Reconciling competing interests in the treatment of respiratory syndrome

Abstract

In preterm infants with respiratory distress syndrome, surfactant treatment improves respiratory function and decreases mortality and morbidity. Initially, surfactant was administered via an endotracheal tube, followed by gradual weaning from mechanical ventilation. Since the early 1990s there have been two practice changes in neonatology that now compete for priority in the treatment of respiratory distress syndrome: the use of analgosedation to decrease the discomfort associated with intubation competes with the pulmonary benefits of extubation immediately after surfactant administration. These compete because drugs commonly used for procedural sedation suppress spontaneous respirations and typically necessitate at least a short period of mechanical ventilation. Preventing procedural pain without compromising spontaneous respiration would facilitate humane treatment of newborns while simultaneously decreasing the risks of mechanical ventilation. Towards that goal, in this volume of The Journal Smits et al report a dose-finding study of propofol for pre-intubation analgosedation in newborn infants, describing both the pharmacodynamics of propofol and the time required for clinical recovery in infants with planned intubation, surfactant administration, and immediate extubation. Although nearly one-half of these patients were not ready for extubation 1 hour after the administration of propofol, the study provides vital information about the dosing, physiologic effects, and duration of action of propofol in preterm infants. In the accompanying editorial, Turner and Davis point out the important features of the study design and place the results in the context of the need for more research on both the pharmacodynamic properties of these medications and the most effective way to intubate, administer surfactant, and extubate preterm infants. Article page 54 ▶ Editorial page 9 ▶ Propofol Dose-Finding to Reach Optimal Effect for (Semi-)Elective Intubation in NeonatesThe Journal of PediatricsVol. 179PreviewTo define the effective dose for 50% of patients (ED50) of propofol for successful intubation and to determine the rate of successful extubation in those patients with planned intubation, surfactant administration, and immediate extubation (INSURE procedure). In addition, pharmacodynamic effects were assessed. Full-Text PDF Propofol as an Adjunct for Neonatal Intubation: The Contribution of Clinical PharmacologyThe Journal of PediatricsVol. 179PreviewAnalgosedation often is used before (semi-)elective neonatal intubation, which raises a number of important questions, including (1) whether medicines should be used to support neonatal intubation at all, (2) which drug(s) should be used, (3) what dose of each drug should be given, and (4) which adverse effects can be anticipated?1 There are 2 approaches to answering these questions: opinion-based and evidence-based.2 Here, we focus on making evidence-based decisions as demonstrated in the study by Smits et al3 of propofol, a drug used widely to facilitate neonatal intubation. Full-Text PDF