Yenidoğanda Surfaktan Tedavisi
Özet
Respiratuvar distres sendromu (RDS), prematüre bebeklerde akciğer immatüritesi ve alveolar surfaktan eksikliğine bağlı olarak gelişen, gestasyon haftası azaldıkça görülme sıklığı artan önemli bir morbidite ve mortalite nedenidir. Pulmoner surfaktan, %90 lipit ve %10 proteinden oluşan, alveollerin solunum döngüsü sırasında kapanmasını önleyerek yüzey gerilimini düşüren hayati bir biyokimyasal karışımdır. Yüzey gerilimini azaltan primer molekül dipalmitoilfosfatidilkolin (DPPC) iken, hidrofilik (SP-A, SP-D) ve hidrofobik (SP-B, SP-C) surfaktan proteinleri doğuştan gelen immün savunma ile biyofiziksel yayılma işlevlerinde kritik roller üstlenir. Ekzojen surfaktan tedavisi günümüzde RDS için standart tedavidir ve klinik uygulamada sığır veya domuz kaynaklı doğal preparatlar (poraktant alfa, beraktant, kalfaktant) tercih edilmektedir. Çalışmalar, özellikle yüksek doz poraktant alfa kullanımının mortaliteyi, ventilasyon ihtiyacını ve bronkopulmoner displazi (BPD) riskini azaltmada daha üstün sonuçlar verebildiğini göstermektedir. Uygulama zamanlamasında ilk iki saat içinde verilen erken kurtarma tedavisi öne çıkarken, uygulama teknikleri klasik endotrakeal entübasyondan INSURE, LISA ve MIST gibi daha az invaziv yöntemlere doğru gelişim göstermiştir. Antenatal steroid kullanımı ve non-invaziv solunum desteği ile kombine edilen surfaktan uygulamaları akciğer kompliansını iyileştirip ventilatör hasarını en aza indirir. Bunlara ek olarak surfaktan tedavisi; mekonyum aspirasyonu sendromu, pulmoner kanama ve yenidoğan pnömonisi gibi ikincil surfaktan eksikliğine yol açan diğer klinik durumlarda da başarıyla kullanılmaktadır.
Referanslar
Warren, J. B., Anderson, J. M. Core concepts: respiratory distress syndrome. NeoReviews 2009; 10 (7), 351–361.
Koc, E, Demirel, N., Bas, A. Y. Early neonatal outcomes of very-low-birth-weight infants in Turkey: A prospective multicenter study of the Turkish Neonatal Society. PLoS One. 2019; 14 (12), e0226679.
Avery, M. E., Mead, J. Surface properties in relation to atelectasis and hyaline membrane disease. AMA J Dis Child. 1959; 97 (5, Part 1), 517–23.
Enhörning, G., Grossmann, G., Robertson, B. Pharyngeal deposition of surfactant in the premature rabbit fetus. Biol Neonate 1973; 22 (1), 126–32.
Adams, F. H., Towers, B., Osher, A. B. Effects of tracheal instillation of natural surfactant in premature lambs. I. Clinical and autopsy findings. Pediatr Res 1978; 12 (8), 841–8.
Jobe, A. H., Ikegami, M. Biology of surfactant. Clin Perinatol. 2001; 28 (3), 655-69.
Suri, L. N., McCaig, L., Picardi, M. V. Adaptation to low body temperature influences pulmonary surfactant composition thereby increasing fluidity while maintaining appropriately ordered membrane structure and surface activity. Biochim. Biophys. Acta 2012; 1818 (7), 1581–1589.
Peca, D., Cutrera, R., Masotti, A. ABCA3, a key player in neonatal respiratory transition and genetic disorders of the surfactant system. Biochem. Soc. Trans. 2015; 43 (5), 913–919.
Hentschel, R., Bohlin, K., van Kaam, A. Surfactant replacement therapy: from biological basis to current clinical practice. Pediatr Res 2020; 88 (2), 176–183.
Parra, E., Perez-Gil, J. Composition, structure and mechanical properties define performance of pulmonary surfactant membranes and films. Chem. Phys. Lipids 2015; 185, 153–175.
Nogee, L. M., Garnier, G, Dietz, H. C. A mutation in the surfactant protein B gene responsible for fatal neonatal respiratory disease in multiple kindreds. J. Clin. Invest. 1994; 93 (4), 1860–1863.
