactant replacement therapy for respiratory distress syndrome. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2015. [DOI: 10.1016/j.epag.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
There is mounting evidence that early continuous positive airway pressure (CPAP) from birth is feasible and safe even in very preterm infants. However, many infants will develop respiratory distress syndrome (RDS) and require surfactant treatment. Combining a noninvasive ventilation approach with a strategy for surfactant administration is important to ensure optimal outcome, but questions remain about the optimal timing, mode of delivery and value of predictive tests for surfactant deficiency. Key findings in this review include the following: (1) a noninvasive ventilation strategy with CPAP from birth has a similar outcome to routine intubation in the delivery room; (2) prophylactic surfactant treatment has no advantage over early CPAP with selective surfactant administration; (3) surfactant during CPAP can be safely administered by rapid intubation-extubation (the INSURE method or via tracheal placement of a thin catheter), and (4) predictive tests for surfactant deficiency are being developed and might in future aid in directing surfactant treatment to infants at risk of developing severe RDS. A strategy for surfactant administration should be part of a noninvasive ventilation approach for preterm infants at risk of developing significant RDS. The different methods for surfactant administration during CPAP are reviewed here.
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Affiliation(s)
- Mats Blennow
- Department of Neonatology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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Aguar M, Nuñez A, Cubells E, Cernada M, Dargaville PA, Vento M. Administration of surfactant using less invasive techniques as a part of a non-aggressive paradigm towards preterm infants. Early Hum Dev 2014; 90 Suppl 2:S57-9. [PMID: 25220131 DOI: 10.1016/s0378-3782(14)50015-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Traditional treatment of respiratory distress syndrome in preterm infants consisted of early intubation, mechanical ventilation and intra-tracheal administration of exogenous surfactant. Recently, non-invasive ventilation, which has shown some advantages in short- and long-term outcomes, has gained popularity for the initial management of respiratory insufficiency in preterm infants. However, non-invasive ventilation from the outset poses difficulties in relation to administration of exogenous surfactant. The customary INSURE technique requires tracheal intubation, surfactant administration, and rapid extubation, but the latter is not always possible. As a more elegant approach, several minimally invasive techniques of delivering surfactant have been developed for babies spontaneously breathing on CPAP. The most extensively studied have been those in which the trachea is briefly catheterized with a nasogastric tube or vascular catheter, and exogenous surfactant is administered. Although results seem promising they are not yet conclusive, and further studies will be needed to answer a number of outstanding questions.
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Affiliation(s)
- Marta Aguar
- University & Polytechnic Hospital La Fe, Valencia, Spain; Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain
| | - Antonio Nuñez
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain
| | - Elena Cubells
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain
| | - Maria Cernada
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Tasmania, Australia; Menzies Research Institute Tasmania, Hobart, Tasmania, Australia
| | - Maximo Vento
- University & Polytechnic Hospital La Fe, Valencia, Spain; Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain.
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Dargaville PA, Kamlin COF, De Paoli AG, Carlin JB, Orsini F, Soll RF, Davis PG. The OPTIMIST-A trial: evaluation of minimally-invasive surfactant therapy in preterm infants 25-28 weeks gestation. BMC Pediatr 2014; 14:213. [PMID: 25164872 PMCID: PMC4236682 DOI: 10.1186/1471-2431-14-213] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/12/2014] [Indexed: 11/23/2022] Open
Abstract
Background It is now recognized that preterm infants ≤28 weeks gestation can be effectively supported from the outset with nasal continuous positive airway pressure. However, this form of respiratory therapy may fail to adequately support those infants with significant surfactant deficiency, with the result that intubation and delayed surfactant therapy are then required. Infants following this path are known to have a higher risk of adverse outcomes, including death, bronchopulmonary dysplasia and other morbidities. In an effort to circumvent this problem, techniques of minimally-invasive surfactant therapy have been developed, in which exogenous surfactant is administered to a spontaneously breathing infant who can then remain on continuous positive airway pressure. A method of surfactant delivery using a semi-rigid surfactant instillation catheter briefly passed into the trachea (the “Hobart method”) has been shown to be feasible and potentially effective, and now requires evaluation in a randomised controlled trial. Methods/design This is a multicentre, randomised, masked, controlled trial in preterm infants 25–28 weeks gestation. Infants are eligible if managed on continuous positive airway pressure without prior intubation, and requiring FiO2 ≥ 0.30 at an age ≤6 hours. Randomisation will be to receive exogenous surfactant (200 mg/kg poractant alfa) via the Hobart method, or sham treatment. Infants in both groups will thereafter remain on continuous positive airway pressure unless intubation criteria are reached (FiO2 ≥ 0.45, unremitting apnoea or persistent acidosis). Primary outcome is the composite of death or physiological bronchopulmonary dysplasia, with secondary outcomes including incidence of death; major neonatal morbidities; durations of all modes of respiratory support and hospitalisation; safety of the Hobart method; and outcome at 2 years. A total of 606 infants will be enrolled. The trial will be conducted in >30 centres worldwide, and is expected to be completed by end-2017. Discussion Minimally-invasive surfactant therapy has the potential to ease the burden of respiratory morbidity in preterm infants. The trial will provide definitive evidence on the effectiveness of this approach in the care of preterm infants born at 25–28 weeks gestation. Trial registration Australia and New Zealand Clinical Trial Registry: ACTRN12611000916943; ClinicalTrials.gov: NCT02140580.
