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Pediatrics and Neonatology Feb 2021Respiratory distress syndrome (RDS) was recognized to be caused by primary surfactant deficiency almost 70 years ago and continuous positive airway pressure was... (Review)
Review
Respiratory distress syndrome (RDS) was recognized to be caused by primary surfactant deficiency almost 70 years ago and continuous positive airway pressure was introduced approximately 50 years ago. Since then, there have been many developments in neonatology; we know many things but others are still controversial. The more we know, the more questions arise. However, this review aims to indicate what is more needed to understand and how should be the modern approach to RDS in the era of precision medicine. The review is divided between new concepts and new tools. We will explain the interaction between steroids, CPAP and surfactant, as well as the surfactant catabolism and the diagnosis of NARDS; lung ultrasound and new tools to optimize CPAP will also be covered. How these concepts are integrated in the author's personal experience is also illustrated.
Topics: Continuous Positive Airway Pressure; Critical Care; Humans; Infant, Newborn; Infant, Premature; Lung; Precision Medicine; Pulmonary Surfactants; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Ultrasonography
PubMed: 33358440
DOI: 10.1016/j.pedneo.2020.11.005 -
Neonatology 2019As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European...
As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
Topics: Consensus; Continuous Positive Airway Pressure; Disease Management; Europe; Humans; Infant; Infant, Newborn; Infant, Premature; Neonatologists; Pulmonary Surfactants; Respiratory Distress Syndrome, Newborn
PubMed: 30974433
DOI: 10.1159/000499361 -
Zhongguo Dang Dai Er Ke Za Zhi =... Sep 2018Acute respiratory distress syndrome (ARDS) is a common clinical critical disease and is one of the main causes of death and disability in neonates. The etiology and... (Review)
Review
Acute respiratory distress syndrome (ARDS) is a common clinical critical disease and is one of the main causes of death and disability in neonates. The etiology and pathogenesis of neonatal ARDS are complicated. It is an acute pulmonary inflammatory disease caused by the lack of pulmonary surfactant (PS) related to various pathological factors. It is difficult to distinguish neonatal ARDS from other diseases. At present, there is no specific treatment method for this disease. Respiratory support, PS replacement, extracorporeal membrane oxygenation, nutrition support and liquid management are main treatment strategies. This paper reviews the research advance in etiology, clinical characteristics, diagnosis and treatment strategies of neonatal ARDS.
Topics: Dyspnea; Extracorporeal Membrane Oxygenation; Humans; Infant, Newborn; Pulmonary Surfactants; Respiratory Distress Syndrome, Newborn
PubMed: 30210023
DOI: 10.7499/j.issn.1008-8830.2018.09.006 -
Archives of Disease in Childhood. Fetal... Nov 2019Non-invasive ventilation and especially the application of continuous positive airway pressure (CPAP) has become standard for the treatment of premature infants with... (Review)
Review
Non-invasive ventilation and especially the application of continuous positive airway pressure (CPAP) has become standard for the treatment of premature infants with respiratory problems. However, CPAP failure may occur due to respiratory distress syndrome, that is, surfactant deficiency. Less invasive surfactant administration (LISA) aims to provide an adequate dose of surfactant while the infant is breathing spontaneously, thus avoiding positive pressure ventilation support. Using a thin catheter for surfactant application allows infants to maintain function of the glottis and continue spontaneous breathing, whereas the INtubate-SURfactant-Extubate (INSURE) procedure is connected with sedation/analgesia, regular intubation and a (brief) period of positive pressure ventilation. Individual studies and meta-analyses summarised in this review point in the direction that LISA is more effective than standard treatment or INSURE both in terms of short-term (avoidance of mechanical ventilation) and long-term (intracerebral haemorrhage and bronchopulmonary dysplasia) outcomes. Open questions include exact treatment thresholds for different gestational ages, the usefulness of devices/catheters that have recently been purpose-built for the LISA technique and especially the question of analgesia/sedation during the procedure. The current technology still demands laryngoscopy with all its unpleasant effects for infants. Therefore, studies with pharyngeal surfactant deposition immediately after delivery, the use of laryngeal airways for surfactant administration and attempts to nebulise surfactant are under way. Finally, LISA is not simply an isolated technical procedure for surfactant delivery but rather part of a comprehensive non-invasive approach supporting the concept of a gentle transition to the extrauterine world enabling preterm infants to benefit from the advantages of spontaneous breathing.
