Lung Recruitment Before Surfactant Administration in Extremely Preterm Neonates
Authors: Gallini Francesca , De Rose Domenico Umberto , Iuliano Roberta , Romeo Domenico Marco , Tana Milena , Paladini Angela , Fusco Francesca Paola , Nobile Stefano , Cota Francesco , Tirone Chiara , Aurilia Claudia , Lio Alessandra , Esposito Alice , Costa Simonetta , D’Andrea Vito , Ventura Maria Luisa , Carnielli Virgilio , Dani Carlo , Mosca Fabio , Fumagalli Monica , Scarpelli Gianfranco , Giordano Lucio , Fasolato Valeria , Petrillo Flavia , Betta Pasqua , Solinas Agostina , Gitto Eloisa , Gargano Giancarlo , Mescoli Giovanna , Martinelli Stefano , Di Fabio Sandra , Bernardo Italo , Tina Lucia Gabriella , Staffler Alex , Stasi Ilaria , Mondello Isabella , Scapillati Eleonora , Vedovato Stefania , Maffei Gianfranco , Bove Adriano , Vitaliti Marcello , Terrin Gianluca , Lago Paola , Gizzi Camilla , Strozzi Chiara , Villani Paolo Ernesto , Berardi Alberto , Cacace Caterina , Bracaglia Giorgio , Pascucci Eleonora , Cools Filip , Pillow Jane J. , Polglase Graeme , Pastorino Roberta , van Kaam Anton H. , Mercuri Eugenio , Orfeo Luigi , Vento Giovanni ,   IN-REC-SUR-E Study Group, Malguzzi Silvia , Rigotti Camilla , Cecchi Alessandra , Nigro Gabriella , Costabile Carmine Deni , Roma Enza , Sindico Paola , Venafra Rita , Mattia Carmine , Conversano Maria , Ballardini Elisa , Manganaro Alessandro , Balestri Eleonora , Gallo Claudio , Catenazzi Piero , Astori Maria Graziana , Maranella Eugenia , Grassia Carolina , Maiolo Kim , Castellano Danilo , Massenzi Luca , Chiodin Elisabetta , Gallina Maria Rita , Consigli Chiara , Sorrentino Elena , Bonato Silvia , Mancini Monica , Perniola Roberto , Giannuzzo Silvia , Tranchina Elisa , Cardilli Viviana , Dito Lucia , Regoli Daniela , Tormena Francesca , Battajon Nadia , Arena Roberta , Allais Benedetta , Guidotti Isotta , Roversi Federica , Meli Valerio , Tulino Viviana , Casati Alessandra 
Published: September 2024

Importance

A multicenter randomized clinical trial (RCT) showed a lung recruitment maneuver using high-frequency oscillatory ventilation just before surfactant administration (ie, intubate-recruit-surfactant-extubate [IN-REC-SUR-E]) improved the efficacy of treatment compared with the standard intubate-surfactant-extubate (IN-SUR-E) technique without increasing the risk of adverse neonatal outcomes.

Objective

To examine follow-up outcomes at corrected postnatal age (cPNA) 2 years of preterm infants previously enrolled in an RCT and treated with IN-REC-SUR-E or IN-SUR-E in 35 tertiary neonatal intensive care units.

Design, Setting, and Participants

This was a follow-up study of infants recruited into the primary RCT from 2015 to 2018 at 35 tertiary neonatal intensive care units (NICUs) in Italy. Follow-up examinations included neurodevelopmental, growth, and respiratory outcomes of these children at cPNA 2 years. Participants included spontaneously breathing extremely preterm neonates (24 0/7 to 27 6/7 weeks’ gestation) reaching failure criteria for continuous positive airway pressure within the first 24 hours of life. Data were analyzed from April 2023 to January 2024.

Intervention

Infants were randomly assigned (1:1) to IN-REC-SUR-E or IN-SUR-E and then followed up.

Main Outcomes and Measures

The primary outcome was the occurrence of death after discharge or major disability at cPNA 2 years. Secondary outcomes were neurodevelopmental outcomes (major disability, cerebral palsy, cognitive impairment, visual deficit, or auditory deficit), anthropometric measurements (weight, length, and head circumference), and recurrent respiratory infections and hospitalizations because of respiratory causes at 2y cPNA.

Results

A total of 137 extremely preterm infants (median [IQR] gestational age, 26.5 [25.3-27.5] weeks and 75 [54.7%] female), initially enrolled in the original RCT, were followed up at cPNA 2 years, including 64 infants in the IN-SUR-E group and 73 infants in the IN-REC-SUR-E group. There were no significant differences in the occurrence of death after discharge or major disability at cPNA 2 years (IN-SUR-E: 13 children [20.3%] vs IN-REC-SUR-E: 10 children [13.7%]; P = .36). There were no significant differences in incidence of disability, cerebral palsy, or cognitive impairment in the IN-REC-SUR-E group compared with the IN-SUR-E group. There were no significant differences in anthropometric measurements (weight, length, and head circumference) between groups. There were no significant differences in the incidence of recurrent respiratory infections or in hospitalizations because of respiratory causes between groups.

Conclusions and Relevance

In this RCT of lung recruitment before surfactant vs standard care there were no significant differences between the 2 groups in death, neurodevelopmental outcomes, anthropometric measurements, or recurrent respiratory infections at the 2-year follow-up. These findings can aid clinicians in decision-making for the best strategy to administer surfactant, considering long-term outcomes.