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Affiliation(s)
- Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital and University of Tasmania, Liverpool Street, Hobart TAS 7000, Australia.
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Use of CPAP and surfactant therapy in newborns with respiratory distress syndrome. Indian J Pediatr 2014; 81:481-8. [PMID: 24722861 DOI: 10.1007/s12098-014-1405-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
Respiratory distress syndrome (RDS) is a major disease burden in the developing countries. Current evidence supports early continuous positive airway pressure (CPAP) use and early selective surfactant administration as the most efficacious interventions in the management of RDS, both in developed and developing countries. In developing countries, it is recommended to increase institutional deliveries and increase the coverage of antenatal steroids in women in preterm labor as preventive measures. Establishing intervention of CPAP and surfactant therapies in the Level II special care newborn units (SCNUs) and Level III units requires focus on training nursing staff and pediatricians across the board. These approaches would pave the way in optimizing the care of the preterm infants with RDS and decrease their mortality and morbidity significantly.
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Fischer HS, Bührer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis. Pediatrics 2013; 132:e1351-60. [PMID: 24144716 DOI: 10.1542/peds.2013-1880] [Citation(s) in RCA: 195] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Mechanical ventilation via an endotracheal tube is a risk factor for bronchopulmonary dysplasia (BPD), one of the most common morbidities of very preterm infants. Our objective was to investigate the effect that strategies to avoid endotracheal mechanical ventilation (eMV) have on the incidence of BPD in preterm infants <30 weeks' gestational age (GA). METHODS In February 2013, we searched the databases Medline, Embase, and the Cochrane Central Register of Controlled Trials. Study selection criteria included randomized controlled trials published in peer-reviewed journals since the year 2000 that compared preterm infants <30 weeks' GA treated by using a strategy aimed at avoiding eMV with a control group in which mechanical ventilation via an endotracheal tube was performed at an earlier stage. Data were extracted and analyzed by using the standard methods of the Cochrane Neonatal Review Group. The authors independently assessed study eligibility and risk of bias, extracted data and calculated odds ratios and 95% confidence intervals, employing RevMan version 5.1.6. RESULTS We identified 7 trials that included a total of 3289 infants. The combined odds ratio (95% confidence interval) of death or BPD was 0.83 (0.71-0.96). The number needed to treat was 35. The study results were remarkably homogeneous. Avoiding eMV had no influence on the incidence of severe intraventricular hemorrhage. CONCLUSIONS Strategies aimed at avoiding eMV in infants <30 weeks' GA have a small but significant beneficial impact on preventing BPD.
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Affiliation(s)
- Hendrik S Fischer
- Klinik für Neonatologie, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Ricotti A, Salvo V, Zimmermann LJI, Gavilanes AWD, Barberi I, Lista G, Colivicchi M, Temporini F, Gazzolo D. N-SIPPV versus bi-level N-CPAP for early treatment of respiratory distress syndrome in preterm infants. J Matern Fetal Neonatal Med 2013; 26:1346-51. [PMID: 23488612 DOI: 10.3109/14767058.2013.784255] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Non-invasive ventilation (NIV) for RDS in extremely/very low birth-weight infants represents the new challenge for neonatologists. In this regard, data comparing the effectiveness of Bi-Level-NCPAP (BiPAP) versus nasal synchronized intermittent positive pressure ventilation (NSIPPV) as primary mode of treatment for RDS are lacking. STUDY DESIGN We conducted a retrospective study from December 2007 to December 2010 in seventy-eight infants, who received NIV (N-SIPPV: 33; BiPAP: 45). The primary outcomes were the length and failure of NIV. Secondary outcomes were adverse short-long term pulmonary outcomes, multiple doses of surfactant and others. RESULTS There were no significant differences (p > 0.05) between the two different NIV modes. CONCLUSION The present findings suggest that N-SIPPV and BiPAP gives similar results in the RDS treatment. We did not find a benefit of one over the other ventilation mode and both could be constitute a valid option to conventional mechanical ventilation. The theoretical benefits of these two different methods of NIV are tidal volume enhancement, improvements of the functional residual capacity and of the mean airway pressure and reducing apnea episodes. Further randomized studies to assess the advantages and the efficacy of different methods of NIV for the treatment of the RDS are needed.
