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Solís-García G, Elias S, Dunn M, Jasani B. Late surfactant administration after 48 hours of age in preterm neonates with respiratory insufficiency: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2024; 109:301-307. [PMID: 38071552 DOI: 10.1136/archdischild-2023-326333] [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] [Received: 09/18/2023] [Accepted: 11/02/2023] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To systematically review and meta-analyse the effect of late surfactant administration versus placebo in reducing the incidence of death or bronchopulmonary dysplasia (BPD) in preterm infants. DESIGN PubMed, EMBASE, CINAHL and Cochrane CENTRAL were searched until 30 May 2023, for randomised controlled trials (RCTs) comparing administration of surfactant after 48 hours of age versus placebo in preterm ventilator-dependent neonates. The primary outcome was incidence of death or BPD at 36 weeks' postmenstrual age (PMA). Secondary outcomes included incidence of BPD at 36 weeks PMA, pre-discharge mortality, use of postnatal steroids, post-discharge respiratory support, treatment with steroids or hospitalisation prior to 1-year corrected age. RESULTS Pooled analyses of four RCTs (N=850) showed no statistically significant difference between groups in the incidence of death or BPD at 36 weeks' PMA (relative risk (RR) 0.99; 95% CI 0.90 to 1.10; Grades of Recommendation, Assessment, Development and Evaluation (GRADE): moderate). Late surfactant administration significantly decreased the need for post-discharge respiratory support prior to 1-year corrected age (two RCTs; N=522; RR 0.72; 95% CI 0.59 to 0.89; GRADE: low). Other secondary outcomes did not differ significantly between the groups. CONCLUSIONS Administration of late surfactant does not improve the rates of death or BPD at 36 weeks when administered to preterm infants with prolonged respiratory insufficiency. Additional adequately powered trials are needed to establish the efficacy of late surfactant therapy in preterm infants. PROSPERO REGISTRATION NUMBER CRD42023432463.
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Affiliation(s)
- Gonzalo Solís-García
- Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Neonatology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Sara Elias
- Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Dunn
- Neonatology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Bonny Jasani
- Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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2
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Desai RK, Yildiz Atar H, Lakshminrusimha S, Ryan RM. Use of surfactant beyond respiratory distress syndrome, what is the evidence? J Perinatol 2024; 44:478-487. [PMID: 38459371 DOI: 10.1038/s41372-024-01921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/18/2024] [Accepted: 02/23/2024] [Indexed: 03/10/2024]
Abstract
Surfactant replacement therapy is currently approved by the United States Food and Drug Administration (FDA) for premature infants with respiratory distress syndrome (RDS) caused by surfactant deficiency due to immaturity. There is strong evidence that surfactant decreases mortality and air leak syndromes in premature infants with RDS. However, surfactant is also used "off-label" for respiratory failure beyond classic RDS. This review discusses current evidence for the use of off-label surfactant therapy for (1) term infants with lung disease such as meconium aspiration syndrome (MAS), pneumonia/sepsis, and congenital diaphragmatic hernia (2) premature infants after 72 h for acute respiratory failure, and (3) the use of surfactant lavage. At last, we briefly describe the use of surfactants for drug delivery and the current evidence on evaluating infants for surfactant deficiency.
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Affiliation(s)
- Riddhi K Desai
- Division of Neonatology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | | | | | - Rita M Ryan
- Division of Neonatology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University Department of Pediatrics, Cleveland, OH, USA
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3
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Wong KL, Siu KL. Pulmonary Complications in Premature Infants Using a Beractant or Poractant for Respiratory Distress Syndrome: A Retrospective Cohort Study. Am J Perinatol 2024; 41:641-648. [PMID: 35098502 DOI: 10.1055/a-1754-0943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Premature infants are at the risk of developing respiratory distress syndrome (RDS). Beractants and poractants are two commonly used natural surfactants. This retrospective cohort study aims to compare the incidence of pulmonary complications between beractant and poractant treatment groups. STUDY DESIGN This study evaluated 29 patients treated with beractant and 49 patients treated with poractant. The primary outcome was the incidence of air leak syndrome (ALS) and pulmonary hemorrhage. Secondary outcomes included mortality and pulmonary outcomes, such as mechanical ventilation duration, oxygen dependence duration, fraction of inspired oxygen, and mean airway pressure (MAP) requirement. Logistic regression analyses were conducted to identify independent risk factors for significant primary outcomes. RESULTS No significant difference was found in the demographics between the two groups. A significantly higher incidence of pulmonary hemorrhage was observed in the poractant group (14.3 vs. 0.0%, p = 0.038). The difference in the incidence of ALS between the groups was insignificant (p = 0.536). Logistic regression for the incidence of pulmonary hemorrhage identified coagulopathy as the only significant independent risk factor (odds ratio 39.855, 95% confidence interval [2.912-545.537]; p = 0.006). Secondary outcomes in both treatment groups were similar, except that patients in the poractant group had a higher MAP before surfactant therapy (9 vs. 8 cmH2O, p < 0.001). CONCLUSION This study showed a significantly higher incidence of pulmonary hemorrhage in the poractant group. Coagulopathy was identified as an independent risk factor for pulmonary hemorrhage. Future long-term prospective studies are essential to establish the temporal and causal relationships between coagulopathy and pulmonary hemorrhage in premature infants receiving surfactant therapy for RDS; hence, there is the need for a screening protocol before surfactant administration. KEY POINTS · A higher incidence of pulmonary hemorrhage was found in the poractant group.. · Coagulopathy was the only significant risk factor that was related to the incidence of pulmonary hemorrhage.. · A screening protocol might be useful to avoid pulmonary hemorrhage in infants receiving surfactant..
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Affiliation(s)
- Kin Lok Wong
- Department of Paediatrics, Queen Elizabeth Hospital, Kowloon, Hong Kong SAR
| | - Kiu Lok Siu
- Department of Paediatrics, Queen Elizabeth Hospital, Kowloon, Hong Kong SAR
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4
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Moya F, Curstedt T, Johansson J, Sweet D. Synthetic surfactants. Semin Fetal Neonatal Med 2023; 28:101503. [PMID: 38036308 DOI: 10.1016/j.siny.2023.101503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Fernando Moya
- Division of Wilmington Pediatric Subspecialties, Department of Pediatrics, UNC School of Medicine, USA
| | - Tore Curstedt
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Jan Johansson
- Dept of Biosciences and Nutrition, Karolinska Institutet, Neo, 141 83, Huddinge Sweden
| | - David Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Grosvenor Road, Belfast, UK.
