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van Kaam AH, Niemarkt HJ, Onland W. Timing of surfactant treatment in respiratory distress syndrome. Semin Fetal Neonatal Med 2023; 28:101495. [PMID: 38012889 DOI: 10.1016/j.siny.2023.101495] [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: 11/29/2023]
Abstract
The introduction of exogenous surfactant in the 1980s has resulted in an improved survival of very preterm infants with respiratory distress syndrome (RDS). Randomized controlled trials conducted before 2000 have shown that the magnitude of this beneficial effect strongly depends on the timing of surfactant treatment, i.e. the earlier surfactant is administered after birth the better. However, the initial mode of respiratory support in infants with RDS has changed dramatically over the last decades, moving from invasive to non-invasive support. Furthermore, new, less invasive techniques to administer surfactant have been introduced to match this non-invasive approach. This review summarizes the evidence on how these practice changes impacted the effect of surfactant timing on mortality and morbidity in preterm infants with RDS.
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Affiliation(s)
- Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Hendrik J Niemarkt
- Department of Neonatology, Maxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands.
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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2
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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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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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Branagan A, Yu I, Gurusamy K, Miletin J. Thresholds for surfactant use in preterm neonates: a network meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2022-324184. [PMID: 36600484 DOI: 10.1136/archdischild-2022-324184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a network meta-analysis of randomised controlled trials of different surfactant treatment strategies for respiratory distress syndrome (RDS) to assess if a certain fraction of inspired oxygen (FiO2) is optimal for selective surfactant therapy. DESIGN Systematic review and network meta-analysis using Bayesian analysis of randomised trials of prophylactic versus selective surfactant for RDS. SETTING Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Science Citation Index Expanded. PATIENTS Randomised trials including infants under 32 weeks of gestational age. INTERVENTIONS Intratracheal surfactant, irrespective of type or dose. MAIN OUTCOME MEASURES Our primary outcome was neonatal mortality, compared between groups treated with selective surfactant therapy at different thresholds of FiO2. Secondary outcomes included respiratory morbidity and major complications of prematurity. RESULTS Of 4643 identified references, 14 studies involving 5298 participants were included. We found no statistically significant differences between 30%, 40% and 50% FiO2 thresholds. A sensitivity analysis of infants treated in the era of high antenatal steroid use and nasal continuous positive airway pressure as initial mode of respiratory support showed no difference in mortality, RDS or intraventricular haemorrhage alone but suggested an increase in the combined outcome of major morbidities in the 60% threshold. CONCLUSION Our results do not show a clear benefit of surfactant treatment at any threshold of FiO2. The 60% threshold was suggestive of increased morbidity. There was no advantage seen with prophylactic treatment. Randomised trials of different thresholds for surfactant delivery are urgently needed to guide clinicians and provide robust evidence. PROSPERO REGISTRATION NUMBER CRD42020166620.