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Affiliation(s)
- Alberto Ricotti
- Neonatal Intensive Care Unit, C. Arrigo Children's Hospital, Alessandria, Italy
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Berger TM, Fontana M, Stocker M. The journey towards lung protective respiratory support in preterm neonates. Neonatology 2013; 104:265-74. [PMID: 24107385 DOI: 10.1159/000354419] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022]
Abstract
The aim of this conceptual review is to provide the reader with a broad perspective on progress made in respiratory support of preterm infants over the past five decades. Landmark discoveries are described in their historical context and underlying theories of lung protection are discussed. The review finishes by integrating different approaches and perspectives into a state-of-the-art concept for lung-protective ventilation in this fragile patient population. Improvements in neonatal respiratory support in the 1970s and 1980s have contributed to dramatic improvements of mortality and morbidity rates among neonates with respiratory failure. Continuous positive airway pressure, antenatal corticosteroids and surfactant replacement therapy revolutionized the care of preterm infants. With the recognition that atelectrauma, volutrauma and oxygen toxicity are the main factors contributing to ventilator-induced lung injury, lung-protective strategies, including noninvasive respiratory support, tidal volume targeting during conventional mechanical ventilation and high frequency ventilation were developed in the 1990s. Given the fact that progress made in the last decade has only resulted in minor improvements in mortality and morbidity rates of neonates with respiratory failure, it seems unlikely that further refinements of current technologies will produce giant leaps forward in high-resource countries. It appears that entirely new approaches would be required. In contrast, knowledge and technology transfer of basic respiratory support strategies (e.g. use of oxygen, simple systems to provide continuous positive airway pressure), could have an enormous impact on the prognosis of neonates with respiratory failure in low-resource countries.
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Affiliation(s)
- Thomas M Berger
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital of Lucerne, Lucerne, Switzerland
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Kandraju H, Murki S, Subramanian S, Gaddam P, Deorari A, Kumar P. Early routine versus late selective surfactant in preterm neonates with respiratory distress syndrome on nasal continuous positive airway pressure: a randomized controlled trial. Neonatology 2013; 103:148-54. [PMID: 23235135 DOI: 10.1159/000345198] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 10/15/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preterm neonates with respiratory distress syndrome (RDS) benefit from early application of nasal continuous positive airway pressure (nCPAP). However, it is not clear whether surfactant should be administered early as a routine to all such infants or later in a selective manner. OBJECTIVE It was the aim of this study to compare the efficacy of early routine versus late selective surfactant treatment in reducing the need for mechanical ventilation (MV) during the first week of life among moderate-sized preterm infants with RDS being supported by nCPAP. METHODS Infants born at 28(0/7) to 33(6/7) weeks of gestation with RDS and on nCPAP were randomly assigned within the first 2 h of life to early routine surfactant administration by the InSurE technique (early surfactant group) or to late selective administration of surfactant (late surfactant group). The primary outcome was need for MV in the first 7 days of life. RESULTS Among 153 infants randomized to early (n = 74) or late surfactant (n = 79) groups, the need for MV was significantly lower in the early surfactant group (16.2 vs. 31.6%; relative risk 0.41, 95% confidence interval 0.19-0.91). The incidence of pneumothorax (1.9 vs. 2.3%) and the need for supplemental O2 at 28 days (2.7 vs. 8.9%) were similar in the two groups. CONCLUSION Early routine surfactant administration within 2 h of life as compared to late selective administration significantly reduced the need for MV in the first week of life among preterm infants with RDS on nCPAP.
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Flow-synchronized nasal intermittent positive pressure ventilation for infants <32 weeks' gestation with respiratory distress syndrome. Crit Care Res Pract 2012; 2012:301818. [PMID: 23227317 PMCID: PMC3514808 DOI: 10.1155/2012/301818] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 11/01/2012] [Indexed: 12/04/2022] Open
Abstract
Aim. To evaluate whether synchronized-NIPPV (SNIPPV) used after the INSURE procedure can reduce mechanical ventilation (MV) need in preterm infants with RDS more effectively than NCPAP and to compare the clinical course and the incidence of short-term outcomes of infants managed with SNIPPV or NCPAP. Methods. Chart data of inborn infants <32 weeks undergoing INSURE approach in the period January 2009–December 2010 were reviewed. After INSURE, newborns born January –December 2009 received NCPAP, whereas those born January–December 2010 received SNIPPV. INSURE failure was defined as FiO2 need >0.4, respiratory acidosis, or intractable apnoea that occurred within 72 hours of surfactant administration. Results. Eleven out of 31 (35.5%) infants in the NCPAP group and 2 out of 33 (6.1%) infants in the SNIPPV group failed the INSURE approach and underwent MV (P < 0.004). Fewer infants in the INSURE/SNIPPV group needed a second dose of surfactant, a high caffeine maintenance dose, and pharmacological treatment for PDA. Differences in O2 dependency at 28 days and 36 weeks of postmenstrual age were at the limit of significance in favor of SNIPPV treated infants. Conclusions. SNIPPV use after INSURE technique in our NICU reduced MV need and favorably affected short-term morbidities of our premature infants.
