Surfactant For Respiratory Distress Syndrome Research Articles

Severe Hereditary Spherocytosis Presenting with Non-Immune Fetal Hydrops

Background: Hereditary spherocytosis (HS) is characterized by spherocytes on the peripheral smear and heterogeneous clinical presentation (mild, moderate, moderate/severe, and severe) depending upon the severity of hemolytic anemia, jaundice, and splenomegaly. The underlying cause is defects in various red blood cell membrane proteins due to pathogenic mutations. Genotype-phenotype correlation is known. Clinical Description: We report a consanguineous family with a healthy daughter, multiple pregnancy losses due to fetal hydrops, and the current daughter. She was diagnosed with fetal anemia at 22 weeks gestation, developed fetal hydrops, was born premature and developed respiratory distress, severe anemia, severe jaundice, and postnatal hemolysis. Management: The case was managed since intrauterine life till date by multispecialty coordination. Intrauterine transfusions were given during pregnancy. In the neonatal period, she received surfactant for respiratory distress syndrome, double volume exchange transfusion and phototherapy for the jaundice, and repeated blood transfusions for the hemolytic anemia, that is still continuing. Rational and sequential investigations were planned and a systematic approach used. She was diagnosed with severe HS due to a homozygous likely pathogenic variant in the SPTA1 gene (affecting formation of spectrin), and heterozygous variant of uncertain significance in the ANK1 gene (that encodes ankyrin). At 3 years she has transfusion dependent hemolytic anemia, moderate splenomegaly, and age appropriate growth and development. Conclusions: HS is a rare but manageable (albeit challenging) cause of nonimmune hydrops fetalis. Genetic diagnosis allows precise management and family counselling.

The use of surfactant for respiratory distress syndrome by minimally invasive technique in a neonatal unit in Belo Horizonte

The use of surfactant for respiratory distress syndrome by minimally invasive technique in a neonatal unit in Belo Horizonte

Lung ultrasound to guide the administration of exogenous pulmonary surfactant in respiratory distress syndrome of newborn infants: A retrospective investigation study.

Respiratory distress syndrome (RDS) is a common disease that seriously endangers the life and safety of newborns, especially premature infants. Exogenous pulmonary surfactant (PS) is the specific agent for the treatment of neonatal RDS. Lung ultrasound (LUS) has been successfully used in the diagnosis of RDS, but its value in guiding the application of PS is still unclear. This paper explored whether the application of PS under LUS monitoring has some advantages, including (1) decreasing the misdiagnosis rate of RDS and decreasing probability of using PS, and (2) reducing the dose of PS without reducing the therapeutic effect. This study included two parts. Part 1: To decide whether the LUS is good to differentiate RDS from other lung diseases in the premature infants. All patients who were diagnosed with RDS and required PS treatment based on conventional criteria were routinely examined by LUS. Then, according to LUS findings, we decided whether they needed to receive PS treatment. Part 2: To see the dose reduction of surfactant is applicable. In RDS patients diagnosed based on LUS presentation and treated with Curosurf (Chiesi Pharmaceutical, Parma, Italy), the dose of Curosurf was compared with that recommended by the European RDS management guidelines. (1) Since March 2017, 385 newborn infants admitted to our neonatal intensive care unit met the traditional diagnostic criteria of RDS. Of these, only 269 cases were diagnosed with RDS and needed PS treatment according to LUS manifestations. The other 116 infants who did not meet the criteria for ultrasound diagnosis of RDS did not receive PS supplementation but obtained good outcomes, that is LUS findings decreased a misdiagnosis rate of RDS by 30.1% and subsequently resulted in a 30.1% reduction in PS use. (2) Among the 269 RDS patients diagnosed based on LUS findings, 148 were treated with Curosurf (another 121 RDS infants who received domestic PS treatment were not included in the study group), and the average dose was 105.4 ± 24.3 mg/kg per time, which is significantly lower than the dose of 200 mg/kg per time recommended by the European RDS guidelines. (3) The mortality rate of RDS patients was 0%, and no patients had ventilator-associated pneumonia or bronchopulmonary dysplasia in this study. LUS can decrease the misdiagnosis rate of RDS, thereby decreasing the probability of using PS and decreasing the dose of PS, and can help RDS infants to achieve better outcomes.

