&get_box_var;ORIGINAL ARTICLE

Intratracheal Administration of Budesonide/Surfactant to PreventBronchopulmonary DysplasiaTsu F. Yeh1,2, Chung M. Chen1,3,4, Shou Y. Wu5, Zahid Husan5, Tsai C. Li6,7, Wu S. Hsieh8, Chang H. Tsai2,9, andHung C. Lin2

1Maternal Child Health Research Center, College of Medicine, and 4Department of Pediatrics, School of Medicine, College of Medicine,Taipei Medical University, Taipei, Taiwan; 2Department of Pediatrics, Children’s Hospital, and 6Graduate Institute of Biostatistics, Collegeof Public Health, China Medical University, Taichung, Taiwan; 3Department of Pediatrics, Taipei Medical University Hospital, Taipei,Taiwan; 5Division of Neonatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois; 7Department of HealthcareAdministration, College of Health Science, and 9Department of Biotechnology, Asian University, Taichung, Taiwan; and 8Department ofPediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan

Abstract

Rationale: Bronchopulmonary dysplasia (BPD) is animportant complication of mechanical ventilation inpreterm infants, and no definite therapy can eliminate thiscomplication. Pulmonary inflammation plays a crucial role in itspathogenesis, and glucocorticoid is one potential therapy toprevent BPD.

Objectives:To compare the effect of intratracheal administration ofsurfactant/budesonide with that of surfactant alone on the incidenceof death or BPD.

Methods: A clinical trial was conducted in three tertiaryneonatal centers in the United States and Taiwan, in which265 very-low-birth-weight infants with severe respiratory distresssyndrome who required mechanical ventilation and inspiredoxygen (fraction of inspired oxygen, >50%) within 4 hours ofbirth were randomly assigned to one of two groups(131 intervention and 134 control). The intervention infantsreceived surfactant (100 mg/kg) and budesonide (0.25 mg/kg),

and the control infants received surfactant only (100 mg/kg),until each infant required inspired O2 at less than 30% or wasextubated.

Measurements and Main Results: The intervention group had asignificantly lower incidence of BPD or death (55 of 131 [42.0%] vs.89 of 134 [66%]; risk ratio, 0.58; 95% confidence interval, 0.44–0.77;P, 0.001; number needed to treat, 4.1; 95% confidence interval,2.8–7.8). The intervention group required significantly fewer doses ofsurfactant than did the control group. The intervention group hadsignificantly lower interleukin levels (IL-1, IL-6, IL-8) in trachealaspirates at 12 hours and lower IL-8 at 3–5 and 7–8 days.

Conclusions: Invery-low-birth-weight infantswith severe respiratorydistress syndrome, intratracheal administration of surfactant/budesonide compared with surfactant alone significantly decreased theincidence of BPD or death without immediate adverse effect.

Clinical trial registeredwithwww.clinicaltrials.gov (NCT-00883532).

Keywords: bronchopulmonary dysplasia; very-low-birth-weightinfants; surfactant; budesonide; respiratory distress syndrome

Bronchopulmonary dysplasia (BPD) is themost important pulmonary complicationfollowing mechanical ventilation in preterminfants. Various strategies including the use

of vitamin A and caffeine have beenreported to be beneficial for BPD (1–3).However, no definite therapy can eliminatethis complication.

Although the mechanism is notcompletely clear, pulmonary inflammationis believed to play a central role in thepathogenesis. Dexamethasone is one of the

(Received in original form May 4, 2015; accepted in final form September 9, 2015 )

Supported in part by the National Health Research Institute, Taiwan (NHRI-EX98-9818PI, NHRI-EX99-9818PI, NHRI-EX100-9818PI, andNHRI-EX101-9818PI).

Author Contributions: Conception and design: T.F.Y.; conduction and coordination: T.F.Y., S.Y.W., W.S.H., and H.C.L.; acquisition of data and statisticalanalyses: Z.H., S.Y.W., T.C.L., and C.H.T.; drafting the manuscript for important intellectual content: T.F.Y. and C.M.C.; review and revision of manuscript:T.F.Y., S.Y.W., Z.H., T.C.L., W.S.H., C.H.T., H.C.L., and C.M.C.

