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Bronchopulmonary dysplasia and surfactant
1Department of Pediatrics, Division of Neonatology, University of Miami School of Medicine, Miami, Fla., 33101, USA. ebancalari@miami.edu
Insights
Surfactant therapy for premature infants reduces respiratory distress but has not decreased bronchopulmonary dysplasia (BPD) incidence. Early surfactant administration may lower mortality and BPD risk, though results are conflicting.
Area of Science:
- Neonatal Medicine
- Respiratory Physiology
Background:
- Bronchopulmonary dysplasia (BPD) is a major complication in preterm infants surviving mechanical ventilation.
- Exogenous surfactant reduces respiratory distress syndrome (RDS) severity, but BPD incidence has not decreased.
Purpose of the Study:
- To analyze the effect of exogenous surfactant administration on BPD incidence and severity.
- To investigate the changing pathogenesis of BPD in the context of modern neonatal care.
Main Methods:
- Review of existing evidence on surfactant therapy in preterm infants.
- Analysis of BPD incidence and mortality data in relation to surfactant use.
Main Results:
- Surfactant therapy reduces RDS and may decrease neonatal mortality and BPD occurrence, especially when administered prophylactically or early.
- The overall incidence of BPD has not significantly decreased, possibly due to increased survival of high-risk infants.
- While severe BPD cases may be less common, the overall impact of surfactant on BPD incidence remains debated due to conflicting data.
Conclusions:
- Exogenous surfactant can reduce mortality and BPD risk in preterm infants with RDS.
- The changing nature of BPD and multiple contributing factors complicate the assessment of surfactant's effect on overall incidence.
- Prophylactic or early surfactant administration appears more beneficial than late treatment for reducing mortality and BPD.
Abstract:
Bronchopulmonary dysplasia (BPD) is the most common respiratory complication in preterm infants who survive prolonged mechanical ventilation. Exogenous surfactant administration clearly reduces the severity of respiratory distress syndrome (RDS) and consequently the need for aggressive ventilation and prolonged oxygen therapy. However, the overall incidence of BPD has not decreased but in fact may even have increased after the introduction of surfactant therapy. There are several reasons for the lack of effect on the incidence of BPD. First, surfactant therapy and antenatal steroids have markedly increased survival of the smallest infants, i.e. those at higher risk of BPD. Second, there has been a change in the pathogenesis and the presentation of BPD. While the classic BPD was mainly the consequence of barotrauma and oxygen toxicity, the new BPD seen in the surfactant era results from the interaction of many factors that lead to prolonged mechanical ventilation and colonization of the airway with pathogens that may trigger an inflammatory cascade. While the overall incidence of BPD has not been substantially modified by surfactant therapy, the more severe cases of BPD have become less common. The data regarding the effect of surfactant administration on the incidence and severity of BPD is conflicting. There is substantial evidence that the administration of exogenous surfactant, either as prophylaxis or as a treatment in infants with established RDS, can reduce neonatal mortality and the occurrence of BPD or death. The data also suggest that prophylactic or early administration is more effective than late treatment in reducing mortality and BPD or death. No clear difference has been documented between natural or synthetic surfactant treatment in terms of their effect on incidence of BPD or mortality. The lack of consistency in the results with surfactant replacement may reflect the changing pathogenesis of BPD and the multiplicity of factors involved among which surfactant deficiency is only one.