1
|
Fishler R, Ostrovski Y, Frenkel A, Dorfman S, Vaknin M, Waisman D, Korin N, Sznitman J. Exploring pulmonary distribution of intratracheally instilled liquid foams in excised porcine lungs. Eur J Pharm Sci 2023; 181:106359. [PMID: 36521723 PMCID: PMC9850415 DOI: 10.1016/j.ejps.2022.106359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/28/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
The applicability of inhalation therapy to some severe pulmonary conditions is often compromised by limited delivery rates (i.e. total dose) and low deposition efficiencies in the respiratory tract, most notably in the deep pulmonary acinar airways. To circumvent such limitations, alternative therapeutic techniques have relied for instance on intratracheal liquid instillations for the delivery of high-dose therapies. Yet, a longstanding mechanistic challenge with such latter methods lies in delivering solutions homogeneously across the whole lungs, despite an inherent tendency of non-uniform spreading driven mainly by gravitational effects. Here, we hypothesize that the pulmonary distribution of instilled liquid solutions can be meaningfully improved by foaming the solution prior to its instillation, owing to the increased volume and the reduced gravitational bias of foams. As a proof-of-concept, we show in excised adult porcine lungs that liquid foams can lead to significant improvement in homogenous pulmonary distributions compared with traditional liquid instillations. Our ex-vivo results suggest that liquid foams can potentially offer an attractive novel pulmonary delivery modality with applications for high-dose regimens of respiratory therapeutics.
Collapse
Affiliation(s)
| | | | | | | | | | - Dan Waisman
- Departments of Neonatology, Carmel Medical Center and the Ruth and Bruce Rappaport Faculty of Medicine
| | | | | |
Collapse
|
2
|
Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
Collapse
|
3
|
Abstract
Mechanical ventilation can be life-saving for the premature infant, but is often injurious to immature and underdeveloped lungs. Lung injury is caused by atelectrauma, oxygen toxicity, and volutrauma. Lung protection must include appropriate lung recruitment starting in the delivery suite and throughout mechanical ventilation. Strategies include open lung ventilation, positive end-expiratory pressure, and volume-targeted ventilation. Respiratory function monitoring, such as capnography and ventilator graphics, provides clinicians with continuous real-time information and an adjunct to optimize lung-protective ventilatory strategies. Further research is needed to assess which lung-protective strategies result in a decrease in long-term respiratory morbidity.
Collapse
|
4
|
Tana M, Paladini A, Tirone C, Aurilia C, Lio A, Bottoni A, Costa S, Tiberi E, Pastorino R, Vento G. Effects of High-Frequency Oscillatory Ventilation With Volume Guarantee During Surfactant Treatment in Extremely Low Gestational Age Newborns With Respiratory Distress Syndrome: An Observational Study. Front Pediatr 2021; 9:804807. [PMID: 35310140 PMCID: PMC8927884 DOI: 10.3389/fped.2021.804807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/28/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the effect of volume guarantee (VG) combined with high-frequency oscillatory ventilation (HFOV) on respiratory and other physiological parameters immediately after lung recruitment and surfactant administration in HFOV elective ventilated extremely low gestational age newborns (ELGAN) with respiratory distress syndrome (RDS). DESIGN Observational study. SETTING Tertiary neonatal intensive care unit. PATIENTS Twenty-two ELGANs of 25.5 ± 1.1 weeks of gestational age requiring invasive mechanical ventilation and surfactant administration for RDS during the first 6 h of life. INTERVENTIONS All infants intubated in delivery room, were managed with elective HFOV and received surfactant after a lung recruitment manoeuver. Eleven infants received HFOV + VG and were compared with a control group of 11 infants receiving HFOV alone. HFOV was delivered in both groups by Dräger Babylog VN500 ventilator (Dräger, Lubeck, Germany). MAIN OUTCOME MEASURES Variations and fluctuations of delivered high-frequency tidal volume (VThf), fluctuation of pressure amplitude (ΔP) and partial pressure of CO2 (pCO2) levels after recruitment manoeuver and immediately after surfactant administration, in HFOV + VG vs. HFOV ventilated infants. RESULTS There were no significant differences in the two groups at starting ventilation with or without VG. The mean applied VThf per kg was 1.7 ± 0.3 ml/kg in the HFOV group and 1.7 ± 0.1 ml/kg in the HFOV + VG group. Thirty minutes after surfactant administration, HFOV group had a significant higher VThf/Kg than HFOV + VG (2.1 ± 0.3 vs. 1.6 ± 0.1 ml/kg, p < 0.0001) with significantly lower pCO2 levels (43.1 ± 3.8 vs. 46.8 ± 1.5 mmHg, p = 0.01), 54.4% of patients having pCO2 below 45 mmHg. Measured post-surfactant ΔP values were higher in HFOV group (17 ± 3 cmH2O) than in HFOV + VG group (13 ± 3 cmH2O, p = 0.01). CONCLUSION HFOV + VG maintains pCO2 levels within target range and reduces VThf delivered variations more consistently than HFOV alone after surfactant administration.
Collapse
Affiliation(s)
- Milena Tana
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Angela Paladini
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Tirone
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Aurilia
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandra Lio
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anthea Bottoni
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simonetta Costa
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eloisa Tiberi
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberta Pastorino
- Section of Hygiene, Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
5
|
The Effect of Modified Porcine Surfactant Alone or in Combination with Polymyxin B on Lung Homeostasis in LPS-Challenged and Mechanically Ventilated Adult Rats. Molecules 2020; 25:molecules25194356. [PMID: 32977392 PMCID: PMC7582504 DOI: 10.3390/molecules25194356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 01/21/2023] Open
Abstract
The study aimed to prove the hypothesis that exogenous surfactant and an antibiotic polymyxin B (PxB) can more effectively reduce lipopolysaccharide (LPS)-induced acute lung injury (ALI) than surfactant treatment alone, and to evaluate the effect of this treatment on the gene expression of surfactant proteins (SPs). Anesthetized rats were intratracheally instilled with different doses of LPS to induce ALI. Animals with LPS 500 μg/kg have been treated with exogenous surfactant (poractant alfa, Curosurf®, 50 mg PL/kg b.w.) or surfactant with PxB 1% w.w. (PSUR + PxB) and mechanically ventilated for 5 hrs. LPS at 500 μg/kg increased lung edema, oxidative stress, and the levels of proinflammatory mediators in lung tissue and bronchoalveolar lavage fluid (BALF). PSUR reduced lung edema and oxidative stress in the lungs and IL-6 in BALF. This effect was further potentiated by PxB added to PSUR. Exogenous surfactant enhanced the gene expression of SP-A, SP-B, and SP-C, however, gene expression for all SPs was reduced after treatment with PSUR + PxB. In mechanically ventilated rats with LPS-induced ALI, the positive effect of exogenous surfactant on inflammation and oxidative stress was potentiated with PxB. Due to the tendency for reduced SPs gene expression after surfactant/PxB treatment topical use of PxB should be considered with caution.
