1. 1 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 16 Surfactant Replacement Therapy

2. 2 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. History of Surfactant Replacement LaPlace: early nineteenth century LaPlace: early nineteenth century Von Neergaard:1929 Von Neergaard:1929 Macklin:1949 Macklin:1949 Mead:1950s Mead:1950s Prattle:1955 Prattle:1955 Avery and Mead:1959 Avery and Mead:1959 Fujiwara:1980 Fujiwara:1980

3. 3 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Surfactant Physiology Any molecule that localizes on aqueous surfaces Any molecule that localizes on aqueous surfaces Creates an air-liquid interface and reduces surface tension Creates an air-liquid interface and reduces surface tension Water molecules pushed apart Water molecules pushed apart Prevent alveolar collapse during exhalation Prevent alveolar collapse during exhalation

4. 4 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Surfactant Physiology (cont.)

5. 5 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Surfactant Metabolism and Composition

6. 6 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Surfactant Composition

7. 7 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Hormonal Effects Antenatal steroids Antenatal steroids Thyroid hormones Thyroid hormones

8. 8 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Fetal Lung Maturity

9. 9 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Surfactant Dysfunction

10. 10 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Clinical Application and Replacement RDS RDS Treatment Treatment Prophylaxis Prophylaxis Rescue and multiple treatments Rescue and multiple treatments Natural vs synthetic Natural vs synthetic Nonresponders Nonresponders

11. 11 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Clinical Application and Replacement (cont.) Pulmonary hemorrhage Pulmonary hemorrhage Meconium aspiration syndrome Meconium aspiration syndrome Pneumonia and sepsis Pneumonia and sepsis Congenital diaphragmatic hernias Congenital diaphragmatic hernias

12. 12 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Clinical Application and Replacement (cont.)

13. 13 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Clinical Application and Replacement (cont.) ARDS ARDS Viral bronchiolitis Viral bronchiolitis Asthma Asthma Cystic fibrosis Cystic fibrosis

14. 14 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Future Directions Administration with LMA Administration with LMA Genetically engineered surfactant- associated proteins Genetically engineered surfactant- associated proteins Understanding of individual genetic polymorphism Understanding of individual genetic polymorphism

15. 15 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Case 16.1 800-gm 26-week gestation baby boy 800-gm 26-week gestation baby boy Spontaneous vaginal delivery due to cervical incompetence Spontaneous vaginal delivery due to cervical incompetence Apgar score of 5 1 and 6 5 Apgar score of 5 1 and 6 5 Positive pressure ventilation (PPV) Positive pressure ventilation (PPV)

16. 16 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Case 16.1 (cont.) Grunting Grunting NCPAP of 5 cm H 2 O NCPAP of 5 cm H 2 O First arterial blood gas at 30 minutes of life on 70% oxygen is: pH 7.10, pCO 2 78 mm Hg, pO 2 52 mm Hg First arterial blood gas at 30 minutes of life on 70% oxygen is: pH 7.10, pCO 2 78 mm Hg, pO 2 52 mm Hg

17. 17 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Case 16.2 A full-term infant A full-term infant Stat C-section for fetal heart rate decelerations Stat C-section for fetal heart rate decelerations Thick meconium Thick meconium Suction by OB Suction by OB Endotracheal intubation/suctioned the airway Endotracheal intubation/suctioned the airway

18. 18 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Case 16.2 (cont.) Significant grunting and intercostals retractions Significant grunting and intercostals retractions Placed on high-frequency oscillatory ventilation Placed on high-frequency oscillatory ventilation Requires an FIO 2 of 1.0 Requires an FIO 2 of 1.0 Preductal saturations of 90%; postductal saturations of 85% Preductal saturations of 90%; postductal saturations of 85% Chest radiograph: bilateral streaky densities throughout the lung fields Chest radiograph: bilateral streaky densities throughout the lung fields