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Meta-Analysis
. 2015 Dec 21;2015(12):CD010249.
doi: 10.1002/14651858.CD010249.pub2.

Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants

Neetu Singh  1 , Henry L Halliday, Timothy P Stevens, Gautham Suresh, Roger Soll, Maria Ximena Rojas-Reyes
Affiliations
Meta-Analysis

Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants

Neetu Singh et al. Cochrane Database Syst Rev. .

Abstract

Background: Animal-derived surfactants have been shown to have several advantages over the first generation synthetic surfactants and are the most commonly used surfactant preparations. The animal-derived surfactants in clinical use are minced or lavaged and modified or purified from bovine or porcine lungs. It is unclear whether significant differences in clinical outcome exist among the available bovine (modified minced or lavage) and porcine (minced or lavage) surfactant extracts.

Objectives: To compare the effect of administration of different animal-derived surfactant extracts on the risk of mortality, chronic lung disease, and other morbidities associated with prematurity in preterm infants at risk for or having respiratory distress syndrome (RDS).

Search methods: We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), MEDLINE via PubMed (1966 to July 31, 2015), EMBASE (1980 to July 31, 2015), and CINAHL (1982 to July 31, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

Selection criteria: Randomized or quasi-randomized controlled trials that compared the effect of animal-derived surfactant extract treatment administered to preterm infants at risk for or having RDS to prevent complications of prematurity and mortality.

Data collection and analysis: Data regarding clinical outcomes were excerpted from the reports of the clinical trials by the review authors. Subgroup analyses were performed based on gestational age, surfactant dosing and schedule, treatment severity and treatment strategy. Data analysis was performed in accordance with the standards of the Cochrane Neonatal Review Group.

Main results: Sixteen randomized controlled trials were included in the analysis. Bovine lung lavage surfactant extract to modified bovine minced lung surfactant extract: Seven treatment studies and two prevention studies compared bovine lung lavage surfactant extract to modified bovine minced lung surfactant extract. The meta-analysis did not demonstrate any significant differences in death or chronic lung disease in the prevention trials (typical RR 1.02, 95% CI 0.89 to 1.17; typical RD 0.01, 95% CI -0.05 to 0.06; 2 studies and 1123 infants; high quality evidence) or treatment trials (typical RR 0.95, 95% CI 0.86 to 1.06; typical RD -0.02 , 95% CI -0.06 to 0.02; 3 studies and 2009 infants; high quality evidence) Modified bovine minced lung surfactant extract compared with porcine minced lung surfactant extract: Nine treatment studies compared modified bovine minced lung surfactant extract to porcine minced lung surfactant extract. Meta-analysis of these trials demonstrate a significant increase in the risk of mortality prior to hospital discharge (typical RR 1.44, 95% CI 1.04 to 2.00; typical RD 0.05, 95% CI 0.01 to 0.10; NNTH 20, 95% CI 10 to 100; 9 studies and 901 infants; moderate quality evidence), death or oxygen requirement at 36 weeks' postmenstrual age (typical RR 1.30, 95% CI 1.04 to 1.64; typical RD 0.11, 95% CI 0.02 to 0.20; NNTH 9, 95% CI 5 to 50; 3 studies and 448 infants; moderate quality evidence), receiving more than one dose of surfactant (typical RR 1.57, 95% CI 1.29 to 1.92; typical RD 0.14, 95% CI 0.08 to 0.20; NNTH 7, 95% CI 5 to 13; 6 studies and 786 infants), and patent ductus arteriosus (PDA) requiring treatment (typical RR 1.86, 95% CI 1.28 to 2.70; typical RD 0.28, 95% CI 0.13 to 0.43; NNTH 4, 95% CI 2 to 8; 3 studies and 137 infants) in infants treated with modified bovine minced lung surfactant extract compared with porcine minced lung surfactant extract. In the subgroup analysis based on initial dose of surfactant, improvement in mortality prior to discharge (typical RR 1.62, 95% CI 1.11 to 2.38; typical RD 0.06, 95% CI 0.01 to 0.11; NNTH 16, 95% CI 9 to 100) and risk of death or oxygen requirement at 36 weeks' postmenstrual age (typical RR 1.39, 95% CI 1.08 to 1.79; typical RD 0.13, 95% 0.03 to 0.23; NNTH 7, 95% CI 4 to 33) was limited to higher initial dose of porcine minced lung surfactant (> 100 mg/kg). Other comparisons: No difference in outcome was noted between bovine lung lavage surfactant extract versus porcine minced lung surfactant extract. There were no studies comparing bovine lung lavage surfactant extract versus porcine lung lavage surfactant; or porcine minced lung surfactant extract versus porcine lung lavage surfactant.