Correspondence and requests for reprints should be addressed to Tsu F. Yeh, M.D., Ph.D., Taipei Medical University, 252 Wu-Hsing Street, Taipei 110, Taiwan.E-mail: tfyeh@mail.ncku.edu.tw

This article has an online supplement, which is accessible from this issue’s table of contents online at www.atsjournals.org

Am J Respir Crit Care Med Vol 193, Iss 1, pp 86–95, Jan 1, 2016

Copyright © 2016 by the American Thoracic Society

Originally Published in Press as DOI: 10.1164/rccm.201505-0861OC on September 9, 2015

Internet address: www.atsjournals.org

86 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 1 | January 1 2016

most effective therapies to treat orprevent BPD. However, systemicdexamethasone therapy is not generallyrecommended because of long-termadverse effects (4, 5). Administeringinhaled glucocorticoids to preterminfants is technically challenging andthe effects are limited (6–8). It istherefore important to find a therapeuticmethod that reduces the systemic adverseeffects of glucocorticoids while at thesame time maintaining localantiinflammatory effects on the lungs.Budesonide is a glucocorticoid withstrong local antiinflammatory effects. Apilot study showed that intratrachealinstillation of budesonide, usingsurfactant as a vehicle, significantlyimproved pulmonary status (9). Amulticenter, randomized clinical trial wastherefore undertaken to determinewhether early intratracheal administrationof budesonide/surfactant would reducethe incidence of BPD or death. Someof the results of these studies have

been previously reported in the formof abstracts and a platform presentationat a Pediatric Academic Societiesmeeting (May 4–7, 2013, Washington,DC) and at a congress of the EuropeanAcademy of Pediatric Societies(October 17–21, 2014, Barcelona, Spain)(10, 11).

Methods

Study PopulationsBetween April 1, 2009 and March 1, 2013,all infants with respiratory distressshortly after birth were assessed foreligibility for the study in three tertiarycenters: John H. Stroger, Jr. Hospital ofCook County (JSH, Chicago, IL), NationalTaiwan University Hospital (NTUH,Taipei, Taiwan), and China MedicalUniversity Hospital (CMUH, Taichung,Taiwan). The inclusion criteria weredetermined within 4 hours after birth andincluded (1) birth weight less than 1,500 g,(2) radiographic evidence of severerespiratory distress syndrome (RDS)(grades III–IV) (12), (3) mechanicalventilation, (4) fraction of inspired oxygen(FIO2

) at least 0.5, and (5) absence ofsevere congenital anomalies or lethalcardiopulmonary disorder. These infantswere considered to be at high risk fordeveloping BPD. The study was

approved by the institutional reviewboard of each participating hospital.Verbal consent was obtained from themother before delivery and writtenconsent was obtained within 4 hours ofbirth when inclusion criteria weredetermined.

Intratracheal Budesonide/SurfactantInstillationInfants were randomized into either theintervention group or control group, basedon an assignment list designed by astatistician (T.C.L.). Concealedrandomization was generated by acomputer with permuted blocks in randomsizes of two, four, six, and eight to maintainbalance. A list of patient assignmentswas given to each participating hospital,with half of the infants assigned tointervention and half to control at eachhospital. When the first dose was to beprescribed, the main investigator inthe participating hospital would open theassignment list and prepare theappropriate syringe. The control groupreceived surfactant only (Survanta,100 mgor 4 ml/kg; Abbott Laboratories, AbbottPark, IL) and the intervention groupreceived surfactant (100 mg or 4 ml/kg) andbudesonide (Pulmicort nebulizingsuspension; Astra Zeneca, London, UK)(0.25 mg or 1 ml/kg). This dose provided aconcentration ratio of surfactant to

1215 VLBW infants assessed for eligibility

858 infants on IMV in NICU (≤ 4 hrs) were eligible

287 infants met study criteria [severe RDS (Grade III–IV); FiO2≥0.5; IMV)]

265 infants were randomized

131 infants in the intervention group 134 infants in the control group

3 infants died of IVH ≥III at <8 hrs6 infants died of lethal cardiopulmonary status <8 hrs2 infants birth weight <500 gm11 infants written consent rejected

Figure 1. Patient disposition. IMV = intermittent mandatory ventilation; IVH = intraventricularhemorrhage; NICU = neonatal intensive care unit; RDS = respiratory distress syndrome; VLBW= verylow birth weight.

At a Glance Commentary

Scientific Knowledge on theSubject: Bronchopulmonarydysplasia (BPD) is an importantcomplication of mechanical ventilationin preterm infants, and no definitetherapy can eliminate thiscomplication. Pulmonaryinflammation plays a crucial role in itspathogenesis. Glucocorticoid is one ofthe most effective therapies to treat orprevent BPD. However, systemicglucocorticoid therapy is not generallyrecommended because of long-termadverse events.

What This Study Adds to theField: Intratracheal administration ofsurfactant/budesonide compared withsurfactant alone significantly decreasedthe incidence of BPD or death in very-low-birth-weight infants with severerespiratory distress syndrome. Theinfants who received intratrachealsurfactant/budesonide hadsignificantly lower interleukin levels intracheal aspirates compared withinfants who received intratrachealsurfactant alone during the studyperiod.

