Protocol for a multicenter, double-blind, randomized, placebo-controlled phase III trial of the inhaled β2-adrenergic receptor agonist salbutamol for transient tachypnea of the newborn (the REFSAL trial)

Abstract

BackgroundTransient tachypnea of the newborn (TTN), which results from inadequate absorption of fetal lung fluid, is the most common cause of neonatal respiratory distress. Stimulation of β-adrenergic receptors enhances alveolar fluid absorption. Therefore, the β2-adrenergic receptor agonist salbutamol has been proposed as a treatment for TTN. This study aims to evaluate the efficacy and safety of salbutamol as supportive pharmacotherapy together with non-invasive nasal continuous positive airway pressure (NIV/nCPAP) for the prevention of persistent pulmonary hypertension of the newborn (PPHN) in infants with TTN.Methods and analysisThis multicenter, double-blind, phase III trial will include infants with a gestational age between 32 and 42 weeks who are affected by respiratory disorders and treated in eight neonatal intensive care units in Poland. A total of 608 infants within 24 h after birth will be enrolled and randomly assigned (1:1) to receive nebulized salbutamol with NIV or placebo (nebulized 0.9% NaCl) with NIV. The primary outcome is the percentage of infants with TTN who develop PPHN. The secondary outcomes are the severity of respiratory distress (assessed with the modified TTN Silverman score), frequency of need for intubation, duration of NIV and hospitalization, acid–base balance (blood pH, partial pressure of O2 and CO2, and base excess), and blood serum ionogram for Na+, K+, and Ca2+.DiscussionThe Respiratory Failure with Salbutamol (REFSAL) study will be the first clinical trial to evaluate the efficacy and safety of salbutamol in the prevention of persistent pulmonary hypertension in newborns with tachypnea, and will improve short term outcomes. If successful, the study will demonstrate the feasibility of early intervention with NIV/nCPAP together with nebulized salbutamol in the management of TTN.Ethics and disseminationThe study protocol was approved by the Bioethics Committee of the Medical University of Warsaw, Warsaw, Poland on November 16, 2020 (decision number KB/190/2020). All procedures will follow the principles of the Declaration of Helsinki. The results of the study will be submitted for knowledge translation in peer-reviewed journals and presented at national and international pediatric society conferences.Clinical Trial RegistrationIt is registered at ClinicalTrials.gov NCT05527704, EudraCT 2020-003913-36; Protocol version 5.0 from 04/01/2022.

Persistent Pulmonary Hypertension of the Newborn Secondary to Labile Hypoxemia Associated With Cyanosis: A Case Series

“…Neonates delivered at or near term (at gestational age > 34 weeks) may have hypoxic respiratory failure due to a variety of problems, including congenital diaphragmatic hernia (CDH), pneumonia or sepsis, aspiration of meconium, respiratory distress syndrome, and primary persistent pulmonary hypertension [ 11 ]. In addition to ECMO, conventional treatment includes oxygen support, mechanical breathing, alkalosis induction, neuromuscular blockade, and sedation.…”

Association between thiol-disulfide hemostasis and transient tachypnea of the newborn in late-preterm and term infants

“…It is known that fetal alveolar fluid, which fills the airways and alveoli in the intrauterine period, affects the lung mechanics positively by stretching the lungs. This fluid needs to be cleaned in order for effective gas exchange to take place after birth [ 2 ]. The main mechanism in TTN is thought to be delayed absorption of fetal alveolar fluid in the perinatal period.…”

“…Since these channels are not activated or being immature at birth, the fluid in the lungs cannot be absorbed and leads to a decrease in respiratory functions of infants after birth. It has been shown that the expression of ENaC subunits is low in late preterm and term infants with transient neonatal tachypnea [ 1 , 2 , 4 ]. Decreased surfactant function has been also shown to contribute to the pathophysiology of TTN.…”