Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA.
J Perinatol. 2010 Oct;30(10):671-6. doi: 10.1038/jp.2010.21. Epub 2010 Mar 25.
Respiratory distress syndrome (RDS), requiring mechanical ventilation and exogenous surfactant treatment, and patent ductus arteriosus (PDA), are common co-morbidities in very premature infants. The effects of intra-tracheal surfactant administration on the cardiovascular and pulmonary systems in very premature infants with RDS and PDAs are not well characterized. We evaluated the effects of poractant alfa and beractant, surfactants with different rapidity of onset and duration of action, in very premature infants with RDS. To assess whether there were differences in PDA hemodynamics in very premature infants with RDS treated with poractant alfa and beractant during the first week of life and to assess whether poractant alfa or beractant had a direct effect on PDAs and PDA hemodynamics following the second dose of surfactant.
We studied 50 in-born, very premature infants with RDS, 24 0 of 7 to 29 6 of 7 weeks gestation, treated with poractant alfa or beractant, in an open label, 1:1, randomized clinical trial. A subgroup of 16 patients with severe RDS, treated with a second dose of surfactant, had echocardiographical assessments before and 20 to 30 min after the second dose of surfactant.
There were 25 infants treated with poractant alfa (27.1±1.6 weeks, birth weight 930±231 g) and 25 treated with beractant (26.7±1.7 weeks, P=0.407 and birth weight 898±282 g, P=0.666). Clinically significant PDAs were diagnosed and treated in 8 of 25 (32%) of the poractant alfa and 19 of 25 (76%) of the beractant group (P=0.002). Indomethacin treatment was slightly earlier (3.4±2.5 days) in the poractant alfa than in the beractant group (5.1±4.9 days, P=0.038). Right ventricle pressure (RVP)/systolic arterial pressure (SAP) ratio in the first week was slightly lower in the poractant alfa (64±20%) than in the beractant (78±26%, P=0.048) group. Following a second dose of surfactant, neither poractant alfa nor beractant changed PDA flow. These hemodynamic observations were associated with less respiratory support in the poractant alfa group, allowing earlier extubation (13 of 25 at 48 h and 15 of 25 at 72 h), than in the beractant group (6 of 25 at 48 h, P=0.044, and 8 of 25 at 72 h, P=0.049).
The more rapid improvement in pulmonary function in the poractant alfa-treated infants was associated with a lower RVP/SAP ratio and a corresponding earlier treatment with indomethacin. Neither surfactant had a significant direct effect on PDA hemodynamics. The lower frequency of clinically significant PDAs in the poractant alfa compared with the beractant group may represent an indirect effect of the differences in the pulmonary improvement induced by the two surfactants.
呼吸窘迫综合征（RDS）需要机械通气和外源性表面活性剂治疗，以及动脉导管未闭（PDA），是极早产儿常见的合并症。气管内表面活性剂给药对 RDS 和 PDA 极早产儿心肺系统的影响尚未得到很好的描述。我们评估了不同起效速度和作用持续时间的表面活性剂猪肺磷脂和牛肺磷脂在 RDS 极早产儿中的作用。评估 RDS 极早产儿在出生后第一周内接受猪肺磷脂和牛肺磷脂治疗时 PDA 血流动力学是否存在差异，并评估猪肺磷脂或牛肺磷脂在第二剂表面活性剂后对 PDAs 和 PDA 血流动力学是否有直接影响。
我们研究了 50 名出生时患有 RDS 的极早产儿，胎龄 24 0 至 29 6 周，接受猪肺磷脂或牛肺磷脂治疗，采用开放标签、1:1 随机临床试验。16 名患有严重 RDS 的患者接受了第二次表面活性剂治疗，在第二次表面活性剂治疗前和 20 至 30 分钟进行了超声心动图评估。
25 名婴儿接受猪肺磷脂（27.1±1.6 周，出生体重 930±231 g）治疗，25 名婴儿接受牛肺磷脂（26.7±1.7 周，P=0.407 和出生体重 898±282 g，P=0.666）治疗。在 25 名接受猪肺磷脂治疗的婴儿中有 8 名（32%）和 25 名接受牛肺磷脂治疗的婴儿中有 19 名（76%）被诊断为并治疗有临床意义的 PDA（P=0.002）。与牛肺磷脂组相比，猪肺磷脂组吲哚美辛治疗时间稍早（3.4±2.5 天）（5.1±4.9 天，P=0.038）。在出生后第一周，猪肺磷脂组右心室压力（RVP）/收缩期动脉压（SAP）比值稍低于牛肺磷脂组（64±20%比 78±26%，P=0.048）。接受第二剂表面活性剂后，猪肺磷脂和牛肺磷脂均未改变 PDA 流量。这些血流动力学观察结果与猪肺磷脂组呼吸支持减少有关，这使得拔管时间更早（25 名婴儿中有 13 名在 48 小时，25 名婴儿中有 15 名在 72 小时），而牛肺磷脂组在 48 小时时（6 名婴儿，P=0.044）和 72 小时时（8 名婴儿，P=0.049）拔管的婴儿较少。
猪肺磷脂治疗的婴儿肺部功能更快改善，与较低的 RVP/SAP 比值和相应的更早使用吲哚美辛有关。两种表面活性剂均未对 PDA 血流动力学产生显著直接影响。与牛肺磷脂组相比，猪肺磷脂组中临床意义重大的 PDAs 频率较低，可能代表两种表面活性剂诱导的肺部改善的间接影响。