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Yeh, Chen, Wu, et al.: Intratracheal Budesonide/Surfactant Prevents BPD 87

budesonide greater than 50:1; this mixturewas demonstrated, in an in vitro studyusing a surfactometer and high-performance liquid chromatography, notto affect the biophysical andchemical properties of surfactant (11) (seethe online supplement). Except for adifference in volume, the solution ineither syringe was clear andindistinguishable. The syringe was coveredby adhesive tape so that the volume of thesolution could not be identified. The maininvestigators were either division directors(W.S.H. and H.C.L.) or a senior consultant(T.F.Y.); they supervised and rarely haddirect responsibility for patient care in theneonatal intensive care unit (NICU).Before intratracheal instillation, thesyringe was gently vortexed, and thesurfactant or surfactant/budesonidemixture was administered in a mannersimilar to that of routine surfactanttherapy. Repeated administrations ofsurfactant/budesonide or surfactant onlywere given every 8 hours to infants inthe intervention or control group,respectively, until they required an FIO2

less than 0.3, were extubated, or received amaximum of six doses.

Respiratory CareDuring the study, only the main investigatorwas aware of the contents of the syringes.The NICU service attending, neonatologyfellows, residents, and nursing practitioner,who were blinded to study assignment,were the primary physicians in charge ofdaily care. A general guideline formanagement of RDS and fluid therapywas followed as described previously (9).For infants who had respiratory distressshortly after birth, a trial of nasalcontinuous positive airway pressure(NCPAP) was initiated in the deliveryroom, and infants with severe retraction orpoor respiratory effort or apnea wereintubated. The goal of ventilation therapyin the NICU was to maintain O2 saturationat 90–95%, PCO2 not more than 50 mm Hg,and pH not less than 7.20. Infants whofailed to respond adequately to NCPAP(FIO2

> 0.6 and O2 saturation, 85%) weresubsequently intubated. The respiratorycare guideline focused on indications forusing an O2 hood, nasal cannula, CPAP(nasal or intubated), intermittentmandatory ventilation (IMV), or high-frequency oscillatory ventilation (HFOV),and for weaning from mechanical

ventilation. Infant who could not tolerateroom air or O2 therapy through a hoodwas given a nasal cannula or CPAP asneeded. During the study, we defined“assisted O2 therapy” as a requirement forany of the followings: nasal cannula,CPAP, IMV, or HFOV. Blood gases andacid–base measurements were obtainedeach morning before the NICU round.Nitric oxide was not given to very-low-birth-weight infants during the studyperiod. Indomethacin was given toinfants who had significant patentductus arteriosus, defined and described

previously (13). Postnatal systemicdexamethasone was reserved only forinfants who had severe underlying lungdisease and had intractable respiratoryfailure (receiving IMV with an FIO2

of1.0, or HFOV). In such cases, a shortcourse of dexamethasone (three to fivedoses of 0.25 mg/kg every 12 h) wasgiven at the discretion of the attendingphysician.

Outcome MeasurementsDiagnosis of BPD was made by the serviceattending if the infant had had continuous

Table 1. Baseline Characteristics

Intervention Group(n = 131)

Control Group(n = 134)

Perinatal characteristicsBirth weight, g 882 (249) 935 (283)

500–749 46 (35%) 42 (31%)750–999 50 (38%) 42 (31%)1,000–1,499 35 (27%) 50 (38%)

Gestational age, postmenstrualweeks

26.5 (2.2) 26.8 (2.2)

SGA* 9 (6.9%) 11 (8.2%)AGA* 122 (93.1%) 123 (91.8%)Sex

Male 71 (54.2%) 72 (53.7%)Female 60 (45.8%) 62 (46.3%)

Prenatal steroid 112 (85%) 106 (79%)Chorioamnionitis 11 (8.4%) 10 (7.4%)Mode of delivery

Cesarean section 83 (63%) 83 (62%)Vaginal 48 (37%) 51 (38%)

Apgar score1 min<3 41 (31%) 48 (36%)4–6 68 (52%) 67 (50%).6 22 (17%) 19 (14%)

5 min<3 3 (2%) 7 (5%)4–6 26 (20%) 36 (27%).6 102 (78%) 91 (68%)

Clinical and laboratory characteristics at time of entry into studyAge, h 2.0 (1.5) 1.8 (1.4)IMV 131 134FIO2

0.61 (0.25) 0.63 (0.26)MAP, cm H2O 7.1 (4.8) 7.2 (1.5)OI 8.0 (4.3) 8.1 (5.1)PO2, mm Hg 70.6 (57.9) 68.5 (43.3)PCO2, mm Hg 48.1 (10.5) 49.7 (18.5)pH 7.25 (0.12) 7.24 (0.14)Blood pressure, mm Hg

Systolic 48.1 (11.9) 46.6 (9.2)Diastolic 29.4 (9.6) 27.5 (8.4)

Hematocrit, % 42.4 (6.6) 42.6 (6.7)

Definition of abbreviations: AGA = appropriate for gestational age; IMV = intermittent mandatoryventilation; MAP =mean airway pressure; OI = oxygen index; SGA = small for gestational age.Data are expressed as mean (SD) or number (%).*SGA and AGA were defined as birth weight less than the 10th percentile and between the 10th and90th percentiles on intrauterine growth chart, respectively.

