Noninvasive Surfactant-Applikation (LISA) – Erkenntnisstand 2016

Einleitung

Das Atemnotsyndrom (ANS) des Frühgeborenen stellt eine akut lebensbedrohliche Erkrankung dar und ist auch heute noch für einen großen Teil der neonatalen Morbidität und Mortalität sehr kleiner Frühgeborener verantwortlich [1]. Zusätzlich verursachen das ANS selbst sowie die notwendigen therapeutischen Maßnahmen Folgezustände, die mit einer Langzeitmorbidität einhergehen, insbesondere mit der sog. chronischen Lungenerkrankung des Frühgeborenen (CLD), die auch als bronchopulmonale Dysplasie (BPD) bezeichnet wird. Man unterscheidet eine überwiegend durch Beatmung induzierte alte Form (old BPD) und eine weitgehend beatmungsunabhängige neue Form (new BPD), die in erster Linie durch eine mangelnde strukturelle Ausreifung ausgelöst wird [2] [3]. Letztere tritt auf, wenn sich die Lunge außerhalb des Mutterleibs unter unphysiologischen Bedingungen weiterentwickeln muss.

In der Pathogenese der CLD spielen also sowohl die Unreife der Lunge selbst als auch die maschinelle Beatmung eine Rolle. Um die Möglichkeit der Schädigung durch maschinelle Beatmung zu minimieren, wurden in den letzten Jahrzehnten schonende Beatmungsformen sowie Strategien zur Beatmungsvermeidung entwickelt. Dazu gehört die Anwendung eines kontinuierlichen positiven Atemwegsdrucks (CPAP: Continuous Positive Airway Pressure) von Geburt an.

Neben der strukturellen Unreife der Lunge mit deutlich verminderter respiratorischer Oberfläche kommt der biochemischen Unreife mit einer stark eingeschränkten Fähigkeit zur Surfactant-Bildung bzw. Surfactant-Release eine erhebliche Bedeutung zu. Daher ist die Substitution von exogenem natürlichem Surfactant seit der Verfügbarkeit entsprechender Präparate ein maßgebliches Therapieprinzip. Die Substitution von Surfactant war bis vor Kurzem in der Regel an Intubation und maschinelle Beatmung gebunden, da Surfactant über den Endotrachealtubus appliziert wurde.

Neben einer pränatalen Lungenreifungsinduktion durch die Gabe von Steroiden an die Mutter, die heute als Standardtherapie bei drohender Frühgeburt gilt, stellen sowohl die Surfactant-Substitution als auch die Vermeidung maschineller Beatmung entscheidende Therapierichtlinien zur Vermeidung der CLD dar. Deshalb wird neuerdings neben den beiden klassischen therapeutischen Wegen zur Behandlung des ANS – reine CPAP-Anwendung oder maschinelle Beatmung über einen Endotrachealtubus, verbunden mit endotrachealer Gabe von Surfactant – die Kombination von CPAP mit einer wenig invasiven Gabe von Surfactant unter CPAP-unterstützter Spontanatmung diskutiert.

