A shared protocol for porcine surfactant use in pediatric acute respiratory distress syndrome: a feasibility study

Abstract

Background: Pediatric ARDS still represents a difficult challenge in Pediatric Intensive Care Units (PICU). Among different treatments proposed, exogenous surfactant showed conflicting results. Aim of this multicenter retrospective observational study was to evaluate whether poractant alfa use in pediatric ARDS might improve gas exchange in children less than 2 years old, according to a shared protocol.

Methods: The study was carried out in fourteen Italian PICUs after dissemination of a standardized protocol for surfactant administration within the Italian PICU network. The protocol provides the administration of surfactant (50 mg/kg) divided in two doses: the first dose is used as a bronchoalveolar lavage while the second as supplementation. Blood gas exchange variations before and after surfactant use were recorded.

Results: Sixty-nine children, age 0-24 months, affected by Acute Respiratory Distress Syndrome treated with exogenous porcine surfactant were enrolled. Data collection consisted of patient demographics, respiratory variables and arterial blood gas analysis. The most frequent reasons for PICU admission were acute respiratory failure, mainly bronchiolitis and pneumonia, and septic shock. Fifty-four children (78.3%) had severe ARDS (define by oxygen arterial pressure and inspired oxygen fraction ratio (P/F) < 100), 15 (21.7%) had moderate ARDS (100 < P/F < 200). PO₂, P/F, Oxygenation Index (OI) and pH showed a significant improvement after surfactant use with respect to baseline (p < 0.001 at each included time-point for each parameter). No significant difference in blood gas variations were observed among four different subgroups of diseases (bronchiolitis, pneumonia, septic shock and others). Overall, 11 children died (15.9%) and among these, 10 (90.9%) had complex chronic conditions. Two children (18.2%) died while being treated with Extracorporeal Membrane Oxygenation (ECMO). Mortality for severe pARDS was 20.4%.

Conclusion: The use of porcine Surfactant improves oxygenation, P/F ratio, OI and pH in a population of children with moderate or severe pARDS caused by multiple diseases. A shared protocol seems to be a good option to obtain the same criteria of enrollment among different PICUs and define a unique way of use and administration of the drug for future studies.

Keywords: Infants; Pediatric intensive care unit; Poractant; Surfactant; pARDS.

Fig. 1

Administration protocol of exogenous surfactant

Fig. 2

Blood gases variations immediately before and after surfactant administration. a: PaO2 variations before and after treatment. b: PaCO2 variations before and after treatment. c: pH variations before and after treatment. d: P/F variations before and after treatment. e: OI variations before and after treatment. Legend: Connecting line in each figure suggests the mean values. PaO₂ = oxygen arterial pressure; PaCO₂ = carbon oxide arterial pressure; P/F = oxygen partial pressure inspired oxygen fraction ratio; OI = Oxygenation Index; pre = before treatment; post = after treatment; d = day; OI data available only for 42 children

Fig. 3

Blood gases variations in different subgroups of diagnosis immediately before and after surfactant administration. a: PaO₂ variations before and after treatment. b: PaCO₂ variations before and after treatment. c: pH variations before and after treatment. d: P/F variations before and after treatment. Legend: Data are expressed as means and standard errors. PaO₂ = oxygen arterial pressure; PaCO₂ = carbon oxide arterial pressure; P/F = oxygen arterial pressure inspired oxygen fraction ratio