Surfactant therapy

surfactant therapy

1. Dr Rakesh Kumar
Asst. Professor
N.M.C.H, Patna

2. Antenatal steroid
Oxygen
CPAP
Mechanical Ventilation
Surfactant

3. Does it work?
When to give?
Which one to give?
How often to give?
How much to give?
How to give?
Does it cause any problems?

4. 1a-Systematic review (with homogeneity) of randomized controlled
trials
1b-Individual randomized controlled trial (with narrow CI)
2a-Systematic review (with homogeneity) of cohort studies
2b-Individual cohort study (or low-quality randomized controlled
trial, eg, <80% follow-up)
3a-Systematic review (with homogeneity) of case-control studies
3b-Individual case-control study
4-Case-series (and poor quality cohort and case-control studies)
5-Expert opinion without explicit critical appraisal, or based on
physiology, bench research or ‘first principles’

5. Grade A-Consistent level 1 studies
Grade B-Consistent level 2 or 3 studies
Grade C-Level 4 studies
Grade D-Level 5 evidence or troublingly
inconsistent or inconclusive studies of any level

6. Surfactant is most widely researched with
maximum RCT’ s in neonatology

7. Odds of death in hospital for VLBW infants
were reduced by 30 % after surfactant was
introduced.

80% of decline in the U.S. neonatal mortality
rate

between 1989 & 1990 could be attributed
solely to the use

of surfactant.
NEJM May 1994

8. Exogenous surfactant replacement has been
established as an appropriate preventive and
treatment therapy for prematurity-related
surfactant deficiency
(AMERICAN ACADEMY OF
PEDIATRICS
Committee on Fetus and Newborn March 1999, pp
684-685)

9. Indian Experience
The mean duration of ventilation 44.1 hours
lesser, and the hospital stay 4.37 days lesser in
babies who received surfactant.

The incidence of sepsis, pneumonia, PDA, IVH
and CLD was lower in babies who received
surfactant.
Narang et al Indian Pediatrics 2001

11. TYPES OF
SURFACTANT
SYNTHETIC MODIFIED NATURAL
(Exosurf, Surfact) (Survanta,
Curosurf,neosurf)
Phospholipids DPPC Animal lung extract
Spreading Cetyl alcholol Surfactant proteins
agents + (SP-B, SP-C)
Tyloxapol

12. •Comparative trials demonstrate greater early
improvement in the requirement for ventilator
support, fewer pneumothoraces, & deaths
associated with natural surfactant.
•Natural surfactant may be associated with an
increase in IVH, though the more serious
hemorrhages (Grade 3 and 4) are not increased.
• Despite these concerns, natural surfactant extracts
would seem to be the more desirable choice when
compared to currently available synthetic
surfactants.
Cochrane 2005

13. Recommendation
Natural surfactants should be used in
preference to any
of the synthetic surfactants available
(grade A).
Cochrane 2005

14. •The animal surfactants have phospholipid compositions

similar to
that of natural surfactant; they contain some SP-B

and SP-C, but
no SP-A.
• The surfactant approved for use in the United States is Survanta

(beractant, Ross Laboratories, Columbus, Ohio) prepared by

mincing bovine lungs in saline and extracting the lipids, SP-B,

and
SP-C with organic solvents. Dipalmitoylphosphatidylcholine,

palmitic acid, and triglyceride are then added to improve the

surface properties of the extract
•. The surface properties

of organic-solvent extracts of lung tissue
also can be improved

by removing neutral lipids by
chromatography, as is done with

Curosurf

15. Absence of Surfactant
High Distending Pressures
Airway Stretch / Distortion
Cellular Membrane Disruption
Edema / Hyaline Membrane Formation
Higher FIO2 / Pressures
Barotrauma, BPD
What happens ?

16. SURFACTANT : DEFICIENCY

18. PRESSURE VOLUME LOOP

19. •There is no indication that exogenously

administered
surfactant inhibits the synthesis and secretion

of
endogenous surfactant
•Two major

benefits result from surfactant treatment:
- The biophysical effects

of the surfactant on the
surfactant-deficient lungs
- And the

provision of phospholipids as substrate
for recycling pathways

20. Timing
Prophylactic
or Rescue

21. The meta-analysis (50 RCT) indicated
that there would be two fewer
pneumothoraces and five fewer deaths
for every 100 babies treated
prophylactically with surfactant.

22. •Prophylactic treatment during the first 15 minutes of life
appears to be more effective
•BUT not all infants that would appear to be at risk of
developing RDS, actually develop the condition.
•May lead to some infants being over treated, and possibly
being exposed to adverse effects, unnecessarily.

23. Trade name Active
ingredient
Source dosing
Survanta Beractant Bovine lung
extract
4ml/kg, maximum upto 4
times 6 hrly
Infasurf Calfactant Calf lung
lavage
3ml/kg, maximum up to 3
doses 12 hrly
Curosurf Poractant alfaPorcine lung
extract
2.5ml/ kg 1
st
dose
maximum upto 1.25ml//kg
up to 2 doses 12hrly
Neosurf Beractant Bovine lung
lavage
5ml/kg 1
st
dose maximum
upto 3 doses 12hrly

24. ARE MULTIPLE DOSES MORE BENEFICIAL ?

25. •Multiple doses of surfactant have been given in most
trials

because the response to an individual dose is often
transient.
•

In preterm animals, exogenously administered surfactant
is can be inhibited by

soluble proteins and other factors in
the small airways and

alveoli.
Multiple doses are thought to be useful because they

can
overcome this functional inactivation of surfactant.
Pediatrics 1991

27. Synergistic effect
Prenatal steroids + Surfactant is better
than either alone
¯ neonatal mortality
¯ air leaks
¯ severe IVH
Give both
Am J Obst Gynec Suppl, 1995

28. A secondary analysis of data from
surfactant trials also indicates a greater
reduction in disease severity in babies
who received antenatal steroids
(evidence level 4).
Combination of antenatal steroids is
more effective than exogenous
surfactant alone (evidence level 2b).

29. INSURE procedure
Early surfactant replacement therapy with
extubation to N CPAP compared with continued
mechanical ventilation with extubation is
associated with a reduced need for mechanical
ventilation and increased utilization of exogenous
surfactant therapy.
COCHRANE 2005

30. “ Options for ventilatory management that
are to be considered after surfactant
therapy include very rapid weaning and
extubation to CPAP (grade B evidence).”

31. Intubate
Give Surfactant
Extubate
Put on Ncpap

34. Infant of diabetic mother
Meconium Aspiration Syndrome
Congenital Diaphragmatic Hernia

35. WHAT ARE THE RISKS OF EXOGENOUS SURFACTANT
THERAPY?

36. The short-term risks of surfactant replacement therapy
• Bradycardia and hypoxemia during instillation,
• Blockage of the endotracheal tube
• Increase in pulmonary hemorrhage following surfactant
treatment
• However, mortality ascribed to pulmonary hemorrhage
is not increased and overall mortality is lower after
surfactant therapy.

37. Is Surfactant
beyond the
reach of the
common
man?

38. Surfactant is expensive
22% reduction in hospital charges per survivor
52 % Reduction in ancillary charges

39. Extremely preterm infants with structurally lung
immaturity
Pneumonia or pulmonary hypoplasia
Perinatal asphyxia
Pulmonary edema from lung damage or fluid
overload
Pulmonary edema from L-R shunting through PDA
Congenital B protein deficiency