Case reports

A case study reports that bronchoscopic surfactant administration is a safe and effective therapeutic option in pediatric patients with lobar atelectasis

Persistent lobar atelectasis is frequently seen in pediatric patients undergoing mechanical ventilation and also occurs in the immediate post-extubation period. Several treatment options have been advocated for patients of all ages but some of them showed no efficacy or were proved to be harmful in a pediatric population. A suitable option can be b ronchoscopic interventions, which are thought to restore functional residual capacity, to reduce intrapulmonary shunt volume and to improve mechanical properties and gas exchange in the lung.

It has been shown in adult patients that pure suctioning of obstructed airways does not restore or maintain the lung volume. Therefore, surfactant administration as a supplementary therapy might help to minimize surface tension and improve mucous transport within pediatric airways. Surfactant has also anti-inflammatory effects and it is able to improve gas exchange and the mechanical properties of the lung. Moreover, atelectasis can occur following surfactant dysfunction and deficiency. This further worsens lung mechanics and gas exchange in a lung treated with mechanical ventilation. Lobar surfactant administration after suctioning is therefore a promising treatment option for persistent lobar atelectasis in mechanically ventilated pediatric patients.

A German group reported a case study (Respiration 2005 Sep 30, PubMed) of bronchoscope-guided administration of surfactant and its short-term effects to the affected lung segments in 5 consecutive mechanically ventilated pediatric patients with different pulmonary diseases, in order to determine if surfactant administration to atelectatic areas could improve gas exchange, resolve atelectasis and allow extubation within 24 hours following the intervention.

After inspection of the bronchial system and suction of mucus from the bronchus opening, the diluted surfactant preparation (Curosurf^® diluted with normal saline) was instilled into the affected lobes in conformity with standard fluid deposition in the airways. The diluted surfactant preparation was divided by the number of segments affected by atelectasis. Chest X-rays showed an improvement in all patients (estimated resolution in atelectasis: 64±29%) concomitant with improvements in PaO₂/FiO₂ and a decrease in respiratory rate. Patients who underwent mechanical ventilation could be extubated within 24 hours after the bronchoscopic administration of surfactant and showed no recurrence of atelectasis during the follow-up period. No serious adverse effects were observed and hemodynamic parameters did not show any important change.

In conclusion, bronchoscopic surfactant administration in pediatric patients on mechanical ventilation or in the immediate post-extubation period with persistent lobar atelectasis appears to be safe and demonstrated a high success rate for short-term parameters such as gas exchange, respiratory rate and radiographic resolution of atelectasis. Anyway, controlled randomized studies of pediatric patients are warranted in order to further elucidate the role of this treatment option.

Top