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5
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Budh HP, Nimbalkar S. Surfactant Replacement Therapy: What’s the New Future? JOURNAL OF NEONATOLOGY 2022; 36:331-347. [DOI: 10.1177/09732179221136963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Surfactant replacement therapy (SRT) can be lifesaving for preterm babies with respiratory distress because of surfactant deficiency. Attempts have been made over the last two decades to make surfactant administration as smooth and as nontraumatic as possible. Lesser invasive techniques, such as less invasive surfactant administration, minimally invasive surfactant therapy, intrapartum pharyngeal surfactant therapy, and the laryngeal mask airway, are preferred over invasive techniques like intubate surfactant extubation to reduce trauma and peridosing adverse effects. However, at present, aerosolized surfactant (AS) via nebulization remains the only truly noninvasive method of SRT. Many animal and human studies have shown promising results with the use of AS with similar clinical effects to an instilled surfactant with greater safety potential. But still AS has not been adapted to routine neonatal care. There is still scope for studies to further strengthen the role of AS. Also, SRT is a constantly changing field with new innovations revolutionizing and replacing old techniques.
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Affiliation(s)
- Hetal Pramod Budh
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
| | - Somashekhar Nimbalkar
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
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6
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Li C, Du Y, Yang K, Cao H, Yang H, Zhang C, Li X, Deng X, Shi Y. Safety and efficacy of a novel double-lumen tracheal tube in neonates with RDS: A prospective cohort study. Front Pediatr 2022; 10:1032044. [PMID: 36545664 PMCID: PMC9760922 DOI: 10.3389/fped.2022.1032044] [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: 08/30/2022] [Accepted: 11/16/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the safety and efficacy of a new double-lumen tracheal tube for neonates, with a conventional tracheal tube as a control. METHOD Newborns with respiratory distress syndrome (RDS) requiring endotracheal intubation admitted to the tertiary neonatal intensive care unit (NICU) of Qujing Maternal and Child Healthcare Hospital in Yunnan Province between March 2021 and May 2022 were enrolled in this prospective cohort study. Outcome indicators related to effectiveness included mainly the number of intubations, duration of ventilation, duration of oxygenation, and length of stay; safety indicators included any clinical adverse effects during and after intubation. Appropriate stratified and subgroup analyses were performed according to the purpose of intubation, gestational age, and whether the drug was administered via endotracheal tube. RESULT A total of 101 neonates were included and divided into two groups based on the choice of tracheal tube: the conventional (n = 50) and new (n = 51) tracheal tube groups. There was no statistical difference between the two groups in terms of adverse effects during and after intubation (p > 0.05). In neonates who were mechanically ventilated without endotracheal surfactant therapy or newborns receiving InSurE technique followed by non-invasive ventilation, no significant differences were found between the two groups regarding any of the efficacy indicators (p > 0.05). However, for neonates on invasive mechanical ventilation, the new tracheal tube allowed for a significant reduction in the duration of mechanical ventilation (96.50[74.00, 144.00] vs. 121.00[96.00, 196.50] hours, p = 0.037) and total ventilation (205.71 ± 80.24 vs. 277.56 ± 117.84 h, p = 0.027), when used as a route for endotracheal drug delivery. Further analysis was performed according to gestational age for newborns requiring intratracheal surfactant administration during mechanical ventilation, and the data showed that for preterm infants, the new tracheal tube not only shortened the duration of mechanical ventilation (101.75 ± 39.72 vs. 155.50 ± 51.49 h, p = 0.026) and total ventilation (216.00 ± 81.60 vs. 351.50 ± 113.79 h, p = 0.010), but also demonstrated significant advantages in reducing the duration of oxygen therapy (9.75 ± 6.02 vs. 17.33 ± 8.43 days, p = 0.042); however, there was no statistical difference in efficacy outcomes between the two groups in full-term infants (p > 0.05). CONCLUSION The efficacy and safety of this new tracheal tube are promising in neonates with RDS, especially those requiring surfactant administration via a tracheal tube during mechanical ventilation. Given the limitations of this study, however, the clinical feasibility of this catheter needs to be further confirmed in prospective randomized trials with larger sample sizes. CLINICAL TRIAL REGISTRATION http://www.chictr.org.cn/showproj.aspx?proj=122073.
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Affiliation(s)
- Chuanfeng Li
- Department of Neonatology, Qujing Maternity and Child Healthcare Hospital, Yunnan, China
| | - Yuxuan Du
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Kaiting Yang
- Department of Neonatology, Qujing Maternity and Child Healthcare Hospital, Yunnan, China
| | - Huiling Cao
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hong Yang
- Department of Neonatology, Qujing Maternity and Child Healthcare Hospital, Yunnan, China
| | - ChunXiu Zhang
- Department of Neonatology, Qujing Maternity and Child Healthcare Hospital, Yunnan, China
| | - Xiongbin Li
- Department of Neonatology, Qujing Maternity and Child Healthcare Hospital, Yunnan, China
| | - Xingmei Deng
- Department of Neonatology, Qujing Maternity and Child Healthcare Hospital, Yunnan, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
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7
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Lane MD, Kishnani S, Udemadu O, Danquah SE, Treadway RM, Langman A, Balevic S, Jackson WM, Laughon M, Hornik CP, Greenberg RG, Clark RH, Zimmerman KO. Comparative efficacy and safety of late surfactant preparations: a retrospective study. J Perinatol 2021; 41:2639-2644. [PMID: 34285358 PMCID: PMC8290378 DOI: 10.1038/s41372-021-01142-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 05/25/2021] [Accepted: 06/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Characterize the use, efficacy, and safety of poractant alfa and calfactant surfactants compared to beractant in preterm infants receiving late surfactant. STUDY DESIGN We included infants <37 weeks gestational age (GA) discharged from Pediatrix Medical Group-managed neonatal intensive care units (1997-2017). Efficacy and safety outcomes of interest were analyzed. RESULTS Of 184,770 infants administered surfactant at any time, 7846 (4.23%) received late surfactant at a median (25th, 75th percentile) PNA of 8 days (3, 22); specifically, 2976 received poractant alfa (38%), 2890 beractant (37%), and 1936 calfactant (25%). We identified no significant differences in composite efficacy or safety outcomes between surfactants in the primary analysis, but 33-36 week GA infants administered poractant alfa had significantly greater odds of developing a safety event. CONCLUSIONS Compared to beractant, there is no evidence of overall superior efficacy or safety of poractant alfa.
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Affiliation(s)
- Morgan D Lane
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Sujata Kishnani
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Obianuju Udemadu
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | | | - Aaliyah Langman
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Stephen Balevic
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Wesley M Jackson
- Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew Laughon
- Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
- Department of Pediatrics, Duke University, Durham, NC, USA.