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Affiliation(s)
- Aoife Branagan
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland .,Division of Surgery and Interventional Science, UCL, London, UK
| | - Ivan Yu
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,Division of Surgery and Interventional Science, UCL, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, UCL, London, UK.,Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moskva, Russian Federation
| | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic.,2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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5
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Flores S, Villarreal EG, Lee B, Morales-Demori R, Farias JS, Ahmed M, Loomba RS, Savorgnan F. Impact of surfactant when utilized during pediatric cardiac surgery admissions: analysis of a nationwide database. J Matern Fetal Neonatal Med 2021; 35:7819-7825. [PMID: 34139955 DOI: 10.1080/14767058.2021.1937981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Surfactant has been routinely used in the neonatal population, particularly in the setting of prematurity and neonatal respiratory distress syndrome. Current evidence, however, does not delineate the effect of surfactant use in neonates and older children during cardiac surgery admissions. This study aimed to characterize the impact of surfactant on pediatric cardiac surgery admissions. METHODS Admissions of those under 18 years of age with cardiac surgery were identified from the Pediatric Health Information System (PHIS) database between 2004 and 2015, using ICD-9 procedure codes. Univariate analyses were conducted to compare admission characteristics between those that did and not utilize surfactant. Variables shown to be significant were then entered as independent variables into the regression analyses. Surfactant was entered into each model as an independent variable. RESULTS A total of 81,313 admissions met the inclusion criteria. Of these, 109 (0.1%) had surfactant utilized. Univariate analyses identified several differences between admissions with and without surfactant use and demonstrated significantly increased mortality in the surfactant group (38.5% versus 4.6%, p < .01). Regression analyses demonstrated that surfactant was independently associated with increased mortality (odds ratio 6.0, 95% confidence interval 3.9-9.3, p < .01). Univariate analysis in only surfactant admissions demonstrated the following to be associated with inpatient mortality: younger age, prematurity, Ebstein anomaly, and hypoplastic left heart syndrome. CONCLUSIONS Surfactant administration during pediatric cardiac surgery admissions is independently associated with a sixfold increase in inpatient mortality. It is likely that these findings are mediated by augmentation of the decrease in pulmonary vascular resistance and a subsequent decrease in systemic blood flow in the setting of parallel circulation. Surfactant should be administered with special consideration in neonates with cardiac disease and may be best avoided in those with parallel circulation.
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Affiliation(s)
- Saul Flores
- Critical Care and Cardiology Department, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Brian Lee
- Cardiology Department, Advocate Children's Hospital, Chicago, IL, USA
| | - Raysa Morales-Demori
- Critical Care and Cardiology Department, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Juan S Farias
- Critical Care and Cardiology Department, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Mubbasheer Ahmed
- Critical Care and Cardiology Department, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Rohit S Loomba
- Cardiology Department, Advocate Children's Hospital, Chicago, IL, USA
| | - Fabio Savorgnan
- Critical Care and Cardiology Department, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
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Cavallin F, Carlone G, Doglioni N, Villani PE, Vecchiato L, Lago P, Trevisanuto D. Surfactant Treatment of Late Preterm Infants during Emergency Transport: A Retrospective, Observational Study. Neonatology 2021; 118:617-623. [PMID: 34569541 DOI: 10.1159/000518986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND In late preterm infants born in nontertiary hospitals, the occurrence of respiratory distress syndrome requires postnatal transport. This study aimed to investigate the impact of the timing of surfactant administration in late preterm infants needing postnatal transport. METHODS This is a retrospective study evaluating surfactant administration in late preterm infants during emergency transports by the Eastern Veneto Neonatal Emergency Transport Service between January 2005 and December 2019. The outcome measures included short-term clinical complications, stabilization time, oxygen concentration, duration of mechanical ventilation and noninvasive respiratory support, length of hospital stay, bronchopulmonary dysplasia, intraventricular hemorrhage, and sepsis. RESULTS Surfactant was administered to 155/303 neonates (51.1%) at 3 different time points: at a referring hospital (50 neonates), when the transport team arrived (25 neonates), or at a referral hospital (80 neonates). Stabilization time was longer in neonates receiving surfactant by the transport team (adjusted mean difference 17 min, 95% confidence interval, 4-29 min; p = 0.01). Decrease in oxygen concentrations during the transport was larger in neonates receiving surfactant at a referring hospital (adjusted mean difference -11%, 95% confidence interval, -15 to -3%; p = 0.01). The other outcome measures were not statistically different according to the timing of surfactant administration. CONCLUSIONS In late preterm infants with respiratory distress needing postnatal transfer, stabilization time was longer when the first surfactant was administered by the transport team, but such delay did not affect safety and clinical outcomes.