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Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2012; 11:CD001456. [PMID: 23152207 PMCID: PMC7057030 DOI: 10.1002/14651858.cd001456.pub2] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinical trials have confirmed that surfactant therapy is effective in improving the immediate need for respiratory support and the clinical outcome of premature newborns. Trials have studied a wide variety of surfactant preparations used either to prevent (prophylactic or delivery room administration) or treat (selective or rescue administration) respiratory distress syndrome (RDS). Using either treatment strategy, significant reductions in the incidence of pneumothorax, as well as significant improvement in survival, have been noted. It is unclear whether there are any advantages to treating infants with respiratory insufficiency earlier in the course of RDS. OBJECTIVES To compare the effects of early versus delayed selective surfactant therapy for newborns intubated for respiratory distress within the first two hours of life. Planned subgroup analyses included separate comparisons for studies utilizing natural surfactant extract and synthetic surfactant. SEARCH METHODS We searched the Oxford Database of Perinatal Trials, MEDLINE (MeSH terms: pulmonary surfactant; text word: early; limits: age, newborn: publication type, clinical trial), PubMed, abstracts, conference and symposia proceedings, expert informants, and journal handsearching in the English language. For the updated search in April 2012 we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2012, Issue 1) and PubMed (January 1997 to April 2012). SELECTION CRITERIA Randomized and quasi-randomized controlled clinical trials comparing early selective surfactant administration (surfactant administration via the endotracheal tube in infants intubated for respiratory distress, not specifically for surfactant dosage) within the first two hours of life versus delayed selective surfactant administration to infants with established RDS were considered for review. DATA COLLECTION AND ANALYSIS Data regarding clinical outcomes were excerpted from the reports of the clinical trials by the review authors. Subgroup analyses were performed based on type of surfactant preparation, gestational age, and exposure to prenatal steroids. Data analysis was performed in accordance with the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Six randomized controlled trials met selection criteria. Two of the trials utilized synthetic surfactant (Exosurf Neonatal) and four utilized animal-derived surfactant preparations.The meta-analyses demonstrate significant reductions in the risk of neonatal mortality (typical risk ratio (RR) 0.84; 95% confidence interval (CI) 0.74 to 0.95; typical risk difference (RD) -0.04; 95% CI -0.06 to -0.01; 6 studies; 3577 infants), chronic lung disease (typical RR 0.69; 95% CI 0.55 to 0.86; typical RD -0.04; 95% CI -0.06 to -0.01; 3 studies; 3041 infants), and chronic lung disease or death at 36 weeks (typical RR 0.83; 95% CI 0.75 to 0.91; typical RD -0.06; 95% CI -0.09 to -0.03; 3 studies; 3050 infants) associated with early treatment of intubated infants with RDS.Intubated infants randomized to early selective surfactant administration also demonstrated a decreased risk of acute lung injury including a decreased risk of pneumothorax (typical RR 0.69; 95% CI 0.59 to 0.82; typical RD -0.05; 95% CI -0.08 to -0.03; 5 studies; 3545 infants), pulmonary interstitial emphysema (typical RR 0.60; 95% CI 0.41 to 0.89; typical RD -0.06; 95% CI -0.10 to -0.02; 3 studies; 780 infants), and overall air leak syndromes (typical RR 0.61; 95% CI 0.48 to 0.78; typical RD -0.18; 95% CI -0.26 to -0.09; 2 studies; 463 infants).A trend toward risk reduction for bronchopulmonary dysplasia (BPD) or death at 28 days was also evident (typical RR 0.94; 95% CI 0.88 to 1.00; typical RD -0.04; 95% CI -0.07 to -0.00; 3 studies; 3039 infants). No differences in other complications of RDS or prematurity were noted.Only two studies reported on infants under 30 weeks' gestation. Decreased risk of neonatal mortality and chronic lung disease or death at 36 weeks' postmenstrual age was noted. AUTHORS' CONCLUSIONS Early selective surfactant administration given to infants with RDS requiring assisted ventilation leads to a decreased risk of acute pulmonary injury (decreased risk of pneumothorax and pulmonary interstitial emphysema) and a decreased risk of neonatal mortality and chronic lung disease compared to delaying treatment of such infants until they develop worsening RDS.