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8
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Arroyo R, Kingma PS. Surfactant protein D and bronchopulmonary dysplasia: a new way to approach an old problem. Respir Res 2021; 22:141. [PMID: 33964929 PMCID: PMC8105703 DOI: 10.1186/s12931-021-01738-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/03/2021] [Indexed: 02/07/2023] Open
Abstract
Surfactant protein D (SP-D) is a collectin protein synthesized by alveolar type II cells in the lungs. SP-D participates in the innate immune defense of the lungs by helping to clear infectious pathogens and modulating the immune response. SP-D has shown an anti-inflammatory role by down-regulating the release of pro-inflammatory mediators in different signaling pathways such as the TLR4, decreasing the recruitment of inflammatory cells to the lung, and modulating the oxidative metabolism in the lungs. Recombinant human SP-D (rhSP-D) has been successfully produced mimicking the structure and functions of native SP-D. Several in vitro and in vivo experiments using different animal models have shown that treatment with rhSP-D reduces the lung inflammation originated by different insults, and that rhSP-D could be a potential treatment for bronchopulmonary dysplasia (BPD), a rare disease for which there is no effective therapy up to date. BPD is a complex disease in preterm infants whose incidence increases with decreasing gestational age at birth. Lung inflammation, which is caused by different prenatal and postnatal factors like infections, lung hyperoxia and mechanical ventilation, among others, is the key player in BPD. Exacerbated inflammation causes lung tissue injury that results in a deficient gas exchange in the lungs of preterm infants and frequently leads to long-term chronic lung dysfunction during childhood and adulthood. In addition, low SP-D levels and activity in the first days of life in preterm infants have been correlated with a worse pulmonary outcome in BPD. Thus, SP-D mediated functions in the innate immune response could be critical aspects of the pathogenesis in BPD and SP-D could inhibit lung tissue injury in this preterm population. Therefore, administration of rhSP-D has been proposed as promising therapy that could prevent BPD.
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Affiliation(s)
- Raquel Arroyo
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. ML7029, Cincinnati, OH, 45229-3039, USA
| | - Paul S Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. ML7029, Cincinnati, OH, 45229-3039, USA. .,Airway Therapeutics Inc, Cincinnati, OH, 45249, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA.
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9
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Roberts K, Stepanovich G, Bhatt-Mehta V, Donn SM. New Pharmacologic Approaches to Bronchopulmonary Dysplasia. J Exp Pharmacol 2021; 13:377-396. [PMID: 33790663 PMCID: PMC8006962 DOI: 10.2147/jep.s262350] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/26/2021] [Indexed: 12/22/2022] Open
Abstract
Bronchopulmonary Dysplasia is the most common long-term respiratory morbidity of preterm infants, with the risk of development proportional to the degree of prematurity. While its pathophysiologic and histologic features have changed over time as neonatal demographics and respiratory therapies have evolved, it is now thought to be characterized by impaired distal lung growth and abnormal pulmonary microvascular development. Though the exact sequence of events leading to the development of BPD has not been fully elucidated and likely varies among patients, it is thought to result from inflammatory and mechanical/oxidative injury from chronic ventilatory support in fragile, premature lungs susceptible to injury from surfactant deficiency, structural abnormalities, inadequate antioxidant defenses, and a chest wall that is more compliant than the lung. In addition, non-pulmonary issues may adversely affect lung development, including systemic infections and insufficient nutrition. Once BPD has developed, its management focuses on providing adequate gas exchange while promoting optimal lung growth. Pharmacologic strategies to ameliorate or prevent BPD continue to be investigated. A variety of agents, to be reviewed henceforth, have been developed or re-purposed to target different points in the pathways that lead to BPD, including anti-inflammatories, diuretics, steroids, pulmonary vasodilators, antioxidants, and a number of molecules involved in the cell signaling cascade thought to be involved in the pathogenesis of BPD.
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Affiliation(s)
- Katelyn Roberts
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Gretchen Stepanovich
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Varsha Bhatt-Mehta
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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10
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Allogeneic administration of human umbilical cord-derived mesenchymal stem/stromal cells for bronchopulmonary dysplasia: preliminary outcomes in four Vietnamese infants. J Transl Med 2020; 18:398. [PMID: 33081796 PMCID: PMC7576694 DOI: 10.1186/s12967-020-02568-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/12/2020] [Indexed: 12/20/2022] Open
Abstract
Background Bronchopulmonary dysplasia (BPD) is a severe condition in premature infants that compromises lung function and necessitates oxygen support. Despite major improvements in perinatal care minimizing the devastating effects, BPD remains the most frequent complication of extreme preterm birth. Our study reports the safety of the allogeneic administration of umbilical cord-derived mesenchymal stem/stromal cells (allo-UC-MSCs) and the progression of lung development in four infants with established BPD. Methods UC tissue was collected from a healthy donor, followed by propagation at the Stem Cell Core Facility at Vinmec Research Institute of Stem Cell and Gene Technology. UC-MSC culture was conducted under xeno- and serum-free conditions. Four patients with established BPD were enrolled in this study between May 25, 2018, and December 31, 2018. All four patients received two intravenous doses of allo-UC-MSCs (1 million cells/kg patient body weight (PBW) per dose) with an intervening interval of 7 days. Safety and patient conditions were evaluated during hospitalization and at 7 days and 1, 6 and 12 months postdischarge. Results No intervention-associated severe adverse events or prespecified adverse events were observed in the four patients throughout the study period. At the time of this report, all patients had recovered from BPD and were weaned off of oxygen support. Chest X-rays and CT scans confirmed the progressive reductions in fibrosis. Conclusions Allo-UC-MSC administration is safe in preterm infants with established BPD. Trial registration This preliminary study was approved by the Vinmec International Hospital Ethics Board (approval number: 88/2019/QĐ-VMEC; retrospectively registered March 12, 2019).
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11
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Gisondo CM, Donn SM. <p>Bronchopulmonary Dysplasia: An Overview</p>. RESEARCH AND REPORTS IN NEONATOLOGY 2020. [DOI: 10.2147/rrn.s271255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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12
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Jackson W, Taylor G, Bamat NA, Zimmerman K, Clark R, Benjamin DK, Laughon MM, Greenberg RG, Hornik CP. Outcomes associated with surfactant in more mature and larger premature infants with respiratory distress syndrome. J Perinatol 2020; 40:1171-1177. [PMID: 32080333 PMCID: PMC8029593 DOI: 10.1038/s41372-020-0625-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/02/2020] [Accepted: 02/11/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Examine the effect of off-label surfactant on mortality and morbidity in more mature and larger premature infants diagnosed with respiratory distress syndrome (RDS). STUDY DESIGN Cohort study of premature infants born at 30-36 weeks, birth weight > 2 kg, and a diagnosis of RDS. We compared the odds of mortality and morbidity between infants who were exposed vs unexposed to surfactant. We used a treatment effects model to balance covariates between groups. RESULTS Of 54,964 included infants, 25,278 (46%) were exposed to surfactant. The frequency of mortality and morbidities were higher in the exposed group in unadjusted analyses. Following adjustment with a doubly robust treatment effects model, we found no significant treatment effect of surfactant on mortality or morbidity. CONCLUSION Surfactant exposure is not associated with reduced or increased mortality or morbidity in more mature premature infants with RDS.