Natural Versus Synthetic Surfactant Therapy in Respiratory Distress Syndrome of Prematurity.

To compare the clinical efficacy and the cost of treatment between the newborns who received either a natural or a protein-free synthetic surfactant for respiratory distress syndrome (RDS) of prematurity. This is a retrospective analytical study incorporating comparisons of clinical parameters and cost in newborns having RDS of prematurity who received either Survanta (bovine lung extract), a natural surfactant or Surfact (protein-free colfosceril palmitate), a synthetic surfactant. There were 100 newborns who received either of the natural (n = 52) or synthetic (n = 48) surfactant with mean (SD) gestational age and mean (SD) birth weight of 31.5 (2.6) wk, 1425 (461) g and 32.2 (2.2) wk, 1519 (413) g, respectively. Majority of the newborns (> 90%) received endotracheal surfactant within the first 24h of life and had similar baseline characteristics in either group. No differences were noted in ventilator settings on admission and 24h after surfactant/admission. Oxygen requirement, extubation age, complications, hospital stay, and mortality were similar across groups, except that the necrotizing enterocolitis was noted only in natural surfactant group. There was a significant pharmacy cost savings in synthetic surfactant group. Synthetic surfactant was comparable to natural surfactant with regard to outcomes, like ventilator settings, hospital stay, and mortality. Pharmacy cost was less in synthetic surfactant group.

SAVING AND EARLY DICHARGE OF A NEONATE WITH SEVERE MECONIUM ASPIRATION SYNDROME

Animal experiments have shown the resolution of radiological infiltrates of meconium aspiration syndrome (MAS) after using surfactant lavage. Intra-tracheal instillation of surfactant, as well as surfactant lavage, is studied in MAS. However, INSURE (INtubation, administration of SURfactant, Extubation) is never reported to have been used for meconium aspiration syndrome although it is used as the standard method of delivery of surfactant for respiratory distress syndrome. This is a case report of the use of INSURE technique for severe Meconium Aspiration syndrome. The baby was born at term gestational age to a primigravida mother by C-section for fetal distress. The baby was vigorous with chest retractions. Hence baby was supported with delivery room Continuous positive airway pressure (CPAP) and shifted to Neonatal Intensive Care Unit (NICU). In NICU, the baby was stabilized and given surfactant using the INSURE technique. Subsequently, a Chest X-ray showed clearing of lung infiltrates and drastically reduced oxygen requirement of the baby and the baby was discharged early to home.

50 Poractant alfa versus bovine lipid extract surfactant for respiratory distress syndrome in preterm infants: A prospective comparative effectiveness cohort study

Abstract Primary Subject area Neonatal-Perinatal Medicine Background There is a paucity of comparative effectiveness data for bovine lipid extract surfactant (BLES) and poractant alfa (Curosurf). Objectives To compare duration of respiratory support and short-term outcomes in very preterm infants treated with bovine lipid extract surfactant and poractant alfa. Design/Methods We performed a prospective, multicentre, comparative effectiveness study. Thirteen Canadian level III neonatal intensive care units (NICUs) provided bovine lipid extract surfactant to infants born <32 weeks’ gestational age (GA) for a set period of time in the year 2019 (3 to 9 months), then changed to poractant alfa for the remainder of the year. The primary outcome was total duration of respiratory support (invasive and non-invasive). We utilized the Canadian Neonatal Network database for all study data. Results A total of 968 eligible infants (530 infants < 28 weeks’ GA and 438 infants 280-316weeks’ GA) were included, of which 494 received bovine lipid extract surfactant and 474 received poractant alfa. In unadjusted analysis, no difference was observed in total duration of any respiratory support (median 38 vs. 40.5 days). After adjusting for baseline characteristics and accounting for cluster effects, infants treated with poractant alfa spent a median of 4.16 fewer days on respiratory support (95% CI 0.05, 8.28 days). This reduction was observed in the subgroup of infants 280-316 weeks’ GA, but not in those < 28 weeks’ GA, and was explained by their shorter time on non-invasive respiratory support. No differences were observed in the need to re-dose surfactant, hospital mortality, bronchopulmonary dysplasia, or length of stay in NICU. Conclusion Administration of poractant alfa was associated with shorter median duration of respiratory support compared to bovine lipid extract surfactant in preterm neonates < 32 weeks’ GA.