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Affiliation(s)
| | - Roger Soll
- University of VermontDivision of Neonatal‐Perinatal MedicineFletcher Allen Health Care, Smith 552A111 Colchester AvenueBurlingtonVermontUSA05401
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Abdel-Latif ME, Osborn DA. Nebulised surfactant in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2012; 10:CD008310. [PMID: 23076945 DOI: 10.1002/14651858.cd008310.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nebulised surfactant has the potential to deliver surfactant to the infant lung with the goal of avoiding endotracheal intubation and ventilation, ventilator-induced lung injury and bronchopulmonary dysplasia (BPD). OBJECTIVES To determine the effect of nebulised surfactant administration either as prophylaxis or treatment compared to placebo, no treatment or intratracheal surfactant administration on morbidity and mortality in preterm infants with, or at risk of, respiratory distress syndrome (RDS). SEARCH METHODS Searches were performed of CENTRAL (The Cochrane Library, January 2012), MEDLINE and PREMEDLINE (1950 to January 2012), EMBASE (1980 to January 2012) and CINAHL (1982 to January 2012), as well as proceedings of scientific meetings, clinical trial registries, Google Scholar and reference lists of identified studies. Expert informants and surfactant manufacturers were contacted. SELECTION CRITERIA Randomised, cluster-randomised or quasi-randomised controlled trials of nebulised surfactant administration compared to placebo, no treatment, or other routes of administration (laryngeal, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and quality, and extracted data. MAIN RESULTS No studies of prophylactic or early nebulised surfactant administration were found. A single small study of late rescue nebulised surfactant was included. The study is of moderate risk of bias. The study enrolled 32 preterm infants born < 36 weeks' gestation with RDS on nasal continuous positive airway pressure (nCPAP). The study reported no significant difference between nebulised surfactant administration compared to no treatment groups in chronic lung disease (risk ratio (RR) 5.00; 95% confidence interval (CI) 0.26 to 96.59) or other outcomes (oxygenation 1 to 12 hours after randomisation, need for mechanical ventilation, days of mechanical ventilation or continuous positive airways pressure (CPAP) or days of supplemental oxygen). No side effects of the nebulised surfactant therapy or aerosol inhalation were reported. AUTHORS' CONCLUSIONS There are insufficient data to support or refute the use of nebulised surfactant in clinical practice. Adequately powered trials are required to determine the effect of nebulised surfactant administration for prevention or early treatment of RDS in preterm infants. Nebulised surfactant administration should be limited to clinical trials.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Department of Neonatology, Australian National University Medical School, Woden, Australia.
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Pfister RH, Soll RF. Initial respiratory support of preterm infants: the role of CPAP, the INSURE method, and noninvasive ventilation. Clin Perinatol 2012; 39:459-81. [PMID: 22954263 DOI: 10.1016/j.clp.2012.06.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article explores the potential benefits and risks for the various approaches to the initial respiratory management of preterm infants. The authors focus on the evidence for the increasingly used strategies of initial respiratory support of preterm infants with continuous positive airway pressure (CPAP) beginning in the delivery room or very early in the hospital course and blended strategies involving the early administration of surfactant replacement followed by immediate extubation and stabilization on CPAP. Where possible, the evidence referenced in this review comes from individual randomized controlled trials or meta-analyses of those trials.
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Affiliation(s)
- Robert H Pfister
- Department of Pediatrics, University of Vermont, FAHC-Smith 556, Burlington, VT 05401, USA.