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Affiliation(s)
| | - Giorgia Carlone
- Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Nicoletta Doglioni
- Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Paolo Ernesto Villani
- Department of Pediatrics, Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Luca Vecchiato
- Department of Pediatrics, Camposampiero Hospital, Camposampierio, Italy
| | - Paola Lago
- Department of Pediatrics, Ca' Foncello Hospital, Treviso, Italy
| | - Daniele Trevisanuto
- Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
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Murki S, Kandraju H, Oleti T, Saikiran, Gaddam P. Predictors of CPAP Failure - 10 years' Data of Multiple Trials from a Single Center: A Retrospective Observational Study. Indian J Pediatr 2020; 87:891-896. [PMID: 32632570 DOI: 10.1007/s12098-020-03399-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify risk factors and outcomes associated with early failure of nasal continuous positive airway pressure (CPAP) in premature infants with respiratory distress (RD). METHODS This is a retrospective observational study of all the preterm infants with RD primarily supported on nasal CPAP and included in CPAP trials conducted at the study site. Data was collected from the raw excel sheets of the previous trials but limited to eligible patients from study site. Early CPAP failure was defined as the need for mechanical ventilation in the first 72 h after birth. Predictor variables for CPAP failure included baseline maternal and infant characteristics, CPAP care practices, morbidities and adjuvant therapies. The morbidities and outcomes were compared among infants with CPAP failure and CPAP success. RESULTS Six hundred and fifty-two infants were enrolled in the study. Early CPAP failure was seen in 96 infants (14.7%, 95% CI: 12%-17.5%). On logistic regression, adjusting for gestation and year of study, time of starting CPAP in hours (OR 1.01, 95% CI: 1.003-1.013), time of surfactant administration in hours (OR 1.12, 95% CI: 1.05-1.19), InSurE (Intubate Surfactant Extubate) (OR 2.7, 95% CI: 1.43-5.06) and higher starting FiO2 (OR 1.03, 95% CI: 1.01-1.05) predicted early CPAP failure. Neonatal morbidities and hospital duration were significantly higher in infants who failed CPAP. CONCLUSIONS Early starting of CPAP, InSurE, early surfactant administration, lower CPAP pressures and lower FiO2 at starting of CPAP were the important determinants of success.
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Affiliation(s)
- Srinivas Murki
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India.
| | - Hemasree Kandraju
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| | - Tejopratap Oleti
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| | - Saikiran
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| | - Pramod Gaddam
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
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Zelasko J, Omotayo MO, Berkelhamer SK, Niermeyer S, Kak L, Kumar S, Ram PK. Neonatal oxygen therapy in low- and middle-income countries: a pragmatic review. JOURNAL OF GLOBAL HEALTH REPORTS 2020. [DOI: 10.29392/001c.12346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background We assessed and summarized the peer-reviewed literature on the state of neonatal oxygen therapy in low and lower-middle income countries. Methods A literature search was performed in 3 online databases (Pub Med, EMBASE, CAB Global Health) and amongst USAID’s Service Provision Assessment (SPA) reports for publications pertaining to neonatal oxygen therapy in low and lower-middle income countries over the past 10 years (2007-2017). Results Our search yielded 474 records, of which 26 were relevant and included in the review. Maintenance and indirect costs associated with the procurement of oxygen may constitute barriers to oxygen supply. The quality of therapy provided to neonates was affected by factors including a lack of necessary equipment at neonatal healthcare facilities and high indirect costs associated with the procurement of oxygen. Pulse oximeters used for monitoring of oxygen therapy were available in healthcare facilities, but there is scant data on the frequency of that monitoring. There are some hospitals that deliver neonatal oxygen therapy without any necessary monitoring equipment. Prevalence of retinopathy of prematurity among neonates with risk factors ranged from 11.9-47.2%, which is notably higher than published rates in neonates of similar gestational age being treated in high-income countries. Conclusion There is a lack of data that provides direct estimates of availability of neonatal oxygen equipment and related clinical applications of oxygen therapy across health systems, particularly around the usage and availability of necessary monitoring equipment. Attention to the maintenance of oxygen and ancillary equipment for neonates and quality improvement initiatives to promote adherence to those guidelines can reduce the morbidity and mortality burden among neonates in low and lower-middle income countries.