• Literatur

• 1 Patel RM, Kandefer S, Walsh MC et al. Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Causes and timing of death in extremely premature infants from 2000 through 2011. N Engl J Med 2015; 372: 331-340
• 2 Kramer BW. Antenatal inflammation and lung injury: prenatal origin of neonatal disease. J Perinatol 2008; 28: 21-27
• 3 Mosca F, Colnaghi M, Fumagalli M. BPD: old and new problems. J Matern Fetal Neonatal Med 2011; 24: 80-82
• 4 Silverman WA, Andersen DH. A controlled clinical trial of effects of water mist on obstructive respiratory signs, death rate and necropsy findings among premature infants. Pediatrics 1956; 17: 1-10
• 5 Ehlen M. Klinikstandards für Neonatologie und pädiatrische Intensivmedizin. Stuttgart: Thieme; 2014
• 6 Obladen M. History of neonatal resuscitation. Part 2: oxygen and other drugs. Neonatology 2009; 95: 91-96
• 7 Campbell K. Intensive oxygen therapy as a possible cause of retrolental fibroplasia; a clinical approach. Med J Aust 1951; 2: 48-50
• 8 Hollenhorst RW. Oxygen therapy in the premature infant as a cause of retrolental fibroplasia. Minn Med 1956; 39: 91-93
• 9 Harrison VC, Heese Hde V, Klein M. The significance of grunting in hyaline membrane disease. Pediatrics 1968; 41: 549-559
• 10 Dunn PM, Thearle MJ, Parsons AC et al. Use of the „Gregory box“ (CPAP) in treatment of RDS of the newborn: preliminary report. Arch Dis Child 1972; 47: 674-675
• 11 Verder H. Nasal CPAP has become an indispensable part of the primary treatment of newborns with respiratory distress syndrome. Acta Paediatr 2007; 96: 482-484
• 12 Jensen EA, DeMauro SB, Kornhauser M et al. Effects of multiple ventilation courses and duration of mechanical ventilation on respiratory outcomes in extremely low-birth-weight infants. JAMA Pediatr 2015; 28: 1-7
• 13 Avery ME, Mead J. Surface properties in relation to atelectasis and hyaline membrane disease. AMA J Dis Child 1959; 97: 517-523
• 14 Fujiwara T, Maeta H, Chida S et al. Artificial surfactant therapy in hyaline-membrane disease. Lancet 1980; 1: 55-59
• 15 Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2012; 11: CD001456
• 16 Morley CJ, Davis PG, Doyle LW et al. COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008; 358: 700-708
• 17 SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal ResearchNetwork. Finer NN, Carlo WA, Walsh MC et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010; 362: 1970-1979
• 18 Dunn MS, Kaempf J, de Klerk A et al. Vermont Oxford Network DRM Study Group. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011; 128: e1069-1076
• 19 Verder H, Agertoft L, Albertsen P et al. Surfactant treatment of newborn infants with respiratory distress syndrome primarily treated with nasal continuous positive air pressure. A pilot study. Ugeskr Laeger 1992; 154: 2136-2139
• 20 Verder H, Robertson B, Greisen G et al. Surfactant therapy and nasal continuous positive airway pressure for newborns with respiratory distress syndrome. Danish-Swedish Multicenter Study Group. N Engl J Med 1994; 331: 1051-1055
• 21 Isayama T, Chai-Adisaksopha C, McDonald SD. Noninvasive ventilation with vs without early surfactant to prevent chronic lung disease in preterm nfants: a systematic review and meta-analysis. JAMA Pediatr 2015; 169: 731-739
• 22 More K, Sakhuja P, Shah PS. Minimally invasive surfactant administration in preterm infants: a meta-narrative review. JAMA Pediatr 2014; 168: 901-908
• 23 Ten Centre Study Group. Ten centre trial of artificial surfactant (artificial lung expanding compound) in very premature babies. BrMed J (Clin Res Ed) 1987; 294: 991-996
• 24 Dambeanu JM, Parmigiani S, Marinescu B et al. Use of surfactant for prevention of respiratory distress syndrome in newborn infants in spontaneous breathing. A randomized multicenter clinical pilot-study. Acta Biomed Ateneo Parmense 1997; 68: 39-45
• 25 Kattwinkel J, Robinson M, Bloom BT et al. Technique for intrapartum administration of surfactant without requirement for an endotracheal tube. J Perinatol 2004; 24: 360-365
• 26 Abdel-Latif ME, Osborn DA. Pharyngeal instillation of surfactant before the first breath for prevention of morbidity and mortality in preterm infants at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2011; 3: CD008311
• 27 Brimacombe J, Gandini D, Keller C. The laryngeal mask airway for administration of surfactant in two neonates with respiratory distress syndrome. Paediatr Anaesth 2004; 14: 188-190
• 28 Trevisanuto D, Grazzina N, Ferrarese P 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
• 29 Micaglio M, Zanardo V, Ori C et al. ProSeal LMA for surfactant administration. PaediatrAnaesth 2008; 18: 91-92
• 30 Attridge JT, Stewart C, Stukenborg GJ et al. Administration of rescue surfactant by laryngeal mask airway: lessons from a pilot trial. Am J Perinatol 2013; 30: 201-206
