| Background and purpose: Respiratory distress syndrome (RDS) in preterm neonates is caused by a lack of alveolar surfactant which leads to decreased pulmonary compliance and increased work of breathing. It continues to account for significant mortality and morbidity in the Neonatal intensive care unit (NICU) despite advances in perinatal care. Survival significantly improved with the introduction of new techniques of prevention and treatment of the disease, in particular, after the introduction of the antenatal corticosteroids (ACS) to mothers, at risk of preterm delivery, thus accelerating fetal lung maturation and giving exogenous surfactant to the needful newborns as early as possible to reduce the surface tension. The efficacy of each of these therapeutic regimens has been well documented in large randomized clinical trials. ACS may act synergistically with postnatal exogenous surfactant therapy. The purpose of the study is to evaluate whether the present treatment trend of RDS by the combine use of ACS and postnatal surfactant is superior over the either of the individual therapy in the better management of RDS.Methods & materials: We performed the retrospective chart review of all the 143 RDS cases considered for our study who were admitted to our NICU from January 2003 to January 2007. The cases of RDS were grouped into the followings: Groupl: Those who received both ACS & postnatal surfactant (n=36). Group 2: Those who received ACS but no postnatal surfactant (n=33). Group 3: Those who received postnatal surfactant but no ACS (n=39). Group 4: Those who didn't receive both ACS and postnatal surfactant (n=35). Among these patients, we analyzed the clinical parameters like sex, gestational age (GA) , birth weight (BW), mode of delivery, associated maternal risk factors, the Apgar score, the need for resuscitation at the time of delivery and associated perinatal complications of the babies. Then we compared the relation between the four groups regarding the different modes of supplemental oxygen use (nasal prong and head box), Continuous positive airway pressure (CPAP), the need for Mechanical Ventilator (MV), the mean NICU days to cure from the RDS and finally the treatment outcomes by Chi-square test (x~2) or ANOVA (F test) where appropriate, using software SPSS version 11.0. The results were considered statistically significant for p<0.05.Results:I. General features and clinical parameters: Infants.admitted were with GA 26 to 38 weeks and BW 0.84 to 2.79 kg. The mean GA and BW of babies were 31.18±0.19 and 1.55±0.03 kg respectively. Out of total 143 RDS cases, 93 (65.0%) babies were male and 50 (35.0%) were female. GA distribution showed that it was common in those with GA≤32 weeks (74.1%) than in those with GA > 32 weeks (25.9%) and as for BW distribution, it was more common in those with BW≤1.5 kg (54.6%) than in those with BW > 1.5 kg (45.4%). Delivery by Caesarean section (66.4%) was more common than the normal delivery (33.6%). There was no significant difference between the four groups with regards to their clinical characteristics; in particular regarding, sex, GA, BW, mode of delivery, Apgar score at both 1 minute and 5 minutes, need for resuscitation at birth (CPR), maternal risk factors and major associated neonatal conditions (p>0.05).II. Need for supplemental oxygen, CPAP and MV:(1) Nasal prong: The mean hour of oxygen supply for group 1 was 75.81±15.63, for group 2 was 130.09±27.32, for group 3 was 150.67±28.59 and for group 4 was 174.32±25.92. A significant difference between the groups (p=0.041) was noted. (2) Head box: The mean hour of oxygen supply for group 1 was 37.16±5.51, group 2 was 55.29±11.71, group 3 was 62.69±12.39 and group 4 was 100.75±28.10. There was a significant difference between the groups (p=0.047).(3) CPAP: Group 1 required the mean hour of 24.33±4.41, group 2 required 27.44±4.47, group 3 required 26.53±3.13 and group 4 required 56.50±5.50. There was a significant difference between the groups (p=0.005) regarding CPAP requirement.(4) MV: The mean hour of MV use for group 1 was 56.12±15.65, for group 2 was 110.19±21.59, for group 3 was 127.79±26.36 and for group 4 was 152.61±12.92. There was a significant difference between four groups in mean hour of use for MV (p=0.009 and F=4.173).The need for MV was least for the combined group (n=16), followed by the ACS (n=17), and then the Surfactant group (n=21) and the no ACS/ no Surfactant group (n=27) needed the most. This shows that the degree of severity of RDS is significantly high in the group 4 (p=0.034 in x~2 test).III. Comparison between the four groups regarding the mean number of days in NICU to recover from RDS:The mean number of days in NICU to recover for group 1 (n=28) was 15.89±1.29, for group 2 (n=23) was 21.61±2.30, for group 3 (n=26) was 28.31±3.40 and for group 4 (n=15) was 32.73±4.57. It shows a significant difference (p=0.000) between the four treatment groups regarding the mean number of days in NICU to recover from RDS.IV. Comparison between the four groups regarding the treatment outcomes:Group 1 (n=36) showed complete cure in 23 (63.89%), RDS cured but othercomplications remained in 5 (13.89%) and death in 8 (22.22%) infants.Group 2 (n=33) showed complete cure in 17 (51.52%), RDS cured but othercomplications remained in 6 (18.18%) and death in 10 (30.30%) infants.Group 3 (n=39) showed complete cure in 14 (35.90%), RDS cured but othercomplications remained in 12 (30.77%) and death in 13 (33.33%) infants.Group 4 (n=35) showed complete cure in 7 (20.00%), RDS cured but othercomplications remained in 8 (22.85%) and death in 20 (57.15%) infants. Comparison of treatment outcomes between the groups using x~2 test:(I) General comparison (between all the four groups): x~2 =18.421, p=0.005 (p<0.05).(II) Between group 1 and group 3: x~2 =6.152, p=0.046 (p<0.05).(III) Between group V and group 4: x~2 =14357, p=0.001 (p<0.05).(IV) Between group 1 and group 2: x~2 =1.085, p=0.581 (p>0.05).[Although percentage wise group 1 shows better treatment trend than group 2],(V) Between group 2 and group 3: x~2 =2.197, p=0.333 (p>0.05).[Although percentage wise group 2 shows better treatment trend than group 3](VI) Between group 2 and group 4: x~2 =7.734, p=0.021 (p<0.05).(VII) Between group 3 and group 4: x~2 =4.415, p=0.110 (p>0.05).[Although percentage wise group 3 shows better treatment trend than group 4].Conclusions:1. By considering the factors like requirement for supplemental oxygen (both nasal prong and head box); CPAP, MV, the mean NICU days to recover from RDS and the treatment outcomes from the comparison between the different therapy groups in our series; we conclude that the combined (ACS+ Surfactant) therapy is the most effective, followed by ACS therapy alone, then surfactant therapy alone and no ACS/ no Surfactant therapy is the least effective.2. Survival from RDS has significantly improved with early provision of intensive observation and care of high-risk mothers and their premature infants, appropriate use of ACS, postnatal surfactant, improved modes of ventilation and supportive NICUs.
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