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SPECIAL ARTICLES: Mario Augusto Rojas, Juan Manuel Lozano, Maria Ximena Rojas, Matthew Laughon, Carl Lewis Bose, Martin Alonso Rondon, Laura Charry, Jaime Alberto Bastidas, Luis Alfonso Perez, Catherine Rojas, Oscar Ovalle, Luz Astrid Celis, Jorge Garcia-Harker, Martha Lucia Jaramillo for the Colombian Neonatal Research Network Very Early Surfactant Without Mandatory Ventilation in Premature Infants Treated With Early Continuous Positive Airway Pressure: A Randomized, Controlled Trial Pediatrics 2009; 123: 137-142 [Abstract] [Full text] [PDF]

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NCPAP and surfactant therapy: always together?

Jucille Amaral Meneses   (21 September 2009)

NCPAP and surfactant therapy: always together? 21 September 2009
Jucille Amaral Meneses, Newborn section Instituto de Medicina Integral Prof Fernando Figueira (IMIP) Recife, PE Brazil Send letter to journal: Re: NCPAP and surfactant therapy: always together? jmeneses{at}elogica.com.br Jucille Amaral Meneses	We read with great interest the article by Rojas et al which demonstrated that preterm infants with RDS  submitted after birth  to NCPAP with very early surfactant therapy,after a brief period of intubation(treatment group),had a lower rate of subsequent MV when compared to infants who were started only on  NCPAP(control group), 26% X 39%. However, they did not find a significant difference between the groups in relation to the  incidence of BPD at 36 weeks  postmenstrual age. Similar findings are reported in other studies by Verder et al, Reininger et al, Thomson et al and  Escobedo et al. In all of these studies  some, but not all of the infants that started  only on  NCPAP, received treatment with rescue surfactant especially if  they were intubated for MV, and  these rates varied between 26 – 66%.In the study by Rojas et al, if only 35 (26%)of the infants in the control group received rescue surfactant treatment. This leads us to wonder how many of the infants in the treatment group needed surfactant therapy and how many would have done well only with NCPAP, considering the very high rate of antenatal steroids(88%)  and the short duration of time the infants needed NCPAP in this study, about 4 to 5 days. The authors stated that this strategy reduces the need for MV and  may be advantageous in medical settings were resources are limited, but we also are aware that surfactant therapy has a substantial cost in these same settings. Another concern is that the intubation of preterm infants can be difficult and may destabilize a infant’s condition.                    A Cochrane meta-analysis from 2009 including six studies indicates that infants with RDS treated with NCPAP and early surfactant therapy (lower treatment threshold) are less likely to need MV and to develop BPD than infants treated with  later surfactant therapy (higher treatment threshold). The authors conclude that there still needs further research to define potential limitations on the type of patients for whom early surfactant therapy with rapid intubation is appropriate and to determine the severity of RDS at which to intervene with this therapy.                     The recent  results of the CURPAP Study involving 208 preterm infants randomized after birth to two groups: Group 1-intubation, surfactant administration within 30 minutes from birth; Group 2-early stabilization on NCPAP with rescue surfactant administration(median age of 4 hours) according to defined clinical criteria demonstrated that  the need of MV in the first 5 days was similar between the two groups(31,4% X 33%) and there was no difference in the incidence of BPD (23.8 X 22.3%).  Only 48,5% of the infants in group 2 received surfactant therapy.The authors  recommend to individualize the approach of NCPAP use and rescue surfactant,based on  clinical criteria.                        Most of the infants with mild to moderate RDS will do well only with NCPAP and the results from Columbia shows us that this is possible. Some infants will certainly benefit from the surfactant treatment with a brief intubation and NCPAP. We need to find out who are the patients that this therapy offers further advantage, especially in medical settings where resources are limited. References:1)Rojas MA, Lozano JM, Rojas MX et al.Very early surfactant without mandatory ventilation in premature infants treated with early continuous positive airway pressure: a randomized, controlled trial. Pediatrics. 2009;123;137-142. 2)Sandri F,Simeoni U, Plavka R on behalf of the CURPAP study group.An international randomized controlled trial to evaluate the efficacy of combining prophylactic surfactant and early nasal CPAP in very preterm infants.Baltimore,MD:The PAS Meeting,2009. Abstract 4110. 3)Stevens TP, Biennow M,Myers EH, Soll R. Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiartory distress syndrome. Cochrane Database Syst Rew 2009;4;CD003063. Conflict of Interest: None declared