Authors' conclusions: Significant differences in clinical outcome were noted in the comparison trials of modified minced lung surfactant extract (beractant) compared with porcine minced lung surfactant extract (poractant alfa) including a significant increase in the risk of mortality prior to discharge, death or oxygen requirement at 36 weeks' postmenstrual age, PDA requiring treatment and "receiving > 1 dose of surfactant" in infants treated with modified bovine minced lung surfactant extract compared with porcine minced lung surfactant extract. The difference in these outcomes was limited to studies using a higher initial dose of porcine minced lung surfactant extract. It is uncertain whether the observed differences are from differences in dose or from source of extraction (porcine vs. bovine) because of the lack of dose-equivalent comparison groups with appropriate sample size. No differences in clinical outcomes were observed in comparative trials between bovine lung lavage surfactant and modified bovine minced lung surfactants.

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Conflict of interest statement

Dr Soll has previously acted as a consultant for several of the pharmaceutical companies that manufacture surfactant preparations (Abbott Laboratories, Ross Laboratories, Chiesi Farmaceutici, Dey Laboratories, Burroughs Wellcome). Dr. Soll has not acted as a paid consultant for the past nine years.

Dr Halliday is currently a consultant for Chiesi Farmaceutici, a pharmaceutical company that manufactures a porcine‐derived surfactant preparation; and has been an invited speaker at meetings supported by Abbott Laboratories, Ross Laboratories and Burroughs Wellcome.

Dr Stevens has no known conflicts of interest. This will be further clarified prior to publication of the review.

Dr Singh has no conflict of interest to report.

Dr Suresh has no conflict of interest to report.

Dr. Rojas has no conflict of interest to report.