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Affiliation(s)
- Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, 101 Manning Drive, Room N4051, CB #7596, Chapel Hill, NC, 27599, USA.
| | - Genevieve Taylor
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, 101 Manning Drive, Room N4051, CB #7596, Chapel Hill, NC 27599, USA
| | - Nicolas A. Bamat
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
| | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
| | | | - Matthew M. Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, 101 Manning Drive, Room N4051, CB #7596, Chapel Hill, NC 27599, USA
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
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13
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Chen IL, Chen HL. Lung function in adults born prematurely with bronchopulmonary dysplasia. Transl Pediatr 2020; 9:210-212. [PMID: 32775238 PMCID: PMC7347762 DOI: 10.21037/tp-20-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- I-Ling Chen
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Hsiu-Lin Chen
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung.,Division of Neonatology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung
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14
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Lewis T, Truog W, Norberg M, Ballard PL, Torgerson D. Genetic variation in CRHR1 is associated with short-term respiratory response to corticosteroids in preterm infants at risk for bronchopulmonary dysplasia. Pediatr Res 2019; 85:625-633. [PMID: 30467342 PMCID: PMC6532775 DOI: 10.1038/s41390-018-0235-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 12/02/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is an orphan disease and advances in prevention and treatment are lacking. The clinical efficacy of systemic corticosteroid therapy to reduce the severity of lung disease and BPD is highly variable. Our objective was to assess whether candidate SNPs in corticosteroid metabolism and response genes are associated with short-term phenotypic response to systemic corticosteroids in infants at high risk for BPD. METHODS Pharmacogenetic analysis of data from a large randomized controlled trial (TOLSURF) in infants treated with dexamethasone or hydrocortisone using multivariate linear regression. The primary outcome was a change in respiratory severity score (RSS, mean airway pressure x FiO2) at day 7 of corticosteroid treatment. RESULTS rs7225082 in the intron of CRHR1 is significantly associated with the magnitude of decrease in RSS 7 days after starting treatment with systemic corticosteroid (meta-analysis P = 2.8 × 10-4). Each T allele at rs7225082 is associated with a smaller absolute change in RSS at day 7, i.e., less response to systemic corticosteroids. CONCLUSIONS Genetic variability is associated with corticosteroid responsiveness with regard to respiratory status in preterm infants. Identification of genetic markers of corticosteroid responsiveness may allow for therapeutic individualization, with the goal of optimizing the risk-to-benefit ratio for an individual child.
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Affiliation(s)
- Tamorah Lewis
- Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA.
| | - William Truog
- Children’s Mercy Hospital, Department of Pediatrics,
University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Mike Norberg
- Children’s Mercy Hospital, Department of Pediatrics,
University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Philip L. Ballard
- Department of Pediatrics, University of California San
Francisco, San Francisco, CA
| | - Dara Torgerson
- Department of Pediatrics, University of California San
Francisco, San Francisco, CA
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15
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Ballard PL, Keller RL, Truog WE, Chapin C, Horneman H, Segal MR, Ballard RA. Surfactant status and respiratory outcome in premature infants receiving late surfactant treatment. Pediatr Res 2019; 85:305-311. [PMID: 30140069 PMCID: PMC6377352 DOI: 10.1038/s41390-018-0144-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/21/2018] [Accepted: 07/27/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Many premature infants with respiratory failure are deficient in surfactant, but the relationship to occurrence of bronchopulmonary dysplasia (BPD) is uncertain. METHODS Tracheal aspirates were collected from 209 treated and control infants enrolled at 7-14 days in the Trial of Late Surfactant. The content of phospholipid, surfactant protein B, and total protein were determined in large aggregate (active) surfactant. RESULTS At 24 h, surfactant treatment transiently increased surfactant protein B content (70%, p < 0.01), but did not affect recovered airway surfactant or total protein/phospholipid. The level of recovered surfactant during dosing was directly associated with content of surfactant protein B (r = 0.50, p < 0.00001) and inversely related to total protein (r = 0.39, p < 0.0001). For all infants, occurrence of BPD was associated with lower levels of recovered large aggregate surfactant, higher protein content, and lower SP-B levels. Tracheal aspirates with lower amounts of recovered surfactant had an increased proportion of small vesicle (inactive) surfactant. CONCLUSIONS We conclude that many intubated premature infants are deficient in active surfactant, in part due to increased intra-alveolar metabolism, low SP-B content, and protein inhibition, and that the severity of this deficit is predictive of BPD. Late surfactant treatment at the frequency used did not provide a sustained increase in airway surfactant.
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Affiliation(s)
- Philip L Ballard
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | - Roberta L. Keller
- Department of Pediatrics, University of California, San Francisco, San Francisco CA
| | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospitals and Clinics/University of Missouri-Kansas City School of Medicine, Kansas City MO
| | - Cheryl Chapin
- Department of Pediatrics, University of California, San Francisco, San Francisco CA
| | - Hart Horneman
- Department of Pediatrics, University of California, San Francisco, San Francisco CA
| | - Mark R. Segal
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco CA
| | - Roberta A Ballard
- Department of Pediatrics, University of California, San Francisco, San Francisco CA
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16
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Hwang JS, Rehan VK. Recent Advances in Bronchopulmonary Dysplasia: Pathophysiology, Prevention, and Treatment. Lung 2018; 196:129-138. [PMID: 29374791 DOI: 10.1007/s00408-018-0084-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/04/2018] [Indexed: 12/16/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is potentially one of the most devastating conditions in premature infants with longstanding consequences involving multiple organ systems including adverse effects on pulmonary function and neurodevelopmental outcome. Here we review recent studies in the field to summarize the progress made in understanding in the pathophysiology, prognosis, prevention, and treatment of BPD in the last decade. The work reviewed includes the progress in understanding its pathobiology, genomic studies, ventilatory strategies, outcomes, and therapeutic interventions. We expect that this review will help guide clinicians to treat premature infants at risk for BPD better and lead researchers to initiate further studies in the field.
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Affiliation(s)
- Jung S Hwang
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Virender K Rehan
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1124 West Carson Street, Torrance, CA, 90502, USA.
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Deshpande S, Suryawanshi P, Ahya K, Maheshwari R, Gupta S. Surfactant Therapy for Early Onset Pneumonia in Late Preterm and Term Neonates Needing Mechanical Ventilation. J Clin Diagn Res 2017; 11:SC09-SC12. [PMID: 28969229 DOI: 10.7860/jcdr/2017/28523.10520] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/21/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pathophysiology of pneumonia involves leakage of plasma proteins into the airways and accumulation of cytokines within the lung. Several in vitro and in vivo studies have demonstrated that this proteinaceous material and lung inflammation inhibit surfactant function. AIM To evaluate whether exogenous surfactant therapy improves oxygenation and gas exchange in late preterm and term neonates with early onset pneumonia and respiratory failure. MATERIALS AND METHODS This prospective interventional cohort study was conducted at a tertiary care neonatal unit. Twenty four late preterm and term neonates with early onset pneumonia requiring mechanical ventilation for respiratory failure were included and received surfactant therapy. Oxygenation index, arterial/alveolar PO2 (a/A ratio), mean airway pressure and fraction of inspired oxygen were calculated from arterial blood gases obtained before and after surfactant therapy. Wilcoxon signed rank sum test was used for assessment of change in oxygenation variables 12 hours after surfactant therapy. Data regarding clinical outcomes and complications were collected and analysed. RESULTS Just over half (54.2%) of the study neonates were of term gestation. After surfactant therapy, the median Oxygenation Index (OI) decreased from 11.15 to 3.7 at one hour and the change was sustained and significant at 12 hours (p<0.05). The median a/A PO2 ratio improved from 0.09 to 0.3 within one hour of surfactant replacement and the improvement was significant at 12 hours (p<0.01). Twenty two neonates (92%) survived to discharge. Median duration of hospital stay was 15 days. CONCLUSION Significant and rapid improvement in oxygenation in late preterm and term neonates with early onset pneumonia was seen after surfactant therapy, which is sustained for a longer period. There could be a substantial role for the use of surfactant in early onset pneumonia, although larger controlled trials are needed before definite recommendations can be made.
