Secondary surfactant administration in neonates with respiratory decompensation

In spite of surfactant treatment of acute RDS in the first days of life, premature infants can have a secondary respiratory decompensation necessitating increased oxygen and ventilator pressures. The clinical sequelae of increased ventilatory support may continue for days or even weeks and carry significant risk for preterm infants. It has been calculated that 30% of low birth weight infants will progress to chronic lung disease (CLD). Although the relationship of decompensation after the first week of life and the development of CLD is complex, there is evidence that this secondary respiratory decompensation involves damage to the surfactant system. For instance, results of a study conducted on 68 infants <30 weeks gestation showed that 75% of infants who remained intubated >7 days had dysfunctional surfactant. Respiratory deterioration, measured by worsening of respiratory severity score (RSS), was evident in those infants with surfactant deficiency. In some studies exogenous surfactant was effective in selected infants with secondary respiratory decompensation from various etiologies.
On this basis, an American group conducted a pilot study to evaluate blood gases and ventilatory parameters before and after two doses of surfactant in premature infants with respiratory decompensation after recovery from primary RDS.
The study included infants with a birth weight = 500 g, from 7 days to 3 months of age, with a secondary respiratory decompensation lasting at least 4 h prior to study entry. Infants received two doses of surfactant, 12 h apart.
A total of 20 neonates were evaluated. The administration of surfactant improved significantly PCO2 (P<0.001), pH (P<0.001), mean airway pressure (P<0.05), FiO2 (P<0.05), modified ventilatory indices (P<0.004) and respiratory severity scores (P<0.001) at both 12 and 24 h after surfactant administration, when compared to baseline values.
In conclusion, secondary surfactant administration led to short-term improvement in blood gas and ventilatory parameters, as well as indices of pulmonary function. However, large, prospective, randomized-controlled studies are needed, evaluating both short- and long-term clinical outcomes, to establish the efficacy of administering surfactant to neonates who experience respiratory failure after recuperation from their initial RDS.

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