RDS Therapies

Henry Halliday
The Queen’s University of Belfast, Belfast, Northern Ireland, UK
From 44th Annual Meeting of the European Society for Paediatric Research (ESPR)

Surfactant state of the art and future developments

The aim of this symposium was to try to develop a protocol for surfactant treatment. Exciting new data were presented here today.

The main topics covered were:

• Type of surfactant — natural, synthetic and new generation agents
  Evidence from clinical trials presented here and from the literature certainly favours the use of natural surfactants rather than synthetic products for the treatment of RDS[1,2]. Newer generation surfactant preparations may have a role to play in treating other respiratory disorders if they can be shown to be more resistant to inactivation. There are some preliminary data indicating that increasing the amount of phospholipids in natural surfactants may overcome inactivation but this remains to be confirmed.
• Timing of surfactant treatment — prophylaxis, early or late treatment
  Evidence favours prophylaxis for infants of = 31 weeks[3,4] and early treatment for others.
• Dose of surfactant — 100 mg/kg or 200 mg/kg
  The recommended dosage may well depend on the timing of administration (prophylaxis, early or late treatment) and the rate of prenatal steroid use.
  Evidence-based surfactant therapy Results of the Vermont-Oxford trial of a multifaceted intervention to promote evidence-based surfactant therapy, provide data from 114 hospitals on surfactant use[5]. The intervention was successful in reducing the time to first surfactant treatment from 78 to 21 minutes with more than half of infants receiving surfactant in the delivery room compared with 18% of controls. While there was no difference in survival rates, overall there were significant reductions in IVH (all grades) and severe IVH (grades 3 and 4), providing another reason for using surfactant prophylactically or early (Table 1). A reduction in severe IVH has already been shown when poractant alfa (Curosurf®, Chiesi Farmaceutici) is given prophylactically rather than as a later treatment[6].

Recommended protocol for surfactant use

Evidence presented here and results of recent trials allow us to recommend a protocol for surfactant use depending on GA. In infants with a GA of <27–28 weeks, prophylaxis with a natural surfactant (100 mg/kg) is recommended. In those of 29–31 weeks GA, early nCPAP with early rescue with natural surfactant (100 mg/kg) is the recommended treatment of choice, while observation is advised initially in those =32 weeks GA with surfactant treatment when more than 40% oxygen is needed (Table 2).

References

1. Halliday HL. Drugs 1996;51:226–37.
2. Ainsworth SB et al. Lancet 2000;355:1387–92.
3. Soll RF, Morley CJ. In: The Cochrane Database of Systematic Reviews, The Cochrane Library, Volume 3, 2003.
4. Egberts J et al. Pediatrics 1997;100(1):E4.
5. Horbar JD et al. Pediatr Res 2003;368A:abstract 2093.
6. Walti H et al. Biol Neonate 2002;81:182–7.

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