Surfactant without Intubation in Preterm Infants with Respiratory Distress: First Multi-center Data

Abstract

Background: Recently in a report of a single center a method has been described to apply surfactant via a thin endotracheal catheter to very low birth weight infants spontaneously breathing with nasal continuous positive airway pressure. We now analyzed available multicenter data.

Patients and Methods: In a multicenter study investigating genetic risk factors, clinical and outcome data and data of antenatal and postnatal treatment of infants with a birth weight below 1 500 g were prospectively recorded. The measures of infants treated with the new method of surfactant application were compared to those of infants who received standard care. The analysis was restricted to infants with a gestational age below 31 weeks (n=1 541).

Results: 319 infants were treated with the new method and 1 222 with standard care. The need for mechanical ventilation during the first 72 h (29% vs. 53%, p<0.001), the rate of bronchopulmonary dysplasia defined as oxygen at 36 weeks of postmenstrual age (10.9 % vs. 17.5%, p=0.004) and the rate of death or bronchopulmonary dysplasia were significantly lower in the treatment group than in the standard care group. Surfactant, theophyllin, caffeine and doxapram were significantly more often and analgetics, catecholamines and dexamethasone were significantly less frequently used in the treatment group.

Conclusions: A new method of surfactant application was associated with a lower prevalence of mechanical ventilation and better pulmonary outcome. A prospective controlled trial is required to determine whether this approach is superior to standard care.

Zusammenfassung

Hintergrund: Aktuell wurde an einem einzelnen Zentrum eine Methode beschrieben, Surfactant über einen dünnen endotrachealen Katheter an sehr kleine Frühgeborene zu verabreichen, die mit Unterstützung durch einen kontinuierlichen positiven Atemwegsdruck spontan atmen. Wir analysierten jetzt verfügbare Multicenterdaten.

Patienten und Methode: In einer Multicenterstudie zur Untersuchung genetischer Risikofaktoren wurden klinische Daten, Daten zu Behandlungsergebnissen und zu vor- und nachgeburtlicher Therapie von Kindern mit einem Geburtsgewicht unter 1 500 g prospektiv erhoben. Die Daten der mit der neuen Methode behandelten Kinder wurden mit denen der mit Standardtherapie behandelten verglichen. Die Auswertung beschränkte sich auf Kinder mit einem Schwangerschaftsalter unter 31 Wochen (n=1 541)

Ergebnisse: 319 Kinder wurden mit der neuen Methode und 1 222 mit Standardtherapie behandelt. Die Häufigkeit mechanischer Beatmung während der ersten 72 Lebensstunden (29% vs. 53%, p<0,001), die einer bronchopulmonalen Dysplasie, definiert als zusätzlicher Sauerstoffbedarf nach Abschluss der 36. postmenstruellen Woche (10,9% vs. 17,5%, p=0,004) und die von Tod oder bronchopulmonaler Dysplasie lagen in der Behandlungsgruppe signifikant niedriger als in der Standardtherapiegruppe. Surfactant, Theophyllin, Koffein und Doxapram wurden signifikant häufiger und Analgetika, Katecholamine und Dexamethason signifikant seltener in der Behandlungsgruppe eingesetzt.

Schlussfolgerung: Der Einsatz der neuen Methode ging einher mit einer geringeren Notwendigkeit maschineller Beatmung und einer geringeren Rate pulmonaler Beeinträchtigung. Eine prospektive, kontrollierte Studie ist erforderlich, um eine mögliche Überlegenheit über die Standardtherapie nachzuweisen.

Key words

surfactant - respiratory distress syndrome (RDS) - very low birth weight infant (VLBW infant) - bronchopulmonary dysplasia (BPD)

Schlüsselwörter

Surfactant - Atemnotsyndrom (ANS) - sehr kleines Früheborenes - nasaler kontinuierlicher positiver Atemwegsdruck (nCPAP) - bronchopulmonale Dysplasie (BPD)

References

• 1 Aly H. et al . Does the experience with the use of nasal continuous positive airway pressure improve over time in extremely low birth weight infants?.  Pediatrics. 2004;  114 697-702
• 2 Ammari A. et al . Variables associated with the early failure of nasal CPAP in very low birth weight infants.  J Pediatr. 2005;  147 341-347
• 3 Attar MA, Donn SM. Mechanisms of ventilator-induced lung injury in premature infants.  Semin Neonatol.. 2002;  7 ((5)) 353-360
• 4 Berggren E. et al . Pilot study of nebulized surfactant therapy for neonatal respiratory distress syndrome.  Acta Paediatr. 2000;  89 460-464
• 5 Booth C. et al . Sustainable use of continuous positive airway pressure in extremely preterm infants during the first week after delivery.  Arch Dis Child. 2006;  91 F398-402
• 6 Brimacombe J. et al . The laryngeal mask airway for administration of surfactant in two neonates with respiratory distress syndrome.  Pediatr Anaesth. 2004;  14 188-190
• 7 Donn SM, Sinha SK. Minimising ventilator induced lung injury in preterm infants.  Arch Dis Child Fetal Neonatal Ed. 2006;  91 ((3)) F226-230
• 8 Finer N. To intubate or not – that is the question: continuous positive airway pressure versus surfactant and extremely low birthweight infants.  Arch Dis Child. 2006;  91 F392-394
• 9 Jorch G. et al . Surfactant aerosol treatment of respiratory distress syndrome in spontaneously breathing premature infants.  Pediatr Pulmonol. 1997;  24 222-224
• 10 Kattwinkel J. et al . Technique for intrapartum administration of surfactant without requirement for an endotracheal tube.  J Perinatol. 2004;  24 360-365
• 11 Kribs A. et al . Early administration of surfactant in spontaneous breathing with nCPAP: feasibility and outcome in extremely premature infants (postmenstrual age ≤27 weeks).  Paediatr Anaesth. 2007;  17 364-369
• 12 Kribs A. et al . Early surfactant in spontaneously breathing with nCPAP in ELBW infants–a single centre four year experience.  Acta Paediatr. 2008;  97 ((3)) 293-298
• 13 Lindner U. et al . Drug utilisation in very preterm infants: Any Changes during the past decade?.  Klin Padiatr. 2008;  220 238-242
• 14 Loeliger M. et al . Cerebral outcomes in a preterm baboon model of early versus delayed nasal continuous positive airway pressure.  Pediatrics. 2006;  118 1640-1653
• 15 Morley CJ. et al . COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants.  N Engl J Med. 2008;  358 ((7)) 700-708
• 16 Schmidt B. et al . Caffeine therapy for apnea of prematurity.  N Engl J Med. 2006;  18 2112-2121
• 17 Soll RF, Morley CJ. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants.  Cochrane Database Syst Rev. 2001;  CD000510
• 18 Stevens TP. et al . Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome.  Cochrane Database Syst Rev. 2004;  CD003063
• 19 Strassburg HM. et al . Long-term prognosis of former very and extremely preterm babies in adulthood in Germany.  Klin Padiatr. 2008;  220 61-65
• 20 Thomson MA. et al . Delayed extubation to nasal continuous positive airway pressure in the immature baboon model of bronchopulmonary dysplasia: Lung clinical and pathological findings.  Pediatrics. 2006;  118 2038-2050
• 21 Trevisanuto D. et al . Laryngeal mask airway used as a delivery conduit for the administration of surfactant to preterm infants with respiratory distress syndrome.  Biol Neonate. 2005;  87 217-220
• 22 Van Marter LJ. et al . Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network.  Pediatrics. 2000;  105 1194-1201

Correspondence