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88 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 1 | January 1 2016

respiratory distress since birth and requiredsupplemental oxygen (.21% O2) at 36weeks’ postmenstrual age. The result wasreported to an outside independentobserver (C.M.C.) who was blinded to thepatient assignment. This definition wasused in this study because it was considereda better predictor of abnormal pulmonaryoutcome for very-low-birth-weight infants(14). At the time of designing this study inearly 2009, we used this definition becauseof two reasons: (1) this definition hadbeen used for many years in our units, andour medical and nursing staffs werefamiliar with this definition; and (2) thisdefinition would provide a chance tocompare BPD incidence with our previousstudy (9) and with important studiesreported by others (2, 3, 15–17). Because ofthe severe, radiographically evident RDSshortly after birth and because of thecontinuous respiratory distress since birth,our infants most likely had a well-established underlying lung disease at thetime of BPD diagnosis. At the end of thisstudy a post hoc analysis was also done,based on the current definition provided bythe Eunice Kennedy Shriver NationalInstitute of Child Health and HumanDevelopment (NICHD, Bethesda, MD), ininfants with less than 32 weeks of gestation(1). This definition is a severity-baseddefinition. In this definition, an infant whorequires supplemental oxygen therapy at 28postnatal days but does not requiresupplemental O2 therapy at 36 weeks’postmenstrual age is considered to havemild BPD. Moderate BPD is defined asthe need for less than 30% oxygen andsevere BPD is defined as the need for atleast 30% oxygen at 36 weeks’postmenstrual age. Tracheal aspirates wereassayed (18) for interleukins (IL-1, IL-6,

and IL-8), using commercial ELISA kits at12 hours, 24 hours, and between 3–5 and7–8 days after starting the study in the first40 infants.

Follow-up StudyA follow-up study was conducted when thesubjects were 2–3 years of age. At eachvisit, an interim medical history wasobtained and a physical examination andneurological examination (including

coordination, general reflex, and muscletone) were performed. Neuromotordysfunction was classified as mild,moderate, or severe based on themobility of the child as described byCostello and colleagues (19).Psychomotor and mental evaluationswere performed using the BayleyScales of Infant Development(BSID-II). Neurodevelopmentalimpairment as defined and described

Table 2. Mortality and Bronchopulmonary Dysplasia Morbidity

Intervention Group (n = 131) Control Group (n = 134) Difference (95% CI) RR (95% CI) P Value

BPD or death 55/131 (42%) 89/134 (66%) 20.24 (20.36 to 20.13) 0.58 (0.44 to 0.77) ,0.001Death 17/131 (13%) 22/134 (16%) 20.03 (20.12 to 0.05) 0.96 (0.87 to 1.06) 0.54BPD 38/131 (29%) 67/134 (50%) 20.21 (20.32 to 20.10) 0.70 (0.58 to 0.86) ,0.001BPD morbidity (NICHD criteria)BPD

Mild 19/131 (15%) 21/134 (16%) 20.01 (20.10 to 0.07) 0.99 (0.89 to 1.09) 0.93Moderate 26/131 (20%) 41/134 (31%) 20.11 (20.21 to 0.00) 0.87 (0.75 to 1.00) 0.06Severe 12/131 (9%) 26/134 (19%) 20.10 (20.19 to 20.02) 0.89 (0.80 to 0.98) 0.03

Definition of abbreviations: BPD = bronchopulmonary dysplasia morbidity; CI = confidence interval; NICHD = Eunice Kennedy Shriver National Institute ofChild Health and Human Development; RR = risk ratio.

Table 3. Baseline Characteristics and Interleukin Concentration in Tracheal Aspirates

Intervention Group(n = 18)

Control Group(n = 20) z Value P Value

Baseline characteristicsBirth weight, g 809 (196) 886 (232) 0.56Gestational age, wk 26.2 (2.4) 26.3 (1.6) 0.86FIO2

0.64 (0.19) 0.59 (0.20) 0.57MAP, cm H2O 6.9 (0.87) 6.9 (0.99) 0.94OI 6.7 (3.7) 7.0 (4.0) 0.44Death 2 (11.1%) 5 (25.0%) 0.41BPD 6 (33.3%) 11 (55%) 0.21Death or BPD 8 (44.4%) 16 (80%) 0.042

Interleukin concentration (pg/ml/mg urea)IL-1

12 h 2.0 (1.4–4.4) 16.5 (6.2–21.0) 22.33 0.0224 h 10.7 (1.5–15.0) 24.0 (2.3–53.0) 213.5 0.183–5 d 13.5 (9.2–23.0) 61.5 (18.0–86.0) 21.43 0.157–8 d 14.2 (7.1–29.0) 17.1 (9.2–26.2) 20.04 0.97