Peca, D. Boldrini, R., Johanson, J. Clinical and ultrastructural spectrum of diffuse lung disease associated with surfactant protein C mutations. Eur. J. Hum. Genet. 2015; 23 (8), 1033–1041.
Fanaroff, A. A., Martin, R. J. (2011). The respiratory distress syndrome. In: A. A. Fanaroff, R.J. Martin (Eds). Diseases of the fetus and infant (9th ed., pp. 1075-1092). St Louis: Missouri, Mosby year book.
Randell, S. H., Young, S. L. (2011). Structure of alveolar epithelial cells and the surface layer during development. In: R. A. Polin, W.W. Fox, S. H. Abman (Eds). Fetal and Neonatal Physiology. (4th ed.. pp.1115-1122) Philadelphia, Saunders.
Dietl, P., Haller, T. Exocytosis of lung surfactant: from the secretory vesicle to the air-liquid interface. Annu Rev Physiol 2005; 67, 595–621.
Fujiwara, T., Maeta, H., Chida, S. Artificial surfactant therapy in hyaline-membrane disease. Lancet 1980; 12, 1 (8159), 55-9.
Schwartz, R. M., Luby, A. M., Scanlon, J. W. Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g. N Engl J Med 1994; 330 (21), 1476–1480.
Jobe, A. H. Pulmonary surfactant therapy. N Engl J Med 1993; 328: 861–868.
Ardell, S., Pfister, R. H. & Soll, R. Animal derived surfactant extract versus protein free synthetic surfactant for the prevention and treatment of respiratory distress syndrome. Cochrane Database Syst. Rev. 2015; 8, CD000144.
Ricci, F., Murgia, X., Razzetti, R. In vitro and in vivo comparison between poractant alfa and the new generation synthetic surfactant CHF5633. Pediatr Res 2017; 81 (2), 369-75.
Sweet, D.G., Turner, M. A, Stranák, Z. A first-in-human clinical study of a new SP-B and SP-C enriched synthetic surfactant (CHF5633) in preterm babies with respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2017; 102 (6), F497-503.
Singh, N., Halliday, H. L., Stevens, T. P. Comparison of animal derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev 2015; CD010249.
Lemyre. B., Fusch, C., Schmölzer, G. M. Poractant alfa versus bovine lipid extract surfactant for infants 24 + 0 to 31 + 6 weeks gestational age: A randomized controlled trial. PLoS One 2017; 12 (5), e0175922.
Rojas-Reyes, M. X., Morley. C.J., Soll. R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2012: CD000510.
Dunn, M.S., Kaempf, J., de Kler,k A.; Vermont Oxford Network DRM Study Group. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011; 128 (5), e1069–76.
Carlo, W.A., Finer, N. N., Walsh, M.C.; SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Target ranges of oxygen saturation in extremely preterm infants. N Engl J Med 2010; 362 (21), 1959–69.
Verder, H., Albertsen, P., Ebbesen, F. Nasal continuous positive airway pressure and early surfactant therapy for respiratory distress syndrome in newborns of less than 30 weeks’ gestation. Pediatrics 1999; 103 (2), E24.
Rojas, M. A., Lozano, J. M., Rojas, M. X.; 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 (1), 137–42.
Ballard, R.A., Keller, R. L., Black, D. M.; TOLSURF Study Group. Randomized trial of late surfactant treatment in ventilated preterm infants receiving inhaled nitric oxide. J Pediatr 2016;168:23–9.e4.
Hascoët, J. M., Picaud. J.C., Ligi, I., et al. Late surfactant administration in very preterm neonates with prolonged respiratory distress and pulmonary outcome at 1 year of age: a randomized clinical trial. JAMA Pediatr 2016; 170 (4), 365–72.
Kribs, A., Pillekamp, F., Hünseler, C. Early administration of surfactant in spontaneous breathing with nCPAP: feasibility and outcome in extremely premature infants (postmenstrual age =27 weeks). Paediatr. Anaesth. 2007; 17 (4), 364–369.
Klotz, D., Porcaro, U., Fleck, T. & Fuchs, H. European perspective on less invasive surfactant administration—a survey. Eur. J. Pediatr. 2017; 176 (2), 147–154.
Aldana-Aguirre, J. C., Pinto, M., Featherstone, R. M. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: A systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2017; 102 (1), F17–23.
Dargaville, P. A., Aiyappan, A., Cornelius, A. Preliminary evaluation of a new technique of minimally invasive surfactant therapy. Arch Dis Child Fetal Neonatal Ed 2011; 96 (4), F243–8.
