key: cord-0005891-5319ywnn
authors: Moreno, M.; López-Herce, J.; Merello, C.; Alcaraz, A.; Carrillo, A.
title: Exogenous surfactant therapy for acute respiratory distress in infancy
date: 1996
journal: Intensive Care Med
DOI: 10.1007/bf01728337
sha: 5880ec72037ce4044c63bbdbf1c5cb43433701b2
doc_id: 5891
cord_uid: 5319ywnn

nan

Sir: Respiratory syncytial virus (RSV) is the most common cause of acute viral disease of the lower respiratory tract in infants and children, and is the agent responsible for bronchiolitis. Approximately i-2% of affected children require hospitalization. Progression to respiratory failure is uncommon [1] and the development of adult respiratory distress syndrome (ARDS) is very rare [2] . Despite a multitude of proposed treatments such as mechanical ventilation with high PEEP, high-frequency ventilation, and the use of pressure-control ventilation with reverse inspiratory-expiratory ratio, the mortality rate from ARDS remains very high. Based on experience with its use in the treatment of respiratory distress syndrome (RDS) in neonates, surfactant therapy has recently been suggested to be of potential benefit in the treatment of ARDS [3, 4] .

We present the case of an infant with RSV-induced ARDS who showed great clinical improvement upon administration of intratracheal surfactant. A 6-week-old male, second twin, with a history of prematurity (36 weeks of gestation), with no respiratory pathology in the neonatal period, was admitted to our pediatric intensive care unit because of bronchiolitis (direct immunofluorescence test positive for RSV is nasopharyngeal smear), manifested by respiratory distress and apneic spells. Two days after admission to the PICU, atelectasis of the left lung developed and the patient required intubation and mechanical ventilation. The patient developed left pneumothorax requiring pleural drainage, and over the next 48 h there was progressive respiratory deterioration with increasing hypoxemia. A chest X-ray revealed generalized bilateral alveolar infiltration and severe hypoxemia (PaO2) 56 mmHg), despite increased respiratory support with pressure-controlled ventilation and continuous flow, with pressures 40/7 cm H20, respiratory rate 42 breaths/rain, FIO z 1, and inspiratory:expiratory ratio 1 : 1.0. As there was no response to elevations of PEEP (maximum PEEP of 12 cm H20), treatment with nitric oxide in concentrations up to 20 ppm was performed 5 days after intubation with no improvement in oxygenation. 24 h later, treatment with porcine surfactant (Curosurf) instilled through the intratracheal tube at 50 mg -1 kg -1 dose was administered. Four doses were administered over a 36-h period. After the second administration of surfactant, a fast improvement in oxygenation occur- Table 1 .

The experience with this patient suggests that administration of surfactant may be useful in some pediatric patients with ARDS [4, 5] . The dosage and administration intervals of surfactant have not yet been defined for this population. In some infants with ARDS, as in our patient, the improvement in alveolar stability achieved through surfactant administration might be a more important factor for the reduction of intrapulmonary shunt fraction than the lowering of pulmonary vascular resistance with NO. In other patients, simultaneous treatment with NO and intratracheal surfactant might have synergic effects.

Pathogenesis and treatment of bronchiolitis

Respiratory syncitial virus triggered adult respiratory distress syndrome in infants: a report of two cases

Recent advances in pulmonary medicine

Improvement of gas exchange following endobronchial instillation of an exogenous surfactant in an infant with respiratory failure by postoperative pulmonary haemorrhage

Presentacidn de un lactante afecto de distr6s respiratorio tipo adulto y tratado con surfactante pulmonar

Alcaraz 9 A. Carrillo Pediatric Intensive Care Unit Hospital General Universitario Gregorio Marafi6n