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Affiliation(s)
- Sujata Deshpande
- Associate Professor, Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| | - Pradeep Suryawanshi
- Professor and Head, Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| | - Kunal Ahya
- Clinical Fellow, Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| | - Rajesh Maheshwari
- Consultant Neonatologist, Westmead Hospital, Westmead, NSW, Australia
| | - Samir Gupta
- Professor, Department of Neonatology, Durham University, University Hospital of North Tees, Stockton-on-Tees, United Kingdom
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18
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Abstract
BACKGROUND Surfactant replacement therapy is an established modality of treatment in preterm neonates with respiratory distress syndrome. In addition, there are various neonatal respiratory disorders which are characterized by surfactant deficiency in which surfactant therapy can be a feasible and safe option. OBJECTIVE To collate the literature on the use of surfactant replacement therapy in neonates beyond respiratory distress syndrome and examine the evidence and newer developments. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, and EMBASE up to June 2015; and previous reviews, including cross-references, abstracts, and conference proceedings. RESULTS Evidence supports surfactant administration via bolus route in neonates with meconium aspiration syndrome, but additional robust evidence is required before its adoption in clinical practice. There is limited evidence to support surfactant therapy in neonates with pneumonia, pulmonary hemorrhage and bronchopulmonary dysplasia. Large multicenter randomized trials are needed to cement or refute the role of surfactant therapy in these disorders.
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19
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Rodríguez-Moya VS, Gallo-Borrero CM, Santos-Áreas D, Prince-Martínez IA, Díaz-Casañas E, López-Herce Cid J. Exogenous surfactant and alveolar recruitment in the treatment of the acute respiratory distress syndrome. CLINICAL RESPIRATORY JOURNAL 2016; 11:1032-1039. [PMID: 26881996 DOI: 10.1111/crj.12462] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 11/13/2015] [Accepted: 12/24/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the effect of alveolar recruitment combined with surfactant administration on children with acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS A prospective, randomized, controlled and sequential study was carried out. Group A (16 children) was treated with both the alveolar recruitment manoeuvres (ARM) and the administration of the surfactant every 8 h for 3 days; group B (15) received the usual treatment only. The alveolar recruitment was carried out by increasing positive end-expiratory pressure 2 by 2 cm H2 O to improve the transcutaneous oxygen saturation values up to 88% and 90%. Demographic data, gasometric and ventilator parameters, chest radiography and 28-day mortality were evaluated. RESULTS There were no significant differences in baseline characteristics between groups. An hour after treatment, significant differences (P < 0.001) were observed in transcutaneous oxygen saturation (SaO2 ; Group A: 94.1%, Group B: 89.9%), PaO2 /FiO2 (212.7 and 126.4) and oxygenation index (OI; 11.4 and 18.5). After 8 h, the differences in SaO2 (Group A: 94.6%, Group B: 90.3%), PaO2 /FiO2 (225.8 and 126.9) and OI (10.8 and 18.4) were also significant (P < 0.001). From the fifth dose of the surfactant, the static compliance (P = 0.0034) and radiological images (P = 0.002) were more greatly improved in group A than in group B. Survival was significantly higher in group A (81.3%) than in group B (26.7%) (P = 0.006). CONCLUSIONS The combined treatment of surfactant administration and ARM resulted in a better oxygenation and survival in children with ARDS than when only recruitment was used.
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Affiliation(s)
- Valentín S Rodríguez-Moya
- Pediatric Intensive Care Department, Pediatric Hospital University Dr. Eduardo Agramonte Piña, Dolores Betancourt No. 2, e/Domingo Puente y Carretera Santa Cruz del Sur, Camagüey, Cuba
| | - Clara M Gallo-Borrero
- Pediatric Intensive Care Department, Pediatric Hospital University Dr. Eduardo Agramonte Piña, Dolores Betancourt No. 2, e/Domingo Puente y Carretera Santa Cruz del Sur, Camagüey, Cuba
| | - Daniuris Santos-Áreas
- Pediatric Intensive Care Department, Pediatric Hospital University Dr. Eduardo Agramonte Piña, Dolores Betancourt No. 2, e/Domingo Puente y Carretera Santa Cruz del Sur, Camagüey, Cuba
| | - Ivette A Prince-Martínez
- Pediatric Intensive Care Department, Pediatric Hospital University Dr. Eduardo Agramonte Piña, Dolores Betancourt No. 2, e/Domingo Puente y Carretera Santa Cruz del Sur, Camagüey, Cuba
| | - Elaine Díaz-Casañas
- Division of Production, National Center for Animal and Plant Health, Carretera de Jamaica y Autopista Nacional, San José de las Lajas. Mayabeque, Cuba
| | - Jesús López-Herce Cid
- Pediatric Intensive Care Department, Gregorio Marañon University General Hospital, c/Puente cesures 1.B 1ºB, 28029, Madrid, Spain
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20
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Randomized Trial of Late Surfactant Treatment in Ventilated Preterm Infants Receiving Inhaled Nitric Oxide. J Pediatr 2016; 168:23-29.e4. [PMID: 26500107 PMCID: PMC4698022 DOI: 10.1016/j.jpeds.2015.09.031] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 08/12/2015] [Accepted: 09/09/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess whether late surfactant treatment in extremely low gestational age (GA) newborn infants requiring ventilation at 7-14 days, who often have surfactant deficiency and dysfunction, safely improves survival without bronchopulmonary dysplasia (BPD). STUDY DESIGN Extremely low GA newborn infants (GA ≤28 0/7 weeks) who required mechanical ventilation at 7-14 days were enrolled in a randomized, masked controlled trial at 25 US centers. All infants received inhaled nitric oxide and either surfactant (calfactant/Infasurf) or sham instillation every 1-3 days to a maximum of 5 doses while intubated. The primary outcome was survival at 36 weeks postmenstrual age (PMA) without BPD, as evaluated by physiological oxygen/flow reduction. RESULTS A total of 511 infants were enrolled between January 2010 and September 2013. There were no differences between the treated and control groups in mean birth weight (701 ± 164 g), GA (25.2 ± 1.2 weeks), percentage born at GA <26 weeks (70.6%), race, sex, severity of lung disease at enrollment, or comorbidities of prematurity. Survival without BPD did not differ between the treated and control groups at 36 weeks PMA (31.3% vs 31.7%; relative benefit, 0.98; 95% CI, 0.75-1.28; P = .89) or 40 weeks PMA (58.7% vs 54.1%; relative benefit, 1.08; 95% CI, 0.92-1.27; P = .33). There were no between-group differences in serious adverse events, comorbidities of prematurity, or severity of lung disease to 36 weeks. CONCLUSION Late treatment with up to 5 doses of surfactant in ventilated premature infants receiving inhaled nitric oxide was well tolerated, but did not improve survival without BPD at 36 or 40 weeks. Pulmonary and neurodevelopmental assessments are ongoing. TRIAL REGISTRATION ClinicalTrials.gov: NCT01022580.