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Botet F, Figueras-Aloy J, Miracle-Echegoyen X, Rodríguez-Miguélez JM, Salvia-Roiges MD, Carbonell-Estrany X. Trends in survival among extremely-low-birth-weight infants (less than 1000 g) without significant bronchopulmonary dysplasia. BMC Pediatr 2012; 12:63. [PMID: 22682000 PMCID: PMC3507706 DOI: 10.1186/1471-2431-12-63] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 05/21/2012] [Indexed: 11/25/2022] Open
Abstract
Objective The aim of this study was to analyze the evolution from 1997 to 2009 of survival without significant (moderate and severe) bronchopulmonary dysplasia (SWsBPD) in extremely-low-birth-weight (ELBW) infants and to determine the influence of changes in resuscitation, nutrition and mechanical ventilation on the survival rate. Study design In this study, 415 premature infants with birth weights below 1000 g (ELBW) were divided into three chronological subgroups: 1997 to 2000 (n = 65), 2001 to 2005 (n = 178) and 2006 to 2009 (n = 172). Between 1997 and 2000, respiratory resuscitation in the delivery room was performed via a bag and mask (Ambu®, Ballerup, Sweden) with 40-50% oxygen. If this procedure was not effective, oral endotracheal intubation was always performed. Pulse oximetry was never used. Starting on January 1, 2001, a change in the delivery room respiratory policy was established for ELBW infants. Oxygenation and heart rate were monitored using a pulse oximeter (Nellcor®) attached to the newborn’s right hand. If resuscitation was required, ventilation was performed using a face mask, and intermittent positive pressure was controlled via a ventilator (Babylog2, Drägger). In 2001, a policy of aggressive nutrition was also initiated with the early provision of parenteral amino acids. We used standardized parenteral nutrition to feed ELBW infants during the first 12–24 hours of life. Lipids were given on the first day. The glucose concentration administered was increased by 1 mg/kg/minute each day until levels reached 8 mg/kg/minute. Enteral nutrition was started with trophic feeding of milk. In 2006, volume guarantee treatment was instituted and administered together with synchronized intermittent mandatory ventilation (SIMV + VG). The complications of prematurity were treated similarly throughout the study period. Patent ductus arteriosus was only treated when hemodynamically significant. Surgical closure of the patent ductus arteriosus was performed when two courses of indomethacin or ibuprofen were not sufficient to close it. Mild BPD were defined by a supplemental oxygen requirement at 28 days of life and moderate BPD if breathing room air or a need for <30% oxygen at 36 weeks postmenstrual age or discharge from the NICU, whichever came first. Severe BPD was defined by a supplemental oxygen requirement at 28 days of life and a need for greater than or equal to 30% oxygen use and/or positive pressure support (IPPV or nCPAP) at 36 weeks postmenstrual age or discharge, whichever came first. Moderate and severe BPD have been considered together as “significant BPD”. The goal of pulse oximetry was to maintain a hemoglobin saturation of between 88% and 93%. Patients were considered to not need oxygen supplementation when it could be permanently withdrawn. The distribution of the variables was not normal based on a Kolmogorov-Smirnov test (p < 0.05 in all cases). Therefore, quantitative variables were expressed as the median and interquartile range (IQR; 25th-75th percentile). Statistical analysis of the data was performed using nonparametric techniques (Kruskal-Wallis test and Mann–Whitney U test). A chi-square analysis was used to analyze qualitative variables. Potential confounding variables were those possibly related to BPD in survivors (p between 0.05 and 0.3 in univariate analysis). Logistic regression analysis was performed with variables related to BPD in survivors (p < 0.05) and potential confounding variables. The forward stepwise method adjusted for confounding factors was used to select the variables, and the enter method using selected variables was used to obtain the odds ratios. Results and conclusion There was an increase in the rate of SWsBPD (1997 to 2000: 58.5%; 2001 to 2005: 74.2%; and 2006 to 2009: 75.0%; p = 0.032). In survivors, the occurrence of significant BPD decreased after 2001 (9.5% vs. 2.3%; p = 0.013). The factors associated with improved SWsBPD were delivery by caesarean section, a reduced endotracheal intubation rate and a reduced duration of mechanical ventilation.While the mortality of ELBW infants has not changed since 2001, the frequency of SWsBPD has significantly increased (75.0%) in association with increased caesarean sections and reductions in the endotracheal intubation rate, as well as the duration of mechanical ventilation.
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Affiliation(s)
- Francesc Botet
- Neonatology Service, Hospital Clínic de Barcelona, Sabino de Arana 1, 08028 Barcelona, Spain.
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Abstract
UNLABELLED There is mounting evidence that early continuous positive airway pressure (CPAP) from birth is feasible and safe even in very preterm infants. However, many infants will develop respiratory distress syndrome (RDS) and require surfactant treatment. Combining a non-invasive ventilation approach with a strategy for surfactant administration is important, but questions remain about the optimal timing, mode of delivery and the value of predictive tests for surfactant deficiency. CONCLUSION Early CPAP in very preterm infants is as safe as routine intubation in the delivery room. However, a strategy for surfactant administration should be part of a non-invasive ventilation approach for those infants at risk of developing significant RDS.
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Affiliation(s)
- Kajsa Bohlin
- Department of Neonatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.
