24/02/2005
Two treatment strategies in preterm infants with, or at risk of, respiratory distress syndrome (RDS) at comparison

The Cochrane review compares early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with, or at risk of, RDS.

The review relied upon the fact that both prophylactic and early surfactant replacement therapy, compared with later selective surfactant administration, reduce mortality and pulmonary complications in ventilated infants with RDS. The authors of the review (Stevens TP, Blennow M, Soll RF) took into account the fact that continued post-surfactant intubation and ventilation are risk factors for chronic lung disease. They analysed clinical studies which compare early surfactant administration with brief mechanical ventilation, followed by prompt extubation, with later, selective use of surfactant followed by continued mechanical ventilation and extubation from low respiratory support.

The review considered two populations of infants receiving early surfactant: spontaneously breathing infants with signs of RDS and infants at high risk for RDS. The search was based on several medical databases (MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Pediatric Research), analysed including a time-span going from 1966 to 2004.

For the purposes of the review, clinical trials, randomised or quasi-randomized controlled, were selected comparing early surfactant administration with planned brief mechanical ventilation (less than one hour) followed by extubation, vs selective surfactant administration, continued mechanical ventilation and extubation from low respiratory support.

The data observed were concerned with the effects on complications of prematurity and on several aspects of infant ventilation such as:

• incidence of mechanical ventilation
• incidence of bronchopulmonary dysplasia (BPD)
• chronic lung disease (CLD)
• mortality
• duration of mechanical ventilation
• duration of hospitalization
• time in oxygen
• duration of respiratory support (including CPAP and nasal cannula)
• number of patients receiving surfactant
• number of surfactant doses administered per patient
• incidence of air leak syndromes (pulmonary interstitial emphysema, pneumothorax)
• patent ductus arteriosus requiring treatment
• pulmonary hemorrhage, and other complications of prematurity.

The review focused on four randomised controlled clinical trials, which met the selection criteria. In these studies, a strong trend towards a reduction in the need for mechanical ventilation occurred in infants with RDS treated with early surfactant therapy followed by extubation to nasal CPAP (NCPAP), compared with later selective surfactant administration and continued mechanical ventilation.

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