IL-612 h 32.0 (2.1–60.0) 79.0 (65.0–112.0) 22.57 0.0124 h 27.0 (7.3–30.0) 27.5 (13.0–47.0) 20.94 0.353–5 d 20.0 (15.0–27.0) 44.5 (18.0–53.0) 21.47 0.147–8 d 9.0 (3.4–12.0) 7.4 (4.0–10.0) 20.12 0.90

IL-812 h 53.0 (20.0–86.0) 198.0 (56.0–405.0) 22.12 0.0324 h 40.0 (21.0–49.0) 152.0 (29.0–540.0) 21.72 0.093–5 d 60.0 (48.0–105.0) 422.0 (180.0–580.0) 22.49 0.017–8 d 146.0 (86.0–210.0) 785.0 (160.0–1,200.0) 22.25 0.02

Definition of abbreviations: BPD = bronchopulmonary dysplasia; MAP =mean airway pressure; OI =oxygen index.Data are expressed as mean (SD) (baseline characteristics on admission to study) or as median(quartile 1–quartile 3) (interleukin concentration).

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by Stoll and colleagues (20) wasdetermined.

Statistical AnalysisBefore data were analyzed, the outsideindependent observer (C.M.C.) would assessand verify again the inclusion and exclusioncriteria and the diagnosis of BPD of eachinfant. The primary outcome assessed wasthe incidence of BPD or death.

Our previous experience indicated thatabout 60% of infants who fulfilled theinclusion criteria would develop BPD or die(9). We hypothesized that 60% in thecontrol group and 40% in the interventiongroup would develop BPD or die. Allowinga 5% chance of type I error and a 10%chance of type II error, the numberrequired in each group would be 130 (21).An estimated 140 patients was consideredan adequate number for each group.

The secondary outcomes assessed wereantiinflammatory mediators in the trachealaspirates. The immediate adverse effects,including changes in serum electrolytes,glucose, blood urea nitrogen, and bloodpressure and changes in physical growthwere evaluated. The incidence ofintraventricular hemorrhage, necrotizingenterocolitis, severe retinopathy ofprematurity (>grade III), and clinical sepsisor bacteremia were all assessed. Cranialultrasounds and eyeground were examined,based on a routine schedule in the NICUfor all infants less than 1,500 g. Mortality,BPD morbidity, requirement for assisted O2

therapy, and the number of surfactantdoses administered were also explored.

All analyses were performed accordingto the intention-to-treat principle, withmissing data being imputed by the last-observation-carried-forward method. Inaddition, we performed a sensitivity analysisby applying multiple imputations formissing data. The results using multipleimputation were similar because fewobservations were missing. Results based onthe last observation carried forward weremore conservative and thus are presented.Means and standard deviation are reportedfor continuous variables, and the numberand percentage are reported for categoricalvariables. The chi-square test or Fisher exacttest was used for categorical variablesincluding death, BPD, BPD or death, andBPD severity. The risk ratio was calculatedas the ratio of the cumulative incidence ratesof an event occurring in the budesonide-treated group to the control group, and the

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Figure 2. Comparison of systolic and diastolic blood pressure (BP), serum electrolytes, glucose,body weight (BW), length (L), and head circumference (HC) between the control and interventiongroups during the study. There was no significant difference in any of these variables between thegroups. BUN = blood urea nitrogen.

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90 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 1 | January 1 2016

number needed to treat as the inverse ofthese two cumulative incidence rates. Forcontinuous variables, the mean values ateach time point in each group for variablessuch as FIO2

, PO2, PCO2, pH, oxygen index,and mean airway pressure were derivedfrom a generalized linear model withgeneralized estimating equations anddifferences in values over time werecompared between the two groups (22).Generalized estimating equations were usedto account for the dependence betweenoutcomes of participants at different times.The Wilcoxon rank-sum test was used tocompare interleukin levels in trachealaspirates between the groups.Kaplan–Meier cumulative incidence plotswere generated to show time-to-event endpoints including being extubated and beingweaned to room air. A post hoc analysis ofthe primary outcome was conducted toadjust for prenatal steroid, Apgar score,and chorioamnionitis. For secondaryoutcomes and immediate side effects, noadjustments were made. All P values weretwo-sided and considered significant ifP was less than 0.05.

Results

Patient PopulationDuring the study period, 1,215 very-low-birth-weight infants were treated forrespiratory distress at birth; 858 infantsrequired intubation within 4 hours of birthand were admitted to the NICU. The finalnumber included for analysis was 265: 131in the intervention group and 134 in thecontrol group (Figure 1). Baseline data werecomparable (Table 1) between the groups.