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21
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Sinha S, Tin W. Adjunctive drug therapies for treatment of respiratory diseases in the newborn: based on evidence or habit? Ther Adv Respir Dis 2014; 8:53-62. [PMID: 24670391 DOI: 10.1177/1753465814526444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory distress syndrome is a disease of prematurity and is caused by a relative deficiency of endogenous surfactant production. Respiratory distress syndrome is the most common cause of mortality and morbidity in the newborn population and the standard of care is to provide exogenous surfactant therapy. This saves lives and reduces respiratory complications but, despite treatment, a significant proportion of these infants go onto develop chronic lung disease, the severest form of which is bronchopulmonary dysplasia. Once developed, this is a multisystem disease and treatment is mostly supportive by using various therapeutic adjuncts. Some of these have been proven to be safe and effective in large randomized, controlled trials but similar evidence for other drugs is lacking. The aim of this paper is to provide an overview and critically appraise the available scientific evidence for or against their use in routine practice.
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Affiliation(s)
- Sunil Sinha
- University of Durham & The James Cook University Hospital, Department of Neonatal Medicine, Marton Road, Middlesbrough TS4 3BW, UK
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22
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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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El-Gendy N, Kaviratna A, Berkland C, Dhar P. Delivery and performance of surfactant replacement therapies to treat pulmonary disorders. Ther Deliv 2013; 4:951-80. [PMID: 23919474 PMCID: PMC3840129 DOI: 10.4155/tde.13.72] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Lung surfactant is crucial for optimal pulmonary function throughout life. An absence or deficiency of surfactant can affect the surfactant pool leading to respiratory distress. Even if the coupling between surfactant dysfunction and the underlying disease is not always well understood, using exogenous surfactants as replacement is usually a standard therapeutic option in respiratory distress. Exogenous surfactants have been extensively studied in animal models and clinical trials. The present article provides an update on the evolution of surfactant therapy, types of surfactant treatment, and development of newer-generation surfactants. The differences in the performance between various surfactants are highlighted and advanced research that has been conducted so far in developing the optimal delivery of surfactant is discussed.
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Affiliation(s)
- Nashwa El-Gendy
- Department of Pharmaceutical Chemistry, The University of Kansas, 1530 W 15th Street, Lawrence, KS 66045, USA
- Department of Pharmaceutics & Industrial Pharmacy, Faculty of Pharmacy, Beni-suef University, Egypt
| | - Anubhav Kaviratna
- Department of Chemical & Petroleum Engineering, The University of Kansas, 1530 W 15th Street, Lawrence, KS 66045, USA
| | - Cory Berkland
- Department of Pharmaceutical Chemistry, The University of Kansas, 1530 W 15th Street, Lawrence, KS 66045, USA
- Department of Chemical & Petroleum Engineering, The University of Kansas, 1530 W 15th Street, Lawrence, KS 66045, USA
| | - Prajnaparamita Dhar
- Department of Chemical & Petroleum Engineering, The University of Kansas, 1530 W 15th Street, Lawrence, KS 66045, USA
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Cytidine 5'-diphosphocholine ameliorates hyperoxic lung injury in a neonatal rat model. Pediatr Res 2013; 74:26-33. [PMID: 23598810 DOI: 10.1038/pr.2013.68] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/26/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is an important cause of morbidity. The aim of this study was to evaluate the preventive effect of cytidine 5'-diphosphocholine (CDP-choline) treatment on hyperoxic lung injury in a neonatal rat model. METHODS A total of 30 newborn pups were divided into control, hyperoxia, and hyperoxia + CDP-choline groups. After birth, pups in the control group were kept in room air and received saline injections, whereas those in hyperoxia and hyperoxia + CDP-choline groups were exposed to 95% O₂ and received daily injections of saline and CDP-choline throughout postnatal day 10, respectively. Histopathological scoring, radial alveolar count, lamellar body membrane protein expression, fibrosis, proinflammatory cytokine levels, lung tissue and bronchoalveolar lavage (BAL) fluid phospholipid content, and apoptosis were evaluated. RESULTS Hyperoxia-induced severe lung damage was reduced significantly by CDP-choline treatment. Radial alveolar count and lamellar body membrane protein expression were significantly recovered, and the number of terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling-positive cells, active caspase-3 expression, and tissue proinflammatory cytokine levels were decreased by CDP-choline administration. Lung tissue and BAL phospholipid contents showed significant increases after CDP-choline administration. CONCLUSION These data show that CDP-choline ameliorates hyperoxic lung injury in a neonatal rat model. It may therefore be suggested that CDP-choline may be a novel therapeutic option for the prevention of BPD.
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Abstract
Bronchopulmonary dysplasia (BPD) is the most prevalent long-term morbidity in surviving extremely preterm infants and is linked to increased risk of reactive airways disease, pulmonary hypertension, post-neonatal mortality, and adverse neurodevelopmental outcomes. BPD affects approximately 20% of premature newborns, and up to 60% of premature infants born before completing 26 weeks of gestation. It is characterized by the need for assisted ventilation and/or supplemental oxygen at 36 weeks postmenstrual age. Approaches to prevention and treatment of BPD have evolved with improved understanding of its pathogenesis. This review will focus on recent advancements and detail current research in pharmacotherapy for BPD. The evidence for both current and potential future experimental therapies will be reviewed in detail. As our understanding of the complex and multifactorial pathophysiology of BPD changes, research into these current and future approaches must continue to evolve.