Collapse
|
6
|
Lung recruitment before surfactant administration in extremely preterm neonates with respiratory distress syndrome (IN-REC-SUR-E): a randomised, unblinded, controlled trial. THE LANCET RESPIRATORY MEDICINE 2020; 9:159-166. [PMID: 32687801 DOI: 10.1016/s2213-2600(20)30179-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The importance of lung recruitment before surfactant administration has been shown in animal studies. Well designed trials in preterm infants are absent. We aimed to examine whether the application of a recruitment manoeuvre just before surfactant administration, followed by rapid extubation (intubate-recruit-surfactant-extubate [IN-REC-SUR-E]), decreased the need for mechanical ventilation during the first 72 h of life compared with no recruitment manoeuvre (ie, intubate-surfactant-extubate [IN-SUR-E]). METHODS We did a randomised, unblinded, controlled trial in 35 tertiary neonatal intensive care units in Italy. Spontaneously breathing extremely preterm neonates (24 + 0 to 27 + 6 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 h of life were randomly assigned (1:1) with a minimisation algorithm to IN-REC-SUR-E or IN-SUR-E using an interactive web-based electronic system, stratified by clinical site and gestational age. The primary outcome was the need for mechanical ventilation in the first 72 h of life. Analyses were done in intention-to-treat and per-protocol populations, with a log-binomial regression model correcting for stratification factors to estimate adjusted relative risk (RR). This study is registered with ClinicalTrials.gov, NCT02482766. FINDINGS Of 556 infants assessed for eligibility, 218 infants were recruited from Nov 12, 2015, to Sept 23, 2018, and included in the intention-to-treat analysis. The requirement for mechanical ventilation during the first 72 h of life was reduced in the IN-REC-SUR-E group (43 [40%] of 107) compared with the IN-SUR-E group (60 [54%] of 111; adjusted RR 0·75, 95% CI 0·57-0·98; p=0·037), with a number needed to treat of 7·2 (95% CI 3·7-135·0). The addition of the recruitment manoeuvre did not adversely affect the safety outcomes of in-hospital mortality (19 [19%] of 101 in the IN-REC-SUR-E group vs 37 [33%] of 111 in the IN-SUR-E group), pneumothorax (four [4%] of 101 vs seven [6%] of 111), or grade 3 or worse intraventricular haemorrhage (12 [12%] of 101 vs 17 [15%] of 111). INTERPRETATION A lung recruitment manoeuvre just before surfactant administration improved the efficacy of surfactant treatment in extremely preterm neonates compared with the standard IN-SUR-E technique, without increasing the risk of adverse neonatal outcomes. The reduced need for mechanical ventilation during the first 72 h of life might facilitate implementation of a non-invasive respiratory support strategy. FUNDING None.
Collapse
|
7
|
Allison BJ, Youn H, Malhotra A, McDonald CA, Castillo-Melendez M, Pham Y, Sutherland AE, Jenkin G, Polglase GR, Miller SL. Is Umbilical Cord Blood Therapy an Effective Treatment for Early Lung Injury in Growth Restriction? Front Endocrinol (Lausanne) 2020; 11:86. [PMID: 32194502 PMCID: PMC7063054 DOI: 10.3389/fendo.2020.00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/11/2020] [Indexed: 11/22/2022] Open
Abstract
Fetal growth restriction (FGR) and prematurity are often co-morbidities, and both are risk factors for lung disease. Despite advances in early delivery combined with supportive ventilation, rates of ventilation-induced lung injury (VILI) remain high. There are currently no protective treatments or interventions available that target lung morbidities associated with FGR preterm infants. Stem cell therapy, such as umbilical cord blood (UCB) cell administration, demonstrates an ability to attenuate inflammation and injury associated with VILI in preterm appropriately grown animals. However, no studies have looked at the effects of stem cell therapy in growth restricted newborns. We aimed to determine if UCB treatment could attenuate acute inflammation in the first 24 h of ventilation, comparing effects in lambs born preterm following FGR with those born preterm but appropriately grown (AG). Placental insufficiency (FGR) was induced by single umbilical artery ligation in twin-bearing ewes at 88 days gestation, with twins used as control (appropriately grown, AG). Lambs were delivered preterm at ~126 days gestation (term is 150 days) and randomized to either immediate euthanasia (unventilated controls, AGUVC and FGRUVC) or commenced on 24 h of gentle supportive ventilation (AGV and FGRV) with additional cohorts receiving UCB treatment at 1 h (AGCELLS, FGRCELLS). Lungs were collected at post-mortem for histological and biochemical examination. Ventilation caused lung injury in AG lambs, as indicated by decreased septal crests and elastin density, as well as increased inflammation. Lung injury in AG lambs was attenuated with UCB therapy. Ventilated FGR lambs also sustained lung injury, albeit with different indices compared to AG lambs; in FGR, ventilation reduced septal crest density, reduced alpha smooth muscle actin density and reduced cell proliferation. UCB treatment in ventilated FGR lambs further decreased septal crest density and increased collagen deposition, however, it increased angiogenesis as evidenced by increased vascular endothelial growth factor (VEGF) expression and vessel density. This is the first time that a cell therapy has been investigated in the lungs of growth restricted animals. We show that the uterine environment can alter the response to both secondary stress (ventilation) and therapy (UCB). This study highlights the need for further research on the potential impact of novel therapies on a growth restricted offspring.
Collapse
Affiliation(s)
- Beth J. Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
- *Correspondence: Beth J. Allison
| | - Hannah Youn
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Atul Malhotra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Monash Newborn, Monash Medical Centre, Clayton, VIC, Australia
| | - Courtney A. McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Amy E. Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology and Paediatrics, Monash University, Clayton, VIC, Australia
| |
Collapse
|
8
|
Spengler D, Rintz N, Krause MF. An Unsettled Promise: The Newborn Piglet Model of Neonatal Acute Respiratory Distress Syndrome (NARDS). Physiologic Data and Systematic Review. Front Physiol 2019; 10:1345. [PMID: 31736777 PMCID: PMC6831728 DOI: 10.3389/fphys.2019.01345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/10/2019] [Indexed: 12/12/2022] Open
Abstract
Despite great advances in mechanical ventilation and surfactant administration for the newborn infant with life-threatening respiratory failure no specific therapies are currently established to tackle major pro-inflammatory pathways. The susceptibility of the newborn infant with neonatal acute respiratory distress syndrome (NARDS) to exogenous surfactant is linked with a suppression of most of the immunologic responses by the innate immune system, however, additional corticosteroids applied in any severe pediatric lung disease with inflammatory background do not reduce morbidity or mortality and may even cause harm. Thus, the neonatal piglet model of acute lung injury serves as an excellent model to study respiratory failure and is the preferred animal model for reasons of availability, body size, similarities of porcine and human lung, robustness, and costs. In addition, similarities to the human toll-like receptor 4, the existence of intraalveolar macrophages, the sensitivity to lipopolysaccharide, and the production of nitric oxide make the piglet indispensable in anti-inflammatory research. Here we present the physiologic and immunologic data of newborn piglets from three trials involving acute lung injury secondary to repeated airway lavage (and others), mechanical ventilation, and a specific anti-inflammatory intervention via the intratracheal route using surfactant as a carrier substance. The physiologic data from many organ systems of the newborn piglet—but with preference on the lung—are presented here differentiating between baseline data from the uninjured piglet, the impact of acute lung injury on various parameters (24 h), and the follow up data after 72 h of mechanical ventilation. Data from the control group and the intervention groups are listed separately or combined. A systematic review of the newborn piglet meconium aspiration model and the repeated airway lavage model is finally presented. While many studies assessed lung injury scores, leukocyte infiltration, and protein/cytokine concentrations in bronchoalveolar fluid, a systematic approach to tackle major upstream pro-inflammatory pathways of the innate immune system is still in the fledgling stages. For the sake of newborn infants with life-threatening NARDS the newborn piglet model still is an unsettled promise offering many options to conquer neonatal physiology/immunology and to establish potent treatment modalities.
Collapse
Affiliation(s)
- Dietmar Spengler
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Nele Rintz
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Martin F Krause
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| |
Collapse
|
9
|
Fetal growth restriction is associated with an altered cardiopulmonary and cerebral hemodynamic response to surfactant therapy in preterm lambs. Pediatr Res 2019; 86:47-54. [PMID: 30982059 DOI: 10.1038/s41390-019-0398-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/03/2019] [Accepted: 04/07/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Efficacy of surfactant therapy in fetal growth restricted (FGR) preterm neonates is unknown. METHODS Twin-bearing ewes underwent surgery at 105 days gestation to induce FGR in one twin by single umbilical artery ligation. At 123-127 days, catheters and flow probes were implanted in pulmonary and carotid arteries to measure flow and pressure. Lambs were delivered, intubated and mechanically ventilated. At 10 min, surfactant (100 mg kg-1) was administered. Ventilation, oxygenation, and hemodynamic responses were recorded for 1 h before euthanasia at 120 min. Lung tissue and bronchoalveolar lavage fluid was collected for analysis of surfactant protein mRNA and phosphatidylcholines (PCs). RESULTS FGR preterm lambs were 26% lighter than appropriate for gestational age (AGA) lambs and had baseline differences in lung mechanics and pulmonary blood flows. Surfactant therapy reduced ventilator and oxygen requirements and improved lung mechanics in both groups, although a more rapid improvement in compliance and tidal volume was observed in AGA lambs. Surfactant administration was associated with decreased mean pulmonary and carotid blood flow in FGR but not AGA lambs. No major differences in surfactant protein mRNA or PC levels were noted. CONCLUSIONS Surfactant therapy was associated with an altered pulmonary and cerebral hemodynamic response in preterm FGR lambs.
