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Koussa S, Sood BG, Xin Y, Sharma A, Maddipati KR. Gastric Aspirate Phosphatidylcholine Species in Preterm Neonates Receiving Aerosolized Surfactant. J Pediatr 2023; 263:113638. [PMID: 37517646 DOI: 10.1016/j.jpeds.2023.113638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/16/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To characterize phosphatidylcholine (PC) molecular species in serial gastric aspirates as biomarkers for lung maturity, delivery of aerosolized surfactant (AS), and need for intubation. METHODS In a phase II clinical trial of aerosolized surfactant in preterm neonates with respiratory distress syndrome receiving noninvasive ventilation, infants received a maximum of 2 doses of nebulized beractant. Gastric aspirates were collected before and after each dose and were analyzed for PCs using liquid chromatography mass spectrometry. RESULTS Of 149 infants enrolled, gastric aspirates were obtained before (n = 91) and after (n = 94) dose 1, and before (n = 56) and after (n = 57) dose 2 of nebulized beractant. The mean ± SD values of birthweight, gestational age, and age at collection of baseline gastric aspirate were 1.7 ± 0.6 kg, 31.7 ± 2.8 weeks, and 5.5 ± 1.7 hours, respectively. The most abundant PC in beractant and gastric aspirates was PC(16:0/16:0). Advancing gestational age and number of antenatal corticosteroid doses predicted increased gastric aspirate PC(16:0/16:0), whereas maternal diabetes predicted a decrease. Several PCs increased significantly (P < .05) after nebulized beractant, consistent with effective aerosol delivery. Infants who received intubation within 72 hours of birth were more likely to have lower PC(16:0/16:0) levels in baseline gastric aspirates compared with those who did not (P = .024). CONCLUSIONS PC molecular species in gastric aspirates of preterm neonates are potentially novel and precise biomarkers to assess lung maturity, aerosol delivery, and need for endotracheal intubation.
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Affiliation(s)
- Sara Koussa
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Beena G Sood
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI.
| | - Yuemin Xin
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Amit Sharma
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Krishna Rao Maddipati
- Department of Pathology, Lipidomics Core Facility, Wayne State University School of Medicine, Detroit, MI
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De Luca D, Loi B, Tingay D, Fiori H, Kingma P, Dellacà R, Autilio C. Surfactant status assessment and personalized therapy for surfactant deficiency or dysfunction. Semin Fetal Neonatal Med 2023; 28:101494. [PMID: 38016825 DOI: 10.1016/j.siny.2023.101494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Surfactant is a pivotal neonatal drug used both for respiratory distress syndrome due to surfactant deficiency and for more complex surfactant dysfunctions (such as in case of neonatal acute respiratory distress syndrome). Despite its importance, indications for surfactant therapy are often based on oversimplified criteria. Lung biology and modern monitoring provide several diagnostic tools to assess the patient surfactant status and they can be used for a personalized surfactant therapy. This is desirable to improve the efficacy of surfactant treatment and reduce associated costs and side effects. In this review we will discuss these diagnostic tools from a pathophysiological and multi-disciplinary perspective, focusing on the quantitative or qualitative surfactant assays, lung mechanics or aeration measurements, and gas exchange metrics. Their biological and technical characteristics are described with practical information for clinicians. Finally, available evidence-based data are reviewed, and the diagnostic accuracy of the different tools is compared. Lung ultrasound seems the most suitable tool for assessing the surfactant status, while some other promising tests require further research and/or development.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit, INSERM U999, Paris Saclay University, Paris, France; Department of Pediatrics, Division of Neonatology, Stanford University, School of Medicine - Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Barbara Loi
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit, INSERM U999, Paris Saclay University, Paris, France
| | - David Tingay
- Neonatal Research Unit, Murdoch Children's Research Institute, Parkville, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia
| | - Humberto Fiori
- Division of Neonatology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Paul Kingma
- Perinatal Institute, Cincinnati Children's University Hospital Medical Center, Cincinnati, OH, USA
| | - Raffaele Dellacà
- Department of Electronics, Information and Bio-engineering, Polytechnical University of Milan, Milan, Italy
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology and Research Institute Hospital October 12 (imas12), Faculty of Biology, Complutense University, Madrid, Spain; Clinical Pathology and Microbiology Unit, San Carlo Hospital, Potenza, Italy
