Pharyngeal instillation of surfactant before the first breath for prevention of morbidity and mortality in preterm infants at risk of respiratory distress syndrome

There is no current evidence from clinical trials to guide the use of pharyngeal instillation of surfactant before the first breath in preterm infants at risk of respiratory distress syndrome.

Respiratory distress syndrome is caused by a deficiency of natural lung detergent (surfactant) and occurs mainly in infants born before term (37 weeks' gestation). The usual treatment includes instilling artificial surfactant directly into the newborn infant's airway followed by mechanical ventilation. However, this process can lead to lung injury which may affect the infant's long-term health. A potential alternative strategy is to instil surfactant into the posterior pharynx as soon as the baby’s head appears, just before delivery of the shoulders. Thereafter, resuscitation measures are instituted as usual. This procedure has the potential to reduce the need to support the infant's breathing after birth, as well as any lung damage caused by mechanical ventilation. We did not find any trials for this review of pharyngeal instillation of surfactant before the first breath in preterm infants at risk of respiratory distress syndrome. In view of the encouraging results from animal studies and preliminary human studies, trials of pharyngeal instillation of surfactant before the first breath in preterm infants at risk of respiratory distress syndrome are needed.

Authors' conclusions: 

There were no data from randomised controlled or quasi-randomised trials that evaluated the effect of intrapartum instillation of pharyngeal surfactant before the first breath. Evidence from animal and observational human studies suggest that pharyngeal instillation of surfactant before the first breath is potentially safe, feasible and may be effective. Well designed trials are needed.

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Background: 

Intrapartum pharyngeal instillation of surfactant before the first breath may result in surfactant administration to the infant lung, with the potential benefit of avoiding endotracheal intubation and ventilation, ventilator induced lung injury and bronchopulmonary dysplasia.

Objectives: 

To determine the effect of pharyngeal instillation of surfactant before the first breath compared to placebo, no treatment or intratracheal surfactant administration followed by intermittent positive pressure ventilation (IPPV) on morbidity and mortality in preterm infants at risk of respiratory distress syndrome (RDS).

Search strategy: 

Searches were made of CENTRAL (The Cochrane Library, to September 2010), MEDLINE and PREMEDLINE (1950 to September 2010), EMBASE (1980 to 2010) and CINAHL (1982 to 2010). This strategy was supplemented by searches of proceedings of scientific meetings, Google Scholar and reference lists of identified studies, as well as contact with expert informants and surfactant manufacturers.

Selection criteria: 

Published, unpublished and ongoing randomised controlled or quasi-randomised trials (using individual or cluster allocation) of pharyngeal instillation of surfactant before the first breath compared to placebo or no treatment, or intratracheal surfactant instillation followed by IPPV, on morbidity and mortality in preterm infants at risk of RDS.

Data collection and analysis: 

Two authors independently assessed study eligibility and quality.

Main results: 

No published, unpublished or ongoing trials that met the inclusion criteria for this review were found.

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