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Affiliation(s)
- Sailaja Ghanta
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA 02115, , Tel: (774) 249 8137, Fax: (617) 730-0260
| | - Kristen Tropea Leeman
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA 02115, , Tel: (919) 475 9260, Fax: (617) 730 0222
| | - Helen Christou
- Division of Newborn Medicine, Brigham and Women’s Hospital, Boston Children’s Hospital, Harvard Medical School, 75 Francis Street, Thorn 1005, Boston, MA 02115, , Tel: (617) 515 8129, Fax: (617) 582 6026
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Guardia CG, Moya FR, Sinha S, Simmons PD, Segal R, Greenspan JS. A pharmacoeconomic analysis of in-hospital costs resulting from reintubation in preterm infants treated with lucinactant, beractant, or poractant alfa. J Pediatr Pharmacol Ther 2012; 17:220-7. [PMID: 23258964 DOI: 10.5863/1551-6776-17.3.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Reintubation and subsequent mechanical ventilation (MV) in preterm infants after surfactant replacement therapy are associated with excess morbidity and mortality and likely increase in-hospital costs. Specific surfactant therapy selection for prevention of respiratory distress syndrome (RDS) in preterm infants receiving conventional MV may impact not only clinical outcomes but also pharmacoeconomic outcomes. METHODS We conducted a pharmacoeconomic analysis of the impact of surfactant selection and reintubation and subsequent MV of preterm infants on health care resource utilization. Rates of reintubation and duration of MV after reintubation were determined from 1546 preterm infants enrolled in two surfactant trials comparing lucinactant to beractant and poractant alfa. Hospital costs were obtained from a 2010 US database from 1564 preterm infants with RDS, with a direct cost of $2637 per day for MV in the neonatal intensive care unit. Cost of reintubation by study and treatment was estimated as the incidence of reintubation multiplied by days on MV therapy after reintubation multiplied by cost per day for direct MV costs, standardized per 100 surfactant-treated infants. RESULTS There were no differences between studies or treatment groups in the overall extubation rate. Average MV duration following reintubation was similar between groups in both trials; however, reintubation rates were significantly lower (p<0 05) for infants treated with lucinactant than for those receiving beractant or poractant alfa. The observed differences in reintubation rates resulted in a projected cost saving of $160,013 to $252,203 per 100 infants treated with lucinactant versus animal-derived surfactants. CONCLUSIONS In this analysis, higher reintubation rates following successful extubation in preterm infants receiving animal-derived surfactant preparations significantly increased estimated in-hospital costs, primarily due to excess costs associated with MV. This analysis suggests that surfactant selection may have a significant pharmacoeconomic impact on cost of patient care. Additional cost assessment of potential reduction in reintubation-associated morbidity is warranted.
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Affiliation(s)
- Carlos G Guardia
- Centro de Investigación Perinatal, Universidad de Chile, Santiago, Chile ; Discovery Laboratories, Inc., Warrington, Pennsylvania
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Late administration of surfactant replacement therapy increases surfactant protein-B content: a randomized pilot study. Pediatr Res 2012; 72:613-9. [PMID: 23037875 PMCID: PMC3548137 DOI: 10.1038/pr.2012.136] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surfactant dysfunction may contribute to the development of bronchopulmonary dysplasia (BPD) in persistently ventilated preterm infants. We conducted a multicenter randomized, blinded, pilot study to assess the safety and efficacy of late administration of doses of a surfactant protein-B (SP-B)-containing surfactant (calfactant) in combination with prolonged inhaled nitric oxide (iNO) in infants ≤1,000 g birth weight (BW). METHODS We randomized 85 preterm infants ventilated at 7-14 d after birth to receive either late administration of surfactant (up to 5 doses) plus prolonged iNO or iNO alone. Large aggregate surfactant was isolated from daily tracheal aspirates (TAs) for measurement of SP-B content, total protein, and phospholipid (PL). RESULTS Late administration of surfactant had minimal acute adverse effects. Clinical status as well as surfactant recovery and SP-B content in tracheal aspirate were transiently improved as compared to the controls; these effects waned after 1 d. The change in SP-B content with surfactant dosing was positively correlated with SP-B levels during treatment (r = 0.50, P = 0.02). CONCLUSION Low SP-B values increased with calfactant administration, but the relationship of this response to SP-B levels suggests that degradation is a contributing mechanism for SP-B deficiency and surfactant dysfunction. We conclude that late therapy with surfactant in combination with iNO is safe and transiently increases surfactant SP-B content, possibly leading to improved short- and long-term respiratory outcomes.
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A pilot, randomized, controlled clinical trial of lucinactant, a peptide-containing synthetic surfactant, in infants with acute hypoxemic respiratory failure. Pediatr Crit Care Med 2012; 13:646-53. [PMID: 22791092 DOI: 10.1097/pcc.0b013e3182517bec] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Inhibition of surfactant function and abnormal surfactant synthesis lead to surfactant dysfunction in children with acute hypoxemic respiratory failure. We evaluated whether intratracheal lucinactant, a synthetic, peptide-containing surfactant, was safe and well-tolerated in infants with acute hypoxemic respiratory failure, and assessed its effects on clinical outcomes. METHODS AND MAIN RESULTS Infants ≤ 2 yrs of age with acute hypoxemic respiratory failure were enrolled in a phase II, double-blind, multinational, placebo-controlled randomized trial across 36 pediatric intensive care units. Infants requiring mechanical ventilation with persistent hypoxemia meeting acute lung injury criteria were randomized to receive intratracheal lucinactant (175 mg/kg) or air placebo. One retreatment was allowed 12-24 hrs after initial dosing if hypoxemia persisted. Peri-dosing tolerability of intratracheal lucinactant and adverse experiences were assessed. Mechanical ventilation duration was analyzed using analysis of variance. The Cochran-Mantel-Haenszel test was used for categorical variables.We enrolled 165 infants (84 lucinactant; 81 placebo) with acute hypoxemic respiratory failure. There were no significant differences in baseline subject characteristics, with the exception of a lower positive end-expiratory pressure and higher tidal volume in placebo subjects. The incidence of transient peri-dosing bradycardia and desaturation was significantly higher in the lucinactant treatment group. There were no statistical differences between groups for other adverse events or mortality. Oxygenation improved in infants randomized to receive lucinactant as indicated by fewer second treatments (67% lucinactant vs. 81% placebo, p = .02) and a trend in improvement in partial pressure of oxygen in arterial blood to fraction of inspired oxygen from eligibility to 48 hrs after dose (p = .06). There was no significant reduction in duration of mechanical ventilation with lucinactant (geometric least square means: 4.0 days lucinactant vs. 4.5 days placebo; p = .254). In a subset of infants (n = 22), the duration of mechanical ventilation in children with acute lung injury (partial pressure of oxygen in arterial blood to fraction of inspired oxygen >200) was significantly shorter with lucinactant (least square means: 2.4 days lucinactant vs. 4.3 days placebo; p = .006). CONCLUSIONS In mechanically ventilated infants with acute hypoxemic respiratory failure, treatment with intratracheal lucinactant appeared to be generally safe. An improvement in oxygenation and a significantly reduced requirement for retreatment suggests that lucinactant might improve lung function in infants with acute hypoxemic respiratory failure.
