Minimally Invasive Surfactant Therapy vs Sham Treatment and Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome
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To the Editor We have several concerns about the sham intervention and the control of factors related to bronchopulmonary dysplasia in the recent study1 of minimally invasive surfactant therapy vs sham treatment in preterm infants with respiratory distress syndrome.Keywords:
Bronchopulmonary Dysplasia
Surfactant therapy
Bronchopulmonary Dysplasia in Post-Surfactant Era: Results of an Objective Assessment of the Disease
Modern methods of respiratory support have led to the transformation of the course of bronchopulmonary dysplasia. A significant role is played by the use of surfactant preparations for the prevention of respiratory distress syndrome and subsequent formation of bronchopulmonary dysplasia in premature infants. In this connection, an objective assessment of the efficacy of surfactant replacement therapy is required. The article presents the results of studying the patterns of development of bronchopulmonary dysplasia in premature infants (n =121) of different gestational age. It was shown that a new form of moderate or mild bronchopulmonary dysplasia prevailed in extremely premature infants in the course of surfactant replacement therapy. Children of a gestational age greater than 32 weeks who do not require surfactant therapy usually have typical bronchopulmonary dysplasia.
Bronchopulmonary Dysplasia
Surfactant therapy
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Since its inception, the neonatal mechanical ventilator has been considered an essential tool for managing preterm neonates with Respiratory Distress Syndrome (RDS) and is still regarded as an integral component in the neonatal respiratory care continuum. Mechanical ventilation of newborn has been practiced for several years with several advances made in the way. This clinical intervention study was done to analyze immediate outcome of preterm neonates with RDS required mechanical ventilation and conducted on preterm neonates with RDS required mechanical ventilation from July 2014 to June 2015. Total of 31 preterm neonates with RDS were mechanically ventilated during the study period, of which 77.42% (N=24) survived. The survival rate was highest among 30- <34 weeks (100%) gestational age (GA) group and lowest in 27- <30 weeks (56%) GA, (p=0.0036). The neonates with Birth Weight (BW) 1500gm -1800gm were higher rate of recovery which was 100% and gradually declined in 1000-1499gm (93.75%) and 800-999gm (33.33%) BW groups (p=0.00083). In this study most of the neonates were male (61.29%) but recovery rate was relatively better among baby girls (83.33%) than baby boys (73.68%) (p=0.53). RDS with surfactant therapy was better outcome than non surfactant group & survival of neonates who got surfactant were 93.33% & non surfactant neonates were 62.50%, (p=0.040). Majority (71.43%) of RDS with surfactant therapy recovered earlier <7 days than non surfactant therapy neonates (30.00%) and most of non surfactant neonates (70.00%) required prolonged ventilator support >7days (p=0.045). During the period of ventilation a total 17(54.84%) neonates developed different complications, of which ventilator associated pneumonia was (16.13%), sepsis (16.13%), pneumothorax (9.68%), pulmonary hemorrhage (6.45%) and intraventricular hemorrhage (6.45%) and among them 10 neonates recovered. No complications encountered in 14(45.16%) neonates, all of them survived, (p=0.0064). All (N=31) preterm neonates were candidate for surfactant therapy but only 15 neonates got surfactant therapy, remaining (N=16) did not get for their financial issue. As mechanical ventilation with surfactant therapy reduces the neonatal mortality; hence, facilities for neonatal ventilation and cost effective surfactant therapy should be included in the regional and central hospitals providing intensive care for neonates.
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Introduction: Prematurity and RDS largely contribute to early neonatal morbidity and mortality. With adequate antenatal steroid and early CPAP, early surfactant therapy improve survival outcome. Material and Methods: Prospective interventional study included newborns with 24-28 weeks prematurity or 28-34 weeks(GA) with clinical RDS and birth weight(BW)>650gms. All subjects were preferably provided early surfactant therapy (within 2hours after birth). Surfactant (Curosurf) was delivered by INSURE technique (Intubate- Surfactant administration- Extubate) and only those who required further respiratory support were ventilated. Records on birth weight, gestational age, timing of therapy (early/late), duration of ventilation, sepsis, complications, and survival/death outcome were collected and data was analysed using SSPS version 17. Results: Out of 100 neonates (49 male, 51 female), 46 received early surfactant therapy and 54 obtained it late; significantly more indoor patients could be treated early (p<0.0001). Although high mortality was observed with both early (65.2%) and late therapy (85.2%), there was significantly higher survival with early therapy (p=0.018). Though no statistical differences of outcome were observed with different GA and BW in study groups; irrespective of timing of therapy, higher mortality occurred in lower BW/GA subgroups with least survival among extremely preterms<27wks(p=0.000057) and ELBW<1000gm(p=0.013). No difference was seen for need of re-intubation/ventilation, but duration of ventilation was more on late group (p=0.043). Culture positive sepsis was found in 68% with higher association with late therapy (p=0.033). Hypotension was frequent complication with late intervention (p=0.029), whereas there was no difference for pulmonary hemorrhage or apnea. Conclusion: Early surfactant administration improved survival with minimal complications in RDS except for extremely premature/LBW babies.