Can first trimester pregnancy-associated plasma protein-A predict the surfactant needs of preterm neonates?

Low values of pregnancy associated plasma protein A (PAPP-A), have been shown to be associated with some poor gestational outcomes, especially those related to placental deficiency such as pre-eclampsia and fetal growth restriction as well as preterm labor. The aim of this study was to compare first trimester PAPP-A MoM values with the surfactant needs of newborns of pregnant women who had a preterm delivery. This study included 216 pregnant women who had a preterm delivery, who were found to be in the low-risk group based on their aneuploidy screening. The women were separated into two groups based on the surfactant receipts of their newborns. A record was made of the obstetric history, birth characteristics of the preterm infants, and whether or not there was a need for surfactant. A comparison of the PAPP-A values of the two groups revealed that the group that received surfactant had statistically significantly lower PAPP-A values (t(-3.97) = 0.203, p < 0.001). When the cut-off value of PAPP-A was taken as 1 MoM and the gestational age was analyzed together with the birth weight, PAPP-A alone was found to be a significant independent variable for the prediction of respiratory distress syndrome (RDS) (p = 0.031; OR:8.2 (1.2-55.6)). The result of this study demonstrated that PAPP-A MoM values may be significant in predicting the need for surfactant in RDS, which is a frequently seen condition in the neonatal period.

Comparative efficacy of pulmonary surfactant in respiratory distress syndrome in preterm infants: a Bayesian network meta-analysis.

The comparative efficacy of pulmonary surfactant in the treatment of respiratory distress syndrome in preterm infants remains unclear. We aimed to evaluate the effectiveness of different pulmonary surfactant in the treatment of respiratory distress syndrome in preterm infants and to provide an evidence-based reference for clinical use. MEDLINE, Embase, The Cochrane Library, and Clinical Trials databases were electronically searched from inception to January 2019. Two reviewers independently screened literature and extracted data, and then R and RevMan 5.3 software packages were used to perform network meta-analysis. The relative risk of respiratory distress syndrome in preterm infants associated with six different pulmonary surfactant was analysed, including beractant (Survanta), surfactant A (Alveofact), calfactant (Infasurf), poractant (Curosurf), lucinactant (Surfaxin), and colfosceril (Exosurf). Patients with the following drugs appeared to have significantly reduced mortality of respiratory distress syndrome compare with beractant: surfactant A (OR = 0.53, 95% CI: 0.31-0.90), calfactant (OR = 0.91, 95% CI: 0.85-0.97), poractant (OR = 0.72, 95% CI: 0.67-0.77), lucinactant (OR = 0.80, 95% CI: 0.71-0.90), and colfosceril (OR = 0.93, 95% CI: 0.87-0.99). The SUCRA (surface under the cumulative ranking) values for each of the drugs were: beractant (8.9%), surfactant A (93.8%), calfactant (40.3%), poractant (65.4%), lucinactant (59.8%), and colfosceril (31.6%). Compared with beractant, other pulmonary surfactants are more effective to reduce the mortality of respiratory distress syndrome in preterm infants. Surfactant A drugs appeared to have the best efficacy in reducing mortality of respiratory distress syndrome in preterm infants.

A descriptive study of racial inequalities in mortality from hepatocellular cancer before and after licensure of lifesaving drugs for hepatitis C virus in the United States

BackgroundSince 1979, mortality from hepatocellular cancer (HCC) has doubled in the United States (US). Lifesaving drugs, prohibitively expensive for some, were approved and marketed to treat hepatitis C virus (HCV), a major risk factor for HCC, beginning in 1997. After the prior introduction of other lifesaving innovations, including active retroviral drug therapy for human immunodeficiency virus and surfactant for respiratory distress syndrome of the newborn, racial inequalities in their mortalities increased in the US. In this descriptive study, we explored racial inequalities in mortality from HCC before and after licensure of HCV drugs in the US. MethodsThe US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (WONDER) were used to describe HCC mortality rates from 1979 to 2016 in those 55 years of age and older, because they suffer the largest disease burden. Joinpoint regression was used to analyze trends. To estimate excess deaths, we applied White age-sex-specific rates to corresponding Black populations. FindingsFrom 1979 to 1998, racial inequalities in mortality from HCC in the US were declining but from 1998 to 2016 racial inequalities steadily increased. From 1998 to 2016, of the 16,770 deaths from HCC among Blacks, the excess relative to Whites increased from 27.8% to 45.4%, and the trends were more prominent in men. Concurrently, racial inequalities in mortality decreased for major risk factors for HCC, including alcohol, obesity and diabetes. InterpretationThese descriptive data, useful to formulate but not test hypotheses, demonstrate decreasing racial inequalities in mortality from HCC which were followed by increases after introduction of lifesaving drugs for HCV in the US. Among many plausible hypotheses generated are social side effects, including unequal accessibility, acceptability and/or utilization. Analytic epidemiological studies designed a priori to do so are necessary to test these and other hypotheses.