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Sibrecht G, Kearl CR, Borys F, Morariu M, Bruschettini M, Soll R. Surfactant therapy guided by tests for lung maturity in preterm infants at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2023; 10:CD013158. [PMID: 37882216 PMCID: PMC10600963 DOI: 10.1002/14651858.cd013158.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Administration of various exogenous surfactant preparations has been shown to decrease lung injury and pneumothorax and improve survival in very preterm infants with respiratory distress syndrome (RDS). There is no consensus on the threshold for surfactant administration, to allow timely intervention and avoid over-treatment, also considering the invasiveness of the procedure and its cost. Rapid tests for lung maturity, which include the click test, lamellar body counts and stable microbubble test, might guide the identification of those infants needing surfactant administration. OBJECTIVES To assess the effects of surfactant treatment guided by rapid tests for surfactant deficiency in preterm infants at risk for or having RDS. Comparison 1: In preterm infants at risk for RDS, does surfactant treatment guided by rapid tests for surfactant deficiency compared to prophylactic surfactant administration to all high-risk infants minimize the need for surfactant treatment and prevent bronchopulmonary dysplasia and mortality? Comparison 2: In preterm infants who require early respiratory support, does surfactant treatment guided by rapid tests for surfactant deficiency compared to surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria minimize the need for surfactant treatment and prevent bronchopulmonary dysplasia and mortality? SEARCH METHODS We searched in October 2022 CENTRAL, PubMed, Embase and three additional trial registries. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs evaluating rapid tests after birth for surfactant deficiency in infants at high risk of RDS or requiring respiratory support. We specified two comparisons: 1)surfactant treatment guided by rapid tests for surfactant deficiency versus prophylactic surfactant administration to all high-risk infants in extremely preterm (less than 28 weeks' gestation) and very preterm (28 to 32 weeks' gestation); 2)surfactant treatment guided by rapid tests for surfactant deficiency versus surfactant therapy provided to preterm infants (less than 37 weeks' gestation) with RDS diagnosed on clinical and radiologic criteria. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD), with their 95% confidence intervals (CIs) for dichotomous data. Our primary outcomes were: neonatal mortality, mortality prior to hospital discharge, bronchopulmonary dysplasia and the composite outcome bronchopulmonary dysplasia or mortality. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included three RCTs enrolling 562 newborn infants in this review. No studies compared surfactant treatment guided by rapid tests for surfactant deficiency versus prophylactic surfactant administration to all high-risk infants. Comparing surfactant therapy guided by rapid tests for surfactant deficiency versus surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported neonatal mortality. Compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria, the evidence is very uncertain about the effect of surfactant treatment guided by rapid tests for surfactant deficiency on mortality prior to hospital discharge: RR 1.25, 95% CI 0.65 to 2.41, RD 0.01, 95% CI -0.03 to 0.05, 562 participants, 3 studies; I² for RR and RD = 75% and 43%, respectively; very low-certainty evidence. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in bronchopulmonary dysplasia: RR 0.90, 95% CI 0.61 to 1.32, RD -0.02, 95% CI -0.08 to 0.04, 562 participants, 3 studies; I² for RR and RD = 0%; low-certainty evidence. No studies reported the composite outcome bronchopulmonary dysplasia or mortality. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in surfactant utilization (RR 0.97, 95% CI 0.85 to 1.11, RD -0.02, 95% CI -0.10 to 0.06, 562 participants, 3 studies, I² for RR and RD = 63% and 65%, respectively, low-certainty evidence), and any pneumothorax (RR 0.53, 95% CI 0.15 to 1.92, RD -0.01, 95% CI -0.04 to 0.01, 506 participants, 2 studies, I² for RR and RD = 0%, low-certainty evidence) compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported moderate to severe neurodevelopmental impairment. We identified two large ongoing RCTs. AUTHORS' CONCLUSIONS No studies compared surfactant treatment guided by rapid tests for surfactant deficiency to prophylactic surfactant administration to all high-risk infants. Low to very low-certainty evidence from three studies is available on surfactant therapy guided by rapid tests for surfactant deficiency versus surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported neonatal mortality, the composite outcome 'bronchopulmonary dysplasia or mortality', or neurodevelopmental outcomes. Compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria, the evidence is very uncertain about the effect of surfactant treatment guided by rapid tests for surfactant deficiency on mortality prior to hospital discharge. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in bronchopulmonary dysplasia, surfactant utilization and any pneumothorax. The findings of the two large ongoing trials identified in this review are likely to have an important impact on establishing the effects of surfactant treatment guided by rapid tests for surfactant deficiency in preterm infants.
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Affiliation(s)
- Greta Sibrecht
- II Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Colby R Kearl
- Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Franciszek Borys
- II Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mihai Morariu
- Obstetric Anesthesia Department, Emergency County Hospital, Tirgu Mures, Romania
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Ramaswamy VV, Bandyopadhyay T, Abiramalatha T, Pullattayil S AK, Szczapa T, Wright CJ, Roehr CC. Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis. EClinicalMedicine 2023; 62:102097. [PMID: 37538537 PMCID: PMC10393620 DOI: 10.1016/j.eclinm.2023.102097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 08/05/2023] Open
Abstract
Background The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS. Methods The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life. Findings 58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) <0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low. Interpretation Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound. Funding None.