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To the Editor We have several concerns about the sham intervention and the control of factors related to bronchopulmonary dysplasia in the recent study1 of minimally invasive surfactant therapy vs sham treatment in preterm infants with respiratory distress syndrome.
Bronchopulmonary Dysplasia
Surfactant therapy
Cite
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Surfactant therapy
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Several randomized clinical trials have now documented a beneficial effect of surfactant replacement in established neonatal respiratory distress syndrome (RDS). These results have been obtained with surfactant isolated from animal lungs or human amniotic fluid. Treatment with exogenous natural surfactant usually reverses the clinical course of severe RDS, reduces the incidence of serious complications including bronchopulmonary dysplasia, and improves survival rate. Prophylactic surfactant treatment at birth reduces the incidence of severe RDS in very premature babies; this effect has been documented with natural as well as synthetic surfactant preparations. Increased incidence of patent ductus arteriosus was reported in one series of RDS patients treated with modified bovine surfactant, but otherwise no adverse effects have been observed.
Bronchopulmonary Dysplasia
Surfactant therapy
Ductus arteriosus
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Surfactant therapy
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Objective: to evaluate the efficacy of alveofact in neonatal infants with respiratory distress syndrome (RDS). Subjects and methods. The trial enrolled 5 premature neonatal infants. Their mean gestational age was 30.2±2.3 weeks; the birth weight was 1422±604 g. All the premature neonates needed mechanical ventilation (MV) because the leading clinical sign was severe respiratory failure. The surfactant alveofact was injected endotracheally in all the neonates at 3—5 minutes of life, by taking into account their gestational age and birth MV. The mean dose of the agent was 50 mg/kg). Results. The pilot study indicated the efficacy of alveofact. There was normalization of lung gasexchange function parameters after alveofact injection within the first 24 hours of life. Alveofact administration allows MV with the parameters close to physiological ones.
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Respiratory distress syndrome (RDS) is a major cause of morbidity and mortality in preterm neonates. Pulmonary surfactant deficiency is the primary cause of RDS. The purpose of this study was to determine the effect of surfactant therapy in reduction of the mortality rate in premature neonates with RDS and to assess the relationship between the efficacy of surfactant therapy and some risk factors associated with RDS.This study comprised 89 premature neonates with signs of RDS. The neonates were selected by simple sampling from those admitted to the Neonatal Intensive Care Unit (NICU) of Shaheed Beheshti Hospital. The eligible neonates received surfactant replacement-therapy (100 mg/kg) during 48 hours after birth.Overall, 34 (38.2%) out of 89 neonates who received surfactant survived. The higher efficacy of surfactant replacement therapy was observed in neonates with gestational age of more than 32 weeks (47.5%), in those who received the first dose of surfactant during the first 24 hours of life (43.3%), in those with an Apgar score of more than 7/10 at 1 and 5 min (48.1%), and in those with a birth weight of more than 1 500 g (52.5%). The neonates whose mother received steroid therapy before labor had higher reduction in mortality after surfactant therapy (41.7% with steroid vs 34.2% without steroid; p<0.05).Surfactant replacement therapy in neonatal RDS should be started as soon as possible after birth. It could reduce the mortality rate from RDS by 38.2%. The efficacy of surfactant therapy for neonatal RDS may be associated with gestational age, Apgar score, birth weight, starting time of surfactant therapy and maternal steroid therapy.
Surfactant therapy
Apgar score
Antenatal steroid
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Surfactant-replacement therapy is a life-saving treatment for preterm infants with respiratory distress syndrome, a disorder characterized by surfactant deficiency. Repletion with exogenous surfactant decreases mortality and thoracic air leaks and is a standard practice in the developed world. In addition to respiratory distress syndrome, other neonatal respiratory disorders are characterized by surfactant deficiency, which may result from decreased synthesis or inactivation. Two of these disorders, meconium aspiration syndrome and bronchopulmonary dysplasia, might also be amenable to surfactant-replacement therapy. This paper discusses the use of surfactant-replacement therapy beyond respiratory distress syndrome and examines the evidence to date.
Bronchopulmonary Dysplasia
Surfactant therapy
Meconium aspiration syndrome
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