Effect of surfactant in respiratory distress syndrome as early rescue therapy verses delayed selective therapy in 28 to 32 weeks of gestation

Background: This prospective interventional study is designed to compare effect of giving surfactant in Respiratory Distress Syndrome (RDS), stabilized on CPAP, as Early Rescue Therapy verses Delayed Selective therapy in Early Pre-terms 28 to 32 weeks, using INSURE method. The main objectives if the studies are to study survival rate and mortality rate in the two groups and to compare the various complications of RDS and surfactant therapy in two groups. Methods: Cases were selected from the Preterm newborn, 28-30 weeks of gestation, confirmed cases of RDS on the basis of Chest X-ray findings and shake test, admitted. Total 96 cases were enrolled, out of which 51 randomly allotted to Early Rescue therapy and 45 to Delayed Selective treatment. Surfactants were administered using INSURE technique. Observations, clinical findings, course of treatment, vitals and outcomes were noted. Data was analyzed using appropriate statistical methods. Efforts were made to study maximum parameters to find out, which treatment strategy provides better outcomes and feasible in our settings. Results: In Early group more cases (68.6%) are discharged than in Delayed group (66.7%). Survival rate is more in Early group. In Early group less mortality is seen 16(31.4%), than in Delayed group 15(33.3%). Mean total duration of stay in NICU is decreased in Early group (7.08±6.209 days) as compared to Delayed group (8.896.±793 days). Conclusion: Early Rescue Therapy increases the survival rate of preterm than the Delayed selective Treatment. Survival rate is increased when surfactant is administered earlier, less than two hours of life, during the course of RDS. Mortality is reduced in Early administration of surfactant but pulmonary causes of mortality is more in them as compared to Delayed administration, where pulmonary as well as non-pulmonary causes of death both affect the mortality.

Audit on the Application of Surfactant in Premature Babies in Assiut University Children Hospital

Abstract Background: To evaluate the use of exogenous natural surfactant for Respiratory Distress Syndrome (RDS) in pre-mature babies, identify areas where European Consensus Guidelines on the Management 2013 Update, modified by The Egyptian Consensus on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants 2014 are applied to as a reference standard in Assiut University Children Hospital and identify those points to be targeted for improve-ment.Patients and Methods: A retrospective audit was under-taken over a 12-month period between 1st of January, 2016 to the 31st of December 2016. It included all babies less than 37 weeks gestation with respiratory distress syndrome who received surfactant as a rescue treatment, guided by European Consensus Guidelines on the Management 2013 Update, modified by The Egyptian Consensus on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants 2014 and admitted to Neonatal Intensive Care Unit of Assiut University Children Hospital during this period. Results: All cases with severe respiratory distress that needed surfactant injection and admitted in Assiut university children hospital from 1st of January to 3 1th of December 2016 were included in the study. The study included 50 patients with severe respiratory distress syndrome.Conclusion: Surfactant replacement therapy has been available for about 37 years, revolutionizing neonatal respi-ratory care after its introduction in the 1980s. Along with antenatal steroids, surfactants improve survival for preterm babies and they are now recommended routinely as early in the course of Respiratory Distress Syndrome (RDS) as possible. The present study aimed to evaluate the use of surfactant for Respiratory Distress Syndrome (RDS) in premature babies admitted at NICU of Assiut university children hospital during the period from 1st of January to 31st of December 2016 using European Consensus Guidelines on the Management 2013 Update, modified by The Egyptian Consensus on the Manage-ment of Neonatal Respiratory Distress Syndrome in Preterm Infants 2014.The study included 50 cases with respiratory distress syndrome who received surfactant therapy.Data of the study showed that treatment regimens for cases of RDS in Assiut University Children Hospital partially followed the reference standard of the study concerning application of surfactant in premature babies.•Data of the gestational age and weight and sex were recorded in 100% of cases.•Data concerning clinical evaluation of the studied group were recorded in 100% cases.•Data concerning obstetric history and prenatal care were fulfilled well but there were no records concerning receiving a course of antibiotics if there is preterm, pre-labor rupture of membranes nor short term tocolytic drugs. Also, the data showed that only 28% of mothers received a course of prenatal steroids if preterm labor was expected.•Data concerning delivery room stabilization were fulfilled well but there were no records concerning delayed cord clamping and there was no available CPAP at the delivery room nor plastic bag for stabilization of preterm baby with respiratory distress syndrome.•Data concerning surfactant therapy were fulfilled well but there was no data that any case received prophylactic surfactant therapy neither with nor without INSURE tech-nique.•Data concerning respiratory support were fulfilled well but no cases received CPAP as a 1st line respiratory support for any spontaneously breathing preterm with RDS at delivery room and no cases received CPAP with early rescue surfactant which is now considered the optimal management for babies with RDS.•Data concerning supportive care were fulfilled in 100% of cases but no cases received enteral feeding from the 1st day which is strongly recommended with careful fluid balance for early aggressive nutritional support.•Data concerning prognosis showed that the vast majority of dead cases were below 32 weeks and below 1KG.