Collapse
|
10
|
Niemarkt H, Hütten M, Kramer BW. Surfactant for Respiratory Distress Syndrome: New Ideas on a Familiar Drug with Innovative Applications. Neonatology 2017; 111:408-414. [PMID: 28538236 PMCID: PMC5516408 DOI: 10.1159/000458466] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the last 4 decades, advances in neonatology have led to a significant increase in the survival of preterm infants. One of the biggest advances was the introduction of surfactant replacement therapy for the treatment of respiratory distress syndrome. This is the main cause of respiratory insufficiency in preterm infants and is one of the major causes of perinatal morbidity and mortality. Surfactant replacement therapy is already a well-investigated and established therapy in neonatology. However, surfactant replacement therapy has progressed and been refined over recent decades, especially with the increasing care for preterm infants born before 26 weeks' gestational age and the recent clinical focus on avoiding mechanical ventilation. Clinical evidence is evolving on new types of surfactant, surfactant dosages, co-medication given before, with, or after surfactant replacement, and new technical advances regarding the mode of administration.
Collapse
Affiliation(s)
- H.J. Niemarkt
- Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - M.C. Hütten
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
- *Prof. Boris W. Kramer, Department of Pediatrics, Maastricht University Medical Center, PO Box 5800, NL-6202 AZ Maastricht (The Netherlands), E-Mail
| |
Collapse
|
11
|
Vento G, Pastorino R, Boni L, Cota F, Carnielli V, Cools F, Dani C, Mosca F, Pillow J, Polglase G, Tagliabue P, van Kaam AH, Ventura ML, Tana M, Tirone C, Aurilia C, Lio A, Ricci C, Gambacorta A, Consigli C, D'Onofrio D, Gizzi C, Massenzi L, Cardilli V, Casati A, Bottino R, Pontiggia F, Ciarmoli E, Martinelli S, Ilardi L, Colnaghi M, Matassa PG, Vendettuoli V, Villani P, Fusco F, Gazzolo D, Ricotti A, Ferrero F, Stasi I, Magaldi R, Maffei G, Presta G, Perniola R, Messina F, Montesano G, Poggi C, Giordano L, Roma E, Grassia C, Ausanio G, Sandri F, Mescoli G, Giura F, Garani G, Solinas A, Lucente M, Nigro G, Del Vecchio A, Petrillo F, Orfeo L, Grappone L, Quartulli L, Scorrano A, Messner H, Staffler A, Gargano G, Balestri E, Nobile S, Cacace C, Meli V, Dallaglio S, Pasqua B, Mattia L, Gitto E, Vitaliti M, Re MP, Vedovato S, Grison A, Berardi A, Torcetta F, Guidotti I, di Fabio S, Maranella E, Mondello I, Visentin S, Tormena F. Efficacy of a new technique - INtubate-RECruit-SURfactant-Extubate - "IN-REC-SUR-E" - in preterm neonates with respiratory distress syndrome: study protocol for a randomized controlled trial. Trials 2016; 17:414. [PMID: 27538798 PMCID: PMC4991115 DOI: 10.1186/s13063-016-1498-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 07/31/2016] [Indexed: 11/15/2022] Open
Abstract
Background Although beneficial in clinical practice, the INtubate-SURfactant-Extubate (IN-SUR-E) method is not successful in all preterm neonates with respiratory distress syndrome, with a reported failure rate ranging from 19 to 69 %. One of the possible mechanisms responsible for the unsuccessful IN-SUR-E method, requiring subsequent re-intubation and mechanical ventilation, is the inability of the preterm lung to achieve and maintain an “optimal” functional residual capacity. The importance of lung recruitment before surfactant administration has been demonstrated in animal studies showing that recruitment leads to a more homogeneous surfactant distribution within the lungs. Therefore, the aim of this study is to compare the application of a recruitment maneuver using the high-frequency oscillatory ventilation (HFOV) modality just before the surfactant administration followed by rapid extubation (INtubate-RECruit-SURfactant-Extubate: IN-REC-SUR-E) with IN-SUR-E alone in spontaneously breathing preterm infants requiring nasal continuous positive airway pressure (nCPAP) as initial respiratory support and reaching pre-defined CPAP failure criteria. Methods/design In this study, 206 spontaneously breathing infants born at 24+0–27+6 weeks’ gestation and failing nCPAP during the first 24 h of life, will be randomized to receive an HFOV recruitment maneuver (IN-REC-SUR-E) or no recruitment maneuver (IN-SUR-E) just prior to surfactant administration followed by prompt extubation. The primary outcome is the need for mechanical ventilation within the first 3 days of life. Infants in both groups will be considered to have reached the primary outcome when they are not extubated within 30 min after surfactant administration or when they meet the nCPAP failure criteria after extubation. Discussion From all available data no definitive evidence exists about a positive effect of recruitment before surfactant instillation, but a rationale exists for testing the following hypothesis: a lung recruitment maneuver performed with a step-by-step Continuous Distending Pressure increase during High-Frequency Oscillatory Ventilation (and not with a sustained inflation) could have a positive effects in terms of improved surfactant distribution and consequent its major efficacy in preterm newborns with respiratory distress syndrome. This represents our challenge. Trial registration ClinicalTrials.gov identifier: NCT02482766. Registered on 1 June 2015.
