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CPS Fetus and Newborn > Neonatal Surfactant Therapy > Flashcards

Neonatal Surfactant Therapy Flashcards

1
Q

Define RDS

A
  • Presence of acute respiratory distress with disturbed gas exchange in a preterm infant with a typical clinical course or CXR (ground glass, air bronchograms, reduced volumes)
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2
Q

Describe lungs of premature babies with RDS

A
  • Anatomically and biochemically immature
  • Neither synthesize nor secrete surfactant well
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3
Q

What is the function of surfactant?

A
  • Lines alveolar surfaces to reduce surface tension and prevent atelectasis
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4
Q

What are the benefits of surfactant replacement?

A
  • Reduced mortality
  • Improve oxygenation
  • Decrease incidence of air leak syndromes (pneumothorax, PIE)
  • Reduced duration of ventilatory support
  • Increased likelihood of survival without BPD
  • Shorter hospital stays and lower costs of intensive care
  • Incerased survival with no increase in adverse neurodevelopmetal outcome
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5
Q

Should intubated infants with RDS get surfactant?

A
  • YES!
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6
Q

What other neonatal pathologies are associated with surfactant deficiency?

A
  • MAS
  • Pneumonia
  • Pulmonary hemorrhage
  • Albumin, meconium and blood inhibit surfactant function
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7
Q

What is the evidence for surfactant in MAS?

A
  • Systematic review reported no differences in mortality or pneumothorax but decreased need for ECMO
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8
Q

Which MAS infants should receive surfactant?

A

Infants with MAS requiring > 50% FiO2

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9
Q

What is the evidence for surfactant use in MAS?

A
  • Only one small controlled trial
  • Possible short term physiological benefits
  • No clinically significant benefits compared to a group who received restricted rescue surfactant
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10
Q

What is the evidence for surfactant in neonatal pneumonia?

A
  • Small subgroup analysis of near-term babies with respiratory failure showed those with sepsis who received surfactant had a 40% decreased need for ECMO
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11
Q

Which infants with pneumonia should receive surfactant?

A

Sick newborn infants with pnuemonia + OI > 15

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12
Q

Which infants with pulmonary hemorrhage should receive surfactant?

A

Intubated newborns with pulmonary hemorrhage leading to clinical deterioration should receive exogenous surfactant

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13
Q

Is surfactant indicated for lung hypoplasia and CDH?

A
  • Only small case series reported
  • No conclusions can be made
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14
Q

What are the risks of exogenous surfactant therapy?

A
  • Bradycardia and hypoxemia during instillation
  • Blockage of endotracheal tube
  • Increase in pulmonary hemorrhage (RR 1.47)
  • Overdistansion and hyperventilation can happen if administered airway pressures and vent settings are not weaned
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15
Q

Are there any immunological changes of clinical concern associated with surfactant administration?

A
  • Known that babies with RDS have circulating immune complexes against surfactant proteins
  • Not more common in babies treated with surfactant
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16
Q

What is the evidence for natural surfactants being better than synthetic?

A
  • 11 RCTs subject to systematic review
  • Synthetic surfactants with overall decreased mortality (RR 0.86)
  • Babies who get natural surfactants have decreased need for O2 and ventilatory support for at least 3 d compared to babies who get synthetic surfactants
  • Natural surfactants improve survival without BPD and with lower incidence of airleak
17
Q
A
18
Q

What confounds the comparison of natural and synthetic surfactants?

A
  • All studies comparing natural to synthetic surfactants used synthetic surfactants that did not contain surfactant protein analogues
  • Newer synthetic surfactants containing these are currently in clinical trials
19
Q

What is the evidence for prophylactic vs rescue surfactant?

A
  • Decreased incidence of mortality, RDS, pneumothorax, PIE
  • No difference in PDA, NEC, IVH
  • 2 fewer deaths and 5 fewer pneumothoraces for every 100 babies treated prophylactically
  • If prophylactic approach is used for all babies < 32 wks, twice as many babies will be treated compared to rescue approach
20
Q

What confounds the studies comparing early vs rescue surfactant?

A
  • Antenatal steroid use ranged from 14-50%
  • Considerably less than current useage
  • ? Applicability of these recommendations when ANCS approaches close to 100%?
21
Q

When should surfactant be given?

A
  • For infants at a significant risk of RDS, prophylactic natural surfactant should be given as soon as they are stable and within a few minutes after intubation
22
Q

How should surfactant be given?

A
  • In liquid form via ETT
  • Slow infusion at least as effective as bolus
  • Can also be given in small aliquots
  • No evidence for changing position of baby during administration
23
Q

What dose of surfactant should be given?

A
  • 120mg phospholipid/1kg body weight
  • Might be that lower doses can be used for prophylaxis and higher doses used for rescue
  • This has not been formally studied
24
Q

Who should get more than one dose of surfactant?

A
  • Infants with RDS with presistent or recurrent O2 and ventilatory requirement within the first 72h of life
  • Giving more than 3 doses not beneficial
25
Q

What are criteria for and timing of re-treatment with surfactant?

A
  • Persistent or recurrent oxygen requirement of 30% or more and it may be given as early as 2h after the initial dose or more commonly 4-6h after the initial dose
26
Q

How should ventilation be managed after surfactant administration?

A
  • Options for ventilatory management after prophylactic surfactant therapy include very rapid weaning and extubation to CPAP within 1h
27
Q

If we plan to give surfactant, do babies still need antenatal steroids?

A
  • Mothers at risk of delivering babies less than 34 weeks GA should be given antenatal steroids regardless of the availability of postnatal surfactant
28
Q

Should surfactant be given before transport?

A
  • Intubated infants with RDS should get exogenous surfactant before transport
  • Reduced incidence of pneumothorax is a benefit as this is a tricky complication to manage during transport
29
Q

What is required of centres adminstering surfactant?

A
  • Centres administering surfactant to newborns must ensure continuous onsite availability of personnel competent and licensed to handle acute complications of assisted ventilation and surfactant therapy
30
Q

What is the most cost effective way to distribute surfactant?

A
  • Regional networks should develop surfactant exchange programs
31
Q

How should surfactant be used outside a tertiary care centre?

A
  • Mothers with threatened preterm delivery before 32 weeks should be transferred to a tertiary care centre
  • Infants delivered < 29 wks outside a tertiary centre should be considered for immediate intubation and surfactant administration after stabilization, if competent personnel are available

CPS Fetus and Newborn (7 decks)

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