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Affiliation(s)
| | | | - Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
| | | | - Tomasz Szczapa
- II Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Newborn Services, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Boyle E, Roehr CC. Surfactant therapy in late preterm and term neonates with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:393-397. [PMID: 34686533 DOI: 10.1136/archdischild-2021-322890] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are no evidence-based recommendations for surfactant use in late preterm (LPT) and term infants with respiratory distress syndrome (RDS). OBJECTIVE To investigate the safety and efficacy of surfactant in LPT and term infants with RDS. METHODS Systematic review, meta-analysis and evidence grading. INTERVENTIONS Surfactant therapy versus standard of care. MAIN OUTCOME MEASURES Mortality and requirement for invasive mechanical ventilation (IMV). RESULTS Of the 7970 titles and abstracts screened, 17 studies (16 observational studies and 1 randomised controlled trial (RCT)) were included. Of the LPT and term neonates with RDS, 46% (95% CI 40% to 51%) were treated with surfactant. We found moderate certainty of evidence (CoE) from observational studies evaluating infants supported with non-invasive respiratory support (NRS) or IMV that surfactant use may be associated with a decreased risk of mortality (OR 0.45, 95% CI 0.32 to 0.64). Very low CoE from observational trials in which surfactant was administered at FiO2 >0.30-0.40 to infants on Continuous Positive Airway Pressure (CPAP) indicated that surfactant did not decrease the risk of IMV (OR 1.20, 95% CI 0.40 to 3.56). Very low to low CoE from the RCT and observational trials showed that surfactant use was associated with a significant decrease in risk of air leak, persistent pulmonary hypertension of the newborn (PPHN), duration of IMV, NRS and hospital stay. CONCLUSIONS Current evidence base on surfactant therapy in LPT and term infants with RDS indicates a potentially decreased risk of mortality, air leak, PPHN and duration of respiratory support. In view of the low to very low CoE and widely varying thresholds for deciding on surfactant replacement in the included studies, further trials are needed.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, Delhi, India
| | - Elaine Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Charles Christoph Roehr
- Nuffield Department of Population Health, Medical Sciences Division, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK .,Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK.,Faculty of Health Sciences, University of Bristol, Bristol, UK
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Lavizzari A, Veneroni C, Beretta F, Ottaviani V, Fumagalli C, Tossici M, Colnaghi M, Mosca F, Dellacà RL. Oscillatory mechanics at birth for identifying infants requiring surfactant: a prospective, observational trial. Respir Res 2021; 22:314. [PMID: 34930247 PMCID: PMC8686669 DOI: 10.1186/s12931-021-01906-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/25/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Current criteria for surfactant administration assume that hypoxia is a direct marker of lung-volume de-recruitment. We first introduced an early, non-invasive assessment of lung mechanics by the Forced Oscillation Technique (FOT) and evaluated its role in predicting the need for surfactant therapy. OBJECTIVES To evaluate whether lung reactance (Xrs) assessment by FOT within 2 h of birth identifies infants who would need surfactant within 24 h; to eventually determine Xrs performance and a cut-off value for early detection of infants requiring surfactant. METHODS We conducted a prospective, observational, non-randomized study in our tertiary NICU in Milan. Eligible infants were born between 27+0 and 34+6 weeks' gestation, presenting respiratory distress after birth. EXCLUSION CRITERIA endotracheal intubation at birth, major malformations participation in other interventional trials, parental consent denied. We assessed Xrs during nasal CPAP at 5 cmH2O at 10 Hz within 2 h of life, recording flow and pressure tracing through a Fabian Ventilator for off-line analysis. Clinicians were blinded to FOT results. RESULTS We enrolled 61 infants, with a median [IQR] gestational age of 31.9 [30.3; 32.9] weeks and birth weight 1490 [1230; 1816] g; 2 infants were excluded from the analysis for set-up malfunctioning. 14/59 infants received surfactant within 24 h. Xrs predicted surfactant need with a cut-off - 33.4 cmH2O*s/L and AUC-ROC = 0.86 (0.76-0.96), with sensitivity 0.85 and specificity 0.83. An Xrs cut-off value of - 23.3 cmH2O*s/L identified infants needing surfactant or respiratory support > 28 days with AUC-ROC = 0.89 (0.81-0.97), sensitivity 0.86 and specificity 0.77. Interestingly, 12 infants with Xrs < - 23.3 cmH2O*s/L (i.e. de-recruited lungs) did not receive surfactant and subsequently required prolonged respiratory support. CONCLUSION Xrs assessed within 2 h of life predicts surfactant need and respiratory support duration in preterm infants. The possible role of Xrs in improving the individualization of respiratory management in preterm infants deserves further investigation.
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Affiliation(s)
- Anna Lavizzari
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy.
| | - Chiara Veneroni
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
| | - Francesco Beretta
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
| | - Valeria Ottaviani
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
| | - Claudia Fumagalli
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
| | - Marta Tossici
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Raffaele L Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
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Autilio C. Techniques to evaluate surfactant activity for a personalized therapy of RDS neonates. Biomed J 2021; 44:671-677. [PMID: 34758409 PMCID: PMC8847822 DOI: 10.1016/j.bj.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/28/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023] Open
Abstract
According to both European and American Guidelines, preterm neonates have to be treated by nasal continuous air pressure (CPAP) early in the delivery room. The administration of surfactant should be reserved only for babies with respiratory distress syndrome (RDS) with increased oxygen requirement, according to different thresholds of FiO2. However, these oxygenation thresholds do not fully take into consideration the lung physiopathology and mechanics or the lung surfactant biology of RDS neonates. Since surfactant replacement therapy (SRT) seems to be more effective if it is initiated within the first 3 hours after birth, the use of a reliable bench-to-bedside biological test able to predict as soon as possible the necessity of SRT will help optimise individualised therapies and personalise the actual collective strategy used to treat RDS neonates. With this in mind, in the present review several quantitative and qualitative biological tests to assess the surfactant status in RDS neonates are introduced as potential candidates for the early prediction of SRT requirement, summarising the state-of-the-art in the evaluation of surfactant activity.
