Improved pulmonary outcome after exogenous surfactant therapy for respiratory failure in term infants requiring extracorporeal membrane oxygenation

doi:10.1016/S0022-3476(06)80131-9

The Journal of Pediatrics

Volume 122, Issue 2, February 1993, Pages 261-268

https://doi.org/10.1016/S0022-3476(06)80131-9 Get rights and content

A blinded, randomized, controlled study was designed to test whether multiple-dose surfactant therapy would improve pulmonary outcome in term infants with respiratory failure, resulting in a shortened period of extracorporeal membrane oxygenation (ECMO). Infants≥34 weeks of gestational age in severe respiratory failure and receiving ECMO were stratified by diagnosis and then randomly assigned to the treatment or the control group. Four doses of modified bovine lung surfactant extract (beractant) were administered to the surfactant group (n=28), and an equal volume of air was administered to the control group (n=28). Lung compliance was initially low in both groups; after treatment, values were higher with time in the surfactant group (F=5.40, p=0.026). The ECMO treatment period was significantly shorter in the surfactant group (mean ±SD: 107±33 hours vs 139±54 hours for the control group; U=232, p=0.023). Tracheal aspirate concentrations of surfactant protein A were low in both groups, and then increased steadily to a higher level in the surfactant group (F=2.58, p=0.04). The overall incidence of complications after ECMO was decreased in the surfactant group (18% vs 46% for the control group; chi-square value=5.004, p=0.025). Radiographic scores, echocardiographic findings, incidence of intracranial or pulmonary hemorrhage and bronchopulmonary dysplasia, time to extubation, duration of oxygen therapy, and duration of hospitalization did not differ between the two groups. Beractant in this population improved pulmonary mechanics, Increased surfactant protein A content in tracheal aspirate, decreased time on ECMO duration, and reduced disease complications.

References (29)

LotzeA et al.
Surfactant protein A concentrations in tracheal aspirate fluid from infants requiring extracorporeal membrane oxygenation
J Pediatr
(1990)
BeckR et al.
Criteria for extracorporeal membrane oxygenation in a population of infants with persistent pulmonary hypertension of the newborn
J Pediatr Surg
(1986)
LowryOH et al.
Protein measurement with the folin phenol reagent
J Biol Chem
(1951)
TaylorGA et al.
Imaging of cerebrovascular injury in infants treated with extracorporeal membrane oxygenation
J Pediatr
(1989)
HolmBA et al.
Surface property changes from interactions of albumin with natural lung surfactant extracted lung lipids
Chem Phys Lipids
(1985)
HolmBA et al.
Effects of hemoglobin and red blood cell membrane lipids on the biophysical and physiological activity of pulmonary surfactant
J Appl Physiol
(1987)
GregoryTJ et al.
Surfactant chemical composition and biophysical activity in acute respiratory distress syndrome
J Clin Invest
(1991)
D'CostaM et al.
Lecithin/sphingomyelin ratios in tracheal aspirates from newborn infants
Pediatr Res
(1987)
ChidaS et al.
Surfactant-associated proteins in tracheal aspirates of infants with respiratory distress syndrome after surfactant therapy
Am Rev Respir Dis
(1988)
LotzeA et al.
Lung compliance as a measure of lung function in newborns with respiratory failure requiring extracorporeal membrane oxygenation
Crit Care Med
(1987)

PokoraTJ et al.

Measurement of esophageal pressure in newborn infants using an esophageal balloon catheter

Crit Care Med

(1982)

McMahanMJ et al.

Surfactant associated protein (SAP-35) in amniotic fluid from diabetic and nondiabetic pregnancies

Obstet Gynecol

(1987)

EdwardsDK et al.

Respiratory distress syndrome treated with human surfactant: radiographic findings

Radiology

(1985)

TaylorGA et al.

Diffuse pulmonary opacification in infants undergoing extracorporeal membrane oxygenation: clinical and pathologic correlation

Radiology

(1986)

Cited by (120)

