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A prospective randomized trial with a crossover design was conducted to compare the efficacy and safety of two distinct strategies of high-frequency oscillatory ventilation (HFOV) to conventional intermittent mandatory ventilation (CV) in the management of respiratory distress syndrome. Only premature neonates with a birth weight less than 1.751 kg were eligible for enrollment into the study. Of 83 patients studied, 26 patients were assigned to CV-only, 27 to HFOV for 72 hours followed by CV (HFOV/CV), and 30 to HFOV-only until extubation. There was no difference among the three groups with respect to the incidence of pulmonary airleak, intraventricular hemorrhage, or death. The highest incidence of chronic lung disease was in the CV-only group. Although both HFOV groups had a lower incidence of chronic lung disease assessed at 30 days and 36 weeks postconception age, the difference was statistically significant only between the CV-only and HFOV-only groups (65% vs 30% at 30 days; P = .008; 38% vs 10% at 36 weeks postconception age, P = .013). These results suggest that use of HFOV as the predominant mode of ventilation in the management of respiratory distress syndrome is as safe as CV and can contribute to a decreased incidence of chronic lung disease. Furthermore, a short (72-hour) period of HFOV support does not provide the same advantage as continuous HFOV.

Infants born prematurely often suffer from hyaline membrane disease, also known as respiratory distress syndrome, in which the lungs are unable to function properly because they are immature. A substance called surfactant is lacking in the infant's lungs. Previous studies have shown that protein-containing lung surfactants from other species can be processed and given to infants with the disease to lessen its severity and increase survival. The protein portion helps in absorption of the surfactant, but increases the risk for infection or immunologic rejection and is difficult to produce on a large scale. This study examined the effectiveness of a new synthetic surfactant, EXOSURF, that does not contain proteins, for treating infants with hyaline membrane disease. The drug was given through the trachea (windpipe) to two sets of infants soon after birth. There were 74 high-risk infants weighing between 700 and 1,350 grams (1.5 to 3 pounds) who were given the drug or a placebo at birth as a preventive measure (prophylactic trial), and 104 infants with the disease weighing more than 650 grams (1.4 pounds), who were given EXOSURF as a treatment or were given a placebo (rescue trial). In the prophylactic trial, 36 received the drug and 38 received the placebo. Within the first three days after birth, six infants given placebo died of respiratory failure while none of the prophylactically treated infants died until one died at age 34 days. In the rescue trial, 53 infants received the surfactant and 51 received a placebo. Complication and death rates were not significantly different between the treated group and the placebo group. In both trials, the treated group did have significantly greater improvements in respiratory function than the placebo group. These results indicate that EXOSURF, a synthetic surfactant, is as effective as surfactants derived from animals in treating hyaline membrane disease, with the added benefit that the former does not contain proteins. (Consumer Summary produced by Reliance Medical Information, Inc.)

Respiratory distress syndrome in premature infants (RDS) results in severely impaired breathing and is the leading cause of death in premature infants born in the US. Pulmonary surfactant is a phosphate and lipid compound that lowers the surface tension of the air and liquid emulsion in the lungs. Surfactant has been administered to prevent RDS in high-risk infants or to treat infants with confirmed RDS. The effect of timing of administering surfactant on the outcome of RDS was assessed in 182 infants who were born at fewer than 30 weeks gestation. Subgroups of 60 infants in each were designated and were given surfactant at birth; surfactant at less than six hours of age; or received no surfactant. Surfactant was not given to infants with clear chest X-rays and whose who did not require supplemental oxygen. Twenty-eight of 60 infants assigned to the late surfactant group, or the group receiving treatment at less than six hours of age, did not require surfactant. The remaining 31 infants of the late surfactant group required surfactant at an average of 2.9 hours of age. Infants treated with surfactant had better gas exchange, and lower incidence of pulmonary air leak and severe chronic lung disease compared with untreated infants. The infants receiving early and late surfactant treatment had similar measures of lung function, although the early treatment group had a higher frequency of mild chronic lung disease. In addition, infants receiving late surfactant treatment required shorter duration of intensive medical treatment and oxygen support. These findings show that surfactant treatment of infants born at less than 30 weeks' gestation decreases the requirements for oxygen and supportive breathing interventions during the first week of life, and also decreases the incidence of pulmonary air leak and severe chronic lung disease. Prophylactic treatment with surfactant was associated with a higher incidence of mild chronic lung disease compared with those receiving late treatment. These results indicate that prophylactic surfactant treatment may not be routinely needed among premature infants. (Consumer Summary produced by Reliance Medical Information, Inc.)

Byline: L. Gupta, M. Singhi, Mohit. Bansal, Rajeev. Khullar, Vinod. Jain, Dilip. Kachhawa Juvenile hyaline fibromatosis (JHF) is a rare, autosomal recessively inherited disorder. We report two siblings with multiple [...]

Objective. To determine whether use of the click test, a rapid bedside test of surfactant function, results in earlier and more appropriate surfactant administration in ventilated preterm infants than does usual early rescue treatment. Study Design. Ventilated preterm infants (n = 126) with inspired oxygen [is greater than or equal to] 25% and mean airway pressure [is greater than or equal to] 7 cm [H.sub.2]O were randomized in gestational strata ([is less than] 28 weeks and 28-36 weeks) to have surfactant therapy determined by the click test or by usual clinical and chest radiograph criteria. The treatment group had the click test performed on a tracheal aspirate as soon as possible after intubation and, if negative or equivocal (surfactant deficient), surfactant was given. The control group had surfactant given as soon as possible based on clinical and chest radiograph diagnoses of respiratory distress syndrome. Results. In infants of [is less than] 28 weeks' gestation, use of the click test resulted in significantly earlier surfactant therapy (median time: 50 vs 159 minutes) and a reduction in the number of infants receiving surfactant (48% vs 79%). In infants of 28 to 36 weeks' gestation, there was no difference in time to surfactant (median time: 300 vs 268 minutes) or in the number of infants receiving surfactant. Neonatal morbidity and mortality were similar in click test and control groups. Conclusions. Use of the click test in ventilated, extremely premature infants results in significantly earlier and more appropriately targeted administration of surfactant than does early rescue therapy based on clinical and radiograph criteria. A randomized trial of targeted early rescue surfactant therapy versus prophylactic surfactant therapy in infants of [is less than] 28 weeks' gestation is warranted. The click test has the potential to improve clinical outcomes and reduce costs. Pediatrics 2000;106(3). URL: http://www.pediatrics.org/cgi/content/full/106/3/e30; click test, hyaline membrane disease, infant-premature, surfactant.