Collapse
Affiliation(s)
- Giovanni Vento
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Roberta Pastorino
- Section of Hygiene, Institute of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Luca Boni
- Clinical Trials Coordinating Center of Istituto Toscano Tumori, Department of Oncology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesco Cota
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Virgilio Carnielli
- Division of Neonatology, Department of Clinical Sciences, Polytechnic University of Marche and Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital, Viale Morgagni 85, 50141, Florence, Italy
| | - Fabio Mosca
- Department of Clinical Sciences and Community Health, University of Milan-Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Jane Pillow
- School of Anatomy, Physiology and Human Biology, University of Western Australia, Crawley, WA, Australia
| | - Graeme Polglase
- The Ritchie Centre Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168, VIC, Australia
| | | | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Milena Tana
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Chiara Tirone
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Claudia Aurilia
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Alessandra Lio
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Cinzia Ricci
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Alessandro Gambacorta
- Division of Neonatology, Department for the Protection of Women's Health and the Nascent Life, Child and Adolescent, Policlinico A. Gemelli - Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
| | | | | | - Camilla Gizzi
- Ospedale S. Giovanni Calibita Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Luca Massenzi
- Ospedale S. Giovanni Calibita Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Viviana Cardilli
- Università di Roma "La Sapienza"/Policlinico Umberto I, Rome, Italy
| | | | | | | | | | | | | | - Mariarosa Colnaghi
- Department of Clinical Sciences and Community Health, University of Milan-Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Piero Giuseppe Matassa
- Department of Clinical Sciences and Community Health, University of Milan-Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | - Valentina Vendettuoli
- Department of Clinical Sciences and Community Health, University of Milan-Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy
| | | | | | - Diego Gazzolo
- Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Alberto Ricotti
- Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Federica Ferrero
- Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Ilaria Stasi
- Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Rosario Magaldi
- Azienda Ospedaliero-Universitaria Ospedali Riuniti, Foggia, Italy
| | | | | | | | | | | | | | | | - Enza Roma
- Casa di Cura Pineta Grande, Castelvolturno (CE), Italy
| | | | - Gaetano Ausanio
- Azienda Ospedaliera Sant' Anna e San Sebastiano, Caserta, Italy
| | | | | | | | - Giampaolo Garani
- Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | - Agostina Solinas
- Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | | | | | | | | | | | | | | | | | | | | | - Giancarlo Gargano
- Azienda Ospedaliera Arcispedale S.Maria Nuova di Reggio Emilia/IRCCS, Reggio Emilia, Italy
| | - Eleonora Balestri
- Azienda Ospedaliera Arcispedale S.Maria Nuova di Reggio Emilia/IRCCS, Reggio Emilia, Italy
| | - Stefano Nobile
- Polytechnic University of Marche and Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | | | | | - Sara Dallaglio
- Azienda Ospedaliera-Universitaria di Parma, Parma, Italy
| | - Betta Pasqua
- Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele- PO G. Rodolico, Catania, Italy
| | - Loretta Mattia
- Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele- PO G. Rodolico, Catania, Italy
| | - Eloisa Gitto
- Azienda Ospedaliero-Universitaria Policlinico "G. Martino", Messina, Italy
| | - Marcello Vitaliti
- Azienda Ospedaliera di rilievo nazionale e di alta specializzazione Arnas Civico, Palermo, Italy
| | - Maria Paola Re
- Azienda Ospedaliera di rilievo nazionale e di alta specializzazione Arnas Civico, Palermo, Italy
| | | | | | | | | | | | | | | | - Isabella Mondello
- Azienda ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | | | | |
Collapse
|
12
|
El-Chimi MS, Awad HA, El-Gammasy TM, El-Farghali OG, Sallam MT, Shinkar DM. Sustained versus intermittent lung inflation for resuscitation of preterm infants: a randomized controlled trial. J Matern Fetal Neonatal Med 2016; 30:1273-1278. [DOI: 10.1080/14767058.2016.1210598] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
13
|
Krafft MP. Overcoming inactivation of the lung surfactant by serum proteins: a potential role for fluorocarbons? SOFT MATTER 2015; 11:5982-5994. [PMID: 26110877 DOI: 10.1039/c5sm00926j] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In many pulmonary conditions serum proteins interfere with the normal adsorption of components of the lung surfactant to the surface of the alveoli, resulting in lung surfactant inactivation, with potentially serious untoward consequences. Here, we review the strategies that have recently been designed in order to counteract the biophysical mechanisms of inactivation of the surfactant. One approach includes protein analogues or peptides that mimic the native proteins responsible for innate resistance to inactivation. Another perspective uses water-soluble additives, such as electrolytes and hydrophilic polymers that are prone to enhance adsorption of phospholipids. An alternative, more recent approach consists of using fluorocarbons, that is, highly hydrophobic inert compounds that were investigated for partial liquid ventilation, that modify interfacial properties and can act as carriers of exogenous lung surfactant. The latter approach that allows fluidisation of phospholipid monolayers while maintaining capacity to reach near-zero surface tension definitely warrants further investigation.
Collapse
Affiliation(s)
- Marie Pierre Krafft
- Institut Charles Sadron (CNRS), University of Strasbourg, 23 rue du Loess, 67034 Strasbourg Cedex, France.
| |
Collapse
|
14
|
Preuss S, Omam FD, Scheiermann J, Stadelmann S, Winoto-Morbach S, von Bismarck P, Adam-Klages S, Knerlich-Lukoschus F, Lex D, Wesch D, Held-Feindt J, Uhlig S, Schütze S, Krause MF. Topical application of phosphatidyl-inositol-3,5-bisphosphate for acute lung injury in neonatal swine. J Cell Mol Med 2014; 16:2813-26. [PMID: 22882773 PMCID: PMC4118249 DOI: 10.1111/j.1582-4934.2012.01618.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Hypoxemic respiratory failure of the neonatal organism involves increased acid sphingomyelinase (aSMase) activity and production of ceramide, a second messenger of a pro-inflammatory pathway that promotes increased vascular permeability, surfactant alterations and alveolar epithelial apoptosis. We comparatively assessed the benefits of topical aSMase inhibition by either imipramine (Imi) or phosphatidylinositol-3,5-bisphosphate (PIP2) when administered into the airways together with surfactant (S) for fortification. In this translational study, a triple-hit acute lung injury model was used that entails repeated airway lavage, injurious ventilation and tracheal lipopolysaccharide instillation in newborn piglets subject to mechanical ventilation for 72 hrs. After randomization, we administered an air bolus (control), S, S+Imi, or S+PIP2. Only in the latter two groups we observed significantly improved oxygenation and ventilation, dynamic compliance and pulmonary oedema. S+Imi caused systemic aSMase suppression and ceramide reduction, whereas the S+PIP2 effect remained compartmentalized in the airways because of the molecule's bulky structure. The surfactant surface tensions improved by S+Imi and S+PIP2 interventions, but only to a minor extent by S alone. S+PIP2 inhibited the migration of monocyte-derived macrophages and granulocytes into airways by the reduction of CD14/CD18 expression on cell membranes and the expression of epidermal growth factors (amphiregulin and TGF-β1) and interleukin-6 as pro-fibrotic factors. Finally we observed reduced alveolar epithelial apoptosis, which was most apparent in S+PIP2 lungs. Exogenous surfactant “fortified” by PIP2, a naturally occurring surfactant component, improves lung function by topical suppression of aSMase, providing a potential treatment concept for neonates with hypoxemic respiratory failure.
Collapse
Affiliation(s)
- Stefanie Preuss
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Department of Pediatrics, Kiel, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Burkhardt W, Kraft S, Ochs M, Proquitté H, Mense L, Rüdiger M. Persurf, a new method to improve surfactant delivery: a study in surfactant depleted rats. PLoS One 2012; 7:e47923. [PMID: 23082229 PMCID: PMC3474734 DOI: 10.1371/journal.pone.0047923] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 09/19/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Exogenous surfactant is not very effective in adults with ARDS, since surfactant does not reach atelectatic alveoli. Perfluorocarbons (PFC) can recruit atelectatic areas but do not replace impaired endogenous surfactant. A surfactant-PFC-mixture could combine benefits of both therapies. The aim of the proof-of-principal-study was to produce a PFC-in-surfactant emulsion (Persurf) and to test in surfactant depleted Wistar rats whether Persurf achieves I.) a more homogenous pulmonary distribution and II.) a more homogenous recruitment of alveoli when compared with surfactant or PFC alone. METHODS Three different PFC were mixed with surfactant and phospholipid concentration in the emulsion was measured. After surfactant depletion, animals either received 30 ml/kg of PF5080, 100 mg/kg of stained (green dye) Curosurf™ or 30 ml/kg of Persurf. Lungs were fixated after 1 hour of ventilation and alveolar aeration and surfactant distribution was estimated by a stereological approach. RESULTS Persurf contained 3 mg/ml phospholipids and was stable for more than 48 hours. Persurf-administration improved oxygenation. Histological evaluation revealed a more homogenous surfactant distribution and alveolar inflation when compared with surfactant treated animals. CONCLUSIONS In surfactant depleted rats administration of PFC-in-surfactant emulsion leads to a more homogenous distribution and aeration of the lung than surfactant alone.
Collapse
Affiliation(s)
- Wolfram Burkhardt
- Department for Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Universitätsklinikum Carl Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden, Dresden, Germany
| | - Stephan Kraft
- Department for Pediatric Surgery, Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - Matthias Ochs
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Hans Proquitté
- Clinic for Neonatology, Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Lars Mense
- Department for Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Universitätsklinikum Carl Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden, Dresden, Germany
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Universitätsklinikum Carl Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden, Dresden, Germany
- * E-mail:
| |
Collapse
|
16
|
Severe airway obstruction during surfactant administration using a standardized protocol: a prospective, observational study. J Perinatol 2012; 32:270-5. [PMID: 21738121 DOI: 10.1038/jp.2011.89] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the occurrence of adverse effects during surfactant delivery, using a standardized protocol for administration and management of complications. STUDY DESIGN The protocol was developed, implemented and used for 6 months. Vital signs and ventilatory parameters were prospectively recorded during the procedure. Infants were classified into three groups, based on the occurrence and severity of complications: no, minor or major. RESULT A total of 39 infants received surfactant and 19 presented some complication: 11 minor and 8 major. Six of the major complications were episodes of severe airway obstruction (SAO) and five occurred in extreme low birth weight (ELBW) infants that had more severe lung disease before surfactant delivery. Two cases of persistent pulmonary hypertension occurred in infants with birth weight>1000 g. CONCLUSION This study identified a high rate of SAO and provides data to support changes in the protocol, which should include faster and more robust increases in positive inspiratory pressures in ELBW infants presenting with SAO.
