Surfactant Utilization Evaluation in a Major Teaching Hospital in West of Iran: An Observational, Prospective Study

Background: The respiratory distress syndrome (RDS) is a common pulmonary disorder that usually occurs as a result of preterm labor and is associated with lack of surfactant. The aim of this study was to evaluate the pattern of surfactant prescription in Alzahra teaching hospital in Tabriz, Iran. Methods: This drug use evaluation (DUE) study was conducted in the neonatal intensive care unit (NICU) of Al-Zahra Hospital, Tabriz, Iran. The demographic and clinical data collection was performed using clinical records of patients. The pattern of surfactant replacement therapy was evaluated and compared with the European Consensus Guideline on the management of respiratory distress syndrome in 2016. Results: A total of 252 premature infants who received surfactant between August 2017 and March 2018 were included. 80.8% of neonates were born by cesarean section. The most used surfactant was Curosurf®, which was used in 82.1% of cases. Only 34.9% of the infants received within 8 hours of birth. Moreover, 79% of infants received the standard dose of surfactant, while 9.5 % and 11.5% were given high and low doses of surfactant, respectively. Conclusion: The pattern of surfactant replacement therapy was not completely according to the guidelines, particularly regarding the time of administration. Considering the importance of dose and timely administration of surfactant, providing strategies to decrease these errors are important.

Clinical case of severe coronavirus infection in a 6-month-old child

Nowadays, the creation of treatment protocols for young children with COVID-19 is especially relevant, as some issues of pathogenesis and genetic determinism of severe lung damage are still unclear. COVID-19-induced respiratory distress syndrome is a predictable severe complication that requires early diagnosis and proper treatment. Given the pathogenetic mechanism of lung damage in COVID-19, surfactant replacement therapy may be useful in the treatment of this cohort of patients. Clinical case. A clinical case of severe coronavirus infection caused by SARS-CoV-2 in a 6-month-old child is presented. The course of the disease was accompanied by severe damage to the lung parenchyma with the development of acute respiratory distress. The examination of the patient confirmed the genetic determinism of severe COVID-19, polymorphic risk alleles of the genes GSTM1, GSTP1, SFTP-B. The child's treatment included not only long-term mechanical ventilation, but also surfactant replacement therapy. The child recovered and was discharged without signs of respiratory failure. Conclusions. This clinical case demonstrates the association of genetic polymorphism with severe virus-induced lung damage. Because severe respiratory failure in COVID-19 is likely to be due to the development of acute respiratory distress syndrome, administration of exogenous surfactant should be considered as a possible treatment option. The research was carried out in accordance with the principles of the Helsinki declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: COVID-19, children, virus-induced respiratory distress syndrome, gene polymorphism, surfactant administration.

Can lung ultrasound score accurately predict the need for surfactant replacement in preterm neonates? A systematic review and meta-analysis protocol

Respiratory distress syndrome (RDS) is a leading cause of morbidity and mortality in preterm infants due to primary surfactant deficiency. Surfactant replacement has greatly improved the short and long term prognosis of RDS but its administration criteria remain uncertain. Lung ultrasound has been recently shown as a non-invasive, repeatable, bedside tool to estimate parenchymal aeration using a semiquantitative score (LUS). The objective of this systematic review and meta-analysis is to evaluate the accuracy of LUS, assessed on the first day of life, to predict surfactant replacement. Methods will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines and the protocol has been registered in PROSPERO database (registration number: CRD42021247888). Primary outcome: in a population of preterm infants, LUS will be compared in neonates who received surfactant replacement versus those who did not. Secondary outcome will be the accuracy of lung ultrasound score to predict the need for ≥ 2 doses of surfactant.

The efficacy of intra-tracheal budesonide with surfactant in treatment of respiratory distress syndrome and prevention of bronchopulmonary dysplasia