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Affiliation(s)
- Chiara Autilio
- Department of Biochemistry and Molecular Biology and Research Institute ``Hospital 12 de Octubre (imas12)'', Faculty of Biology, Complutense University, Jose Antonio Novais 12, Madrid, Spain; Clinical Pathology and Microbiology Unit, "San Carlo" Hospital, Potenza, Italy.
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Verder H, Heiring C, Verder P, Schousboe P. Early prediction of bronchopulmonary dysplasia is possible and important. Acta Paediatr 2021; 110:725. [PMID: 32875661 DOI: 10.1111/apa.15508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Henrik Verder
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Christian Heiring
- Department of Neonatology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Povl Verder
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Peter Schousboe
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
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Verder H, Heiring C, Ramanathan R, Scoutaris N, Verder P, Jessen TE, Höskuldsson A, Bender L, Dahl M, Eschen C, Fenger‐Grøn J, Reinholdt J, Smedegaard H, Schousboe P. Bronchopulmonary dysplasia predicted at birth by artificial intelligence. Acta Paediatr 2021; 110:503-509. [PMID: 32569404 PMCID: PMC7891330 DOI: 10.1111/apa.15438] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 11/29/2022]
Abstract
Aim To develop a fast bedside test for prediction and early targeted intervention of bronchopulmonary dysplasia (BPD) to improve the outcome. Methods In a multicentre study of preterm infants with gestational age 24‐31 weeks, clinical data present at birth were combined with spectral data of gastric aspirate samples taken at birth and analysed using artificial intelligence. The study was designed to develop an algorithm to predict development of BPD. The BPD definition used was the consensus definition of the US National Institutes of Health: Requirement of supplemental oxygen for at least 28 days with subsequent assessment at 36 weeks postmenstrual age. Results Twenty‐six (43%) of the 61 included infants developed BPD. Spectral data analysis of the gastric aspirates identified the most important wave numbers for classification and surfactant treatment, and birth weight and gestational age were the most important predictive clinical data. By combining these data, the resulting algorithm for early diagnosis of BPD had a sensitivity of 88% and a specificity of 91%. Conclusion A point‐of‐care test to predict subsequent development of BPD at birth has been developed using a new software algorithm allowing early targeted intervention of BPD which could improve the outcome.
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Affiliation(s)
- Henrik Verder
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Christian Heiring
- Department of Neonatology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Rangasamy Ramanathan
- Department of Pediatrics Division of Neonatology LAC+USC Medical Center & PH Good Samaritan Hospital Los Angeles CA USA
| | | | - Povl Verder
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Torben E. Jessen
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Agnar Höskuldsson
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Lars Bender
- Department of Paediatrics Aalborg Hospital University of Aalborg Aalborg Denmark
| | - Marianne Dahl
- Department of Paediatrics Odense Hospital University of Southern Denmark Odense Denmark
| | - Christian Eschen
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
| | - Jesper Fenger‐Grøn
- Department of Paediatrics Kolding Hospital University of Southern Denmark Kolding Denmark
| | - Jes Reinholdt
- Department of Paediatrics Herlev Hospital University of Copenhagen Copenhagen Denmark
| | - Heidi Smedegaard
- Department of Paediatrics Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Peter Schousboe
- Department of Pediatrics Holbaek University Hospital Holbaek Denmark
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De Luca D, Autilio C, Pezza L, Shankar-Aguilera S, Tingay DG, Carnielli VP. Personalized Medicine for the Management of RDS in Preterm Neonates. Neonatology 2021; 118:127-138. [PMID: 33735866 DOI: 10.1159/000513783] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022]
Abstract
Continuous positive airway pressure and surfactant represent the first- and second-line treatment for respiratory distress syndrome in preterm neonates, as European and American guidelines, since 2013 and 2014, respectively, started to recommend surfactant replacement only when continuous positive airway pressure fails. These recommendations, however, are not personalized to the individual physiopathology. Simple clinical algorithms may have improved the diffusion of neonatal care, but complex medical issues can hardly be addressed with simple solutions. The treatment of respiratory distress syndrome is a complex matter and can be only optimized with personalization. We performed a review of tools to individualize the management of respiratory distress syndrome based on physiopathology and actual patients' need, according to precision medicine principles. Advanced oxygenation metrics, lung ultrasound, electrical impedance tomography, and both quantitative and qualitative surfactant assays were examined. When these techniques were investigated with diagnostic accuracy studies, reliability measures have been meta-analysed. Amongst all these tools, quantitative lung ultrasound seems the more developed for the widespread use and has a higher diagnostic accuracy (meta-analytical AUC = 0.952 [95% CI: 0.951-0.953]). Surfactant adsorption (AUC = 0.840 [95% CI: 0.824-0.856]) and stable microbubble test (AUC = 0.800 [95% CI: 0.788-0.812]) also have good reliability, but need further industrial development. We advocate for a more accurate characterization and a personalized approach of respiratory distress syndrome. With the above-described currently available tools, it should be possible to personalize the treatment of respiratory distress syndrome according to physiopathol-ogy.