Collapse
|
17
|
Preuss S, Stadelmann S, Omam FD, Scheiermann J, Winoto-Morbach S, von Bismarck P, Knerlich-Lukoschus F, Lex D, Adam-Klages S, Wesch D, Held-Feindt J, Uhlig S, Schütze S, Krause MF. Inositol-trisphosphate reduces alveolar apoptosis and pulmonary edema in neonatal lung injury. Am J Respir Cell Mol Biol 2012; 47:158-69. [PMID: 22403805 DOI: 10.1165/rcmb.2011-0262oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
D-myo-inositol-1,2,6-trisphosphate (IP3) is an isomer of the naturally occurring second messenger D-myo-inositol-1,4,5-trisphosphate, and exerts anti-inflammatory and antiedematous effects in the lung. Myo-inositol (Inos) is a component of IP3, and is thought to play an important role in the prevention of neonatal pulmonary diseases such as bronchopulmonary dysplasia and neonatal acute lung injury (nALI). Inflammatory lung diseases are characterized by augmented acid sphingomyelinase (aSMase) activity leading to ceramide production, a pathway that promotes increased vascular permeability, apoptosis, and surfactant alterations. A novel, clinically relevant triple-hit model of nALI was developed, consisting of repeated airway lavage, injurious ventilation, and lipopolysaccharide instillation into the airways, every 24 hours. Thirty-five piglets were randomized to one of four treatment protocols: control (no intervention), surfactant alone, surfactant + Inos, and surfactant + IP3. After 72 hours of mechanical ventilation, lungs were excised from the thorax for subsequent analyses. Clinically, oxygenation and ventilation improved, and extravascular lung water decreased significantly with the S + IP3 intervention. In pulmonary tissue, we observed decreased aSMase activity and ceramide concentrations, decreased caspase-8 concentrations, reduced alveolar epithelial apoptosis, the reduced expression of interleukin-6, transforming growth factor-β1, and amphiregulin (an epithelial growth factor), reduced migration of blood-borne cells and particularly of CD14(+)/18(+) cells (macrophages) into the airspaces, and lower surfactant surface tensions in S + IP3-treated but not in S + Inos-treated piglets. We conclude that the admixture of IP3 to surfactant, but not of Inos, improves gas exchange and edema in our nALI model by the suppression of the governing enzyme aSMase, and that this treatment deserves clinical evaluation.
Collapse
Affiliation(s)
- Stefanie Preuss
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Dani C, Corsini I, Poggi C. Risk factors for intubation-surfactant-extubation (INSURE) failure and multiple INSURE strategy in preterm infants. Early Hum Dev 2012; 88 Suppl 1:S3-4. [PMID: 22266202 DOI: 10.1016/j.earlhumdev.2011.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The INSURE method, which consists of an intubation-surfactant-extubation sequence, is effective in reducing the need for mechanical ventilation (MV), the duration of respiratory support, and the need for surfactant replacement in preterm infants with respiratory distress syndrome. Although beneficial, the INSURE method fails to avoid MV in selected patients. We demonstrated that body weight <750 g, pO(2)/FiO(2) <218, and a/ApO(2) <0.44 at the first blood gas analysis are independent risk factors for INSURE failure in infants with gestational age <30 weeks. Moreover, we demonstrated that the INSURE treatment can be safely repeated with the aim to avoid MV, since the respiratory outcome did not differ between infants treated with single or multiple INSURE procedures.
Collapse
Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, University of Florence, Viale Morgagni 85, Florence, Italy.
| | | | | |
Collapse
|
19
|
Quantitative computed tomography in porcine lung injury with variable versus conventional ventilation: Recruitment and surfactant replacement*. Crit Care Med 2011; 39:1721-30. [DOI: 10.1097/ccm.0b013e3182186d09] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
20
|
Dani C, Corsini I, Bertini G, Pratesi S, Barp J, Rubaltelli FF. Effect of multiple INSURE procedures in extremely preterm infants. J Matern Fetal Neonatal Med 2011; 24:1427-31. [PMID: 21506654 DOI: 10.3109/14767058.2011.572203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Our aim was to evaluate whether single and multiple intubation-surfactant-extubation (INSURE) procedures have similar effects on the need of mechanical ventilation (MV) and occurrence of bronchopulmonary dysplasia (BPD) in extremely preterm infants. METHODS We studied infants of <30 weeks of gestation with respiratory distress syndrome (RDS) who were treated with single (FiO(2)>0.30 without need of MV) or multiple (FiO(2)>0.40 without need of MV) INSURE procedures. RESULTS Seventy-five infants were studied: 53 (71%) received single INSURE and 22 (29%) received multiple INSURE procedures. Infants in the single and multiple groups had similar rates of need of MV (15 vs. 23%) and occurrence of BPD (9 vs. 9%), although the latter were more immature and affected by more severe RDS (higher FiO(2), lower a/ApO(2), and pO(2)/FiO(2)) than the former. CONCLUSIONS Single and multiple INSURE procedures were followed by similar respiratory outcome in a cohort of extremely preterm infants. Further studies are warranted to evaluate whether the multiple INSURE strategy enhances the success rate of INSURE in preventing the need of MV and the occurrence of BPD.
Collapse
Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Viale Morgagni 85, Florence, Italy.
| | | | | | | | | | | |
Collapse
|
21
|
von Bismarck P, Klemm K, García Wistädt CF, Winoto-Morbach S, Schütze S, Krause MF. Selective NF-kappaB inhibition, but not dexamethasone, decreases acute lung injury in a newborn piglet airway inflammation model. Pulm Pharmacol Ther 2009; 22:297-304. [PMID: 19254776 DOI: 10.1016/j.pupt.2009.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 01/20/2009] [Accepted: 02/19/2009] [Indexed: 10/21/2022]
Abstract
Acute respiratory failure in neonates (e.g. ARDS, meconium aspiration pneumonitis, pneumonia) is characterized by an excessive inflammatory response, governing the migration of polymorpho-nuclear leukocytes (PMNLs) into lung tissue and causing consecutive impairment of gas exchange and lung function. Critical to this inflammatory response is the activation of nuclear factor-kappaB (NF-kappaB) that is required for transcription of the genes for many pro-inflammatory mediators. We asked whether the inhibition of NF-kappaB activity using either a selective inhibitor (IKK-NBD peptide) or dexamethasone would be more effective in decreasing NF-kappaB activity and chemokine expression in pulmonary cells. Changes in lung function were repeatedly assessed for 24h following induction of acute respiratory failure and therapeutic intervention. We conducted a randomized, controlled, prospective animal study with mechanically ventilated newborn piglets which underwent repeated airway lavage (20+/-2 [SEM]) to remove surfactant and to induce lung inflammation. Admixed to 100 mg kg(-1) surfactant, piglets then received either IKK-NBD peptide (S+IKK), a selective inhibitor of NF-kappaB activation, its control peptide without intrinsic activity, dexamethasone (S+Dexa), its solvent aqua, or an air bolus only (all groups n=8). After 24h of mechanical ventilation, the following differences were measured: PaO(2)/FiO(2) (S+IKK 230+/-9 mm Hg vs. S+Dexa 188+/-14, p<0.05); ventilation efficiency index (0.18+/-0.01 [3800/(PIP-PEEP)(*)f(*)PaCO(2)] vs. 0.14+/-0.01, p<0.05); extravascular lung water (24+/-1 ml kg(-1) vs. 29+/-2, p<0.05); PMNL in BAL fluid (112+/-21 cells microl(-1) vs. 208+/-34, p<0.05), IL-8 (351+/-117 pg ml(-1) vs. 491+/-144, p=ns) and leukotriene B(4) (23+/-7 pg ml(-1) vs. 71+/-11, p<0.01) in BAL fluid. NF-kappaB activity in the nucleus of pulmonary cells differed by 32+/-5% vs. 55+/-3, p<0.001. Differences between these two intervention groups were more pronounced in the second half of the observation period (hours 12-24). At 24h of mechanical ventilation, inhibition of NF-kappaB activity by IKK-NBD peptide admixed to surfactant as a carrier caused improved gas exchange, lung function and reduced pulmonary inflammation, as evidenced by reduction in PMNL migration into lung tissue due to reduced nuclear NF-kappaB activity. We conclude that IKK-NBD admixture to surfactant in acute neonatal respiratory failure is superior to dexamethasone administration within the first 24h.
