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Chapter 16Chapter 16

Surfactant Replacement TherapySurfactant Replacement Therapy

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History of Surfactant ReplacementHistory of Surfactant Replacement

LaPlace: early nineteenth centuryLaPlace: early nineteenth century Von Neergaard:1929Von Neergaard:1929 Macklin:1949Macklin:1949 Mead:1950sMead:1950s Prattle:1955Prattle:1955 Avery and Mead:1959Avery and Mead:1959 Fujiwara:1980Fujiwara:1980

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Surfactant PhysiologySurfactant Physiology

Any molecule that localizes on aqueous Any molecule that localizes on aqueous surfacessurfaces

Creates an air-liquid interface and reduces Creates an air-liquid interface and reduces surface tensionsurface tension Water molecules pushed apart Water molecules pushed apart Prevent alveolar collapse during exhalationPrevent alveolar collapse during exhalation

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Surfactant Physiology Surfactant Physiology (cont.)(cont.)

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Surfactant Metabolism and Surfactant Metabolism and CompositionComposition

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Surfactant CompositionSurfactant Composition

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Hormonal EffectsHormonal Effects

Antenatal steroidsAntenatal steroids Thyroid hormonesThyroid hormones

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Fetal Lung MaturityFetal Lung Maturity

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Surfactant DysfunctionSurfactant Dysfunction

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Clinical Application and Clinical Application and ReplacementReplacement

RDSRDS TreatmentTreatment Prophylaxis Prophylaxis Rescue and multiple treatmentsRescue and multiple treatments Natural vs syntheticNatural vs synthetic NonrespondersNonresponders

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Clinical Application and Clinical Application and Replacement Replacement (cont.)(cont.)

Pulmonary hemorrhagePulmonary hemorrhage Meconium aspiration syndromeMeconium aspiration syndrome Pneumonia and sepsisPneumonia and sepsis Congenital diaphragmatic herniasCongenital diaphragmatic hernias

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Clinical Application and Clinical Application and Replacement Replacement (cont.)(cont.)

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Clinical Application and Clinical Application and Replacement Replacement (cont.)(cont.)

ARDSARDS Viral bronchiolitisViral bronchiolitis AsthmaAsthma Cystic fibrosisCystic fibrosis

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Future DirectionsFuture Directions

Administration with LMAAdministration with LMA Genetically engineered surfactant-Genetically engineered surfactant-

associated proteins associated proteins Understanding of individual genetic Understanding of individual genetic

polymorphism polymorphism

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Case 16.1Case 16.1

800-gm 26-week gestation baby boy 800-gm 26-week gestation baby boy Spontaneous vaginal delivery due to Spontaneous vaginal delivery due to

cervical incompetence cervical incompetence Apgar score of 5Apgar score of 511 and 6 and 655

Positive pressure ventilation (PPV)Positive pressure ventilation (PPV)

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Case 16.1 Case 16.1 (cont.)(cont.)

Grunting Grunting NCPAP of 5 cm HNCPAP of 5 cm H22O O First arterial blood gas at 30 minutes of life First arterial blood gas at 30 minutes of life

on 70% oxygen is: pH 7.10, pCOon 70% oxygen is: pH 7.10, pCO22 78 mm 78 mm

Hg, pOHg, pO22 52 mm Hg 52 mm Hg

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Case 16.2Case 16.2

A full-term infant A full-term infant Stat C-section for fetal heart rate Stat C-section for fetal heart rate

decelerationsdecelerations Thick meconium Thick meconium Suction by OB Suction by OB Endotracheal intubation/suctioned the Endotracheal intubation/suctioned the

airwayairway

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Case 16.2 Case 16.2 (cont.)(cont.)

Significant grunting and intercostals Significant grunting and intercostals retractionsretractions

Placed on high-frequency oscillatory Placed on high-frequency oscillatory ventilation ventilation

Requires an FIORequires an FIO22 of 1.0 of 1.0 Preductal saturations of 90%; postductal Preductal saturations of 90%; postductal

saturations of 85% saturations of 85% Chest radiograph: bilateral streaky Chest radiograph: bilateral streaky

densities throughout the lung fieldsdensities throughout the lung fields