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Ernesto Valdes MD, Guest Editor
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Meconium Aspiration Syndrome- Is Surfactant Lavage the Answer? Kinsella, John P. Am J of Resp & Crit Care Med (August 2003); 168;No. 4; 413-414.
Dr. Kinsella mentions that hypoxemic respiratory failure affects approximately 80,000 newborn infants each year in the USA (greater than ARDS in adults). Estimated hospital cost of $4.4 billion. About 1/3 are born at or near full term. With the most common etiology in this group being MAS, it is the most common indication for treatment with ECMO. Meconium contaminated amniotic fluid occurs in 10-15% of all pregnancies. 5-10% of these infants develop MAS and respiratory failure. Aspiration of particulate meconium causes check valve obstruction, causing some of the symptomatology. But in most severe cases of MAS, airway and alveolar dysfunction is accompanied by compromised cardiac performance and pulmonary vascular abnormalities, which develop over time in utero, leading to PPHN. Survival of MAS with ECMO support is approximately 95%, suggesting these abnormalities resolve.
KL4-surfactant for bronchoalveolar lavage in newborn study is pending. But a small pilot study showed no significant advantage. 20% of infants had to have the procedure halted because of deterioration.
Dr. Kinsella suggests his approach, of early use of exogenous surfactant as a small bolus, inhaled NO and lung recruitment with HFOV for hypoinflation. But for MAS with hyperinflation, the proposed strategy is more analogous to managing asthmatics; using slow ventilator rate & allowing increased time for expiration.
Comment: I think the trend is to use the asthmatic strategy
these days for management of MAS. Again more support for surfactant lavage.
E.V.
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