Collapse
Affiliation(s)
- Philipp von Bismarck
- Department of Paediatrics, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schwanenweg 20, Kiel, Germany
| | | | | | | | | | | |
Collapse
|
22
|
von Bismarck P, García Wistädt CF, Klemm K, Winoto-Morbach S, Uhlig U, Schütze S, Adam D, Lachmann B, Uhlig S, Krause MF. Improved Pulmonary Function by Acid Sphingomyelinase Inhibition in a Newborn Piglet Lavage Model. Am J Respir Crit Care Med 2008; 177:1233-41. [DOI: 10.1164/rccm.200705-752oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
23
|
von Bismarck P, Klemm K, Wistädt CFG, Winoto-Morbach S, Uhlig U, Schütze S, Uhlig S, Lachmann B, Krause MF. Surfactant “fortification” by topical inhibition of nuclear factor-κB activity in a newborn piglet lavage model*. Crit Care Med 2007; 35:2309-18. [DOI: 10.1097/01.ccm.0000281472.47067.45] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
24
|
Frerichs I, Dargaville PA, van Genderingen H, Morel DR, Rimensberger PC. Lung Volume Recruitment after Surfactant Administration Modifies Spatial Distribution of Ventilation. Am J Respir Crit Care Med 2006; 174:772-9. [PMID: 16840739 DOI: 10.1164/rccm.200512-1942oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Although surfactant replacement therapy is an established treatment in infant respiratory distress syndrome, the optimum strategy for ventilatory management before, during, and after surfactant instillation remains to be elucidated. OBJECTIVES To determine the effects of surfactant and lung volume recruitment on the distribution of regional lung ventilation. METHODS Acute lung injury was induced in 16 newborn piglets by endotracheal lavage. Optimum positive end-expiratory pressure was identified after lung recruitment and surfactant was administered either at this pressure in the "open" lung or after disconnection of the endotracheal tube in the "closed" lung. An additional recruitment maneuver with subsequent optimum end-expiratory pressure finding was executed in eight animals; in the remaining eight animals, end-expiratory pressure was set at the same level as before surfactant without further recruitment. ("Open" and "closed" lung surfactant administration was evenly distributed in the groups.) Regional ventilation was assessed by electrical impedance tomography. MEASUREMENTS AND MAIN RESULTS Impedance tomography data, airway pressure, flow, and arterial blood gases were acquired during baseline conditions, after induction of lung injury, after the first lung recruitment, and before as well as 10 and 60 min after surfactant administration. Significant shift in ventilation toward the dependent lung regions and less asymmetry in the right-to-left lung ventilation distribution occurred in the postsurfactant period when an additional recruitment maneuver was performed. Surfactant instillation in an "open" versus "closed" lung did not influence ventilation distribution in a major way. CONCLUSIONS The spatial distribution of ventilation in the lavaged lung is modified by a recruitment maneuver performed after surfactant administration.
Collapse
Affiliation(s)
- Inéz Frerichs
- Department of Anesthesiological Research, University of Göttingen, Germany.
| | | | | | | | | |
Collapse
|
25
|
Ankermann T, Reisner A, Wiemann T, Koehler H, Krams M, Krause MF. Intrapulmonary application of a 5-lipoxygenase inhibitor using surfactant as a carrier reduces lung edema in a piglet model of airway lavage. Pediatr Pulmonol 2006; 41:452-62. [PMID: 16547963 DOI: 10.1002/ppul.20392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Leukotriene-generated effects on microvascular integrity and polymorphonuclear leukocytes (PMNL) play a key role in the inflammatory process of the alveolar-capillary unit in neonatal acute respiratory distress syndrome. We asked if intrapulmonary application of MK886, a 5-lipoxygenase inhibitor, and the use of a porcine surfactant preparation (Curosurftrade mark) as a carrier substance would improve lung function in a neonatal piglet model of airway lavage. Anesthetized, mechanically ventilated newborn piglets (n = 19) underwent repeated airway lavage to induce acute lung injury. Piglets then received either surfactant alone (S, n = 6), or MK886 admixed with surfactant (S + MK, n = 7), or an air-bolus injection as control (C, n = 6). Measurements of gas exchange, lung function, extravascular lung water (EVLW), cell counts, and leukotriene B(4) (LTB(4)) concentrations in bronchoalveolar lavage fluid (BAL) were performed during 6 hr of mechanical ventilation. Arterial oxygen partial pressure (PaO(2)) (S, 13.8 +/- 4.2 kPa, vs. S + MK, 20 +/- 6.6; P < 0.05), functional residual capacity (S, 15.1 +/- 6.8 ml/kg, vs. S + MK, 18.8 +/- 3.7 ml/kg; P < 0.05), and EVLW (S, 29 +/- 14 ml/kg, vs. S + MK 24 +/- 4 ml/kg; P < 0.05) were significantly improved in the MK886 group. This clinical effect was linked with a decrease in LTB(4) concentration in BAL (S, 3.5 (1.9-5.4) pg/ml, vs. S + MK, 1.6 (0.7-4.7) pg/ml; P < 0.05) and an increase in IL-8 (S, 2,103 (852-4,243) pg/ml, vs. S + MK, 3,815 (940-26,187) pg/ml; P < 0.05). PMNL counts in BAL were reduced (S, 570 +/- 42 cells/ml, vs. 275 +/- 35 cells/ml; P < 0.05). In conclusion, intrapulmonary application of the 5-lipoxygenase inhibitor MK886 with surfactant as a carrier improves lung function by decreasing EVLW as the main response to LTB(4) reduction.
Collapse
Affiliation(s)
- Tobias Ankermann
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Germany.
| | | | | | | | | | | |
Collapse
|
26
|
Lindner W, Högel J, Pohlandt F. Sustained pressure-controlled inflation or intermittent mandatory ventilation in preterm infants in the delivery room? A randomized, controlled trial on initial respiratory support via nasopharyngeal tube. Acta Paediatr 2005; 94:303-9. [PMID: 16028648 DOI: 10.1111/j.1651-2227.2005.tb18431.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To prove the hypothesis that sustained pressure-controlled inflation compared to intermittent mandatory ventilation for lung recruitment via nasopharyngeal tube after delivery is more effective in reducing the rate of endotracheal intubation and mechanical ventilation in very preterm infants. METHODS The study was designed as a randomized, controlled trial. The setting was the delivery room and neonatal intensive care unit of a university hospital in Germany. Subjects were 61 infants (25.0-28.9 wk of gestation) with signs of respiratory distress immediately after birth. The infants were randomized in the delivery room to two different respiratory interventions: either to sustained pressure-controlled inflation (15 s) or to intermittent mandatory ventilation (rate 60 min(-1)). This respiratory support was given by a nasopharyngeal tube. The inflation pressure or peak inspiratory pressure was increased stepwise (20-25-30 cm H2O) according to the response of heart rate and oxygenation. RESULTS The main outcome measure was treatment failure, i.e., endotracheal intubation and mechanical ventilation according to given intubation criteria. Treatment failure occurred in 61% (95% CI, sustained pressure-controlled inflation: 42-78) and 70% (95% CI, intermittent mandatory ventilation: 51-85) (p = 0.59). The rates of mortality (3/61), severe intraventricular haemorrhage (5/61) and chronic lung disease (10/58) were not different between groups. CONCLUSION Sufficient spontaneous breathing within the first 48 h of life without endotracheal intubation and mechanical ventilation was achieved in about 30% with both methods of initial respiratory support.