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Dani C, Corsini I, Poggi C. Risk factors for intubation-surfactant-extubation (INSURE) failure and multiple INSURE strategy in preterm infants. Early Hum Dev 2012; 88 Suppl 1:S3-4. [PMID: 22266202 DOI: 10.1016/j.earlhumdev.2011.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The INSURE method, which consists of an intubation-surfactant-extubation sequence, is effective in reducing the need for mechanical ventilation (MV), the duration of respiratory support, and the need for surfactant replacement in preterm infants with respiratory distress syndrome. Although beneficial, the INSURE method fails to avoid MV in selected patients. We demonstrated that body weight <750 g, pO(2)/FiO(2) <218, and a/ApO(2) <0.44 at the first blood gas analysis are independent risk factors for INSURE failure in infants with gestational age <30 weeks. Moreover, we demonstrated that the INSURE treatment can be safely repeated with the aim to avoid MV, since the respiratory outcome did not differ between infants treated with single or multiple INSURE procedures.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, University of Florence, Viale Morgagni 85, Florence, Italy.
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Göpel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C, Siegel J, Avenarius S, von der Wense A, Vochem M, Groneck P, Weller U, Möller J, Härtel C, Haller S, Roth B, Herting E. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011; 378:1627-34. [PMID: 21963186 DOI: 10.1016/s0140-6736(11)60986-0] [Citation(s) in RCA: 298] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Surfactant is usually given to mechanically ventilated preterm infants via an endotracheal tube to treat respiratory distress syndrome. We tested a new method of surfactant application to spontaneously breathing preterm infants to avoid mechanical ventilation. METHOD In a parallel-group, randomised controlled trial, 220 preterm infants with a gestational age between 26 and 28 weeks and a birthweight less than 1·5 kg were enrolled in 12 German neonatal intensive care units. Infants were independently randomised in a 1:1 ratio with variable block sizes, to standard treatment or intervention, and randomisation was stratified according to centre and multiple birth status. Masking was not possible. Infants were stabilised with continuous positive airway pressure and received rescue intubation if necessary. In the intervention group, infants received surfactant treatment during spontaneous breathing via a thin catheter inserted into the trachea by laryngoscopy if they needed a fraction of inspired oxygen more than 0·30. The primary endpoint was need for any mechanical ventilation, or being not ventilated but having a partial pressure of carbon dioxide more than 65 mm Hg (8·6 kPa) or a fraction of inspired oxygen more than 0·60, or both, for more than 2 h between 25 h and 72 h of age. Analysis was by intention to treat. This study is registered, number ISRCTN05025922. FINDINGS 108 infants were assigned to the intervention group and 112 infants to the standard treatment group. All infants were analysed. On day 2 or 3 after birth, 30 (28%) infants in the intervention group were mechanically ventilated versus 51 (46%) in the standard treatment group (number needed to treat 6, 95% CI 3-20, absolute risk reduction 0·18, 95% CI 0·30-0·05, p=0·008). 36 (33%) infants in the intervention group were mechanically ventilated during their stay in the hospital compared with 82 (73%) in the standard treatment group (number needed to treat: 3, 95% CI 2-4, p<0·0001). The intervention group had significantly fewer median days on mechanical ventilation, (0 days. IQR 0-3 vs 2 days, 0-5) and a lower need for oxygen therapy at 28 days (30 infants [30%] vs 49 infants [45%], p=0·032) compared with the standard treatment group. We recorded no differences between groups for mortality (seven deaths in the intervention group vs five in the standard treatment group) and serious adverse events (21 vs 28). INTERPRETATION The application of surfactant via a thin catheter to spontaneously breathing preterm infants receiving continuous positive airway pressure reduces the need for mechanical ventilation. FUNDING German Ministry of Research and Technology, University of Lübeck, and Chiesi Pharmaceuticals.
