Objectives To assess whether late surfactant treatment of extremely low gestational age newborn (ELGAN) infants requiring ventilation at 7–14 days, who often have surfactant deficiency and dysfunction, safely improves survival without bronchopulmonary dysplasia (BPD). Study design ELGAN infants (≤ 28 0/7 weeks) who required mechanical ventilation at 7–14 days were enrolled in a randomized, masked controlled trial at 25 US centers. All infants received inhaled nitric oxide (INO) and either surfactant (calfactant/Infasurf®) or sham instillation every 1–3 days to a maximum of 5 doses while intubated. The primary outcome was survival at 36 weeks postmenstrual age (PMA) without BPD, evaluated by physiologic oxygen/flow reduction. Results Between January 2010 and September 2013, 511 infants were enrolled. There were no differences between treatment groups in mean birth weight (701±164 g), gestational age (25.2±1.2 weeks), percentage <26 weeks (70.6%), race, sex, severity of lung disease at enrollment, or co-morbidities of prematurity. Survival without BPD was not different between treated vs. controls at 36 weeks PMA (31.3% vs. 31.7%; relative benefit 0.98 (95% CI: 0.75, 1.28 p=0.89) or 40 weeks (58.7% vs. 54.1%; relative benefit 1.08:0.92, 1.27 p=0.33). There were no differences between groups in serious adverse events, co-morbidities of prematurity, nor in the severity of lung disease to 36 weeks. Conclusions Late treatment with up to 5 doses of surfactant in ventilated premature infants receiving iNO was well tolerated but did not improve survival without BPD at 36 or 40 weeks. Pulmonary and neurodevelopmental assessments are ongoing.

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During recent years it has been suggested that forced expiratory measurements, derived from a lung volume set by a standardized inflation pressure, are more reproducible than those attained during tidal breathing when the rapid thoracoabdominal compression technique is used in infants. The aim of this study was to evaluate the feasibility of obtaining measurements from raised lung volumes in unsedated preterm infants. Measurements were made in 18 infants (gestational age 26-35 wk, postnatal age 1-10 wk, test weight 1.4-3. 5 kg). Several inflations [1.5-2.5 kPa (15-25 cmH2O)] were used to briefly inhibit respiratory effort before the rapid thoracoabdominal compression was performed. Conventional analysis of flows and volumes at fixed times and percentages of the forced expiration resulted in a relatively high variability in this population. However, by using the elastic equilibrium point (i.e., the passively determined lung volume, derived from passive expirations before the forced expiration) as a volume landmark, it was feasible to achieve reproducible results in unsedated preterm infants, despite their strong respiratory reflexes and rapid respiratory rates. Because this approach is independent of changes in expiratory time, expired volume, or applied pressures, it may facilitate investigation of the effects of growth, development, and disease on airway function in infants, particularly during the first weeks of life, when conventional analysis of forced expirations may be inappropriate.

Objective: To assess whether the slopes of volumetric capnography differ in preterm compared to term-born ventilated newborn infants and whether they are related to gestational age and the duration of ventilation. Approach: The slopes of phase II (SII) and III (SIII) of volumetric capnographs were measured in ventilated term and preterm infants at King’s College Hospital NHS Foundation Trust. The correlations of the slopes with gestational age (GA), duration of invasive ventilation and fraction of inspired oxygen (FIO2) were assessed. The slopes were normalised by multiplying the results with the expiratory tidal volume (VT) measurement. Main results: Fifty-six infants (44 preterm) were assessed. The preterm infants had a median (IQR) gestational age of 26 (25–29) weeks and were ventilated for 8 (3–32) days with a VT of 5.4 (4.1–6.8) ml kg−1. The term infants had a gestational age of 39 (37–40) weeks and were ventilated for 1 (1–6) day with a VT of 4.0 (3.6–5.3) ml kg−1. The SII (85.9 (76.2–98.4) mmHg) and SIII (16.5(10.0–21.9) mmHg) of the preterm infants were not significantly different compared to the SII (88.0 (74.6–110.0) mmHg) and SIII (13.5 (9.2–15.9) mmHg) of term infants (p = 0.625 and p = 0.144 respectively). SII was not significantly related to GA, duration of ventilation or FIO2. SIII was positively related to the duration of ventilation (r = 0.729, p < 0.001) and FIO2 (r = 0.704, p < 0.001). Significance: The volumetric capnography phase III slope was steeper in infants with higher ventilatory requirements, hence could potentially be used as an index of disease severity in ventilated newborns.