Collapse
Affiliation(s)
- Wolfgang Lindner
- Division of Neonatology and Paediatric Critical Care, Department of Paediatrics, University of Ulm, Ulm, Germany.
| | | | | |
Collapse
|
27
|
Krause MF, Wiemann T, Reisner A, Orlowska-Volk M, Köhler H, Ankermann T. Surfactant reduces extravascular lung water and invasion of polymorphonuclear leukocytes into the lung in a piglet model of airway lavage. Pulm Pharmacol Ther 2004; 18:129-39. [PMID: 15649855 DOI: 10.1016/j.pupt.2004.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2004] [Revised: 10/29/2004] [Accepted: 11/07/2004] [Indexed: 10/26/2022]
Abstract
Acute respiratory distress syndrome (ARDS) in newborns and young infants is linked with an inflammatory response of the lungs which affects the capillary-alveolar permeability, epithelial integrity and type I and II pneumocyte function. Abundant extravascular lung water with a high protein content inactivates surfactant together with the enzymatic action of polymorphonuclear leukocytes (PMNL). We asked if a decrease in extravascular lung water and a reduction in lung infiltration with PMNL could be achieved by surfactant administration (Curosurf) within 6 h of mechanical ventilation when given in a newborn piglet model of repeated airway lavage. Improvements in gas exchange and lung mechanics were predominantly caused by resorption of extravascular lung water rather than by the reopening of alveolar atelectases. PMNL were significantly reduced in the bronchoalveolar lavage fluid after 6 h of mechanical ventilation. However, acute phase cytokines (IL-6, TNF-alpha) remained unchanged, except for IL-8 which increased after administration of surfactant. We conclude that the decrease in extravascular lung water and in infiltration with PMNL following surfactant administration is accomplished within 6 h through mechanisms different from attenuation of pro-inflammatory cytokines. Surfactant treatment for newborn and infant ARDS might therefore improve fluid overload and atelectasis and reduce PMNL infiltration.
Collapse
Affiliation(s)
- Martin F Krause
- Department of General Pediatrics, University Children's Hospital, Christian-Albrechts-University, Schwanenweg 20, D-24105 Kiel, Germany.
| | | | | | | | | | | |
Collapse
|
28
|
Ankermann T, Wiemann T, Reisner A, Orlowska-Volk M, Köhler H, Krause MF. Topical interleukin-8 antibody attracts leukocytes in a piglet lavage model. Intensive Care Med 2004; 31:272-80. [PMID: 15502932 DOI: 10.1007/s00134-004-2464-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Accepted: 09/07/2004] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) in young infants is linked with a pulmonary inflammatory response part of which are increased interleukin-8 (IL-8) levels and migration of polymorphonuclear leukocytes (PMNL) into lung tissue. A topical application of an antibody against IL-8 might therefore decrease PMNL migration and improve lung function. DESIGN Randomized, controlled, prospective animal study. SETTING Research laboratory of a university children's hospital. SUBJECTS AND INTERVENTIONS Anesthetized, mechanically ventilated newborn piglets (n=22) underwent repeated airway lavage to remove surfactant and to induce lung inflammation. Piglets then received either surfactant alone (S, n=8), or a topical antibody against IL-8 admixed to surfactant (S+IL-8, n=8), or an air bolus injection (control, n=6). MEASUREMENTS AND RESULTS After 6 h of mechanical ventilation following intervention, oxygenation [S 169+/-51 (SD) vs S+IL-8 139+/-61 mmHg] and lung function (compliance: S 1.3+/-0.4 vs S+IL-8 0.9+/-0.4 ml/cmH(2)O/kg; extra-vascular lung-water: S 27+/-9 vs S+IL-8 52+/-28 ml/kg) were worse in the S+IL-8 group because reactive IL-8 production [S 810 (median, range 447-2323] vs S+IL-8 3485 (628-16180) pg/ml; P<0.05) with facilitated migration of PMNL into lung tissue occurred. Moreover, antibody application caused augmented chemotactic potency of IL-8 [linear regression of migrated PMNL and IL-8 levels: S r(2)=0.30 (P=ns) vs S+IL-8 r(2)=0.89 (P=0.0002)]. CONCLUSION Topical anti-IL-8 treatment after lung injury increases IL-8 production, PMNL migration, and worsens lung function in our piglet lavage model. This effect is in contrast to current literature using pre-lung injury treatment protocols. Our data do not support anti-IL-8 treatment in young infants with ARDS.
Collapse
Affiliation(s)
- Tobias Ankermann
- Department of General Pediatrics, Christian-Albrechts University, Schwanenweg 20, 24105 Kiel, Germany
| | | | | | | | | | | |
Collapse
|
29
|
Anderson JC, Molthen RC, Dawson CA, Haworth ST, Bull JL, Glucksberg MR, Grotberg JB. Effect of ventilation rate on instilled surfactant distribution in the pulmonary airways of rats. J Appl Physiol (1985) 2004; 97:45-56. [PMID: 14990558 DOI: 10.1152/japplphysiol.00609.2003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Liquid can be instilled into the pulmonary airways during medical procedures such as surfactant replacement therapy, partial liquid ventilation, and pulmonary drug delivery. For all cases, understanding the dynamics of liquid distribution in the lung will increase the efficacy of treatment. A recently developed imaging technique for the study of real-time liquid transport dynamics in the pulmonary airways was used to investigate the effect of respiratory rate on the distribution of an instilled liquid, surfactant, in a rat lung. Twelve excised rat lungs were suspended vertically, and a single bolus (0.05 ml) of exogenous surfactant (Survanta, Ross Laboratories, Columbus, OH) mixed with radiopaque tracer was instilled as a plug into the trachea. The lungs were ventilated with a 4-ml tidal volume for 20 breaths at one of two respiratory rates: 20 or 60 breaths/min. The motion of radiodense surfactant was imaged at 30 frames/s with a microfocal X-ray source and an image intensifier. Dynamics of surfactant distribution were quantified for each image by use of distribution statistics and a homogeneity index. We found that the liquid distribution depended on the time to liquid plug rupture, which depends on ventilation rate. At 20 breaths/min, liquid was localized in the gravity-dependent region of the lung. At 60 breaths/min, the liquid coated the airways, providing a more vertically uniform liquid distribution.
Collapse
Affiliation(s)
- Joseph C Anderson
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109-2099, USA
| | | | | | | | | | | | | |
Collapse
|
30
|
Ainsworth SB, Milligan DWA. Surfactant therapy for respiratory distress syndrome in premature neonates: a comparative review. ACTA ACUST UNITED AC 2004; 1:417-33. [PMID: 14720029 DOI: 10.1007/bf03257169] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Exogenous surfactant therapy has been part of the routine care of preterm neonates with respiratory distress syndrome (RDS) since the beginning of the 1990s. Discoveries that led to its development as a therapeutic agent span the whole of the 20th century but it was not until 1980 that the first successful use of exogenous surfactant therapy in a human population was reported. Since then, randomized controlled studies demonstrated that surfactant therapy was not only well tolerated but that it significantly reduced both neonatal mortality and pulmonary air leaks; importantly, those surviving neonates were not at greater risk of subsequent neurological impairment. Surfactants may be of animal or synthetic origin. Both types of surfactants have been extensively studied in animal models and in clinical trials to determine the optimum timing, dose size and frequency, route and method of administration. The advantages of one type of surfactant over another are discussed in relation to biophysical properties, animal studies and results of randomized trials in neonatal populations. Animal-derived exogenous surfactants are the treatment of choice at the present time with relatively few adverse effects related largely to changes in oxygenation and heart rate during surfactant administration. The optimum dose of surfactant is usually 100 mg/kg. The use of surfactant with high frequency oscillation and continuous positive pressure modes of respiratory support presents different problems compared with its use with conventional ventilation. The different components of surfactant have important functions that influence its effectiveness both in the primary function of the reduction of surface tension and also in secondary, but nonetheless just as important, role of lung defense. With greater understanding of the individual surfactant components, particularly the surfactant-associated proteins, development of newer synthetic surfactants has been made possible. Despite being an effective therapy for RDS, surfactant has failed to have a significant impact on the incidence of chronic lung disease in survivors. Paradoxically the cost of care has increased as surviving neonates are more immature and consume a greater proportion of neonatal intensive care resources. Despite this, surfactant is considered a cost-effective therapy for RDS compared with other therapeutic interventions in premature infants.
