Nasal Continuous Positive Airway Pressure and Early Surfactant Therapy for Respiratory Distress Syndrome in Newborns of Less Than 30 Weeks' Gestation

Abstract

ABSTRACT. Objective. To determine whether early versus late treatment with porcine surfactant (Curosurf) reduces the requirement of mechanical ventilation in very preterm infants primarily supported by nasal continuous positive airway pressure (nasal CPAP).Design. Multicenter randomized, controlled trial.Patients. The study population comprised 60 infants <30 weeks' gestation with respiratory distress syndrome (RDS) who had an arterial to alveolar oxygen tension ratio (a/APO 2 ) of 0.35 to 0.22.The cohort from which the study population was generated comprised 397 infants.Results. The need for mechanical ventilation or death within 7 days of age was reduced from 63% in the latetreated infants to 21% in early-treated infants. Increasing numbers of antenatal steroid doses also improved the outcome, especially in the early-treated infants. Six hours after randomization mean a/APO 2 rose to 0.48 in the earlytreated infants compared with 0.36 in the late-treated. The need of mechanical ventilation before discharge was reduced from 68% in the late-treated to 25% in the earlytreated infants.Conclusions. Nasal CPAP in combination with early treatment with Curosurf significantly improves oxygenation and reduces the subsequent need for mechanical ventilation in infants <30 weeks' gestational age with RDS. Pediatrics 1999;103(2). URL: http://www.pediatrics. org/cgi/content/full/103/2/e24; respiratory distress syndrome, pulmonary surfactant, Curosurf, nasal continuous positive airway pressure.ABBREVIATIONS. RDS, respiratory distress syndrome; nasal CPAP, nasal continuous positive airway pressure; a/APo 2 , arterial to alveolar oxygen tension ratio; Fio 2 , fraction of inspired oxygen; TcPo 2 , transcutaneous partial pressure of oxygen; TcPco 2 , transcutaneous partial pressure of carbon dioxide; PDA, patent ductus arteriosus; NEC, necrotizing enterocolitis; BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage; PVL, periventricular leucomalacia; ROP, retinopathy of prematurity. I n a randomized, controlled study we have shown that a single dose of surfactant (Curosurf, Chiesi Farmateutici, Parma, Italy) given by short-lasting intubation reduces the need for mechanical ventilation and improves oxygenation in infants with moderate to severe respiratory distress syndrome (RDS) treated with early nasal continuous positive airway pressure (nasal CPAP).1 Very few pulmonary and extrapulmonary complications were observed in these infants. However, some of the surfactanttreated infants supported by nasal CPAP developed apnea despite good oxygenation and needed mechanical ventilation for that reason. In the same trial, there seemed to be a higher need for ventilation among infants randomized relatively late after birth and in infants with relatively low birth weight. From the literature we know that surfactant given prophylactically, 2-4 or as early treatment to infants requiring mechanical ventilation, 5 is more effective than late rescue treatment.The present study was designed to test the hypothesis that infants Ͻ30 we...

Comparação dos níveis de pressão positiva contínua nas vias aéreas através de dois sistemas

“…22 This last has been considered to be a ventilation mode with advantages over conventional mechanical ventilation in certain clinical situations, proving efficient at CO 2 elimination and capable of reducing the duration of ventilatory support and oxygen therapy because it makes use of different gas transport mechanisms than does conventional mechanical ventilation. 21,22 Lee et al, studying newborn babies, observed vibrations similar to those found in our study. They state that the vibrations produced by the water seal CPAP s bubbling are transmitted to the chests of the babies on this type of ventilatory support and could contribute to gas exchange.…”

“…8 The mechanism by which gas exchanges occur during high-frequency ventilation have not been completed explained, but they probably include direct ventilation of the proximal alveoli and increased diffusion because of the increased activity of the gas molecules or even by means of coaxial diffusion in which the air enters via the center and the CO 2 and other gasses are exhaled via the peripheries of the airways. 1,21,22 …”

“…2,5,16,17 Endotracheal CPAP is less often used, since, despite being a safe method for maintaining average airway pressure (Paw) and to control the fraction of inspired oxygen (FiO 2 ), it presents the disadvantages associated with tracheal intubation, in addition to creating airflow resistance, which could increase respiratory workload. [17][18][19][20][21] When CPAP is offered with a ventilator, the gas supplies are part of the apparatus and flow rate and FiO 2 are adjusted with specific devices for each parameter, while positive pressure is offered by an expiratory circuit on the mechanical ventilator. 5,22 With, homemade CPAP, also known as water-seal CPAP, flowmeters are used on the compressed air and oxygen supplies, with the total flow being worked out from their sum and controlling FiO 2 by means of their relative proportions in the mixture.…”

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

“…4 Early surfactant administration followed by extubation to nasal continuous positive airway pressure (NCPAP) or NCPAP alone without surfactant therapy have been shown to decrease the incidence of BPD in very low birth weight infants in observational studies. 5,6 Findings of a multicenter randomized controlled trial 7 investigating whether early versus late treatment with surfactant reduced the requirement of mechanical ventilation in very preterm infants primarily supported by NCPAP found that early surfactant treatment improved oxygenation 6 h after randomization and reduced the need for mechanical ventilation via endotracheal tube (MVET) before discharge from 68 to 25%. In addition, early surfactant administration followed by extubation to NCPAP in infants <30 weeks gestational age significantly decreased the need for MVET to 0% by 7 days of age compared with 43% in the mechanical ventilation group.…”

Surfactant therapy in preterm infants with respiratory distress syndrome and in near-term or term newborns with acute RDS

“…Since 1999, there have been six trials [29][30][31][32][33][34] evaluating the outcome of early surfactant therapy followed by extubation to NCPAP (Table 3). Overall, these reports demonstrated decreased duration of mechanical ventilation and length of stay, and decreased need for additional doses of surfactant.…”