Neonatal surfactant therapy beyond respiratory distress syndrome
2023, Seminars in Fetal and Neonatal Medicine
Whilst exogenous surfactant therapy is central to the management of newborn infants with respiratory distress syndrome, its use in other neonatal lung diseases remains inconsistent and controversial. Here we discuss the evidence and experience in relation to surfactant therapy in newborns with other lung conditions in which surfactant may be deficient or dysfunctional, including meconium aspiration syndrome, pneumonia, congenital diaphragmatic hernia and pulmonary haemorrhage. We find that, for all of these diseases, administration of exogenous surfactant as bolus therapy is frequently associated with transient improvement in oxygenation, likely related to temporary mitigation of surfactant inhibition in the airspaces. However, for none of them is there a lasting clinical benefit of surfactant therapy. By virtue of interrupting disease pathogenesis, lavage therapy with dilute surfactant in MAS offers the greatest possibility of a more pronounced therapeutic effect, but this has yet to be definitively proven. Lavage therapy also involves a greater degree of procedural risk.
Advances in pulmonary management and weaning from ECLS
2023, Seminars in Pediatric Surgery
ECMO for neonatal and pediatric respiratory failure provides gas exchange to allow lung recovery from reversible pulmonary ailments. This is a comprehensive discussion on the various strategies and advances utilized by pediatric ECLS specialists today. ECMO patients require continual monitoring, serial gasses and radiographs, near-infrared spectroscopy (NIRS - to monitor oxygen delivery to regional tissue beds), and more quality ECLS directed care. As the foundation to lung recovery, good EMCO closely monitors ECLS flow rates, sweep gasses, and membrane lung function. Mixed venous oxygen saturation (Sv0₂) greater than 65% indicates good oxygen delivery and sweep gas adjustments maintain PaCO2 of 40–45 mm Hg. Lung recovery ventilatory settings do not fully rest the lungs but maintain normal or nontoxic pressure and oxygen levels. Neonatal recovery settings are PIP (cm H₂0) of 15–20, PEEP of 5–10, ventilator rate of 12–20 and an inspiratory time of 0.5–1 s, and FiO2 of 0.3–0.5. Pediatric recovery settings are PIP (cm H₂0) < 25, PEEP of 5–15, ventilator rate of 10–20 and an inspiratory time of 0.8–1 s, and FiO2 of <0.5. Some studies demonstrate a higher recovery PEEP level decreases duration of ECMO, but do not demonstrate a mortality difference. Multiple adjunctive therapies such as surfactant, routine pulmonary clearance and respiratory physiotherapy, iNO, prone positioning, bronchoscopy, POCUS, CT imaging, and extubation or “awake ECLS” can significantly affect pulmonary recovery. Patience is necessary as lung recovery may take weeks or even months on the nontoxic settings. On these settings, dynamic recovery will be revealed by improvement in tidal volume, minute ventilation and radiographic pulmonary aeration, prompting discussion about weaning. When this pulmonary compliance recovery becomes evident, decreasing ECLS flow while also decreasing circuit FiO2 and/or sweep gas are common components to ECMO weaning strategies.
Changing populations being treated with ECMO in the neonatal period – who are the others?
2022, Seminars in Fetal and Neonatal Medicine
Extracorporeal life support via extracorporeal membrane oxygenation (ECMO) has served the sickest of neonates for almost 50 years. Naturally, the characteristics of neonates receiving ECMO have changed. Advances in care have averted the need for ECMO for some, while complex cases with uncertain outcomes, previously not eligible for ECMO, are now considered. Characterizing the disease states and outcomes for neonates on ECMO is challenging as many infants do not fall into classic categories, i.e. meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or congenital diaphragmatic hernia (CDH). Since 2017, over one third of neonatal respiratory ECMO runs reported to the Extracorporeal Life Support Organization Registry are grouped as Other, a catch-all that encompasses those with a diagnosis not included in the classic categories. This review summarizes the historical neonatal ECMO population, reviews advances in therapy and technology impacting neonatal care, and addresses the unknowns in the ever-growing category of Other.
Exogenous surfactant therapy
2022, Goldsmith's Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care, Seventh Edition
The Surfactant System
2019, Kendig's Disorders of the Respiratory Tract in Children
Pulmonary surfactant is a complex substance with multiple functions in the microenvironments of the alveoli and small airways. The traditional functions of surfactant are biophysical activities to keep the lungs open, to decrease the work of breathing, and to prevent alveolar edema. Most of the components of surfactant also contribute to innate host defenses and to injury responses of the lung. Surfactant deficiency states occur with prematurity and with severe lung injury syndromes. Recent studies in humans and in mice are defining an expanding number of genetic and metabolic abnormalities that disrupt the surfactant and cause lung diseases, which range from lethal respiratory failure at birth to chronic interstitial lung disease in later life. This chapter summarizes the aspects of surfactant biology that are relevant to children.
Pharmacologic Therapies I: Surfactant Therapy
2017, Assisted Ventilation of the Neonate: An Evidence-Based Approach to Newborn Respiratory Care: Sixth Edition

View all citing articles on Scopus

View full text

Improved pulmonary outcome after exogenous surfactant therapy for respiratory failure in term infants requiring extracorporeal membrane oxygenation

J Pediatr

J Pediatr Surg

J Biol Chem

J Pediatr

Chem Phys Lipids

J Appl Physiol

J Clin Invest

Pediatr Res

Surfactant-associated proteins in tracheal aspirates of infants with respiratory distress syndrome after surfactant therapy

Am Rev Respir Dis

Lung compliance as a measure of lung function in newborns with respiratory failure requiring extracorporeal membrane oxygenation

Crit Care Med

Measurement of esophageal pressure in newborn infants using an esophageal balloon catheter

Crit Care Med

Surfactant associated protein (SAP-35) in amniotic fluid from diabetic and nondiabetic pregnancies

Obstet Gynecol

Respiratory distress syndrome treated with human surfactant: radiographic findings

Radiology

Diffuse pulmonary opacification in infants undergoing extracorporeal membrane oxygenation: clinical and pathologic correlation

Radiology