Surfactant for Diaphragmatic Hernia?

Is surfactant therapy beneficial in the treatment of the term newborn infant with congenital diaphragmatic hernia? Van Meurs K and the Congenital Diaphragmatic Hernia Study Group. J Pediatr 2004; 145:312-316.

Objectives To determine the impact of surfactant replacement on survival, need for extracorporeal membrane oxygenation (ECMO), and chronic lung disease in term infants with prenatally diagnosed congenital diaphragmatic hernia (CDH).

Study design Prenatally diagnosed infants born at

37 weeks' gestation with immediate distress at delivery and no other major congenital anomalies, who were enrolled in the CDH Registry, were analyzed.

Results Eligible infants (n=522) were identified. Demographic variables were similar between the surfactant-treated (n=192) and nonsurfactant-treated (n=330) groups, with the exception of race (white, 88.0% vs. 71.2%; P=.0007). The use of ECMO and incidence of chronic lung disease were higher (59.8 vs. 50.6, P=.04; 59.9 vs. 47.6, P=.0066) and survival lower in the surfactant-treated cohort (57.3 vs. 70.0, P=.0033). Adjusted logistic regression for use of ECMO, survival, and chronic lung disease resulted in odds ratios inconsistent with an improved outcome associated with surfactant use.

Conclusions This analysis shows no benefit associated with surfactant therapy for term infants with a prenatal diagnosis of isolated CDH.

Commentary: Clearly, these data from 81 participating registry centers cannot be interpreted to support the use of surfactant therapy for infants with CDH. The usual demographic variables did not identify a difference in risk between the surfactant and non-surfactant treated groups, so one would expect major outcomes to be similar (and they were not). But consider this: infants treated with surfactant were significantly more likely to have been treated with vasopressors, inhaled bronchodilators, sedation, paralysis, alkalinization, postnatal steroids, and (implied in the article) inhaled nitric oxide. Might not an alternative explanation be that centers differed with respect to ventilation therapy and proclivity for medical mega-therapy; that these therapies acted alone or in concert to increase the risk of mortality; and that surfactant use simply falls out as a marker of concomitant treatment with other unproven therapies? I personally think this is as or more likely an explanation than the hypothesis that surfactant therapy produces such an increase in physiological instability that these additional therapies become necessary. In any case, for patients with CDH, we are still bereft of the appropriate randomized controlled study of the best surfactant administered in the correct dose and at the optimal time. And this post hoc analysis has probably shut the door forever on a prospective study. – MLH

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