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Abdel-Latif ME, Osborn DA. Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2011:CD008309. [PMID: 21735428 DOI: 10.1002/14651858.cd008309.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Laryngeal mask airway (LMA) administration is one way of delivering surfactant to the infant lung, with the potential benefit of avoiding endotracheal intubation and ventilation, ventilator induced lung injury and bronchopulmonary dysplasia (BPD). OBJECTIVES To determine the effect of LMA surfactant administration either as prophylaxis or treatment compared to placebo, no treatment, or intratracheal surfactant administration on morbidity and mortality in preterm infants with, or at risk of, respiratory distress syndrome (RDS). SEARCH STRATEGY We searched CENTRAL (The Cochrane Library, October 2010), MEDLINE and PREMEDLINE (1950 to October 2010), EMBASE (1980 to October 2010) and CINAHL (1982 to October 2010). We also searched proceedings of scientific meetings, clinical trial registries, Google Scholar and reference lists of identified studies, as well as contacting expert informants and surfactant manufacturers. SELECTION CRITERIA Randomised, cluster-randomised or quasi-randomised controlled trials of laryngeal mask surfactant administration compared to placebo, no treatment, or other routes of administration (nebulised, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and quality, and extracted data. MAIN RESULTS We found no studies of prophylactic or early LMA surfactant administration. A single small study of late rescue LMA surfactant was identified as eligible for inclusion. The study enrolled 26 preterm infants born ≥ 1200 g with RDS on continuous positive airway pressure (nCPAP). LMA surfactant administration compared to no treatment resulted in a reduction in mean FiO(2) required to maintain oxygen saturation between 88% and 92% for 12 hours after the intervention. No significant difference was reported in subsequent mechanical ventilation and endotracheal surfactant, pneumothorax, days on intermittent positive airway pressure (IPPV), and days on IPPV or oxygen. AUTHORS' CONCLUSIONS There is evidence from a single small trial that LMA surfactant administration in preterm infants ≥ 1200 g with established RDS may have a short term effect in reducing oxygen requirements although the study is underpowered to detect important clinical effects. Adequately powered trials are required to determine the effect of LMA surfactant administration for prevention or treatment of RDS in preterm infants. LMA surfactant administration should be limited to clinical trials.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Department of Neonatology, Australian National University Medical School, PO Box 11, Woden, ACT, Australia, 2606
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Dani C, Corsini I, Bertini G, Pratesi S, Barp J, Rubaltelli FF. Effect of multiple INSURE procedures in extremely preterm infants. J Matern Fetal Neonatal Med 2011; 24:1427-31. [PMID: 21506654 DOI: 10.3109/14767058.2011.572203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Our aim was to evaluate whether single and multiple intubation-surfactant-extubation (INSURE) procedures have similar effects on the need of mechanical ventilation (MV) and occurrence of bronchopulmonary dysplasia (BPD) in extremely preterm infants. METHODS We studied infants of <30 weeks of gestation with respiratory distress syndrome (RDS) who were treated with single (FiO(2)>0.30 without need of MV) or multiple (FiO(2)>0.40 without need of MV) INSURE procedures. RESULTS Seventy-five infants were studied: 53 (71%) received single INSURE and 22 (29%) received multiple INSURE procedures. Infants in the single and multiple groups had similar rates of need of MV (15 vs. 23%) and occurrence of BPD (9 vs. 9%), although the latter were more immature and affected by more severe RDS (higher FiO(2), lower a/ApO(2), and pO(2)/FiO(2)) than the former. CONCLUSIONS Single and multiple INSURE procedures were followed by similar respiratory outcome in a cohort of extremely preterm infants. Further studies are warranted to evaluate whether the multiple INSURE strategy enhances the success rate of INSURE in preventing the need of MV and the occurrence of BPD.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Viale Morgagni 85, Florence, Italy.
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Abdel-Latif ME, Osborn DA. Pharyngeal instillation of surfactant before the first breath for prevention of morbidity and mortality in preterm infants at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2011:CD008311. [PMID: 21412918 DOI: 10.1002/14651858.cd008311.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intrapartum pharyngeal instillation of surfactant before the first breath may result in surfactant administration to the infant lung, with the potential benefit of avoiding endotracheal intubation and ventilation, ventilator induced lung injury and bronchopulmonary dysplasia. OBJECTIVES To determine the effect of pharyngeal instillation of surfactant before the first breath compared to placebo, no treatment or intratracheal surfactant administration followed by intermittent positive pressure ventilation (IPPV) on morbidity and mortality in preterm infants at risk of respiratory distress syndrome (RDS). SEARCH STRATEGY Searches were made of CENTRAL (The Cochrane Library, to September 2010), MEDLINE and PREMEDLINE (1950 to September 2010), EMBASE (1980 to 2010) and CINAHL (1982 to 2010). This strategy was supplemented by searches of proceedings of scientific meetings, Google Scholar and reference lists of identified studies, as well as contact with expert informants and surfactant manufacturers. SELECTION CRITERIA Published, unpublished and ongoing randomised controlled or quasi-randomised trials (using individual or cluster allocation) of pharyngeal instillation of surfactant before the first breath compared to placebo or no treatment, or intratracheal surfactant instillation followed by IPPV, on morbidity and mortality in preterm infants at risk of RDS. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and quality. MAIN RESULTS No published, unpublished or ongoing trials that met the inclusion criteria for this review were found. AUTHORS' CONCLUSIONS There were no data from randomised controlled or quasi-randomised trials that evaluated the effect of intrapartum instillation of pharyngeal surfactant before the first breath. Evidence from animal and observational human studies suggest that pharyngeal instillation of surfactant before the first breath is potentially safe, feasible and may be effective. Well designed trials are needed.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Department of Neonatology, Australian National University Medical School, PO Box 11, Woden, ACT, Australia, 2606
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