Topics: Gestational Age; Humans; Infant, Newborn; Infant, Premature; Noninvasive Ventilation; Pulmonary Surfactants; Respiratory Distress Syndrome, Newborn
PubMed: 31296694
DOI: 10.1136/archdischild-2018-316557 -
Science (New York, N.Y.) Feb 2020Current influenza vaccines only confer protection against homologous viruses. We synthesized pulmonary surfactant (PS)-biomimetic liposomes encapsulating 2',3'-cyclic...
Current influenza vaccines only confer protection against homologous viruses. We synthesized pulmonary surfactant (PS)-biomimetic liposomes encapsulating 2',3'-cyclic guanosine monophosphate-adenosine monophosphate (cGAMP), an agonist of the interferon gene inducer STING (stimulator of interferon genes). The adjuvant (PS-GAMP) vigorously augmented influenza vaccine-induced humoral and CD8 T cell immune responses in mice by simulating the early phase of viral infection without concomitant excess inflammation. Two days after intranasal immunization with PS-GAMP-adjuvanted H1N1 vaccine, strong cross-protection was elicited against distant H1N1 and heterosubtypic H3N2, H5N1, and H7N9 viruses for at least 6 months while maintaining lung-resident memory CD8 T cells. Adjuvanticity was then validated in ferrets. When alveolar epithelial cells (AECs) lacked or gap junctions were blocked, PS-GAMP-mediated adjuvanticity was substantially abrogated in vivo. Thus, AECs play a pivotal role in configuring heterosubtypic immunity.
Topics: Adjuvants, Immunologic; Administration, Intranasal; Animals; Biomimetic Materials; CD8-Positive T-Lymphocytes; Ferrets; Immunologic Memory; Influenza A Virus, H1N1 Subtype; Influenza A Virus, H3N2 Subtype; Influenza A Virus, H5N1 Subtype; Influenza A Virus, H7N9 Subtype; Influenza Vaccines; Liposomes; Membrane Proteins; Mice; Mice, Inbred BALB C; Mice, Inbred C57BL; Mice, Mutant Strains; Nanoparticles; Nucleotides, Cyclic; Orthomyxoviridae Infections; Pulmonary Surfactants; Vaccination
PubMed: 32079747
DOI: 10.1126/science.aau0810 -
Paediatric Anaesthesia Feb 2022Extremely preterm infants commonly suffer from respiratory distress syndrome. Ventilatory management of these infants starts from birth and includes decisions such as... (Review)
Review
Extremely preterm infants commonly suffer from respiratory distress syndrome. Ventilatory management of these infants starts from birth and includes decisions such as timing of respiratory support in relation to umbilical cord management, oxygenation targets, and options of positive pressure support. The approach of early intubation and surfactant administration through an endotracheal tube has been challenged in recent years by primary noninvasive respiratory support and newer methods of surfactant administration via thin catheters. Available data comparing the thin catheter method to endotracheal tube and delayed extubation in extremely preterm infants born before 28 weeks of gestation did not show differences in survival free of bronchopulmonary dysplasia. Data from numerous randomized trials comparing conventional ventilation with high-frequency oscillatory ventilation did not show differences in meaningful outcomes. Among conventional modes of ventilation, there is good evidence to favor volume-targeted ventilation over pressure-limited ventilation. The former reduces the combined risk of bronchopulmonary dysplasia or death and several important secondary outcomes without an increase in adverse events. There are no evidence-based guidelines to set positive end-expiratory pressure in ventilated preterm infants. Recent research suggests that the forced oscillation technique may help to find the lowest positive end-expiratory pressure at which lung recruitment is optimal. Benefits and risks of the various modes of noninvasive ventilation depend on the clinical setting, degree of prematurity, severity of lung disease, and competency of staff in treating associated complications. Respiratory care after discharge includes home oxygen therapy, lung function monitoring, weaning from medication started in the neonatal unit, and treatment of asthma-like symptoms.
Topics: Humans; Infant, Extremely Premature; Infant, Newborn; Intensive Care Units, Neonatal; Pulmonary Surfactants; Respiration, Artificial; Respiratory Distress Syndrome, Newborn
PubMed: 34878697
DOI: 10.1111/pan.14369 -
Pediatric Research Apr 2023The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway... (Review)
Review
The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. Although preterm infants are increasingly being admitted to the neonatal intensive care unit on CPAP, centers differ in the ability to manage infants primarily on CPAP. Over the last decade, less invasive surfactant administration (LISA), a method of administering surfactant with a thin catheter, has been devised and has been shown to decrease the need for MV and improve outcomes compared to surfactant administration via an endotracheal tube following intubation. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States. This article provides a summary of the existing evidence on LISA, and practical guidance for US units choosing to implement a change of practice incorporating optimization of CPAP and LISA. IMPACT: The accumulated body of evidence for less invasive surfactant administration (LISA), a widespread practice in other countries, justifies its use as an alternative to intubation and surfactant administration in US neonatal units. This article summarizes the current evidence for LISA, identifies gaps in knowledge, and offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy. This article will help neonatal units in the US develop guidelines for LISA, provide optimal respiratory support for infants with respiratory distress syndrome, improve short- and long-term outcomes of preterm infants, and potentially decrease costs of NICU care.
