Respiratory distress syndrome (RDS) in preterm infants/Neonates Prophylactic and early surfactant administration

Later surfactant administration

O: Reduced mortality and pulmonary complications (Bronchopulmonary dysplasia-BPD and other)

Surfactant therapy involves intervention via various methods like oxygen, CPAP, mechanical ventilation, and surfactant. Many ask if surfactant therapy works. They also ask what is the ideal dose and when to administer the dose. Too much and too late could cause problems versus early with a low dose. When surfactant was introduced in neonatology, it reduced VLBW infant deaths by 30%. Surfactant use two decades ago also led to an 80% decline in neonatal mortality in the United States.

However, surfactant can fail and normally does so because of certain factors like when infants are extremely preterm and developed poorly structured longs and when there an infant develops perinatal asphyxia. When those factors are not present, surfactant reduces incidence of PDA, sepsis pneumonia, and most importantly, reduces the need for mechanical ventilation. When there is absence of surfactant, infants may present with high distending pressures, airway distortion/stretch, cellular membrane disruption that could lead to edema or hyaline membrane formation, and other complications. From here it could advance to higher pressures/FiO2 and then eventually BPD, barotrauma.

Prophylactic treatment of infants during the first fifteen minutes of life seems more effective than later treatment. However, not all infants that show signs of developing RDS develop the condition. Overtreatment, especially with higher doses could expose infants to adverse effects, needlessly. In fact, multiple doses of surfactant, which has been a treatment of choice shown in the majority of trials may not be as helpful as thought. While functional inactivation of surfactant may be the reason why multiple doses are recommended, early treatment at low dose could be the best option.

Increased use of exogenous surfactant therapy is a better option when using extubation to NCPAP because it lessens the need for mechanical ventilation. When combined with early surfactant replacement therapy application, it greatly diminishes the probability of complications. Effective ventilatory management consists of rapid weaning and extubation to CPAP. While surfactant can be costly, the overall reduction in hospital and ancillary charges warrant early use of it.

Prophylactic and early surfactant replacement therapy minimizes pulmonary complications and mortality in ventilated infants that suffer from RDS or respiratory distress syndrome when compared to...

While early treatment seems to reduce pulmonary complications and mortality, continued ventilation and post-surfactant intubation presents risks factors for BPD or bronchopulmonary dysplasia. In a 2010 review by Stevens, Blennow, Myers & Soll, the review compares results among two strategies of surfactant administration in RDS-afflicted infants.
The researchers examined early intervention of surfactant administration proceeded with quick extubation, and then compared results collected from this approach to later, selective use of surfactant administration proceeded with ongoing mechanical ventilation. Respiratory distress syndrome has remained a major problem for neonatal care. As the single most significant cause of mortality and morbidity in preterm infants, strategies must be changed in order to reduce infant mortality and development of pulmonary problems associated with continued ventilation and delayed treatment protocols. Evidence from clinical trials reveal surfactant replacement therapy in infants with RDS reduces mortality, improving clinical outcomes.

Reduction in mortality was identified by discovering the optimal dose, surfactant preparation, and time of administration. "For infants at high risk for RDS, prophylactic (pre- or post-ventilation) or early (< 2 hours of age) surfactant replacement therapy compared to later selective surfactant administration of established RDS significantly improves survival and reduces the incidence of bronchopulmonary dysplasia or death" (Stevens, Blennow, Myers & Soll, 2010, p. 3). This optimal method also reduces incidence of air leak proving to be an efficient and suitable means of treatment. Even with evidence of optimal dose and methods, BDP remains a prevalent issue and complication of RDS and preterm birth.

The Cochrane review states how earlier systematic reviews of surfactant replacement therapy assessed trials that utilized a different surfactant administration model consisting of surfactant administration, endotracheal intubation, IPPV (intermittent positive pressure ventilation), and stabilization proceeded by extubation when patients were on low respiratory support and stable. Lung injury has been seen with preterm infants with RDS when treated with IPPV. Lung injury increases the chances of developing BPD (bronchopulmonary dysplasia). Researchers also noted the positive effects of prolonged distending pressure for infants with RDS. Prolonged distending pressure comes from CPAP (continuous positive airway pressure) machines, especially when using nasal prongs or a nasopharyngeal tube. It removes the need for mechanical ventilation and provides treatment for RDS.…