Background: Premature birth is an important issue in developed and developing countries. Surfactant replacement therapy of respiratory distress syndrome (RDS) causes a change in the normal pattern of the disease and increases the likelihood of survival of more premature newborns with chronic pulmonary damage. The purpose of this study was to investigate the effects of budesonide and surfactant on the treatment of respiratory distress syndrome and the prevention of bronchopulmonary dysplasia. Methods: In a randomized clinical trial, 128 preterm infants less than 1250 g or gestational age of 26-30 weeks that were admitted to Al-Zahra Hospital from 2017 to 2018 with RDS and needed surfactant replacement therapy were enrolled. They were randomly allocated into two groups. In one group (group Surfactant), the surfactant was administered intratracheally 2.5 cc/kg and in the second group (group Surfactant + Budesonide), budesonide was administered 0.25 mg/kg in addition to the intratracheal surfactant. The primary outcome was bronchopulmonary dysplasia and the secondary outcome was complications of prematurity. Results: In this study 128 neonates including 48 (60.9%) boys and 50 (39.1%) girls were studied. The mean gestational ages of studied neonates were 28.32±1.60 weeks. The mean duration of mechanical ventilation, continuous positive airway pressure (CPAP), high flow nasal cannulae (HFNC), and need for supplemental oxygen were significantly shorter in the group that received surfactant and budesonide combination. The required FiO2 at four hours after surfactant treatment was significantly lower in group Surfactant + Budesonide than the Surfactant group (p = 0.01). In the group Surfactant, 38 neonates (59.4%) and in group S+B, 24 cases (37.5%) developed bronchopulmonary dysplasia (BPD), (p = 0.04). The mortality rate was 15 neonates that 6 cases were in group S+B (p =0.29). Conclusion: In our study, using surfactant with budesonide combination in comparison with surfactant alone is associated with less respiratory support and BPD rate. Future studies with a larger number of patients before routine use of surfactant and budesonide combination is recommended.

A comparison of LISA versus insure: A single center experience

BACKGROUND: Less invasive surfactant replacement therapy (SRT) methods have been linked to better respiratory outcomes. The primary aim of this study was to determine if Less Invasive Surfactant Administration (LISA) altered the rate of bronchopulmonary dysplasia (BPD) in preterm infants. Secondary objectives were to determine if LISA compared to Intubation Surfactant Extubation (InSurE) resulted in different respiratory outcomes and hospital course. METHODS: In this retrospective chart review, outcomes were compared in two preterm infant groups (25–32 weeks gestation). Infants in Group 1 received surfactant replacement therapy (SRT) via InSurE method, while infants in Group 2 received SRT via LISA method. RESULTS: Regardless of SRT method utilized, there were no significant differences in rates of BPD between the two groups in infants born at 25–32 weeks gestation (30.6% vs 33.3% ; P = 0.47). CONCLUSIONS: Despite using LISA method rather than InSurE for SRT, premature infants continue to be at high risk for BPD. LISA shows promise as a safe, noninvasive SRT alternative to invasive methods like InSurE.

The Potential Role of Bioactive Plasmalogens in Lung Surfactant

Neonatal respiratory distress syndrome (NRDS) is a type of newborn disorder caused by the deficiency or late appearance of lung surfactant, a mixture of lipids and proteins. Studies have shown that lung surfactant replacement therapy could effectively reduce the morbidity and mortality of NRDS, and the therapeutic effect of animal-derived surfactant preparation, although with its limitations, performs much better than that of protein-free synthetic ones. Plasmalogens are a type of ether phospholipids present in multiple human tissues, including lung and lung surfactant. Plasmalogens are known to promote and stabilize non-lamellar hexagonal phase structure in addition to their significant antioxidant property. Nevertheless, they are nearly ignored and underappreciated in the lung surfactant-related research. This report will focus on plasmalogens, a minor yet potentially vital component of lung surfactant, and also discuss their biophysical properties and functions as anti-oxidation, structural modification, and surface tension reduction at the alveolar surface. At the end, we boldly propose a novel synthetic protein-free lung surfactant preparation with plasmalogen modification as an alternative strategy for surfactant replacement therapy.

Guidelines for surfactant replacement therapy in neonates

Surfactant replacement therapy (SRT) plays a pivotal role in the management of neonates with respiratory distress syndrome (RDS) because it improves survival and reduces respiratory morbidities. With the increasing use of noninvasive ventilation as the primary mode of respiratory support for preterm infants at delivery, prophylactic surfactant is no longer beneficial. For infants with worsening RDS, early rescue surfactant should be provided. While the strategy to intubate, give surfactant, and extubate (INSURE) has been widely accepted in clinical practice, newer methods of noninvasive surfactant administration, using thin catheter, laryngeal mask airway, or nebulization, are being adopted or investigated. Use of SRT as an adjunct for conditions other than RDS, such as meconium aspiration syndrome, may be effective based on limited evidence.