Surfactant Therapy in Infants and Children: Three Years Experience in a Pediatric Intensive Care Unit

Abstract

Despite the established success of surfactant application in neonates, the use of surfactant in older children is still a matter of discussion. We hypothesized that surfactant application in children with acute respiratory distress syndrome (ARDS) secondary to a pulmonary or systemic disease or after cardiac surgery improves pulmonary function. We also asked whether repeated treatment could further improve pulmonary function. To answer these questions, we measured oxygenation index (OI) and hypoxemia score after the first and after a second application of surfactant (50-100 mg/kg body wt) at least 24 h later. We enrolled 19 children (older than 4 weeks) for a retrospective chart review study, and six of them underwent cardiac surgery. Demographic data were extracted. OI and hypoxemia score were estimated before and 2 and 24 h after surfactant application. Lung injury score was calculated before and 24 h after surfactant application. Outcome measures included survival, duration of mechanical ventilation, and pediatric ICU and hospital stay. The median patient age was 9.0 (quarter percentile 3.7/25) months. The median weight was 8.4 (4.1/11.5) kg. The median lung injury score before the first surfactant application was 2.3 (2.3/2.6). Hospital duration and pediatric ICU stay for all patients was 31.0 (20.0/49.5) days and 27.0 (15.5/32.5) days, respectively. The duration of mechanical ventilation was 24.0 (18.5/31.0) days. The overall mortality was 53%. Twenty-four hours after the first surfactant application, pulmonary function significantly improved. The median OI was 14 (5.5/26) before and 7 (4.5/14.5) 24 h after surfactant application (P= 0.027). The hypoxemia score was 91.7 (69.9/154.2) before and 148.4 (99.2/167.6) 24 h after surfactant application (P = 0.0026). Seven children received a second application, which did not further improve pulmonary function. The lung injury score was not influenced by either surfactant application. We conclude that a single surfactant application improves pulmonary function in children with ARDS. A second application of surfactant showed no further benefit. Outcome was not affected in our study population.

The Future of Exogenous Surfactant Therapy

“…A number of uncontrolled and controlled studies have documented clinical benefit from exogenous surfactant replacement therapy in term infants, children, and adults with acute respiratory failure (ALI/ARDS) [66][67][68][69]154,[186][187][188][189][190][191][192][193][194][195][196][197][198][199][200] ( Table 2). Of the 19 positive studies listed in Table 2, 9 were controlled trials [67][68][69]154,192,[197][198][199][200] and 10 were uncontrolled treatment trials, in which the risk of selection bias is inherent.…”

Surfactant for Pediatric Acute Lung Injury

“…A significant number of clinical studies have reported benefits following the instillation of exogenous surfactants to term infants, children, or adults with ALI/ARDS or related acute respiratory failure [25,[120][121][122][123][124][125][126][127][128][129][130][131][132][133][134][135] (Table 4). However, many of these are small case series or pilot studies, and found only improvements in acute lung function (oxygenation).…”

“…Studies of surfactant therapy in children and adults with ALI/ARDS show positive results in a number of case reports or relatively small pilot trials [120,121,[124][125][126][127][128]. However, particularly in adults, controlled clinical trials have been less successful.…”

Surfactant Therapy for Patients with ARDS After Cardiac Surgery

“…Few data are available on the efficacy of surfactant therapy in patients developing ARDS after cardiac surgery (Satoh et al, 1998;Hermon et al, 2002). In 19 children with ARDS (6 of them after open heart surgery) who received surfactant administration at a dose of 50-100 mg/kg, Hermon et al (2002) noted that there was no improvement in gas exchange, with the mortality rate of 50%.…”

“…Few data are available on the efficacy of surfactant therapy in patients developing ARDS after cardiac surgery (Satoh et al, 1998;Hermon et al, 2002). In 19 children with ARDS (6 of them after open heart surgery) who received surfactant administration at a dose of 50-100 mg/kg, Hermon et al (2002) noted that there was no improvement in gas exchange, with the mortality rate of 50%. The results of another study (Satoh et al, 1998) investigating the effect of the administration of 30 mg/kg Surfactant TA in 11 patients (6 patients randomized to the therapeutic and 5 patients to the control group) with ARDS after resection of aneurism of thoracic aorta also showed significant improvement in oxygenation, but no data on the mortality rate were presented.…”