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Affiliation(s)
- Jon Zelasko
- Jacobs School of Medicine at the University at Buffalo, Buffalo, New York, USA
| | - Moshood O Omotayo
- School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | | | - Susan Niermeyer
- USAID, Washington, District of Columbia, USA; University of Colorado School of Medicine and Colorado School of Public Health, Aurora, Colorado, USA
| | - Lily Kak
- USAID, Washington, District of Columbia, USA
| | - Smita Kumar
- USAID, Washington, District of Columbia, USA
| | - Pavani K Ram
- School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA; USAID, Washington, District of Columbia, USA
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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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Mize CH, Dorji L, Zafren K. Prehospital administration of surfactant to a premature neonate in respiratory distress. Scand J Trauma Resusc Emerg Med 2019; 27:95. [PMID: 31665094 PMCID: PMC6819493 DOI: 10.1186/s13049-019-0664-9] [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] [Received: 06/26/2019] [Accepted: 08/29/2019] [Indexed: 12/02/2022] Open
Abstract
The population of the Kingdom of Bhutan is scattered in small villages throughout the eastern Himalaya. Infants born prematurely in villages have no access to neonatal intensive care until they are transported to the national referral hospital, a process that once took hours, if not days. After the introduction of a helicopter critical-care retrieval team, we were able to send a trained team to a remote location that successfully administered surfactant and initiated critical care to a premature, extreme low birth weight infant in severe respiratory distress in the first hour of life. Although the infant was in shock and in a near-arrest state at the time the team arrived, he made an excellent recovery after resuscitation by the team.
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Affiliation(s)
- Charles Haviland Mize
- Bhutan Emergency Aeromedical Retrieval, Emergency Department, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.
| | - Lhab Dorji
- Bhutan Emergency Aeromedical Retrieval, Emergency Department, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, USA.,Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zürich, Switzerland
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Abstract
With the improvement in neonatal care in last two decades, the survival of very low birth weight (VLBW), extremely low birth weight (ELBW), fetus diagnosed with malformations, and congenital heart disease and severe birth asphyxia has increased significantly. These infants when admitted to the neonatal intensive care unit (NICU) need numerous interventions depending upon the severity of sickness and postnatal course like need of mechanical ventilation (MV) or noninvasive ventilation, surfactant administration, placement of central lines, total parenteral nutrition, and numerous medications. The duration of NICU and hospital stay of these high-risk infants varies from few days to few weeks to few months. Long stay in the hospital leads to high hospital bills and increase the cost of neonatal care substantially. The cost of NICU stay varies from 90 USD to 1250-2500 USD per day as per various studies, depending upon the level of care and sickness of the admitted infants. In developed countries, the burden of NICU cost is often taken care by the government or insurance companies but in many developing countries the parents bear the substantial cost of NICU admission of their infants. There are many interventions which when implemented in the NICU will lead to reduction of the cost and will make the NICU cost effective. In this review, we cover various interventions mostly from our own published work which have shown to reduce the NICU cost and make it more cost effective with equivalent and better neonatal outcomes, especially in developing countries like ours.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Sciences, Jaipur, India
| | - Srinivas Murki
- Department of Neonatology, Paramitha Children Hospital, Kothapet, Hyderabad, India
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O'Brien F, Clapham D, Krysiak K, Batchelor H, Field P, Caivano G, Pertile M, Nunn A, Tuleu C. Making Medicines Baby Size: The Challenges in Bridging the Formulation Gap in Neonatal Medicine. Int J Mol Sci 2019; 20:E2688. [PMID: 31159216 PMCID: PMC6600135 DOI: 10.3390/ijms20112688] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/17/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022] Open
Abstract
The development of age-appropriate formulations should focus on dosage forms that can deliver variable yet accurate doses that are safe and acceptable to the child, are matched to his/her development and ability, and avoid medication errors. However, in the past decade, the medication needs of neonates have largely been neglected. The aim of this review is to expand on what differentiates the needs of preterm and term neonates from those of the older paediatric subsets, in terms of environment of care, ability to measure and administer the dose (from the perspective of the patient and carer, the routes of administration, the device and the product), neonatal biopharmaceutics and regulatory challenges. This review offers insight into those challenges posed by the formulation of medicinal products for neonatal patients in order to support the development of clinically relevant products.
