Surfactant replacement therapy in preterm infants: a European survey

Exogenous surfactant is the gold standard treatment for neonatal respiratory distress syndrome (RDS) as it optimizes gas exchange, reduces the risk of air leaks and, more important, reduces mortality. However, the efficacy of exogenous surfactant is highly dependent on the treatment strategy adopted, including timing of administration, surfactant preparation, and dosage regimen.
International guidelines have summarized the available evidence from randomized controlled trials on surfactant therapy and recommendations on the optimal surfactant replacement strategy have been published. These guidelines should assist the clinician in determining best practices and promote the clinical implementation of the available evidence on surfactant replacement therapy.
However, studies investigating surfactant treatment practices in preterm infants are still scant, and therefore the actual level of implementation of current guidelines into clinical practice needs further investigations.
On this basis, the Neovent Study Group, an International Panel of expert neonatologists, has conducted a large survey in 173 neonatal intensive care units (NICUs) of 21 European countries, in order to determine how evidence-based guidelines on surfactant replacement therapy are implemented in daily clinical practice. Data on surfactant replacement therapy, including preparation, dosing and timing, were collected by questionnaire and in a cohort of preterm infants mechanically ventilated.
All NICUs used animal-derived surfactant in the treatment of respiratory distress syndrome, with Poractant being the most widely used (86%) surfactant, followed by Beractant (24%) and Bovactant (15%). The most frequently used first dose was 100 mg/kg (58%), followed by 200 mg/kg (39%); all NICUs allowed for repeat dosing. FiO2 was the main indicator used for rescue surfactant treatment with a median FiO2 value at administration of 0.40. 39% of the NICUs claimed to use prophylactic treatment (<15 min of life) based on gestational age and birthweight criteria.
Data on surfactant treatment were collected in 338 infants (median gestational age: 27 weeks), who were all treated with animal-derived surfactant. The median first dose was 168 mg/kg in the Poractant group compared with 100 mg/kg in the Beractant and Bovactant groups. Prophylactic treatment was used in 23% of the infants and 28% of the infants received surfactant >2 h after birth. 43% of the infants received multiple doses.
This study provides, for the first time, valuable information on how recommendations from international guidelines on surfactant replacement therapy are implemented in clinical practices.
Overall, guidelines on surfactant replacement therapy seem to be implemented in daily clinical practice in European NICUs, with the notable exception of surfactant timing: despite recommendations to consider prophylactic administration of surfactant in infants <26 weeks, only 39% of the NICUs have adopted prophylactic treatment. Several reasons may contribute to this difference. First, most of the studies on surfactant timing were conducted in the 1980s, when the use of antenatal steroids was much lower than today. Considering the fact that antenatal steroids have a profound effect on RDS severity, clinicians might be less convinced of a clinically relevant treatment effect of prophylactic surfactant administration. Secondly, until recently there were no trials comparing prophylactic to early rescue surfactant treatment. Being in equipoise, clinicians may have opted for early rescue treatment once RDS has been established, thereby reducing unnecessary treatment with surfactant. Last, there has been a growing use of early nasal continuous positive airway pressure in the delivery room, thereby avoiding intubation and mechanical ventilation, and reducing the need for surfactant treatment.
In conclusion, the present study shows that, consistent with international guidelines, most NICUs in Europe use animal-derived surfactant products in a dose of either 100 or 200 mg/kg, allowing for multiple doses. However, the recommended use of prophylactic surfactant treatment in extremely preterm infants has been adopted in only 39% of the NICUs and 28% of the patients receive rescue treatment >2 h after birth.

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