Minimally invasive surfactant administration in preterm infants: a meta-narrative review.

Surfactant administration by minimally invasive methods that allow for spontaneous breathing might be safer and more effective than administration with endotracheal intubation and mechanical ventilation; however, the efficacy and safety of minimally invasive methods have not been reviewed. To conduct a meta-narrative review of the efficacy and safety of minimally invasive surfactant administration using a thin catheter, aerosolization, a laryngeal mask airway, and pharyngeal administration in preterm infants with or at risk for respiratory distress syndrome. We searched the PubMed, EMBASE, Cochrane, and CINAHL databases, published journals, and conference proceedings from inception to June 30, 2013. Randomized clinical trials or observational studies of preterm infants who were given surfactant for respiratory distress syndrome by minimally invasive methods. An overall meta-narrative review was conducted encompassing the evolution of noninvasive surfactant therapy. Risk ratios and 95% confidence intervals are reported when appropriate. Chronic lung disease diagnosed by the need for oxygen therapy at a postmenstrual age of 36 weeks, need for mechanical ventilation within the first 72 hours of birth, need for mechanical ventilation any time during the hospital stay, and adverse events associated with administration of surfactant by various methods. We included 10 studies (6 randomized and 4 observational) of 3081 neonates. Thin catheter administration was evaluated in 6 studies (2 randomized and 4 observational); aerosolization, in 2 randomized studies; and laryngeal mask and pharyngeal administration, in 1 observational study each. The meta-narrative review confirmed the slow evolution and challenges of the different modes of administration, with thin catheter administration being the most studied intervention. Two randomized studies of surfactant administration using a thin catheter revealed no significant difference in the outcome of bronchopulmonary dysplasia but a potential reduction in the need for mechanical ventilation within 72 hours of birth when compared with standard care. Surfactant administration via a thin catheter may be an efficacious and potentially safe method; however, further studies are needed. Further studies are also needed for other methods of minimally invasive surfactant administration.

How Mary Ellen Avery Influenced my Career as an Investigator.

OPINION article Front. Pediatr., 24 April 2014Sec. Neonatology Volume 2 - 2014 | https://doi.org/10.3389/fped.2014.00020

Early prophylactic versus late selective use of surfactant for respiratory distress syndrome in very preterm infants: a collaborative study of 53 multi-center trials in Korea.