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Affiliation(s)
- Fiona O'Brien
- School of Pharmacy, Royal College of Surgeons in Ireland, 111 St Stephens Green Dublin 2, Ireland.
| | | | - Kamelia Krysiak
- School of Pharmacy, Royal College of Surgeons in Ireland, 111 St Stephens Green Dublin 2, Ireland.
| | - Hannah Batchelor
- College of Medical and Dental Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Peter Field
- University College London School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK.
| | - Grazia Caivano
- Chiesi Farmaceutici S.p.A. Largo Francesco Belloli 11/A-43122 Parma, Italy.
| | - Marisa Pertile
- Chiesi Farmaceutici S.p.A. Largo Francesco Belloli 11/A-43122 Parma, Italy.
| | - Anthony Nunn
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool L8 7SS, UK.
| | - Catherine Tuleu
- University College London School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK.
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Abelenda VLB, Valente TCO, Marinho CL, Lopes AJ. Effects of underwater bubble CPAP on very-low-birth-weight preterm newborns in the delivery room and after transport to the neonatal intensive care unit. J Child Health Care 2018; 22:216-227. [PMID: 29325421 DOI: 10.1177/1367493517752500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The development of less invasive ventilatory strategies in very-low-birth-weight (VLBW) preterm newborns has been a growing concern in recent decades. This study aimed to measure differences in the clinical progression of preterm newborns using two distinct periods in a university hospital: before and after using underwater bubble continuous positive airway pressure (ubCPAP). This is a retrospective study of VLBW preterm newborns with gestational ages less than or equal to 32 weeks admitted to the neonatal intensive care unit. The time series was divided into two groups: a pre-CPAP group ( n = 45) and a post-CPAP group ( n = 40). The post-CPAP group had fewer resuscitations, required fewer surfactant doses, spent fewer days on mechanical ventilation, and demonstrated less of a need for fraction of inspired oxygen > 30%. UbCPAP is an easy to use, minimally invasive, and effective ventilatory strategy for VLBW preterm newborns that can be used in environments with limited resources. Thus, adopting this simple strategy as part of a service organization and health policy can positively impact outcomes.
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Affiliation(s)
- Vera Lucia Barros Abelenda
- 1 Department of Physical Therapy, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Vila Isabel, Rio de Janeiro, Brazil.,2 Federal University of the State of Rio de Janeiro (UNIRIO), Urca, Rio de Janeiro, Brazil
| | | | - Cirlene Lima Marinho
- 1 Department of Physical Therapy, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Vila Isabel, Rio de Janeiro, Brazil.,3 School of Medical Sciences, State University of Rio de Janeiro, Avenida Professor Manuel de Abreu, Vila Isabel, Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- 4 Augusto Motta University Center, Avenida Paris, Bonsucesso, Rio de Janeiro, Brazil
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Murki S, Singh J, Khant C, Kumar Dash S, Oleti TP, Joy P, Kabra NS. High-Flow Nasal Cannula versus Nasal Continuous Positive Airway Pressure for Primary Respiratory Support in Preterm Infants with Respiratory Distress: A Randomized Controlled Trial. Neonatology 2018; 113:235-241. [PMID: 29393237 DOI: 10.1159/000484400] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure (nCPAP) is the standard noninvasive respiratory support for newborns with respiratory distress. Evidence for high-flow nasal cannula (HFNC) as an alternative mode of respiratory support is inconclusive. OBJECTIVE The aim of this work was to evaluate whether HFNC is not inferior to nCPAP in reducing the need for higher respiratory support in the first 72 h of life when applied as a noninvasive respiratory support mode for preterm neonates with respiratory distress. METHODS Preterm infants (gestation ≥28 weeks and birth weight ≥1,000 g) with respiratory distress were randomized to either HFNC or nCPAP in a non-inferiority trial. Failure of the support mode in the first 72 h after birth was the primary outcome. Infants failing HFNC were rescued either with nCPAP or mechanical ventilation, and those failing nCPAP received mechanical ventilation. RESULTS