Randomized controlled trial of very early continuous distending pressure in the management of preterm infants. Combined hormonal therapy for the prevention of respiratory distress syndrome and its consequences. Risk of respiratory distress syndrome after prenatal dexamethasone treatment.
Application of continuous distending pressure at birth (very early CDP) should stabilize the immature airways and reduce the severity of respiratory distress syndrome (RDS) in preterm infants. Eighty-two preterm infants of less than 32 weeks gestation were randomly assigned at birth to early treatment group (TG), in which CDP of 6 cm water pressure was applied at birth by the nasopharyngeal route (NP-CDP), or to control group (CG), in which CDP was applied when indicated for established criteria (pO2 less than 50 mmHg in FiO2 greater than 0.5). Characteristics of the infants in the two groups were comparable. No statistically significant difference between the two groups was found in the incidence of RDS. The course of RDS, and oxygen and ventilatory requirements also did not appear to be changed. In blood gas parameters of most of the time frames, no significant difference was found between the two groups when the results were analyzed according to the assigned group. When the results were analyzed separately for the infants who developed RDS, infants in TG appear to have fared worse from the therapy in terms of oxygenation, as indicated by significantly higher FiO2 (P less than 0.01) and lower a/A (P less than 0.01) values on the third day of the course of RDS, as compared to infants in CG. The incidence of complications was comparable in the two groups. Four infants from TG (9.3%) and one from CG (2.6%) died (P = NS). We conclude that VECDP by nasopharyngeal route does not reduce the incidence of RDS and does not appear to improve the outcome and may worsen the severity of RDS when compared to application of CDP for established criteria. In performing this meta-analysis, we have attempted to use comparable data, but there are limitations to the information that is available at present. Some studies reported results for all patients entered, whereas others reported only optimally treated patients (Table 2). Many of the trials have not yet been published in final form and subjected to peer review. In addition, all the studies reported here were conducted before the widespread use of surfactant therapy. It is unclear whether the benefit of antenatal TRH and steroid therapy on end points such as death or BPD would persist if surfactant was also used. (Surfactant has, however, little impact on the percentage of survivors with BPD, perhaps because sicker infants survive with this treatment and go on to develop BPD.) Studies comparing antenatal TRH plus steroid plus postnatal surfactant to antenatal steroid plus postnatal surfactant are clearly required, and are in progress in a number of centers around the world. Because of these limitations, the routine use of antenatal TRH plus steroid cannot be currently recommended. However, the apparent benefits of this therapy in terms of RDS, death, and CLD that have been reported here do suggest that it might be used in selected situations. An example is threatened delivery of a very premature infant with an immature amniotic fluid pulmonary maturation profile. These infants are at risk for RDS and CLD, even if antenatal steroid and postnatal surfactant therapy is used.(ABSTRACT TRUNCATED AT 250 WORDS) A prospective double-blind randomized clinical trial was carried out to determine whether glucocorticoid treatment reduces the risk of respiratory distress syndrome (RDS) in prematurely born infants. There were 127 infants born to 122 mothers who received either steroid (dexamethasone phosphate) or placebo. No differences between groups occurred in risk factors for RDS (eg, prepartum asphyxia, male sex, cesarean section). When those who received a full course of dexamethasone therapy were compared with those who received placebo, a significant reduction was found in risk, severity, and deaths due to RDS. An increased incidence of infection in mothers treated with steroid was evident, particularly after premature rupture of membranes. We conclude that steroids are effective in reducing risk of RDS, but safer and more efficacious approaches for the prevention of RDS should be sought.
Early application of CDP has a clinical benefit in the treatment of RDS in that it reduces subsequent use of IPPV and thus may be useful in preventing the adverse effects of this treatment. However, many of the trials were done in the 1970s and 1980s and re-evaluation of the strategy of early CDP in the era of antenatal steroid use and early surfactant administration is indicated focusing on administration methods.