Topics: Infant; Infant, Newborn; Humans; Infant, Premature; Surface-Active Agents; Pulmonary Surfactants; Respiration, Artificial; Continuous Positive Airway Pressure; Respiratory Distress Syndrome, Newborn; Lipoproteins; Intubation, Intratracheal
PubMed: 35986148
DOI: 10.1038/s41390-022-02265-8 -
Clinics in Chest Medicine Sep 2016Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by the accumulation of surfactant in alveoli and terminal airways resulting in respiratory failure.... (Review)
Review
Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by the accumulation of surfactant in alveoli and terminal airways resulting in respiratory failure. PAP comprises part of a spectrum of disorders of surfactant homeostasis (clearance and production). The surfactant production disorders are caused by mutations in genes required for normal surfactant production. The PAP syndrome is identified based on history, radiologic, and bronchoalveolar lavage and/or histopathologic findings. The diagnosis of PAP-causing diseases in secondary PAP requires further studies. Whole-lung lavage is the current standard therapy and promising new pharmacologic therapies are in development.
Topics: Autoantibodies; Autoimmune Diseases; Bronchoalveolar Lavage; Granulocyte-Macrophage Colony-Stimulating Factor; Humans; Macrophages, Alveolar; Pulmonary Alveolar Proteinosis; Pulmonary Surfactants
PubMed: 27514590
DOI: 10.1016/j.ccm.2016.04.006 -
Biochimica Et Biophysica Acta Oct 2016Lung surfactant lines the gas-exchange interface in the lungs and reduces the surface tension, which is necessary for breathing. Lung surfactant consists mainly of... (Review)
Review
Lung surfactant lines the gas-exchange interface in the lungs and reduces the surface tension, which is necessary for breathing. Lung surfactant consists mainly of lipids with a small amount of proteins and forms a monolayer at the air-water interface connected to bilayer reservoirs. Lung surfactant function involves transfer of material between the monolayer and bilayers during the breathing cycle. Lipids and proteins are organized laterally in the monolayer; selected species are possibly preferentially transferred to bilayers. The complex 3D structure of lung surfactant and the exact roles of lipid organization and proteins remain important goals for research. We review recent simulation studies on the properties of lipid monolayers, monolayers with phase coexistence, monolayer-bilayer transformations, lipid-protein interactions, and effects of nanoparticles on lung surfactant. This article is part of a Special Issue entitled: Biosimulations edited by Ilpo Vattulainen and Tomasz Róg.
Topics: Computer Simulation; Lipid Bilayers; Membrane Lipids; Membrane Proteins; Nanoparticles; Pulmonary Surfactants; Surface Tension
PubMed: 26922885
DOI: 10.1016/j.bbamem.2016.02.030 -
Frontiers in Immunology 2022Pulmonary surfactant constitutes an important barrier that pathogens must cross to gain access to the rest of the organism the respiratory surface. The presence of... (Review)
Review
Pulmonary surfactant constitutes an important barrier that pathogens must cross to gain access to the rest of the organism the respiratory surface. The presence of pulmonary surfactant prevents the dissemination of pathogens, modulates immune responses, and optimizes lung biophysical activity. Thus, the application of pulmonary surfactant for the treatment of respiratory diseases provides an effective strategy. Currently, several clinical trials are investigating the use of surfactant preparations to treat patients with coronavirus disease 2019 (COVID-19). Some factors have been considered in the application of pulmonary surfactant for the treatment COVID-19, such as mechanical ventilation strategy, timing of treatment, dose delivered, method of delivery, and preparation utilized. This review supplements this list with two additional factors: accurate measurement of surfactants in patients and proper selection of pulmonary surfactant components. This review provides a reference for ongoing exogenous surfactant trials involving patients with COVID-19 and provides insight for the development of surfactant preparations for the treatment of viral respiratory infections.
Topics: Humans; Lung; Pulmonary Surfactants; Respiration, Artificial; Surface-Active Agents; COVID-19 Drug Treatment
PubMed: 35592339
DOI: 10.3389/fimmu.2022.842453