Surfactant therapy for COVID-19 related ARDS: a retrospective case\u2013control pilot study

Simone Piva,Michele Bertoni,Michael A Portman,Matteo Filippini,John C Marshall,Aldo M Roccaro,Alan H Jobe,Robert M Diblasi,Nicola Latronico,April E Slee

doi:10.1186/s12931-020-01603-w

Abstract

BackgroundCOVID-19 causes acute respiratory distress syndrome (ARDS) and depletes the lungs of surfactant, leading to prolonged mechanical ventilation and death. The feasibility and safety of surfactant delivery in COVID-19 ARDS patients have not been established.MethodsWe performed retrospective analyses of data from patients receiving off-label use of exogenous natural surfactant during the COVID-19 pandemic. Seven COVID-19 PCR positive ARDS patients received liquid Curosurf (720 mg) in 150 ml normal saline, divided into five 30 ml aliquots) and delivered via a bronchoscope into second-generation bronchi. Patients were matched with 14 comparable subjects receiving supportive care for ARDS during the same time period. Feasibility and safety were examined as well as the duration of mechanical ventilation and mortality.ResultsPatients showed no evidence of acute decompensation following surfactant installation into minor bronchi. Cox regression showed a reduction of 28-days mortality within the surfactant group, though not significant. The surfactant did not increase the duration of ventilation, and health care providers did not convert to COVID-19 positive.ConclusionsSurfactant delivery through bronchoscopy at a dose of 720 mg in 150 ml normal saline is feasible and safe for COVID-19 ARDS patients and health care providers during the pandemic. Surfactant administration did not cause acute decompensation, may reduce mortality and mechanical ventilation duration in COVID-19 ARDS patients. This study supports the future performance of randomized clinical trials evaluating the efficacy of meticulous sub-bronchial lavage with surfactant as treatment for patients with COVID-19 ARDS.

Highlights

COVID-19 causes acute respiratory distress syndrome (ARDS) and depletes the lungs of surfactant, leading to prolonged mechanical ventilation and death
We sought to test the hypothesis that a level of combined ’primary’ and/or secondary ventilator-induced lung injury (VILI) induced surfactant-deficiency occurs with COVID-19 ARDS, and the corollary that meticulous surfactant replacement can improve clinical outcome
We provide one of the first reports on surfactant administration for COVID-19 H type ARDS

Summary

Introduction

COVID-19 causes acute respiratory distress syndrome (ARDS) and depletes the lungs of surfactant, leading to prolonged mechanical ventilation and death. The feasibility and safety of surfactant delivery in COVID-19 ARDS patients have not been established. The SARS-CoV-2 associated disease (COVID-19) has caused massive mortality worldwide. Those patients requiring hospitalization frequently have bilateral pneumonia, and about 15% develop ARDS [1]. COVID-19 produces diffuse alveolar damage, similar to the pathology seen in other forms of viral pneumonia, two different "phenotypes" have been identified in COVID-19 related ARDS. In the course (Type L: Low), patients display nearly normal compliance, low ventilation-to-perfusion (VA/Q) ratio, low lung weight, and low lung recruitability. Later (Type H: High), patients show low compliance, right-to-left shunting, high lung weight, and high lung recruitability [3].

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