During the study period, 139 and 133 infants were randomized to the nCPAP and HFNC groups, respectively. The study was stopped after an interim analysis showed a significant difference (p < 0.001) in the primary outcome between the 2 groups. The treatment failure was significantly higher in the HFNC group (HFNC, n = 35, 26.3%, vs. CPAP, n = 11, 7.9%, risk difference 18.4 percentage points, 95% CI 9.7-27). Among the infants in the HFNC group who had treatment failure (n = 35), 32 were initially rescued with CPAP. The rate of mechanical ventilation in the first 3 and 7 days of life was similar between the 2 groups. Treatment failure was significantly higher in the HFNC group per protocol and also in the subgroups of infants with moderate (Silverman Anderson score, SAS ≤5) or severe respiratory distress (SAS score >5). CONCLUSIONS When comparing HFNC to nCPAP as a primary noninvasive respiratory support in preterm infants with respiratory distress, HFNC is inferior to nCPAP in avoiding the need for a higher mode of respiratory support in the first 72 h of life.
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Affiliation(s)
| | | | | | | | | | - Percy Joy
- Fernandez Hospital, Hyderabad, India
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Abstract
"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.
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Affiliation(s)
- Deepak Sharma
- National Institute of Medical Science, Jaipur, Rajasthan India
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16
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Abstract
"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.
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Sankar MJ, Gupta N, Jain K, Agarwal R, Paul VK. Efficacy and safety of surfactant replacement therapy for preterm neonates with respiratory distress syndrome in low- and middle-income countries: a systematic review. J Perinatol 2016; 36 Suppl 1:S36-48. [PMID: 27109091 PMCID: PMC4848743 DOI: 10.1038/jp.2016.31] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/07/2015] [Accepted: 01/27/2016] [Indexed: 11/09/2022]
Abstract
Surfactant replacement therapy (SRT) has been shown to reduce mortality and air leaks in preterm neonates from high-income countries (HICs). The safety and efficacy of SRT in low- and middle- income countries (LMICs) have not been systematically evaluated. The major objectives of this review were to assess the (1) efficacy and safety, and (2) feasibility and cost effectiveness of SRT in LMIC settings. We searched the following databases-MEDLINE, CENTRAL, CINAHL, EMBASE and WHOLIS using the search terms 'surfactant' OR 'pulmonary surfactant'. Both experimental and observational studies that enrolled preterm neonates with or at-risk of respiratory distress syndrome (RDS) and required surfactant (animal-derived or synthetic) were included. A total of 38 relevant studies were found; almost all were from level-3 neonatal units. Pooled analysis of two randomized controlled trials (RCTs) and 22 observational studies showed a significant reduction in mortality at the last available time point in neonates who received SRT (relative risk (RR) 0.67; 95% confidence interval (CI) 0.57 to 0.79). There was also a significant reduction in the risk of air leaks (five studies; RR 0.51; 0.29 to 0.90). One RCT and twelve observational studies reported the risk of bronchopulmonary dysplasia (BPD) with contrasting results; while the RCT and most before-after/cohort studies showed a significant reduction or no effect, the majority of the case-control studies demonstrated significantly higher odds of receiving SRT in neonates who developed BPD. Two studies-one RCT and one observational-found no difference in the proportion of neonates developing pulmonary hemorrhage, while another observational study reported a higher incidence in those receiving SRT. The failure rate of the intubate-surfactant-extubate (InSurE) technique requiring mechanical ventilation or referral varied from 34 to 45% in four case-series. No study reported on the cost effectiveness of SRT. Available evidence suggests that SRT is effective, safe and feasible in level-3 neonatal units and has the potential to reduce neonatal mortality and air leaks in low-resource settings as well. However, there is a need to generate more evidence on the cost effectiveness of SRT and its effect on BPD in LMIC settings.