Figures

1
1
Forest plot of comparison: 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, outcome: 1.2 Mortality prior to discharge.
2
2
Forest plot of comparison: 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, outcome: 1.4 Oxygen requirement at 36 weeks postmenstrual age (all infants).
1.1
1.1. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 1 Neonatal mortality.
1.2
1.2. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 2 Mortality prior to discharge.
1.3
1.3. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 3 Oxygen requirement at 28 to 30 days of age (all infants).
1.4
1.4. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 4 Oxygen requirement at 36 weeks postmenstrual age (all infants).
1.5
1.5. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 5 Death or oxygen requirement at 28 to 30 days of age.
1.6
1.6. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 6 Death or oxygen requirement at 36 weeks postmenstrual age.
1.7
1.7. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 7 Received > one dose of surfactant.
1.8
1.8. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 8 Pneumothorax.
1.9
1.9. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 9 Air leak syndromes.
1.10
1.10. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 10 Pulmonary hemorrhage.
1.11
1.11. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 11 Treated patent ductus arteriosus (PDA).
1.12
1.12. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 12 Culture‐confirmed bacterial sepsis.
1.13
1.13. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 13 Necrotizing enterocolitis (any stage).
1.14
1.14. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 14 Periventricular leukomalacia.
1.15
1.15. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 15 Retinopathy of prematurity in infants examined (all stages).
1.16
1.16. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 16 Retinopathy of prematurity in infants examined (severe stage 3 or greater).
1.17
1.17. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 17 Intraventricular hemorrhage in infants receiving neuroimaging (all grades).
1.18
1.18. Analysis
Comparison 1 Bovine lung lavage surfactant extract vs. modified bovine minced lung surfactant extract, Outcome 18 Severe IVH in infants receiving neuroimaging.
2.1
2.1. Analysis
Comparison 2 Bovine lung lavage surfactant vs. porcine minced lung, Outcome 1 Mortality prior to discharge.
2.2
2.2. Analysis
Comparison 2 Bovine lung lavage surfactant vs. porcine minced lung, Outcome 2 Oxygen requirement at 36 weeks postmenstrual age.
2.3
2.3. Analysis
Comparison 2 Bovine lung lavage surfactant vs. porcine minced lung, Outcome 3 Air leak syndromes.
2.4
2.4. Analysis
Comparison 2 Bovine lung lavage surfactant vs. porcine minced lung, Outcome 4 Necrotizing enterocolitis (any stage).
2.5
2.5. Analysis
Comparison 2 Bovine lung lavage surfactant vs. porcine minced lung, Outcome 5 Retinopathy of prematurity in infants examined (all stages).
2.6
2.6. Analysis
Comparison 2 Bovine lung lavage surfactant vs. porcine minced lung, Outcome 6 Severe IVH.
3.1
3.1. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 1 Neonatal mortality.
3.2
3.2. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 2 Mortality prior to discharge.
3.3
3.3. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 3 Oxygen requirement at 28 to 30 days of age.
3.4
3.4. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 4 Oxygen requirement at 36 weeks postmenstrual age.
3.5
3.5. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 5 Death or oxygen requirement at 36 weeks postmenstrual age.
3.6
3.6. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 6 Received > one dose of surfactant.
3.7
3.7. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 7 Pneumothorax.
3.8
3.8. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 8 Air leak syndromes.
3.9
3.9. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 9 Pulmonary hemorrhage.
3.10
3.10. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 10 Treated patent ductus arteriosus (PDA).
3.11
3.11. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 11 Culture‐confirmed bacterial sepsis.
3.12
3.12. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 12 Necrotizing enterocolitis (any stage).
3.13
3.13. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 13 Periventricular leukomalacia.
3.14
3.14. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 14 Retinopathy of prematurity in infants examined (all stages).
3.15
3.15. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 15 Retinopathy of prematurity in infants examined (severe stage 3 or greater).
3.16
3.16. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 16 Intraventricular hemorrhage (all grades).
3.17
3.17. Analysis
Comparison 3 Modified bovine minced lung vs. porcine minced lung, Outcome 17 Severe IVH.
4.1
4.1. Analysis
Comparison 4 Modified bovine minced lung vs. porcine lung lavage, Outcome 1 Mortality prior to discharge.
4.2
4.2. Analysis
Comparison 4 Modified bovine minced lung vs. porcine lung lavage, Outcome 2 Pneumothorax.
5.1
5.1. Analysis
Comparison 5 Modified bovine minced lung vs. porcine minced lung (based on initial surfactant dosage), Outcome 1 Neonatal mortality.
5.2
5.2. Analysis
Comparison 5 Modified bovine minced lung vs. porcine minced lung (based on initial surfactant dosage), Outcome 2 Mortality prior to discharge.
5.3
5.3. Analysis
Comparison 5 Modified bovine minced lung vs. porcine minced lung (based on initial surfactant dosage), Outcome 3 Oxygen requirement at 28 to 30 days of age.
5.4
5.4. Analysis
Comparison 5 Modified bovine minced lung vs. porcine minced lung (based on initial surfactant dosage), Outcome 4 Oxygen requirement at 36 weeks postmenstrual age.
5.5
5.5. Analysis
Comparison 5 Modified bovine minced lung vs. porcine minced lung (based on initial surfactant dosage), Outcome 5 Death or oxygen requirement at 36 weeks postmenstrual age.
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