Aerosolized Surfactant for Preterm Infants with Respiratory Distress Syndrome

Abstract

Currently, the administration of surfactant to preterm infants with respiratory distress syndrome (RDS) mainly relies on intratracheal instillation; however, there is increasing evidence of aerosolized surfactant being an effective non-invasive strategy. We present a historical narrative spanning sixty years of development of aerosolization systems. We also offer an overview of the pertinent mechanisms needed to create and manage the ideal aerosolization system, with a focus on delivery, distribution, deposition, and dispersion in the context of the human lung. More studies are needed to optimize treatment with aerosolized surfactants, including determination of ideal dosages, nebulizer types, non-invasive interfaces, and breath synchronization. However, the field is rapidly evolving, and widespread clinical use may be achieved in the near future.

Efficacy, dose–response, and aerosol delivery of dry powder synthetic lung surfactant treatment in surfactant-deficient rabbits and premature lambs

“…At present, surfactant treatment of premature infants with respiratory distress syndrome (RDS) depends on intratracheal instillation, either by tracheal intubation in combination with mechanical ventilation or by less invasive surfactant administration (LISA) via a thin intratracheal catheter during NIV [ 7 ]. However, efficacy of aerosol delivery of surfactant depends not only on the composition of the surfactant formulation, its safety and efficacy, but also on the type of aerosolization device and non-invasive interface used, and the possibility to synchronize surfactant delivery with spontaneous breathing [ 16 ]. Three recent clinical studies have shown that non-invasive aerosol delivery of animal-derived surfactant can prevent the need for early intubation [ 17 – 20 ].…”

Surfactant Replacement Therapy: What’s the New Future?

“…52 Animal and human studies have shown that the dosage range of 50-200 mg/kg AS has resulted in improved lung gas exchange. 53-55 Studies have shown that redosing requirement decreased with the use of the initial higher concentration of surfactant. Comparison of high dose (200 mg/kg) versus low dose (100 mg/kg) of poractant alfa has shown that a high initial dose of surfactant was associated with lesser need for retreatment (odds ratio (OR) 0.93; 95% CI 0.90-0.96) when administered via less invasive surfactant administration (LISA) and intubate surfactant extubation (InSurE) and shorter duration of oxygenation and MV support (OR 0.92; 95% CI, 0.90-0.95) (with LISA only, not with InSurE) compared with initial low-dose surfactant.…”

“…52 Animal and human studies have shown that the dosage range of 50-200 mg/kg AS has resulted in improved lung gas exchange. [53][54][55] Studies have shown that redosing requirement decreased with the use of the initial higher concentration of surfactant. [56][57][58] Porcine surfactant preparation has also shown decrease in retreatment requirement compared with bovine surfactant.…”

The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review

“…During the last decades, attempts to treat RDS with aerosolized surfactant using different nebulization methods failed to prove the undisputed effectiveness of this method. Only recently, randomized clinical studies using modern nebulization methods demonstrated the feasibility and effectiveness of aerosolized surfactant nebulization in preventing intubation and mechanical ventilation [54]. The study by Cummins et al that enrolled 457 neonates with a wide range of GA (23 to 41 weeks, median 33 weeks) showed that in neonates with mild-moderate respiratory distress, aerosolized surfactant decreased the intubation rate and surfactant instillation by 50% [55].…”