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Affiliation(s)
- M J Sankar
- Department of Pediatrics, Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, India
| | - N Gupta
- Department of Pediatrics, Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, India
| | - K Jain
- Department of Pediatrics, Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, India
| | - R Agarwal
- Department of Pediatrics, Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, India
| | - V K Paul
- Department of Pediatrics, Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, India
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Kong X, Cui Q, Hu Y, Huang W, Ju R, Li W, Wang R, Xia S, Yu J, Zhu T, Feng Z. Bovine Surfactant Replacement Therapy in Neonates of Less than 32 Weeks' Gestation: A Multicenter Controlled Trial of Prophylaxis versus Early Treatment in China--a Pilot Study. Pediatr Neonatol 2016; 57:19-26. [PMID: 26059103 DOI: 10.1016/j.pedneo.2015.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/31/2015] [Accepted: 03/05/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND A domestic surfactant preparation has been used in China for a number of years. However, as for other surfactant preparations, there is debate among neonatologists regarding the optimal dose, mode of administration, and the best time of intervention. OBJECTIVE To evaluate whether prophylactic administration of surfactant is superior to early treatment in preterm infants < 32 weeks with a high risk of respiratory distress syndrome (RDS). METHODS We prospectively compared small premature infants (< 32 weeks) receiving 70 mg/kg bovine surfactant within 30 minutes after birth (prophylactic group, N = 116) with infants who received surfactant therapy for established RDS (early treatment group, N = 91). The primary outcome assessed was the incidence of RDS. The secondary outcomes assessed were severity of RDS, mortality, and bronchopulmonary dysplasia morbidity. RESULTS Compared with the early treatment group, the prophylactic group had a significantly better PaO2 (at 1 hour, 4 hours, and 12 hours postdose, respectively), better a/APO2 (at 1 hour, 4 hours, 12 hours, and 24 hours postdose, respectively), lower PaCO2 (at 1 hour postdose), and a significantly decreased need for mean airway pressure (MAP) and FiO2 on ventilation (p < 0.05). The prophylactic group had shorter durations for mechanical ventilation and supplemental oxygen compared with the early treatment group (p < 0.01 and p < 0.05, respectively). The incidence of RDS was comparable between the groups; however, the prophylactic group had a significantly lower incidence of severe RDS and significantly lower rate of repeated doses of surfactant than the early treatment group (p < 0.05). The incidences of bronchopulmonary dysplasia and patent ductus arteriosus were also lower in the prophylactic group than the early treatment group (p < 0.05). The two groups were comparable in mortality rate. CONCLUSION In preterm infants under 32 weeks' gestation, prophylactic use of a domestic surfactant preparation is better than early surfactant treatment in improving pulmonary status and in decreasing the incidence of severe RDS and duration on mechanical ventilation.
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Affiliation(s)
- Xiangyong Kong
- Newborn Care Center, Bayi Children's Hospital, the Military General Hospital of Beijing P.L.A., Beijing, China
| | - Qiliang Cui
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuhua Hu
- Department of Pediatrics, Jiangsu Province Hospital, Nanjing, China
| | - Weimin Huang
- Department of Pediatrics, Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Rong Ju
- Newborn Care Center, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Wen Li
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Ruijuan Wang
- Newborn Care Center, Bayi Children's Hospital, the Military General Hospital of Beijing P.L.A., Beijing, China
| | - Shiwen Xia
- Department of Pediatrics, Hospital of Hubei Province, Wuhan, China
| | - Jialin Yu
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Tian Zhu
- Department of Neonatology, Daping Hospital, The Third Military Medical University, Chongqing, China
| | - Zhichun Feng
- Newborn Care Center, Bayi Children's Hospital, the Military General Hospital of Beijing P.L.A., Beijing, China.
