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Manley BJ, Kamlin COF, Donath S, Huang L, Birch P, Cheong JLY, Dargaville PA, Dawson JA, Doyle LW, Jacobs SE, Wilson R, Davis PG, McKinlay CJD. Intratracheal budesonide mixed with surfactant to increase survival free of bronchopulmonary dysplasia in extremely preterm infants: study protocol for the international, multicenter, randomized PLUSS trial. Trials 2023; 24:320. [PMID: 37161488 PMCID: PMC10169381 DOI: 10.1186/s13063-023-07257-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/14/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), an inflammatory-mediated chronic lung disease, is common in extremely preterm infants born before 28 weeks' gestation and is associated with an increased risk of adverse neurodevelopmental and respiratory outcomes in childhood. Effective and safe prophylactic therapies for BPD are urgently required. Systemic corticosteroids reduce rates of BPD in the short-term but are associated with poorer neurodevelopmental outcomes if given to ventilated infants in the first week after birth. Intratracheal administration of corticosteroid admixed with exogenous surfactant could overcome these concerns by minimizing systemic sequelae. Several small, randomized trials have found intratracheal budesonide in a surfactant vehicle to be a promising therapy to increase survival free of BPD. METHODS An international, multicenter, double-blinded, randomized trial of intratracheal budesonide (a corticosteroid) mixed with surfactant for extremely preterm infants to increase survival free of BPD at 36 weeks' postmenstrual age (PMA; primary outcome). Extremely preterm infants aged < 48 h after birth are eligible if: (1) they are mechanically ventilated, or (2) they are receiving non-invasive respiratory support and there is a clinical decision to treat with surfactant. The intervention is budesonide (0.25 mg/kg) mixed with poractant alfa (200 mg/kg first intervention, 100 mg/kg if second intervention), administered intratracheally via an endotracheal tube or thin catheter. The comparator is poractant alfa alone (at the same doses). Secondary outcomes include the components of the primary outcome (death, BPD prior to or at 36 weeks' PMA), potential systemic side effects of corticosteroids, cost-effectiveness, early childhood health until 2 years of age, and neurodevelopmental outcomes at 2 years of age (corrected for prematurity). DISCUSSION Combining budesonide with surfactant for intratracheal administration is a simple intervention that may reduce BPD in extremely preterm infants and translate into health benefits in later childhood. The PLUSS trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants regardless of their initial mode of respiratory support. Should intratracheal budesonide mixed with surfactant increase survival free of BPD, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au ), ACTRN12617000322336. First registered on 28th February 2017.
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Affiliation(s)
- Brett J Manley
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia.
| | - C Omar F Kamlin
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Susan Donath
- Department of Paediatrics, Murdoch Children's Research Institute, the University of Melbourne, Melbourne, Australia
| | - Li Huang
- The University of Melbourne, Melbourne, Australia
| | - Pita Birch
- Department of Neonatology, Mater Mother's Hospitals South Brisbane, Brisbane, Australia
| | - Jeanie L Y Cheong
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter A Dargaville
- Royal Hobart Hospital, Hobart, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Jennifer A Dawson
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Lex W Doyle
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Susan E Jacobs
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Peter G Davis
- The Royal Women's Hospital, Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, Australia
| | - Christopher J D McKinlay
- Department of Paediatrics: Child and Youth Health, the University of Auckland, Kidz First Neonatal Care, TeWhatu Ora Counties Manukau, Auckland, New Zealand
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