Early surfactant replacement guided by lung ultrasound in preterm newborns with RDS: the ULTRASURF randomised controlled trial

Abstract

This study aimed to investigate whether using lung ultrasound (LUS) scores in premature newborns with respiratory distress syndrome (RDS) allows for earlier surfactant therapy (within the first 3 h of life) than using FiO 2 criteria. This was a randomised, non-blinded clinical trial conducted in a neonatal intensive care unit. The inclusion criteria were newborns with a gestational age of ≤ 32 weeks and RDS. Patients meeting the inclusion criteria were randomly assigned to two groups: the ultrasound group, administered surfactant based on LUS score and/or FiO 2 threshold, and the control group, guided by FiO 2 only. Fifty-six patients were included. The ultrasound group received surfactant earlier (1 h of life vs. 6 h, p < 0.001), with lower FiO 2 (25% vs. 30%, p = 0.016) and lower CO 2 (48 vs. 54, p = 0.011). After surfactant treatment, newborns in the ultrasound group presented a greater SpO 2 (p = 0.001) and SpO 2 /FiO 2 ratio (p = 0.012). Conclusions: LUS score allowed an earlier surfactant therapy, reduced oxygen exposure early in life and a better oxygenation after the treatment. This early surfactant replacement may lead to reduced oxygen exposure. Keywords Lung ultrasound. Respiratory distress syndrome. Premature newborns. Surfactant Abbreviations CXR Chest X-ray GA Gestational age LUS Lung ultrasound NA Neonatologist-assistant nCPAP Nasal continuous positive airway pressure What is Known: • Lung ultrasound scores predict the need for surfactant therapy in premature newborns. What is New: • This study shows that using lung ultrasound scores improves the timeliness of surfactant replacement compared with using FiO 2 alone.

Modified lung ultrasound score predicts ventilation requirements in neonatal respiratory distress syndrome

“…The current treatment paradigm requires verification in properly designed clinical trials where surfactant would be LUS guided. Papers describing the use of the LUS score as a criterion for the administration of surfactant have already emerged, presenting clinical benefits of this novel approach, e.g., an increased number of ventilator-free days [ 21 ] or reduced oxygen exposure [ 36 ], while maintaining unchanged pharmaceutical expenditures [ 37 ]. It is essential that in future studies, the primary outcome is not CPAP failure, as it is at present, but the development of bronchopulmonary dysplasia.…”

Lung ultrasound for early surfactant treatment: Development and validation of a predictive model

“…Despite an earlier surfactant administration in the ESTER period, the authors found no differences in the need for a second dose of surfactant, days of oxygen or BPD when comparing both periods. In a recent study published by Rodriguez‐Fanjul et al 36 surfactant was administered before 3 h of life in all VPI with RDS using only LUS score to guide treatment and without finding significant differences in surfactant treatment between groups. The main concern when using only an echographic criteria to guide surfactant administration is the treatment of some patients that could have been managed with noninvasive ventilation only.…”

Lung ultrasound-guided surfactant administration: time for a personalized, physiology-driven therapy

“…They applied the ESTHER policy and, notably, all infants in the first group reached the lung ultrasound score threshold before the momentous brink of 0.3 FiO 2 demand and received surfactant within the first hour of life (versus 6 hours in the control group). Together, these two papers provide good evidence for a timelier and more physiology-based surfactant administration in preterm babies with RDS [14,15]. Interestingly, the lung ultrasound-guided surfactant replacement reduced oxygen exposure but did not change the overall surfactant use.…”

“…A recent quality improvement project showed that when surfactant is given based on lung ultrasound score (versus the oxygen requirement), more babies received surfactant within 3 hours of life with less oxygen exposure; this has been called ESTHER (Echography-guided Surfactant THERapy) [14]. Rodriguez Fanjul and coworkers should be commended for being the first colleagues to confirm these results in a randomized controlled trial where lung ultrasound score and FiO 2 thresholds are compared [15]. They applied the ESTHER policy and, notably, all infants in the first group reached the lung ultrasound score threshold before the momentous brink of 0.3 FiO 2 demand and received surfactant within the first hour of life (versus 6 hours in the control group).…”