Primary OutcomesInfants in the intervention group comparedwith the control group had a lower incidenceof BPD or death (55 of 131 [42.0%] vs. 89 of134 [66%], respectively; risk ratio, 0.58; 95%confidence interval [CI], 0.44–0.77; P,0.001; number needed to treat, 4.1 [95% CI,2.8–7.8]) (Table 2).

Secondary OutcomesOf the 40 infants studied for trachealaspirate interleukins, 2 were excludedbecause of incomplete sampling. Theintervention was associated withsignificantly lower median values for IL-1,IL-6, and IL-8 at 12 hours (all P, 0.05)and lower IL-8 on Days 3–5 and Days 7–8

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Control

Intervention

Figure 3. Changes in blood gases, oxygen index (OI), and mean airway pressure (MAP) duringthe study. Mean values, derived from a generalized linear model with generalized estimatingequations, are presented for each group. As compared with the control group, infants in theintervention group had a significantly lower FIO2

on Day 1 (mean difference [95% confidenceinterval], –6.1 [–4.06 to –3.12]; P = 0.04), higher PO2 on Day 2 (5.6 [4.26–19.4]; P = 0.04), lowerPCO2 on Day 1 (–5.1 [–1.8 to –4.5]; P = 0.01), lower OI on Day 1 (–0.07 [–1.71 to –1.06]; P = 0.01)and Day 5 (–2.1 [–2.94 to –1.35]; P = 0.01), and lower MAP on Day 1 (–1.08 [–2.61 to –0.46]; P =0.002), Day 2 (–0.66 [–2.27 to –0.94]; P = 0.04), and Day 3 (–1.37 [–3.22 to –0.48]; P = 0.02). Day0 on the x axis represents less than 24 hours, as all blood samples for blood gases were obtainedeach morning before the morning round.

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Yeh, Chen, Wu, et al.: Intratracheal Budesonide/Surfactant Prevents BPD 91

as compared with surfactant alone(Table 3).

The groups were comparable in bloodpressure, serum glucose, and electrolytesand in physical growth during the study(Figure 2). The two groups werecomparable in incidence of intraventricularhemorrhage (53 of 131 [40.5%] vs. 57 of134 [42.5%]; P = 0.80), necrotizingenterocolitis [4 of 131 [3.1%] vs. 7 of 134[5.2%]; P = 0.56), severe retinopathy ofprematurity (7 of 131 [5.2%] vs. 9 of 134[6.8%]; P = 0.79), and clinical sepsis and/orbacteremia (29 of 131 [22%] vs. 38 of 134[28%]; P = 0.31).

Exploratory OutcomesThe two groups were comparable inmortality; however, the intervention wasassociated with a significantly lowerincidence of BPD compared with surfactantalone (38 of 131 [29.0%] vs. 67 of 134[50.0%]; relative risk, 0.70; 95% CI,0.58–0.86; P, 0.001) (Table 2).

The intervention compared withsurfactant alone was associated with asignificantly lower oxygen index on Days 1and 5, a lower FIO2

requirement on Day 1,and lower mean airway pressure during thefirst 3 days (Figure 3). Among the survivinginfants during the study, those in theintervention group had a significantly lower

requirement for assisted O2 therapy ascompared with those in the control groupon Day 3 (120 of 129 vs. 131 of 132; riskratio and 95% CI, 0.93 [0.89–0.98];P = 0.017), Day 7 (110 of 127 vs. 119 of 124,0.91 [0.84–0.97]; P = 0.021), Day 21 (82 of116 vs. 99 of 116, 0.82 [0.73–0.95];P = 0.01), and Day 28 (73 of 115 vs. 88 of115, 0.83 [0.69–0.98]; P = 0.044) (Figure 4).Many of the infants in the control grouprequired nasal cannula or CPAP even withlow FIO2

for a period of time. Theintervention was associated with asignificantly (P = 0.03) higher chance ofweaning to room air (Figure 5) and asignificantly lower incidence of significantpatent ductus arteriosus (40 of 131 vs. 59 of134, 0.69 [0.49–0.97]; P = 0.032). The totaldurations of IMV (median and range, 8[4–62] vs. 16 [9–58] d) and O2 therapy (32[4–82] vs. 48 [8–102] d) were notsignificantly different between groups.Four infants in the intervention group andnine infants in the control group receivedsystemic dexamethasone therapy.

Infants in the intervention grouprequired significantly fewer doses ofsurfactant than did infants in the controlgroup (one dose: 85 of 131 [64.9%] vs. 49 of134 [36.6%]; P, 0.001; two doses: 43 of131 [32.8%] vs. 58 of 134 [43.3%]; P = 0.09;three doses: 3 of 131 [2.3%] vs. 23 of 134

[17.2%], P, 0.001; four doses: 0 of 131[0%] vs. 1 of 134 [0.7%]; six doses: 0 of 131[0%] vs. 3 of 134 [2.2%]).