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Shamliyan T, Kane RL. Clinical research involving children: registration, completeness, and publication. Pediatrics 2012; 129:e1291-300. [PMID: 22529271 DOI: 10.1542/peds.2010-2847] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Effective health care for children must be based on thorough analyses of the best research evidence. The objective of this study was to examine registration, completeness, and publication of studies involving children. METHODS We searched the ClinicalTrials.gov registry to identify all closed studies involving children and examined them for completeness and availability of results. We examined publication in peer-reviewed journals for 160 randomly selected National Institutes of Health (NIH)-funded studies from 2000 through 2010 and for 758 randomly selected completed studies. RESULTS Of 3428 closed studies involving children identified in ClinicalTrials.gov, 2385 (70%) were completed, 28 (0.8%) suspended, 152 (4.4%) terminated, and 38 (1.1%) withdrawn. The proportion of non-completed studies (terminated and suspended) increased linearly by 186% between 2001 and 2009, from 1.9% to 8.4%. Of the 152 terminated studies, 48 did not report reasons for termination, 21 cited safety concerns, and 83 cited poor recruitment or other administrative reasons. Only 29% of completed studies were published. Publication that did occur was an average of 2 years after study completion. Completed interventional studies were published more often than observational studies. Completed industry-funded studies were published less often than studies funded by the NIH. Registered NIH-funded trials were published more often than unregistered. CONCLUSIONS Results are unavailable for more than half of the studies involving children, revealing a substantial publication bias. Registration and posting of results on ClinicalTrials.gov should be mandatory for all studies involving children.
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Affiliation(s)
- Tatyana Shamliyan
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Abstract
OBJECTIVE Many premature infants at risk for bronchopulmonary dysplasia experience episodes of surfactant dysfunction with reduced surfactant protein B (SP-B). In this study, we investigated the safety and responses to booster doses of surfactant. STUDY DESIGN A total of 87 infants, 500 to 1250 g birth weight, who were ventilated at 7 to 10 days received 2 or 3 doses of Infasurf (Calfactant, Forest Pharmaceuticals, St Louis, MO, USA) within a 1-week period. RESULT For 184 doses, occurrence rates of transient bradycardia (13) and plugged endotracheal tube (5) were low, and no other adverse effects were noted. Treatment transiently improved the respiratory severity score (FiO(2) × mean airway pressure), SP-B content (+75%) and surface properties of isolated surfactant. Levels of eight proinflammatory cytokines in tracheal aspirate were interrelated and unchanged from baseline after surfactant treatment. CONCLUSION Booster doses of surfactant for premature infants with lung disease are safe and transiently improve respiratory status as well as composition and function of endogenous surfactant.
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Gizzi C, Papoff P, Barbàra CS, Cangiano G, Midulla F, Moretti C. Old and new uses of surfactant. J Matern Fetal Neonatal Med 2011; 23 Suppl 3:41-4. [PMID: 20836732 DOI: 10.3109/14767058.2010.509912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Exogenous surfactant has been the primary life-saving therapy for respiratory distress syndrome (RDS) of preterm infants for many years. More recently, early surfactant treatment administered less invasively by transient endotracheal intubation and combined to nasal ventilation has been shown to further improve neonatal outcome by reducing the need of mechanical ventilation. In addition to RDS, other neonatal and pediatric respiratory disorders characterized by surfactant inactivation or dysfunction, such as pulmonary hemorrhage, aspiration pneumonia, and viral lower respiratory tract infection, might also be amenable to surfactant replacement therapy. However, the nature of lung injury and the influence of co-morbidities may reduce the efficacy of surfactant in these conditions. Currently under investigation are new synthetic surfactant formulations which may be more effective and resistant to inactivation than natural ones and could be produced at a lower cost. The use of surfactants to deliver drugs directly to the lung also seems to be a promising technique worthy of study.
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Affiliation(s)
- Camilla Gizzi
- Division of Neonatology, S. Giovanni Calibita Hospital, Fatebenfratelli, Isola Tiberina, Rome, Italy
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Pharmacokinetics and clinical predictors of surfactant redosing in respiratory distress syndrome. Intensive Care Med 2010; 37:510-7. [DOI: 10.1007/s00134-010-2091-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 11/07/2010] [Indexed: 11/24/2022]
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Abstract
Bronchopulmonary dysplasia (BPD) is associated with increased mortality and significant long-term cardiorespiratory and neurodevelopmental sequelae. Treatment of evolving BPD in the neonatal intensive care unit (NICU) is challenging due to the complex interplay of contributing risk factors which include preterm birth per se, supplemental oxygen, positive pressure ventilation, patent ductus arterious, and pre- and postnatal infection. Management of evolving BPD requires a multimodal approach including adequate nutrition, careful fluid management, effective and safe pharmacotherapy, and respiratory support aiming at minimal lung injury. Among pharmacological interventions, caffeine has the best risk-benefit profile. Systemic postnatal corticosteroids should be reserved to ventilated infants at highest risk of BPD who cannot be weaned from the ventilator. Several ongoing randomised trials are evaluating optimal oxygen saturation targets in preterm infants. The most beneficial respiratory support strategy to minimise lung injury remains unclear and requires further investigation.
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Affiliation(s)
- Sven M Schulzke
- School of Women's and Infants' Health, The University of Western Australia, Perth, Australia.
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Combined effects of polymers and KL4 peptide on surface activity of pulmonary surfactant lipids. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2010; 1798:1129-34. [DOI: 10.1016/j.bbamem.2010.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 01/29/2010] [Accepted: 02/22/2010] [Indexed: 01/08/2023]
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Abstract
Considerable effort has been devoted to the development of strategies to reduce the incidence of bronchopulmonary dysplasia (BPD), including use of medications, nutritional therapies, and respiratory care practices. Unfortunately, most of these strategies have not been successful. To date, the only two treatments developed specifically to prevent BPD whose efficacy is supported by evidence from randomized, controlled trials are the parenteral administration of vitamin A and corticosteroids. Two other therapies, the use of caffeine for the treatment of apnea of prematurity and aggressive phototherapy for the treatment of hyperbilirubinemia, were evaluated for the improvement of other outcomes and found to reduce BPD. Cohort studies suggest that the use of continuous positive airway pressure as a strategy for avoiding mechanical ventilation might also be beneficial. Other therapies reduce lung injury in animal models but do not appear to reduce BPD in humans. The benefits of the efficacious therapies have been modest, with an absolute risk reduction in the 7-11% range. Further preventive strategies are needed to reduce the burden of this disease. However, each will need to be tested in randomized, controlled trials, and the expectations of new therapies should be modest reductions of the incidence of the disease.
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Affiliation(s)
- Matthew M. Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, NC, CB# 7596, 4 Floor, UNC Hospitals, Chapel Hill, NC 27599-7596, Phone: (919) 966-5063, Fax: (919) 966-3034
| | - P. Brian Smith
- Duke University, Durham, NC, PO Box 17969, Durham, NC 27715, Phone: (919) 668-8951, Fax: (919) 668-7058
| | - Carl Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, CB# 7596, 4 Floor, UNC Hospitals, Chapel Hill, NC 27599-7596, Phone: (919) 966-5063, Fax: (919) 966-3034
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Affiliation(s)
- William E Truog
- Children's Mercy Hospitals and Clinics, Section of Neonatology, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64108, USA.
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