Pinheiro, J.M., Santana-Rivas, Q., Pezzano, C. Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery. J Perinatol 2016; 36 (3), 196–201
Ten Centre Study Group. Ten Centre trial of artificial surfactant (artificial lung expanding compound) in very premature babies. Br Med J (Clin Res Ed) 1987; 294 (6578), 991–6.
Minocchieri, S., Berry, C.A., Pillow, J. J. CureNeb Study Team. Nebulised surfactant to reduce severity of respiratory distress: A blinded, parallel, randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2019; 104 (3), F313–9.
Vyas, J., Kotecha, S. Effects of antenatal and postnatal corticosteroids on the preterm lung. Arch. Dis. Child 1997; 77 (2), F147–F150.
Gladstone, I. M., Mercurio, M. R., Devenny, S. G.. Antenatal steroids, postnatal surfactant, and pulmonary function in premature rabbits. J. Appl. Physiol. 1989; 67 (4), 1377–1382.
Björklund, L. J.,Ingimarsson, J., Curstedt, T., et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr. Res. 1997; 42 (3), 348–355.
van Kaam, A. H., Haitsma, J.J., Dik, W. A., et al. Response to exogenous surfactant is different during open lung and conventional ventilation. Crit. Care Med. 2004; 32 (3), 774–780.
Klingenberg, C., Wheeler, K. I., McCallion, N., et al. Volume-targeted versus pressure-limited ventilation in neonates. Cochrane Database Syst Rev 2017; 10, CD003666.
Sweet, D. G., Carnielli, V., Greisen, G., et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology. 2019; 115 (4), 432-450.
Ng, E. H., Shah, V. Guidelines for surfactant replacement therapy in neonates. Paediatr Child Health. 2021; 26 (1), 35-49.
Natarajan, C. K., Sankar, M. J., Jain, K., et al. Surfactant therapy and antibiotics in neonates with meconium aspiration syndrome: a systematic review and meta-analysis. J. Perinatol. 2016; 36 (Suppl 1), 49–54.
El Shahed, A. I., Dargaville, P. A., Ohlsson, A, et al. Surfactant for meconium aspiration syndrome in term and late preterm infants. Cochrane Database Syst Rev 2014; (12), CD002054.
Amizuka, T., Shimizu, H., Niida, Y., et al. Surfactant therapy in neonates with respiratory failure due to haemorrhagic pulmonary oedema. Eur. J. Pediatr. 2003; 162 (10), 697–702.
Pandit, P. B., Dunn, M. S., Colucci, E. A. Surfactant therapy in neonates with respiratory deterioration due to pulmonary hemorrhage. Pediatrics 1995; 95 (1), 32–6.
Raju, T. N., Langenberg, P. Pulmonary hemorrhage and exogenous surfactant therapy: A metaanalysis. J Pediatr 1993;123 (4), 603–10.
Hahn, S., Choi, H. J., Soll, R., et al A. Lung lavage for meconium aspiration syndrome in newborn infants. Cochrane Database Syst. Rev. 2013; 4, CD003486
Aziz, A., Ohlsson, A. Surfactant for pulmonary haemorrhage in neonates. Cochrane Database Syst. Rev. 2012; 7, CD005254
Been, J. V., Rours, I. G., Kornelisse, R. F., et al. Chorioamnionitis alters the response to surfactant in preterm infants. J. Pediatr. 2010; 156 (1), 10–15.e1
Herting, E., Gefeller, O., Land, M., et al. Surfactant treatment of neonates with respiratory failure and group B streptococcal infection. Members of the Collaborative European Multicenter Study Group. Pediatrics 2000; 106 (5), 957–6.
Fajardo, C., Levin, D., Garcia, M., et al. Surfactant versus saline as a vehicle for corticosteroid delivery to the lungs of ventilated rabbits. Pediatr. Res. 1998; 43 (4 pt 1), 542–547.
Kothe, T. B., Royse, E., Kemp, M. W., et al. Effects of budesonide and surfactant in preterm fetal sheep. Am. J. Physiol. Lung Cell Mol. Physiol. 2018; 315 (2), L193–L201.
Yeh, T. F., Chen, C. M., Wu, S. Y., et al. Intratracheal administration of budesonide/surfactant to prevent bronchopulmonary dysplasia. Am. J. Respir. Crit. Care Med. 2016; 193 (1), 86–95.