Post Hoc AnalysesThe post hoc analysis of the primaryoutcome adjusted for prenatal steroid,Apgar score, and chorioamnionitis alsoshowed a significant difference between theintervention group and control group (oddsratio, 0.37; 95% CI, 0.22–0.54; P, 0.01).On the basis of the NICHD definition,infants in the intervention group had asignificantly lower incidence of severe BPDthan did infants in the control group(Table 2).

Follow-up StudyUp to this time, 192 (85.0%) of the 226surviving infants are being monitored. Theperinatal characteristics and the physical,neurological, and cognitive outcomes areshown in Table 4. Except for the lowerincidence of BPD (25 of 85 [29.4%] vs. 39of 87 [44.8%]; P = 0.04) in the interventiongroup at the time of discharge, there wasno significant difference between thegroups in any of these follow-up variables.Frequent upper respiratory infection (.10times/yr) was seen less often in theintervention group than in the controlgroup (15 of 89 [16.9%] vs. 24 of 87[27.6%]; P = 0.15); this difference was notstatistically significant.

Discussion

This study demonstrated that in very-low-birth-weight infants with severe RDS,intratracheal instillation of budesonide/surfactant significantly reduced theincidence of BPD or death compared withsurfactant alone. No serious adverseeffects were seen. Budesonide plussurfactant was associated with betterpulmonary status in the early course oftherapy and a decreased need for assistedO2 therapy subsequently. Theimprovement in these parameters in theintervention group may account for thelower incidence of BPD.

The rationale for using surfactant as avehicle is based on a physical phenomenon,the “Marangoni effect” (23). This effect isbasically the mass transfer along aninterface between two fluids due to asurface tension gradient. Thus, whensurfactant is instilled into the lungs of

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Figure 4. Number of infants needing assisted O2 therapy during the study. Assisted O2 therapy wasdefined as a requirement for any of the following: nasal cannula, continuous positive airway pressure(CPAP), intermittent mandatory ventilation (IMV), or high-frequency oscillatory ventilation (HFOV).Survivors in the intervention group required less assisted O2 therapy than did those in the controlgroup on Day 3 (P = 0.017), Day 7 (P = 0.021), Day 21 (P = 0.01), and Day 28 (P = 0.044) (see text).

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92 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 1 | January 1 2016

infants with RDS, a convection flow isgenerated that may facilitate the delivery ofmedications, such as budesonide, to thelung periphery. Various animal studiesindicated that intratracheal administrationof surfactant and corticosteroid improvedlung function (24–27). Direct intratrachealinstillation of budesonide without usingsurfactant as vehicle has not been shown tobe effective (28). A randomized controlledtrial showing reduction of death or BPD byinhaled budesonide in extremely low birthweight infants was of borderline statisticalsignificance (29).

Our pilot study indicated that morethan 80% of budesonide may remain in thelungs for up to 8 hours after intratrachealinstillation of Survanta/budesonide (9).Besides its use as a vehicle, surfactant mayalso enhance the solubility of budesonideand increase budesonide absorption (30).Budesonide is not metabolized by lungcells; rather, it is conjugated extensivelywith fatty acids, resulting in the formationof budesonide esters at the C-21 hydroxyl

group (31). This conjugation process isreversible, and the conjugates can behydrolyzed inside the cell, graduallyreleasing free budesonide into thesurrounding medium. This reversibleconjugation may improve airway selectivityand prolong its local antiinflammatoryaction in the lungs, possibly explaining whybudesonide was effective for days, eventhough only one or two doses wereadministered. On the basis of thepharmacokinetic data (9), we estimate that5–10% of budesonide may still remain inthe lungs by 1 week. Budesonide that isabsorbed into the circulation is rapidlymetabolized in the liver to 16-a-hydroxyprednisolone, which has lowglucocorticoid activity. The eliminationhalf-life of plasma budesonide is about 4hours (9). The results of our study alsosuggest that a similar therapeutic methodmay be applied in cases of shock lung,pneumonia, severe acute respiratorysyndrome, or malignancy. The systemicadverse effects associated with steroids,

antibiotics, and chemotherapeutic agentscould be markedly reduced. Further studiesare needed to explore this clinicalimplication.