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19
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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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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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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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Kültürsay N, Uygur Ö, Yalaz M. The use of surfactant in the neonatal period- the known aspects, those still under research and those which need to be investigated further. TURK PEDIATRI ARSIVI 2014; 49:1-12. [PMID: 26078625 PMCID: PMC4462258 DOI: 10.5152/tpa.2014.963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 04/18/2013] [Indexed: 11/22/2022]
Abstract
Respiratory distress syndrome is pulmoner insufficiency caused by the lack of surfactant and the main reason of morbidity and mortality in preterm infants. Mothers at high risk of preterm birth should be transferred to perinatal centers with experience for respiratory distress syndrome and ante-natal steroids should be given before 35 weeks' of gestational age. Surfactant treatment should be applied to babies with or at high risk for respiratory distress syndrome. Prophylaxis should be given to infants of <26 weeks of gestational age and to infants requiring entubation in the delivery room. Nasal continuous positive airway pressure should be considered in infants with complete steroid treatment and without entubation need. Early surfactant may be given if entubation is performed during follow-up. Natural forms of surfactant should be preferred when needed. If the infant is stable, early extubation and non-invasive respiratory support should be considered. In this review, the recent studies' current data about surfactant treatment will be discussed.
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Affiliation(s)
- Nilgün Kültürsay
- Department of Pediatrics, Division of Neonatology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Özgün Uygur
- Department of Pediatrics, Division of Neonatology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Mehmet Yalaz
- Department of Pediatrics, Division of Neonatology, Ege University Faculty of Medicine, İzmir, Turkey
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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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Lopez E, Gascoin G, Flamant C, Merhi M, Tourneux P, Baud O. Exogenous surfactant therapy in 2013: what is next? Who, when and how should we treat newborn infants in the future? BMC Pediatr 2013; 13:165. [PMID: 24112693 PMCID: PMC3851818 DOI: 10.1186/1471-2431-13-165] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 09/19/2013] [Indexed: 11/10/2022] Open
Abstract
Background Surfactant therapy is one of the few treatments that have dramatically changed clinical practice in neonatology. In addition to respiratory distress syndrome (RDS), surfactant deficiency is observed in many other clinical situations in term and preterm infants, raising several questions regarding the use of surfactant therapy. Objectives This review focuses on several points of interest, including some controversial or confusing topics being faced by clinicians together with emerging or innovative concepts and techniques, according to the state of the art and the published literature as of 2013. Surfactant therapy has primarily focused on RDS in the preterm newborn. However, whether this treatment would be of benefit to a more heterogeneous population of infants with lung diseases other than RDS needs to be determined. Early trials have highlighted the benefits of prophylactic surfactant administration to newborns judged to be at risk of developing RDS. In preterm newborns that have undergone prenatal lung maturation with steroids and early treatment with continuous positive airway pressure (CPAP), the criteria for surfactant administration, including the optimal time and the severity of RDS, are still under discussion. Tracheal intubation is no longer systematically done for surfactant administration to newborns. Alternative modes of surfactant administration, including minimally-invasive and aerosolized delivery, could thus allow this treatment to be used in cases of RDS in unstable preterm newborns, in whom the tracheal intubation procedure still poses an ethical and medical challenge. Conclusion The optimization of the uses and methods of surfactant administration will be one of the most important challenges in neonatal intensive care in the years to come.
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Affiliation(s)
- Emmanuel Lopez
- Réanimation et Pédiatrie Néonatales, Groupe Hospitalier Robert Debré, APHP, 48 Bd Sérurier, Paris, 75019, France.
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