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Surfactant (beractant) therapy for infants with congenital diaphragmatic hernia on ECMO: evidence of persistent
A Lotze1, G R Knight, K D Anderson
1Department of Neonataology, George Washington University School of Medicine and Health Sciences, Washington, DC.
Insights
Surfactant therapy did not improve outcomes for infants with congenital diaphragmatic hernia (CDH) on ECMO. These infants showed persistent low surfactant protein-A and elevated right ventricular pressure, suggesting ongoing respiratory challenges.
Area of Science:
- Neonatal Medicine
- Pediatric Surgery
- Respiratory Physiology
Background:
- Infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) often experience lung atelectasis that improves over time in survivors.
- Surfactant deficiency is a potential contributing factor to respiratory distress in these infants.
Purpose of the Study:
- To investigate the potential benefits of surfactant therapy in infants with CDH receiving ECMO.
- To assess the impact of surfactant administration on lung function and clinical outcomes.
Main Methods:
- A randomized trial involving infants with CDH (gestation > 34 weeks) on ECMO.
- Comparison between a group receiving beractant (surfactant extract) and a control group receiving air.
- Measurement of tracheal aspirate surfactant protein-A (SP-A) concentrations, lung compliance (CL), and clinical outcomes including time to extubation and hospital stay.
Main Results:
- Tracheal aspirate SP-A concentrations were initially low and increased over time in CDH infants, but remained lower than in non-CDH infants on ECMO.
- No significant differences were observed in lung compliance, time to extubation, oxygen duration, or hospital days between the surfactant and control groups.
- Infants with CDH exhibited persistently elevated right ventricular pressure (RVP) compared to non-CDH infants on ECMO.
Conclusions:
- Postnatal surfactant deficiency may be more prolonged in CDH infants on ECMO.
- Surfactant therapy did not demonstrate significant clinical benefits in this cohort.
- Congenital diaphragmatic hernia is a complex condition with multifactorial causes for delayed recovery, including pulmonary hypertension and compromised respiratory mechanics.
Abstract:
Infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) can have initial lung atelectasis which, in survivors, gradually improves over time. To test the hypothesis that these patients could benefit from surfactant therapy, infants with CDH (born at > 34 weeks' gestation) on ECMO received either four doses of modified bovine lung surfactant extract (beractant) (surfactant group, n = 9) or an equal volume of air (control group, n = 8). Tracheal aspirate surfactant protein-A (SP-A) concentrations were initially low, and then increased over time in both CDH groups (P = .0021); however, levels remained low when compared with those of infants on ECMO who had other diagnoses (P = .04). Lung compliance (CL), time to extubation, time on oxygen, and total no. of hospital days were not different between the two groups. Infants with CDH had persistently elevated right ventricular pressure (RVP) at cessation of bypass when compared with non-CDH infants on ECMO (RVP = 53.25 mm Hg +/- 19.52 in the CDH group, 32.90 +/- 10.63 in the non-CDH group; P = .0121). The findings suggest that the postnatal surfactant deficiency may be more persistent in CDH infants than in non-CDH infants on ECMO. However, CDH remains a multifactorial condition, with delayed improvement, because of persistence of pulmonary hypertension, difficulties with vascular remodeling, degree of lung hypoplasia, or compromised respiratory mechanics.