• 31 Pinheiro JM, Santana-Rivas Q, Pezzano C. Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery. J Perinatol 2016; 36: 196-201
• 32 Jorch G, Hartl H, Roth B et al. Surfactant aerosol treatment of respiratory distress syndrome in spontaneouslybreathing premature infants. PediatrPulmonol 1997; 24: 222-224
• 33 Berggren E, Liljedahl M, Winbladh B et al. Pilot study of nebulized surfactant therapy for neonatal respiratory distress syndrome. ActaPaediatr 2000; 89: 460-464
• 34 Minocchieri S, Berry CA, Pillow J. Nebulized surfactant for treatment of respiratory distress in the first hours of life: the CureNeb study. Abstract presented at: Annual Meeting of the Pediatric Academic Society. May 6, 2013; Washington, DC. Session 3500
• 35 Kribs A, Pillekamp F, Hünseler C et al. Early administration of surfactant in spontaneous breathing with nCPAP: feasibility and outcome in extremely premature infants (postmenstrual age ≤ 27 weeks). PaediatrAnaesth 2007; 17: 364-369
• 36 Dargaville PA, Aiyappan A, Cornelius A et al. Preliminary evaluation of a new technique of minimally invasive surfactant therapy. Arch Dis Child Fetal Neonatal Ed 2011; 96: F243-248
• 37 Ramos-Navarro C, Sánchez-Luna M, Zeballos-Sarrato S et al. Less invasive beractant administration in preterm infants: a pilot study. Clinics (SaoPaulo) 2016; 71: 128-134
• 38 Kribs A, Vierzig A, Hünseler C et al. Early surfactant in spontaneously breathing with nCPAP in ELBW infants – a single centre four year experience. ActaPaediatr 2008; 97: 293-298
• 39 Kribs A, Härtel C, Kattner E et al. Surfactant without intubation in preterm infants with respiratory distress: first multi-center data. KlinPadiatr 2010; 222: 13-17
• 40 Mehler K, Grimme J, Abele J et al. Outcome of extremely low gestational age newborns after introduction of a revised protocol to assist preterm infants in their transition to extrauterine life. Acta Paediatr 2012; 101: 1232-1239
• 41 Dargaville PA, Aiyappan A, De Paoli AG et al. Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 2013; 98: F122-126
• 42 Klebermass-Schrehof K, Wald M, Schwindt J et al. Less invasive surfactant administration in extremely preterm infants: impact on mortality and morbidity. Neonatology 2013; 103: 252-258
• 43 Aguar M, Cernada M, Brugada M et al. Minimally invasive surfactant therapy with a gastric tube is as effective as the intubation, surfactant, and extubation technique in preterm babies. Acta Paediatr 2014; 103: e229-233
• 44 Canals Candela FJ, Vizcaíno Díaz C, FerrándezBerenguer MJ et al. Surfactant replacement therapy with a minimally invasive technique: Experience in a tertiary hospital. AnPediatr (Barc) 2015; 28: pii: S1695 4033(15)00204-0
• 45 Göpel W, Kribs A, Härtel C et al. German Neonatal Network (GNN). Less invasive surfactant administration is associated with improved pulmonary outcomes in spontaneously breathing preterm infants. ActaPaediatr 2015; 104: 241-246
• 46 Krajewski P, Chudzik A, Strzalko-Gloskowska B et al. Surfactant administration without intubation in preterm infants with respiratory distress syndrome – our experiences. J Matern Fetal Neonatal Med 2015; 28: 1161-1164
• 47 Göpel W, Kribs A, Ziegler A et al. German Neonatal Network. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011; 378: 1627-1634
• 48 Kanmaz HG, Erdeve O, Canpolat FE et al. Surfactant administration via thin catheter during spontaneous breathing: randomized controlled trial. Pediatrics 2013; 131: e502-509
• 49 Heidarzadeh M, Mirnia K, Hoseini MB et al. Surfactant administration via thin catheter during spontaneous breathing: randomized controlled trial in Alzahra hospital. Iran J Neonatol 2013; 4: 5-9
• 50 NINSAPP Trial Investigators. Kribs A, Roll C, Göpel W et al. Nonintubated surfactant application vs conventional therapy in extremely preterm infants: a randomized clinical trial. JAMA Pediatr 2015; 169: 723-730
• 51 Mohammadizadeh M, Ardestani AG, Sadeghnia AR. Early administration of surfactant via a thin intratracheal catheter in preterm infants with respiratory distress syndrome: Feasibility and outcome. J Res Pharm Pract 2015; 4: 31-36
• 52 Bao Y, Zhang G, Wu M et al. A pilot study of less invasive surfactant administration in very preterm infants in a Chinese tertiary center. BMC Pediatr 2015; 15: 21
• 53 Porath M, Korp L, Wendrich D et al. Surfactant in spontaneous breathing with nCPAP: neurodevelopmental outcome at early school age of infants ≤ 27 weeks. Acta Paediatr 2011; 100: 352-359
• 54 Teig N, Weitkämper A, Rothermel J et al. Observational study on Less Invasive Surfactant Administration (LISA) in preterm infants < 29 weeks – short and long-term outcomes. Z Geburtshilfe Neonatol 2015; 219: 266-273