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Affiliation(s)
- Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, "A. Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France, .,Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France,
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology and Research Institute "Hospital 12 de Octubre," Complutense University, Madrid, Spain
| | - Lucilla Pezza
- Paediatric Intensive Care Unit, Department of Anaesthesiology and Critical Care, University Hospital "A. Gemelli"- IRCCS, Rome, Italy
| | - Shivani Shankar-Aguilera
- Division of Paediatrics and Neonatal Critical Care, "A. Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neonatology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Virgilio P Carnielli
- Division of Neonatology, "G. Salesi" Women and Children Hospital, Polytechnical University of Marche, Ancona, Italy
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Heiring C, Verder H, Schousboe P, Jessen TE, Bender L, Ebbesen F, Dahl M, Eschen C, Fenger‐Grøn J, Höskuldsson A, Matthews M, Reinholdt J, Scoutaris N, Smedegaard H. Predicting respiratory distress syndrome at birth using a fast test based on spectroscopy of gastric aspirates: 2. Clinical part. Acta Paediatr 2020; 109:285-290. [PMID: 31038796 PMCID: PMC7004016 DOI: 10.1111/apa.14831] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/16/2019] [Accepted: 04/26/2019] [Indexed: 01/25/2023]
Abstract
AIM To evaluate the accuracy of our new rapid point-of-care (POC) test for lung maturity. The method as we describe in an accompanying article was developed with the purpose of improving the outcome from respiratory distress syndrome (RDS). The test enables the delivery of surfactant in infants with immature lungs already at birth and ensures that infants with mature lungs are not treated unnecessarily. METHODS Fresh gastric aspirate (GAS) was sampled at birth in a cohort of preterm infants with gestational ages ranging between 24 and 31 completed weeks for lung surfactant measurement as lecithin-sphingomyelin ratio (L/S). L/S was prospectively compared with RDS development. The clinical outcome was blinded for the investigators of L/S. The time for analysis was <15 minutes. RESULTS GAS was obtained from 72 infants. Forty-four (61%) developed RDS. The cut-off for L/S was 3.05; predicting RDS with a sensitivity of 91% and specificity of 79%. CONCLUSION The new improved spectroscopic L/S method of lung maturity on GAS has high sensitivity. The method is designed for use as a POC test at birth, and a spectroscopic prototype has been developed for bedside use. Clinical trials with this new lung maturity test are planned.
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Affiliation(s)
- Christian Heiring
- Department of Neonatology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Henrik Verder
- Departments of PaediatricsHolbaek University HospitalHolbaekDenmark
| | - Peter Schousboe
- Departments of PaediatricsHolbaek University HospitalHolbaekDenmark
| | - Torben E. Jessen
- Department of Clinical BiochemistryHolbaek University HospitalHolbaekDenmark
| | - Lars Bender
- Department of PaediatricsAalborg HospitalUniversity of AalborgAalborgDenmark
| | - Finn Ebbesen
- Department of PaediatricsAalborg HospitalUniversity of AalborgAalborgDenmark
| | - Marianne Dahl
- Department of PaediatricsOdense HospitalUniversity of Southern DenmarkOdenseDenmark
| | - Christian Eschen
- Departments of PaediatricsHolbaek University HospitalHolbaekDenmark
| | - Jesper Fenger‐Grøn
- Department of PaediatricsKolding HospitalUniversity of Southern DenmarkKoldingDenmark
| | | | | | - Jes Reinholdt
- Department of PaediatricsHerlev HospitalUniversity of CopenhagenCopenhagenDenmark
| | | | - Heidi Smedegaard
- Department of Neonatology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
- Department of PaediatricsHvidovre HospitalUniversity of CopenhagenCopenhagenDenmark
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12
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Hagman C, Björklund LJ, Hellgren G, Tufvesson E, Hansen-Pupp I. Club cell secretory protein (CC16) in gastric fluid at birth and subsequent lung disease in preterm infants. Pediatr Pulmonol 2018; 53:1399-1406. [PMID: 29992757 DOI: 10.1002/ppul.24128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/31/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Club cell secretory protein (CC16) probably has a role in protecting the lung from inflammation. AIM To evaluate if low levels of CC16 in gastric fluid at birth, reflecting low levels of CC16 in the lung, would be associated with lung inflammation and respiratory morbidity. METHODS A study of 64 infants with mean gestational age 26.1 weeks. CC16 was analyzed in gastric fluid at birth. CC16, pro-inflammatory cytokines, and MMP-9 were analyzed in tracheal aspirate within 24 h from birth. RESULTS CC16 in gastric fluid increased with gestational age (P = 0.033). Lower concentrations of CC16 in gastric fluid at birth were associated with higher concentrations of IL-1β (P = 0.028), TNF-α (P = 0.034), and MMP-9 (P = 0.015) in tracheal aspirate. Infants who needed mechanical ventilation at 24 and 72 h of age had lower CC16 in gastric fluid than those not ventilated at these ages (P = 0.011 and P = 0.024, respectively). Lower CC16 in gastric fluid was associated with higher FiO2 at 6 h (P = 0.009), higher PaCO2 at 24 h (P = 0.03), more ventilator days (P = 0.012) and more days with supplemental oxygen (P = 0.03). Infants who had either died or were still treated with supplemental oxygen at 36 weeks postmenstrual age had lower CC16 in gastric fluid than infants with none of these outcomes (P = 0.049). CONCLUSION A low CC16 concentration in gastric fluid at birth was associated with increased inflammation in the trachea within the first 24 h of life and with more need for respiratory support in the neonatal period.
