late exogenous surfactant therapy in preterm neonates with respiratory distress syndrome by dr....

Late Exogenous Surfactant Late Exogenous Surfactant Therapy In Preterm Therapy In Preterm

Neonates With Respiratory Neonates With Respiratory Distress Syndrome Distress Syndrome

By By

Dr. Mohamed El- Sherbini Dr. Mohamed El- Sherbini

IntroductionIntroduction

• The most common cause of RD in the

preterm infant is RDS.

• The incidence of RDS is from 5% in infants

of 35-36 Ws GA to >50% in infants of 26-

28 Ws GA.

Pathophysiology Of RDSPathophysiology Of RDS

• The stiff atelectatic lung of the preterm

infant with RDS does not inflate easily.

• With the deficiency of surfactant in RDS,

the alveoli resist inflation because of the

high surface tension at the air- fluid

interface.

Role Of Surfactant Therapy In Role Of Surfactant Therapy In IRDSIRDS

• Surfactant lowers the surface tension at the

air- fluid interface of the atelectatic alveoli

allowing them to remain inflated.

• It markedly reduced mortality rate of

premature infants and is now established as

a safe and effective standard of care.

Aim Of The WorkAim Of The Work

To assess the effect and outcome of

late first dose of rescue bovine surfactant

therapy administered to preterm infants

with RDS on mechanical ventilation

(between 24 –48 hr postnatal age).

Patients & MethodsPatients & Methods

• The study included 30 preterm infants admitted to

NICU and divided into 2 equal groups (1&2)

• Inclusion criteria: preterm infants with RDS on

MV, not suffering from any cong. anomalies, their

mothers didn’t receive corticosteroids or other

medications and with no history of PROM or

hypoxia- ischemia.

Patients & Methods (cont.)

• Group (1) : The surfactant group: Each received a single bolus therapy of a bovine extract surfactant (beractant) in a dose of 4 ml/kg/dose at a mean age of 29.27 + 4.13 hr.

• Group (2) : The comparison group : They were gestational age, sex and weight matched with group (1) but with no surfactant therapy.

Patients & Methods ( cont.)

Both groups were subjected to:

1. Full perinatal history& postnatal examination.

2. Plain CXR and ABG analysis.

3. MV, SIMV mode (with a back- up rate of 30 bpm).

4. Full record of clinical picture, CX R, ABGs,

ventilation parameters at 24& 48 hr of age.

5. Outcome study (including investigations).

6. Statistical analysis of results.

Results & DiscussionResults & Discussion Table 1. Baseline characteristics of the two groups.

CharacteristicSurfactant

Group (n = 15)Comparison

Group (n = 15)P value

Birth weight (Kg) mean±SD1.31±0.341.32±0.09>0.05

Gestational age (wks) mean±SD

29.93±2.1530.27±2.05>0.05

Presence of maternal disease (n, %)

9 (60)8 (53.3)>0.05

C.S. delivery (n, %)13 (86.7)13 (86.7)>0.05

GenderMales (n, %)

Females (n, %)8 (53.3)7 (46.7)

8 (53.3)7 (46.7)

>0.05

N.B. The mean age at which surfactant was administered to group (1) patients = 29.27 (± 4.13)hr

Results & Discussion(cont.) Table 2. Clinical outcome and X-ray improvement of the

two groups at 24 and 48 hours of life.Surfactant

Group (n = 15)

Comparisongroup

(n = 15)P value

Respiratory rate at 24 hr Mean ± SD

60.67± 3.6761.8 ± 6.05>0.05

Respiratory rate at 48 hr Mean ± SD

51.13± 5.2266.07 ± 5.18<0.001**

Retractions at 24 hr (n, %)15 (100)15 (100)--Retractions at 48 hr (n, %)2 (13.3)15 (100)<0.001**Air entry at 24 hr (n, %)15 (100)15 (100)--Air entry at 48 hr (n, %)2 (13.3)15 (100)<0.001**X-ray improvement at 48 hr (n,%)

13 (86.7)0 (0)<0.001**

** Highly significant

Results & Discussion(cont.)

13(87)

2(13) 15

(100)

Improved Not improved

Surfactant group(n = 15)

X-ray improvement at 48 hours

Comparison group(n = 15)

p<0.001

Fig. (1):Comparison between the surfactant and the non surfactant groups in X-ray improvement at 48 hr of age


Fig.(2): Chest X-ray of a case of the surfactant group before and after surfactant administration

AfterBefore


Table 3. Outcome of arterial blood gases at 24 and 48 hours of life of the two groups.