Collapse
|
31
|
Ingimarsson J, Björklund LJ, Curstedt T, Larsson A, Robertson B, Werner O. A lung recruitment maneuver immediately before rescue surfactant therapy does not affect the lung mechanical response in immature lambs with respiratory distress syndrome. Acta Anaesthesiol Scand 2003; 47:968-72. [PMID: 12904188 DOI: 10.1034/j.1399-6576.2003.00202.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In animals with acquired surfactant-deficiency, a recruitment maneuver by increased tidal volumes enhances the effect of exogenous surfactant. In contrast, in the preterm lamb model, hyperinflation early after birth impairs the effect of surfactant prophylaxis. Here we examined whether a lung recruitment maneuver just before surfactant would affect the response to rescue treatment in immature lambs with established respiratory distress syndrome (RDS). METHODS Five pairs of preterm twin lambs with gestational age 127 days were delivered by cesarean section and supported by pressure-limited mechanical ventilation for 4 h. At 30 min of age, when all the lambs were in severe respiratory failure, they were treated with porcine surfactant, 200 mg x kg-1. One lamb in each pair was subjected to a lung recruitment maneuver consisting of five sustained inflations of 20 ml x kg-1 just before surfactant instillation. RESULTS At 10 min after surfactant treatment, all the lambs showed a large improvement in oxygenation and an increase in inspiratory capacity and static compliance. Except for a transiently better oxygenation after surfactant therapy in the recruitment group (P < 0.05), there was no significant between-group differences in gas exchange or lung mechanics at any time point during the study. There was no difference in post mortem intrapulmonary air volume or alveolar expansion in histologic lung sections between groups. CONCLUSION This small study does not show any positive or negative effect of a lung recruitment maneuver on the response to rescue surfactant therapy in immature animals with RDS.
Collapse
Affiliation(s)
- J Ingimarsson
- Department of Anesthesiology, University Hospital MAS, Malmö, Sweden.
| | | | | | | | | | | |
Collapse
|
32
|
Abstract
A number of conditions, such as pneumonia, trauma, or systemic sepsis arising from the gut, may result in the acute respiratory distress syndrome (ARDS). Because of its significant morbidity and mortality, ARDS has been the focus of extensive research. One specific area of interest has been the investigation of the role of the surfactant system in the pathophysiology of this disease. Several studies have demonstrated that alterations of surfactant contribute to the lung dysfunction associated with ARDS, which has led to investigations into the use of exogenous surfactant as a therapy for this syndrome. Clinical experience with surfactant therapy has been variable owing to a number of factors including the nature of the injury at the time of treatment, the specific surfactant preparation utilized, the dose and delivery method chosen, the timing of surfactant administration over the course of the disease, and the mode of ventilation used during and after surfactant administration.
Collapse
Affiliation(s)
- James F Lewis
- Department of Medicine, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada.
| | | |
Collapse
|
33
|
Luchetti M, Ferrero F, Gallini C, Natale A, Pigna A, Tortorolo L, Marraro G. Multicenter, randomized, controlled study of porcine surfactant in severe respiratory syncytial virus-induced respiratory failure. Pediatr Crit Care Med 2002; 3:261-268. [PMID: 12780967 DOI: 10.1097/00130478-200207000-00011] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE: Recently, natural exogenous surfactant replacement has been used in experimental models and clinical trials for the treatment of severe respiratory syncytial virus (RSV) disease. The present study was aimed at verifying this hypothesis and confirming the results of our previous pilot study by assessing the effect of surfactant treatment in mechanically ventilated infants with severe RSV-induced respiratory failure. DESIGN: Multicenter, randomized, controlled study. SETTING: Six pediatric intensive care units staffed by full-time intensive care physicians. PATIENTS: A total of 40 infants (20 treated and 20 controls) with RSV-induced respiratory failure requiring conventional mechanical ventilation (CMV) were randomly assigned to either exogenous surfactant (treated group) or conventional treatment (control group) over a 1-yr period. INTERVENTIONS: Fifty milligrams per kilogram of body weight of porcine-derived natural surfactant (Curosurf) was administered. The drug was instilled by means of a syringe attached to a small suction catheter inserted into the endotracheal tube down to its tip, momentarily disconnecting the patient from CMV. Main Outcome Measures: The assessment consisted of the following outcome variables: duration of CMV, length of intensive care unit stay, gas exchange, respiratory mechanics, re-treatment need, complications, and mortality. RESULTS: The two groups were similar with regard to demographics, Pediatric Risk of Mortality scores, and baseline Pao(2)/Fio(2), Paco(2), and ventilator settings. A marked increase in Pao(2)/Fio(2) and decrease in Paco(2) were observed in the treated group after surfactant administration. Hemodynamic parameters remained unchanged throughout the study period. Peak inspiratory pressure and static compliance were similar at baseline in the two groups. A decrease in peak inspiratory pressure and increase in static compliance were observed in the treated group after surfactant administration. Among surfactant-treated patients, 15 received the treatment within 24 hrs of admission, whereas the remainder (five patients) were treated later. Among children who were treated later, three needed an additional dose of surfactant. None of the children treated within 24 hrs needed an additional dose. Duration of CMV and length of stay in the intensive care unit were significantly shorter in the treated group (4.6 +/- 0.8 and 6.4 +/- 0.9 days, respectively) compared with the control group (5.8 +/- 0.7 and 8.2 +/- 1.1 days, respectively) (p <.0001). No relevant complications were observed, and all the infants survived. CONCLUSIONS: Consistent with our previous study and others, this study shows that surfactant therapy improves gas exchange and respiratory mechanics and shortens CMV and intensive care unit stay in infants with severe RSV-induced respiratory failure.
Collapse
Affiliation(s)
- Marco Luchetti
- Pediatric Intensive Care Units at "Fatebenefratelli" and Ophthalmiatric Hospital (ML, GM), Milano, Italy; "Regina Margherita" Hospital, Torino, Italy; "S.Antonio e Biagio" Hospital, Alessandria, Italy; "Santobono" Children's Hospital, Napoli, Italy; "S. Orsola Malpighi" Hospital, Bologna, Italy; and "Gemelli" Hospital, Roma, Italy
| | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
The classic entity of neonatal distress syndrome, as a lung disease expressing predominant surfactant deficiency, is currently changing to a more complex disease of the developing lung as a result of the number of extremely immature preterm infants. Prenatal factors, such as the fetal inflammatory response syndrome influence short- and long-term outcome in these premature infants presenting with respiratory distress syndrome at birth. Therefore, various previously dismissed treatment strategies, such as surfactant prophylaxis or newer anti-inflammatory approaches have to be reinvestigated in this emerging population. Despite the resurrection of a new picture of bronchopulmonary dysplasia, lung injury induced by mechanical ventilation remains a major issue in neonatal intensive care. With the advance in understanding of mechanical ventilation, it is becoming evident, that improvement in outcome can not be achieved by restoring normal lung physiology in the diseased lung using sophisticated ventilators and ventilation modes. A more disease specific ventilator strategy that will target as early as possible homogenous lung opening while at the same time avoiding overdistention of the lung, has the potential to affect outcome. The possible antiinflammatory properties of surfactant-proteins, nitric oxide and corticosteroids, despite some drawbacks, may show to have a synergistic effect. However, this needs further exploration.
Collapse
Affiliation(s)
- Peter C Rimensberger
- Division of Pediatric and Neonatal and Intensive Care, University Children's Hospital, University of Geneva, Switzerland.
| |
Collapse
|
35
|
Affiliation(s)
- L J Björklund
- Department of Pediatrics, University Hospital, SE-221 85 Lund, Sweden
| | | |
Collapse
|