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Affiliation(s)
- Cecilia Hagman
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden
| | - Lars J Björklund
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden
| | - Gunnel Hellgren
- Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ellen Tufvesson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Ingrid Hansen-Pupp
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden
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13
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Jensen CF, Ebbesen F, Petersen JP, Sellmer A, Bach CC, Henriksen TB. Hypothermia at neonatal intensive care unit admission was not associated with respiratory disease or death in very preterm infants. Acta Paediatr 2017; 106:1934-1939. [PMID: 28731511 DOI: 10.1111/apa.13998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/31/2017] [Accepted: 07/18/2017] [Indexed: 11/30/2022]
Abstract
AIM This study investigated the association between hypothermia and respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD) or death in very preterm infants admitted to a Danish neonatal intensive care unit (NICU). METHODS We studied 675 infants born at Aalborg University Hospital before 32 weeks and admitted to the NICU from April 1997 to December 2011. Hypothermia was defined as a core temperature of <36.5°C on admission. The primary outcome was severe RDS or death within the first three days of life, and the secondary outcome was BPD or death before 36 postmenstrual weeks. The multivariable logistic regression was adjusted for early-onset infection, gestational age, Apgar score, sex, treatment year and birth weight. RESULTS Infants with hypothermia had a twofold increase (OR) in the odds for RDS or death (2.03), but the adjusted OR was not statistically significant (1.36). They also demonstrated a twofold increase (OR) in the odds for BPD or death (2.28), but again the adjusted OR was not statistically significant (1.03). CONCLUSION After adjusting for confounders, we found that the association between hypothermia on admission to the NICU and RDS or death, or BPD or death was statistically insignificant.
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Affiliation(s)
- CF Jensen
- Perinatal Epidemiology Research Unit; Aarhus University Hospital; Aarhus Denmark
| | - F Ebbesen
- Department of Pediatrics; Aalborg University Hospital; Aalborg Denmark
- Department of Clinical Medicine; Aalborg University; Aalborg Denmark
| | - JP Petersen
- Perinatal Epidemiology Research Unit; Aarhus University Hospital; Aarhus Denmark
- Department of Pediatrics; Aarhus University Hospital; Aarhus Denmark
| | - A Sellmer
- Perinatal Epidemiology Research Unit; Aarhus University Hospital; Aarhus Denmark
- Department of Pediatrics; Aarhus University Hospital; Aarhus Denmark
| | - CC Bach
- Perinatal Epidemiology Research Unit; Aarhus University Hospital; Aarhus Denmark
- Department of Pediatrics; Aarhus University Hospital; Aarhus Denmark
| | - TB Henriksen
- Perinatal Epidemiology Research Unit; Aarhus University Hospital; Aarhus Denmark
- Department of Pediatrics; Aarhus University Hospital; Aarhus Denmark
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Sozo F, Ishak N, Bhatia R, Davis PG, Harding R. Surfactant phospholipid composition of gastric aspirate samples differs between male and female very preterm infants. Pediatr Res 2017; 82:839-849. [PMID: 28665932 DOI: 10.1038/pr.2017.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 06/09/2017] [Indexed: 12/22/2022]
Abstract
BackgroundAmong preterm infants, males have a greater incidence of respiratory distress and death than do females born at the same gestational age, likely due to sex-related differences in lung maturation. Our aim was to determine whether surfactant phospholipid composition differs between male and female preterm infants.MethodsGastric aspirate samples from male and female infants born between 25 and 30 weeks of gestation at The Royal Women's Hospital, Melbourne, Australia, were collected within 1 h after birth. Phospholipid composition was analyzed by electrospray ionization tandem mass spectrometry.ResultsPreterm males had higher proportions of total phosphatidylinositol (PI) and phosphatidylserine 36:2, lower proportions of total sphingomyelin (S) and S 33:1 and 35:1, and a greater phosphatidylcholine (PC)/S ratio than did females. The proportions of PC 30:0, PC 34:0, PC 34:2, PC 36:2, PC 36:3, and PC 38:2 differed between the sexes at different gestational weeks of birth; the proportion of PC 32:0 (dipalmitoylphosphatidylcholine) in males was lower than that in females at 25 weeks of gestation but higher at 27 weeks.ConclusionPhospholipid composition in pulmonary surfactant is different between male and female preterm infants of the same gestational age, which may contribute to the increased risk for respiratory morbidities in one sex.