Pulmonary surfactant (PS) therapy was proven to be highly successful for the treatment of respiratory distress syndrome in premature infants. As a results, early prophylactic (EP) PS therapy has been introduced recently in Europe, the US and Korea. However, no multi-center study was compared EP and late selective (LS) PS therapies in Korea. We performed a retrospective multi-center study to compare the outcomes of EP and LS PS therapies in very preterm infants. We analyzed clinical morbidity and mortality for 1,291 infants in 2010 (LS group) and 1,249 infants in 2011 (EP group); the infants were born <30 weeks of gestation and had birth weight ≤1,250 g, and were chosen from 53 neonatal intensive care units in Korea. Compared to the LS group (22.5%), the overall mortality was better in the EP group (19.9%) and there was no increased need for retreatment.There were additional benefits in the EP group such as fewer associated complications. To the best of knowledge, our study is the first nationwide Korean study to compare the outcomes of EP and LS therapies, and it provides evidences that EP PS therapy is important in very preterm infants to improve for survival and reduce morbidities.Graphical

Current Issues and Challenges in the Use of Aerosolized Surfactant for Respiratory Distress Syndrome in the Newborns

BACKGROUND: Surfactant replacement therapy is a recognized treatment for respiratory distress syndrome (RDS) in the newborns. Over the past 30 years, human and animal trials have been performed regarding administration of aerosolized surfactant to the injured lung, however the result has been unsatisfactory when compared with instilled surfactant delivery via endotracheal tube (ETT). This review aims to investigate the current issues, challenges and future recommendation of aerosolized surfactant therapy.CONTENT: Five randomized clinical trials in humans and 13 animal trials met the inclusion criteria and were reviewed. Most animal trials agree that this method of treatment is feasible. However, human trials presented conflicting results, and generally showed it to be ineffective. When compared with surfactant delivery via ETT, aerosolized surfactant is less effective in improving respiratory function.SUMMARY: The current data from human trials does not support the implementation of aerosolized surfactant therapy to treat newborns with RDS. Further research is necessary to improve nebulization, delivery, distribution and deposition in the lung, to investigate aerosolized surfactant delivery via ETT and to determine the appropriate dose.KEYWORDS: surfactant, aerosol, prematurity, respiratory distress syndrome

Optimization of Airway Medications in the Infant

Airway medications are frequently used in the care of the sick neonate. The most prominent airway medication, surfactant for respiratory distress syndrome, will be discussed elsewhere in this issue of Neonatology. Other indications for airway medications have included the prevention and treatment of bronchopulmonary dysplasia, pulmonary hypertension, persistent atelectasis, transient tachypnea of the newborn and upper airway edema. Indications such as the prevention of bronchopulmonary dysplasia are currently the focus of a large multicenter international trial. Other indications require further study.

The role of surfactant in respiratory distress syndrome.

The key feature of respiratory distress syndrome (RDS) is the insufficient production of surfactant in the lungs of preterm infants. As a result, researchers have looked into the possibility of surfactant replacement therapy as a means of preventing and treating RDS. We sought to identify the role of surfactant in the prevention and management of RDS, comparing the various types, doses, and modes of administration, and the recent development. A PubMed search was carried out up to March 2012 using phrases: surfactant, respiratory distress syndrome, protein-containing surfactant, protein-free surfactant, natural surfactant, animal-derived surfactant, synthetic surfactant, lucinactant, surfaxin, surfactant protein-B, surfactant protein-C.Natural, or animal-derived, surfactant is currently the surfactant of choice in comparison to protein-free synthetic surfactant. However, it is hoped that the development of protein-containing synthetic surfactant, such as lucinactant, will rival the efficacy of natural surfactants, but without the risks of their possible side effects. Administration techniques have also been developed with nasal continuous positive airway pressure (nCPAP) and selective surfactant administration now recommended; multiple surfactant doses have also reported better outcomes. An aerosolised form of surfactant is being trialled in the hope that surfactant can be administered in a non-invasive way. Overall, the advancement, concerning the structure of surfactant and its mode of administration, offers an encouraging future in the management of RDS.

Nasal intermittent positive pressure ventilation after surfactant treatment for respiratory distress syndrome in preterm infants &lt;30 weeks’ gestation: a randomized, controlled trial