The mechanism responsible for theeffectiveness of budesonide most likelyinvolves its antiinflammatory effects.Improvement was seen early afterintratracheal surfactant/budesonideinstillation as opposed to 2–3 days aftersystemic administration of dexamethasone(32). The direct local antiinflammatoryeffect may have played an important role inthis rapid improvement. The rapidimprovement may also be related to thehigher volume of instillation in theintervention group (5 ml/kg) as comparedwith the control group (4 ml/kg); this mighthave facilitated surfactant/budesonidedelivery. However, the higher volume couldalso dilute surfactant concentration at theliquid–air surface and decrease the surfacetension–reducing property of thesurfactant. Although there were smallchanges in FIO2

, PO2, and PCO2 during thefirst few days, the intervention groupneeded less assisted O2 therapy on Days 3,7, 21, and 28, suggesting a longer effect onthe lungs. Lung inflammation occurs earlyafter mechanical ventilation, and anytherapy beneficial for BPD prevention mustbe administered as early as possible. Theresults from our study indicated thatbudesonide was effective early in the courseof therapy, which might translate to longerterm effects on the lungs.

Corticosteroids are known to causegrowth impairment. In this study we didnot find any immediate alteration inserum glucose, electrolytes, blood pressure,and physical growth with budesonidetherapy. Another major concern aboutglucocorticoid therapy is the occurrence oflong-term adverse effects. Budesonide hasbeen used in children with asthma for yearswithout significant long-term side effects(33–36).Although the follow-up study isstill in progress, our preliminary data on84% of the survivors up to 2–4 yearsindicate no apparent long-term adverseeffect on physical growth, or onneuromotor and cognitive function. On thebasis of our previous follow-up study (33)and the current preliminary results, and inview of the fact that most of the infants(65%) in the intervention group receivedonly one dose of budesonide and that therewere no immediate adverse effects, thelong-term side effects are probably

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Figure 5. Number and proportion of (A) infants extubated or (B) infants weaned to room air over timeduring the study. Kaplan–Meier cumulative incidence plots were generated to show time to event forall end points. Infants in the intervention group had a significantly higher chance to be weaned toroom air than infants in the control group.

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Yeh, Chen, Wu, et al.: Intratracheal Budesonide/Surfactant Prevents BPD 93

negligible. A complete and longer follow-upstudy is needed before this therapeuticregimen can be generally recommended.

This study was done in three tertiarycenters in two countries, which may raisethe question of its general application.However, diagnostic criteria and assessment

tools that have good predictive accuracyand have been evaluated across differenthospital settings were used. All theparticipating hospitals followed a standardprotocol for respiratory care. In addition,an independent observer unaware ofthe treatment assignment monitored

the outcome; this may decrease the studybias.

In conclusion, in very-low-birth-weightinfants with severe RDS, intratrachealadministration of surfactant and budesonidecompared with surfactant alone significantlydecreased the incidence of BPD or death.Further large-sample, double-blind trials arewarranted. n

Author disclosures are available with the textof this article at www.atsjournals.org.

Acknowledgment: The authors thank RobertaA. Ballard, M.D., Ph.D., and Philip L. Ballard,M.D., Ph.D. (UCSF, San Francisco, CA) andWilliam Oh, M.D. (Brown University, Providence,RI) for expert comments; Ju C. Cheng, Ph.D.(Department of Biotechnology, China MedicalUniversity, Taichung, Taiwan) for performance ofthe interleukin assay; and Mei H. Wang, Ph.D.(Institute of Nuclear Energy Research [INER],Longtan, Taiwan) for performance of the nano/PET digital scan for 18F-labeled budesonide inrats. The authors also thank Ms. Audrey Yeh,Yu C. Pan, and Hsiang T. Chou for manuscriptpreparation and the NICU nursing staffs at JohnH. Stroger, Jr. Hospital of Cook County(Chicago, IL), China Medical University Hospital(Taichung, Taiwan), and National TaiwanUniversity Hospital (Taipei, Taiwan) for theircooperation. None of the people listed in thisacknowledgment received compensation fortheir contribution.

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Table 4. Follow-up Study

Characteristic Intervention Group (n = 85) Control Group (n = 87)

PerinatalBirth weight, g 907 (215) 920 (240)Gestational age, wk 26.5 (1.8) 26.7 (2.1)Sex

Male 45 (53%) 41 (47%)Female 40 (47%) 46 (53%)

Follow-up studyAge, m 30.1 (4.2) 30.1 (3.9)Weight, kg 11.7 (1.8) 11.8 (2.3)HC, cm 47.7 (2.7) 46.9 (2.8)L, cm 86.7 (5.2) 85.8 (5.4)Neuromotor dysfunction 23 (27.1%) 20 (23.0%)

Moderate to severe 8 (9.4%) 8 (9.2%)MDI 83.4 (18.7) 81.5 (2.8)

MDI< 69 18 (21.2%) 19 (21.8%)PDI 77.9 (18.7) 77.6 (20.1)

PDI< 69 24 (28.2%) 26 (29.9%)NDI 26 (30.6%) 34 (39.1%)

Definition of abbreviations: HC = head circumference; L = length; MDI =mental developmental index;NDI = neurodevelopmental impairment; PDI = psychomotor developmental index.Data are expressed as mean (SD) or number (%).

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