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Affiliation(s)
- Foula Sozo
- Development and Stem Cells Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia
| | - Noreen Ishak
- Development and Stem Cells Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia
| | - Risha Bhatia
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Department of Newborn Research, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Richard Harding
- Development and Stem Cells Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia
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15
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Verder H, Heiring C, Clark H, Sweet D, Jessen TE, Ebbesen F, Björklund LJ, Andreasson B, Bender L, Bertelsen A, Dahl M, Eschen C, Fenger‐Grøn J, Hoffmann SF, Höskuldsson A, Bruusgaard‐Mouritsen M, Lundberg F, Postle AD, Schousboe P, Schmidt P, Stanchev H, Sørensen L. Rapid test for lung maturity, based on spectroscopy of gastric aspirate, predicted respiratory distress syndrome with high sensitivity. Acta Paediatr 2017; 106:430-437. [PMID: 27886403 PMCID: PMC5324669 DOI: 10.1111/apa.13683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/26/2016] [Accepted: 11/22/2016] [Indexed: 11/27/2022]
Abstract
AIM Respiratory distress syndrome (RDS) is a major cause of mortality and morbidity in premature infants. By the time symptoms appear, it may already be too late to prevent a severe course, with bronchopulmonary dysplasia or mortality. We aimed to develop a rapid test of lung maturity for targeting surfactant supplementation. METHODS Concentrations of the most surface-active lung phospholipid dipalmitoylphosphatidylcholine and sphingomyelin in gastric aspirates from premature infants were measured by mass spectrometry and expressed as the lecithin/sphingomyelin ratio (L/S). The same aspirates were analysed with mid-infrared spectroscopy. Subsequently, L/S was measured in gastric aspirates and oropharyngeal secretions from another group of premature infants using spectroscopy and the results were compared with RDS development. The 10-minute analysis required 10 μL of aspirate. RESULTS An L/S algorithm was developed based on 89 aspirates. Subsequently, gastric aspirates were sampled in 136 infants of 24-31 weeks of gestation and 61 (45%) developed RDS. The cut-off value of L/S was 2.2, sensitivity was 92%, and specificity was 73%. In 59 cases, the oropharyngeal secretions had less valid L/S than gastric aspirate results. CONCLUSION Our rapid test for lung maturity, based on spectroscopy of gastric aspirate, predicted RDS with high sensitivity.
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Affiliation(s)
- Henrik Verder
- Departments of PediatricsHolbaek University HospitalHolbaekDenmark
| | - Christian Heiring
- Department of NeonatologyRigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Howard Clark
- Department of NeonatologySouthampton HospitalUniversity of SouthamptonEnglandUK
| | - David Sweet
- Department of NeonatologyRoyal Maternity HospitalBelfastNorthern IrelandUK
| | - Torben E. Jessen
- Department of Clinical BiochemistryHolbaek University HospitalHolbaekDenmark
| | - Finn Ebbesen
- Department of Pediatrics Aalborg HospitalUniversity of AalborgAalborgDenmark
| | - Lars J. Björklund
- Departments of Pediatric Surgery and NeonatologySkåne University HospitalLundSweden
- Department of Clinical SciencesUniversity of LundLundSweden
| | - Bengt Andreasson
- Departments of Pediatric Surgery and NeonatologySkåne University HospitalLundSweden
| | - Lars Bender
- Department of Pediatrics Aalborg HospitalUniversity of AalborgAalborgDenmark
| | - Aksel Bertelsen
- Departments of PediatricsHolbaek University HospitalHolbaekDenmark
| | - Marianne Dahl
- Department of PediatricsOdense HospitalUniversity of SouthernOdenseDenmark
| | - Christian Eschen
- Departments of PediatricsHolbaek University HospitalHolbaekDenmark
| | - Jesper Fenger‐Grøn
- Department of PediatricsKolding HospitalUniversity of SouthernKoldinDenmark
| | - Stine F. Hoffmann
- Departments of PediatricsHerlev HospitalUniversity of CopenhagenCopenhagenDenmark
| | | | | | - Fredrik Lundberg
- Department of Neonatology LinköpingUniversity of LinköpingLinköpingSweden
| | - Anthony D. Postle
- Child HealthAcademic Unit of Clinical and Experimental Sciences and Respiratory Biomedical Research UnitSouthampton General HospitalUniversity of SouthamptonEnglandUK
| | - Peter Schousboe
- Departments of PediatricsHolbaek University HospitalHolbaekDenmark
| | - Peter Schmidt
- Department of PediatricsHvidovre HospitalUniversity of CopenhagenCopenhagenDenmark
| | - Hristo Stanchev
- Department of PediatricsNæstved University HospitalNæstvedDenmark
| | - Lars Sørensen
- Departments of PediatricsHolbaek University HospitalHolbaekDenmark
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16
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update. Neonatology 2017; 111:107-125. [PMID: 27649091 DOI: 10.1159/000448985] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023]
Abstract
Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
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Sin SY, Jin MJ, Lee NH, Park JH, Kim CS, Lee SL. Lung Ultrasonography for the Diagnosis of Respiratory Distress Syndrome in Late Preterm Infants: Changing Incidence – A Single Center Experience. NEONATAL MEDICINE 2017. [DOI: 10.5385/nm.2017.24.1.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- So Young Sin
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Min Ji Jin
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Na Hyun Lee
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jae Hyun Park
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Chun Soo Kim
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Sang Lak Lee
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