To compare the effect of early extubation to nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) on the need for mechanical ventilation via endotracheal tube (MVET) at 7 days of age in preterm infants <30 weeks' gestation requiring intubation and surfactant for respiratory distress syndrome (RDS) within 60 min of delivery. Multicenter, randomized, controlled trial. A total of 57 infants were randomized within 120 min of birth to NCPAP (BW 1099 g and GA 27.8 weeks) and 53 infants to NIPPV (BW 1052 g, and GA 27.8 weeks). Infants were stabilized on NCPAP at birth and were given poractant alfa combined with MVET within 60 min of age. When stabilized on MVET, they were extubated within the next hours or days to NCPAP or NIPPV. A total of 42% [corrected] of infants needed MVET at 7 days of age in the NCPAP group compared with 17% in the NIPPV group (OR: 3.6; 95% CI: 1.5, 8.7). Days on MVET were 12 ± 11 days in NCPAP group compared with 7.5 ± 12 days in the NIPPV group (median 1 vs 7 days; P=0.006). Clinical bronchopulmonary dysplasia (BPD) was 39% in the NCPAP group compared to 21% in the NIPPV group (OR: 2.4; 95% CI: 1.02, 5.6). Physiological BPD was 46% in the NCPAP group compared with 11% in the NIPPV group (OR: 6.6, 95% CI: 2.4, 17.8; P=0.001). There were no differences in any other outcomes between the two groups. NIPPV compared with NCPAP reduced the need for MVET in the first week, duration of MVET, and clinical as well as physiological BPD in preterm infants receiving early surfactant for RDS.

Late Surfactant Therapy for Postsurfactant Slump in Extremely Low Birth Weight Infants

Aim: To evaluate late suine surfactant therapy for the pulmonary disease in extremely low birth weight infants (ELBW). Methods: A retrospective study of all ELBW admitted in the NICU of Vicenza during 2007-2009. Patients were divided into three groups: early surfactant for respiratory distress syndrome (Group 1), late surfactant for postsurfactant slump (respiratory failure after six days of life) (Group 2) and no surfactant (Group 3). A respiratory severity score (RSS) was used to measure the severity of lung disease and response to surfactant therapy. In group 2 ventilatory parameters before, after 12 and 24 hours the administration of late surfactant were also evaluated. Results: Over three years, 58 ELBW were analyzed, 36 of group 1, 14 of group 2 and 8 of group 3. Patients of group 2 had lower gestational age and birth weights compared to patients of group 1 and 3 (EGA 25 +/− 1.27 in group 2 vs 26 +/− 1.92 and 30 +/− 3.06; birth weight 670 grams +/− 155 vs 732 +/− 136 and 884 +/− 104). More prenatal steroids were used in group 1 than in group 2 (72% vs 57%). Patients of group 2 had an improvement of their lung disease showed by a reduction of their RSS for 48 hours. PCO2, pH, MAP improved at both 12 and 24 hours after surfactant administration. Conclusions: Late surfactant therapy led to a short-term improvement of lung disease in ELBW with postsurfactant slump. These patients were more premature and with lower birth weight.

Neonatal resuscitation and respiratory support in prevention of bronchopulmonary dysplasia

<h3>Educational aims</h3> To understand the physiology of respiratory support immediately after birth To learn the current guidelines for neonatal resuscitation To discuss noninvasive ventilation strategies in relation to development of bronchopulmonary dysplasia <h3>Summary</h3> Bronchopulmonary dysplasia (BPD) remains the most common severe adverse pulmonary outcome of preterm birth. Low gestational age and birth weight are the strongest risk factors for the development of BPD, but the pathogenesis is complex. The strategy for respiratory support immediately after birth and during the initial neonatal period may have a critical impact on the development of BPD. The preterm lung is highly susceptible to injury. An understanding the physiology of the first breath, the initiation of breathing and respiratory adaptation after birth is essential for adequate resuscitation measures and a lung protective ventilation strategy. Excessive oxygen use in preterm infants can increase the risk of BPD. The recently developed nomograms for oxygen saturation levels during the neonatal transition phase have become part of the newly revised resuscitation guidelines. For term neonates, starting resuscitation with air, rather than 100% oxygen, is now advised. Preterm infants may require a higher initial inspiratory oxygen fraction than term infants; however, the ideal level remains to be defined. Primary intubation is no longer a prerequisite for preterm survival. Recent trials have demonstrated that even very preterm infants can be safely stabilised after delivery with continuous positive airway pressure and later be selectively treated with surfactant for respiratory distress syndrome. This initially less invasive strategy has the advantage of reducing the need for mechanical ventilation and, thereby, the risk of lung injury; however, to date, it has not been clearly shown to reduce the incidence of BPD. Combining an approach of noninvasive ventilator support with a strategy of minimally invasive surfactant administration is important, but questions remain about the optimal timing, mode of delivery and value of predictive tests for surfactant deficiency.