早产儿表面活性剂给药的临床决策阈值：一项系统评价和网状荟萃分析。
Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis.
作者信息
Ramaswamy Viraraghavan Vadakkencherry, Bandyopadhyay Tapas, Abiramalatha Thangaraj, Pullattayil S Abdul Kareem, Szczapa Tomasz, Wright Clyde J, Roehr Charles Christoph
机构信息
Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India.
Department of Neonatology, ABVIMS and Dr. RML Hospital, New Delhi, India.
出版信息
EClinicalMedicine. 2023 Jul 20;62:102097. doi: 10.1016/j.eclinm.2023.102097. eCollection 2023 Aug.
BACKGROUND
The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS.
METHODS
The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life.
FINDINGS
58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO) <0.36 (FiO: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO ≥ 40%. There was insufficient evidence for the comparison of FiO thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO < 30% and 40%, and less invasive surfactant administration at FiO 40%, certainty very low.
INTERPRETATION
Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO requirement is ≥40%. Future trials are required comparing lower FiO thresholds of 30% vs. 40% and that guided by lung ultrasound.
FUNDING
None.
背景
对于患有呼吸窘迫综合征（RDS）的早产儿，给予表面活性剂最有益的理想阈值存在争议。本系统评价的目的是确定指导患有RDS的早产儿使用表面活性剂的最佳临床标准。
方法
该系统评价已在PROSPERO（CRD42022309433）注册。检索了Medline、Embase、CENTRAL和CINAHL数据库，检索时间从数据库建立至2023年5月16日。仅纳入随机对照试验（RCT）。进行了一项评估33种干预措施的贝叶斯随机效应网络荟萃分析（NMA）。主要结局是出生后7天内有创机械通气（IMV）的需求。
结果
纳入了58项RCT。在对表面活性剂给药方式的混杂因素进行调整后，对于孕周≤30周的早产儿，动脉肺泡氧分压比（aAO）<0.36（FiO₂：37 - 55%）被列为降低IMV风险的最佳阈值，确定性极低。此外，与呼吸衰竭诊断时的挽救治疗相比，在FiO₂ 40 - 45%时给予表面活性剂可能降低死亡率，确定性极低。从这些结果中可以得出的合理推断是，对于孕周≤30周、患有RDS且需要FiO₂≥40%的早产儿，可考虑给予表面活性剂。比较FiO₂阈值30%与40%时证据不足。以肺部超声指导表面活性剂给药的证据稀少。对于孕周>30周的亚组，与在FiO₂<30%和40%时进行插管 - 表面活性剂 - 拔管以及在FiO₂ 40%时进行侵入性较小的表面活性剂给药相比，在FiO₂<30%时雾化吸入表面活性剂可能增加IMV风险，确定性极低。
解读
如果FiO₂需求≥40%，对于孕周≤30周、患有RDS的早产儿可考虑给予表面活性剂。未来需要进行试验比较30%与40%的较低FiO₂阈值以及以肺部超声指导的情况。
资金来源
无。
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