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Petersen JP, Ebbesen F, Hollegaard MV, Andersson S, Hougaard DM, Thorlacius-Ussing O, Henriksen TB. UGT1A1*28 Genotypes and Respiratory Disease in Very Preterm Infants: A Cohort Study. Neonatology 2016; 109:124-9. [PMID: 26666247 DOI: 10.1159/000442042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Respiratory disease in the very preterm infant is frequent and often severe. Bilirubin is both a potent neurotoxin and antioxidant, and may have a clinical impact on preterm respiratory disease. The Gilbert genotype, the UGT1A1*28 allele, is the major known genetic cause of variation in bilirubin. OBJECTIVES To study the association between respiratory disease in the very preterm infant and the UGT1A1*28 allele. METHODS This is a cohort study of 1,354 very preterm infants (gestational age <32 weeks) born in Jutland, Denmark in 1997-2011. Genotypes were obtained from the Danish Neonatal Screening Biobank, and clinical information was obtained from the databases of two tertiary neonatal intensive care units. Outcomes were the need for surfactant therapy, any need for and duration of supplementary oxygen and bronchopulmonary dysplasia (BPD). RESULTS Per UGT1A1*28 allele, odds were increased for any need of supplementary oxygen (odds ratio 1.26; 1.05-1.50) and for BPD (odds ratio 1.71; 1.23-2.39), the need of supplementary oxygen increased by 6.38 days (1.87-10.89), and chance per day of no longer needing supplementary oxygen was reduced (hazard rate 0.84; 0.76-0.93). No effect was observed for need of surfactant treatment (odds ratio 1.08; 0.91-1.28). Hardy-Weinberg equilibrium was unlikely for the cohort (p < 0.012). This could be explained by death prior to genotype sampling. In tests of robustness this failed to explain the primary results. CONCLUSIONS Compared to the common genotype, UGT1A1*28 genotypes were associated with an increased need of oxygen supplementation and risk of BPD in very preterm newborns.
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Curstedt T, Halliday HL, Speer CP. A unique story in neonatal research: the development of a porcine surfactant. Neonatology 2015; 107:321-9. [PMID: 26044099 DOI: 10.1159/000381117] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Surfactant deficiency was identified as the cause of respiratory distress syndrome (RDS) as long ago as 1959. Trials of surfactant replacement in the 1960s were unsuccessful because the preparations used contained only phospholipids and they were administered inefficiently by nebulization. In the 1970s Bengt Robertson and Göran Enhörning showed that natural surfactant, containing both phospholipids and proteins, could ameliorate the signs of RDS in immature rabbits. In the 1980s Bengt Robertson and Tore Curstedt developed a porcine surfactant, Curosurf (named after their surnames), which was effective in immature animals and was used in a pilot clinical trial beginning in 1983. Subsequent randomized clinical trials were planned a year later by Bengt Robertson, Tore Curstedt and Henry Halliday, and the first trial was begun in 1985. This showed that Curosurf reduced pulmonary air leaks and neonatal mortality in preterm infants with severe RDS. A second trial, coordinated by Christian Speer, demonstrated that multiple doses of Curosurf were more effective than a single dose. Subsequent trials conducted by the Collaborative European Multicenter Study Group, which included among others Guilio Bevilacqua, Janna Koppe, Ola Saugstad, Nils Svenningsen and Jean-Pierre Relier, showed that early treatment was more effective than later administration and that infants treated at birth had similar neurodevelopmental status to untreated controls at a corrected age of 2 years. Members of the Collaborative European Multicenter Study Group in Denmark and Sweden performed studies to demonstrate the benefits of a combination of surfactant treatment and early continuous positive airway pressure. Curosurf has also been compared with several synthetic and natural surfactants, and at a dose of 200 mg/kg Curosurf has been shown to be superior to either Survanta or Curosurf used at a dose of 100 mg/kg. Recently, new-generation synthetic surfactants containing both phospholipids and proteins have been developed. After preclinical testing, CHF5633 (developed by Tore Curstedt and Jan Johansson in collaboration with Chiesi Farmaceutici) has undergone a preliminary first study in humans under the guidance of Christian Speer. If effective, this new surfactant preparation could revolutionize the treatment of preterm infants worldwide as it could be made consistently and safely in almost unlimited quantities. This story of a porcine surfactant preparation has been truly remarkable, and many thousands of preterm babies worldwide are now alive and well because of it.
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Affiliation(s)
- Tore Curstedt
- Section of Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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20
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Fiori HH, Fiori RM. Why not use a surfactant test for respiratory distress syndrome? Neonatology 2015; 107:312. [PMID: 25790960 DOI: 10.1159/000369376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Humberto Holmer Fiori
- Graduate Program in Medicine, Pediatrics and Child Health, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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21
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Sweet DG, Halliday HL, Speer CP. Surfactant therapy for neonatal respiratory distress syndrome in 2013. J Matern Fetal Neonatal Med 2013; 26 Suppl 2:27-9. [DOI: 10.3109/14767058.2013.829695] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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