Evans D A, Wilmott R W, Whitsett J A
Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
Pediatr Pulmonol. 1996 May;21(5):328-36. doi: 10.1002/(SICI)1099-0496(199605)21:5<328::AID-PPUL9>3.0.CO;2-I.
Surfactant replacement therapy may have a role in the treatment of ARDS in children. The current studies suggest that rapid instillation of exogenous surfactant is more effective than slow tracheal instillation or aerosolized delivery. Studies suggest that exogenous surfactant given early in the development of ARDS is more effective than therapy provided late in the course of the disease. Natural surfactants appear to be more effective than artificial surfactants due to the presence of SP-B and SP-C, which prevent inhibition of the exogenous surfactant by the protein leakage into the alveolus that is characteristic of ARDS. Exogenous surfactant replacement therapy appears to be safe and well tolerated. A surfactant that can be delivered by aerosol would be useful since this is more easily tolerated by the patients, requires less surfactant, and would be more cost effective when compared with tracheal instillation. Aerosolized surfactant could be given to patients who have not yet required mechanical ventilation, thus potentially preventing the progression of the acute lung injury to respiratory failure. The recent failure of a large multi-center trial of aerosolized Exosurf for the treatment of sepsis-related ARDS72 may have been due to the failure of the delivery system as opposed to the surfactant used in the trial; therefore, further research into aerosol delivery systems is needed. There may be different responses to exogenous surfactant therapy by patients with ARDS of different etiologies, such as aspiration pneumonia, sepsis, or trauma. Well-planned placebo-controlled trials will be required to determine these differences. The data supporting the role of surfactant replacement for the treatment of ARDS in children is growing. However, before widespread use of surfactant is considered, a multi-center, placebo-controlled trial will be required to establish the safety and efficacy of surfactant replacement in such patients.
表面活性剂替代疗法可能在儿童急性呼吸窘迫综合征（ARDS）的治疗中发挥作用。目前的研究表明，快速滴注外源性表面活性剂比缓慢气管内滴注或雾化给药更有效。研究表明，在ARDS发病早期给予外源性表面活性剂比在病程后期进行治疗更有效。由于存在表面活性蛋白B（SP-B）和表面活性蛋白C（SP-C），天然表面活性剂似乎比人工表面活性剂更有效，这两种蛋白可防止ARDS特征性的蛋白质漏入肺泡对外源性表面活性剂产生抑制作用。外源性表面活性剂替代疗法似乎是安全的，且耐受性良好。一种可通过雾化给药的表面活性剂将很有用，因为患者更容易耐受，所需表面活性剂较少，与气管内滴注相比成本效益更高。雾化表面活性剂可给予尚未需要机械通气的患者，从而有可能防止急性肺损伤进展为呼吸衰竭。近期一项大型多中心试验中，雾化Exosurf治疗脓毒症相关ARDS失败，可能是由于给药系统故障而非试验中使用的表面活性剂所致；因此，需要进一步研究雾化给药系统。不同病因（如吸入性肺炎、脓毒症或创伤）的ARDS患者对外源性表面活性剂治疗可能有不同反应。需要精心设计的安慰剂对照试验来确定这些差异。支持表面活性剂替代疗法治疗儿童ARDS作用的数据正在增加。然而，在考虑广泛使用表面活性剂之前，需要进行一项多中心、安慰剂对照试验，以确定表面活性剂替代疗法在此类患者中的安全性和有效性。