Surfactant group(n = 15)

Mean±SD

Comparison group(n = 15)

Mean±SDP value

pH at 24 hr7.23 ± 0.047.21 ±0.034>0.05pH at 48 hr7.29±0.0487.19 ± 0.03<0.001**PaO2 at 24 hr (mmHg)55.82±3.6256.33± 3.63>0.05PaO2 at 48 hr (mmHg)63.9± 5.2754.73± 3.41<0.001**PaCO2 at 24 hr (mmHg)57.13±5.6157.7± 5.55>0.05PaCO2 at 48 hr (mmHg)46.93±6.1660.51± 4.24<0.001**

HCO3 at 24 hr (mmol/L)22.13±2.7422.61± 2.11>0.05

HCO3 at 48 hr (mmol/L)21.6± 1.8622.37± 1.72>0.05

**Highly significant


Table 4. Outcome of ventilatory parameters at 48 hours of life of the two groups.

Surfactant group (n = 15)

Mean±SD

Comparison group (n =15)

Mean±SDP value

PIP (cm H2O) 18.73± 1.6923.73± 1.28<0.001**

PEEP (cm H2O)4.13± 0.355.0± 0<0.001**

FiO20.38± 0.130.73± 0.08<0.001**

Ti at (sec)0.5± 0.050.59± 0.06<0.05*

Te at (sec)1.41±0.381.21± 0.11>0.05

MAP (cm H2O)7.99± 1.5411.1± 0.613<0.001**

OI5.16± 3.114.8± 2.02<0.001**

* significant ** Highly significant


• Mean Airway Pressure:

• Oxygenation Index :

MAP = PEEP +(PIP – PEEP)

× TiTi + Te

OI = MAP × FiO2× 100

Pa O2


Fig.(3): Mean airway pressure at 24 and 48 hr of age


Fig. (4): Oxygenation index at 24 and 48 hr of age

Results & Discussion(cont.) Table 5. Median duration of hospitalization and mechanical

ventilation in surfactant and comparison groups.

Surfactant group

(n = 15)Mean±SD

Comparison group

(n = 15)Mean±SD

P value

Duration of hospitalization (days)

20.93 ±10.6436.1±14.22<0.05*

Duration of mechanical ventilation (days)

7.13 ± 3.216.33± 9.47<0.001**

* Significant ** Highly significant


Fig. (5):Duration of hospitalization and mechanical ventilation

20.93

36.1

7.13

16.33

Surfactant group Comparison group0

10

20

30

40

Du

rati

on

(d

ay

s)

Hospitalization Mech. ventilationp<0.001

(n = 15) (n = 15)

p<0.05

Results & Discussion(cont.) Table 6. Outcome comparison between surfactant and non-

surfactant groups.

CLD = chronic lung disease; ICH = intracranial hemorrhagePDA=patent ductus arteriosus; NEC =necrotizing enterocolitis

Surfactant group(n = 15) n (%)

Comparison group(n = 15) n (%)

P value

Death due to RDS0 (0)2 (13.3)>0.05

CLD0 (0)3 (20)>0.05Air leak0 (0)3 (20)>0.05

Pulmonary hemorrhage1 (6.67)1 (6.67)---

ICH1 (6.67)1 (6.67)---PDA1 (6.67)1 (6.67)---

Sepsis2 (13.3)3 (20)>0.05NEC1 (6.67)1 (6.67)---


Fig. (6): Outcome of the two study groups

0 0 0

6. 67

6. 67

6. 67

13. 3

6. 67

13. 3

20

20

6. 67

6. 67

6. 67

20

6. 67

0

5

10

15

20

25

Pe

rc

en

t o

f p

os

i ti v

e c

as

es

Surfactant group Comparison group

Summary & ConclusionSummary & Conclusion1. Late (24 – 48 hr of age) single dose of rescue

therapy of bovine surfactant administered to preterms with RDS on MV has shown effectiveness.

2. The improvement was obvious clinically, in CXR, ABGs, needs and parameters of ventilation.

3. Highly significant in MAP, OI and duration of MV and a significant in duration of hospitalization were obvious in the surfactant group.

4. No mortality, CLD and air leak were detected among surfactant-treated preterms.

RecommendationRecommendation

The use of a single dose of bovine

surfactant replacement therapy, (even appears to

be late after the first 24 hr of age), is beneficial

and recommended in cases of preterm infants

with RDS on mechanical ventilation.

late exogenous surfactant therapy in preterm neonates with respiratory distress syndrome by dr....

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