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Comparative Efficacy of Pulmonary Surfactant in Respiratory Distress Syndrome in Preterm Infants: a Bayesian Network Meta-Analysis

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Comparative Efficacy of Pulmonary Surfactant in Respiratory Distress Syndrome in Preterm Infants: a Bayesian Network Meta-Analysis Systematic review/Meta-analysis Comparative efficacy of pulmonary surfactant in respiratory distress syndrome in preterm infants: a Bayesian network meta-analysis Caihong Qiu, Cui Ma, Nana Fan, Xiaoyu Zhang, Guofeng Zheng Maternity and Child Health Care of Zaozhuang, China Corresponding author: Guofeng Zheng PhD Submitted: 4 April 2020 Maternity and Child Accepted: 18 June 2020 Health Care of Zaozhuang China Arch Med Sci E-mail: zheng__guofeng@ DOI: https://doi.org/10.5114/aoms.2020.97065 sina.com Copyright © 2020 Termedia & Banach Abstract Introduction: The comparative efficacy of pulmonary surfactant in the treat- ment of respiratory distress syndrome in preterm infants remains unclear. We aimed to evaluate the effectiveness of different pulmonary surfactant in the treatment of respiratory distress syndrome in preterm infants and to provide an evidence-based reference for clinical use. Material and methods: MEDLINE, Embase, The Cochrane Library, and Clini- cal Trials databases were electronically searched from inception to January 2019. Two reviewers independently screened literature and extracted data, and then R and RevMan 5.3 software packages were used to perform net- work meta-analysis. Results: The relative risk of respiratory distress syndrome in preterm infants associated with six different pulmonary surfactant was analysed, including beractant (Survanta), surfactant A (Alveofact), calfactant (Infasurf), porac- tant (Curosurf), lucinactant (Surfaxin), and colfosceril (Exosurf). Patients with the following drugs appeared to have significantly reduced mortality of respiratory distress syndrome compare with beractant: surfactant A (OR = 0.53, 95% CI: 0.31–0.90), calfactant (OR = 0.91, 95% CI: 0.85–0.97), porac- tant (OR = 0.72, 95% CI: 0.67–0.77), lucinactant (OR = 0.80, 95% CI: 0.71– 0.90), and colfosceril (OR = 0.93, 95% CI: 0.87–0.99). The SUCRA (surface under the cumulative ranking) values for each of the drugs were: beractant (8.9%), surfactant A (93.8%), calfactant (40.3%), poractant (65.4%), lucinac- tant (59.8%), and colfosceril (31.6%). Conclusions: Compared with beractant, other pulmonary surfactants are more effective to reduce the mortality of respiratory distress syndrome in preterm infants. Surfactant A drugs appeared to have the best efficacy in reducing mortality of respiratory distress syndrome in preterm infants. Key words: respiratory distress syndrome, pulmonary surfactant, randomised control trials, network meta-analysis. Introduction Neonatal respiratory distress syndrome (NRDS) refers to acute and progressive anoxic respiratory failure in neonates caused by various ex- ternal and internal pathogenic factors [1]. NRDS is one of the most im- portant causes of death in neonatal intensive care units (NICU) [2, 3]. Abnormality of endogenous pulmonary surfactant (PS) is an important cause of NRDS. Lack of PS or abnormal function in NRDS results in an im- balance of ventilation/blood flow, decreased pulmonary compliance, and Caihong Qiu, Cui Ma, Nana Fan, Xiaoyu Zhang, Guofeng Zheng severe hypoxaemia [4, 5]. Studies have found that Our study patients included preterm infants with PS replacement therapy can significantly improve respiratory distress syndrome, and treatment with the morbidity and mortality of NRDS, and PS has a stable, recommended dose of pulmonary surfac- become the main treatment of NRDS [6]. tants was required before entry into the enrich- At present, there are three kinds of PS prepara- ment period. The control group was given conven- tions for clinical application at home and abroad: tional treatment, and the experimental group was 1) Containing natural PS protein SP-B and SP-C, in- given conventional treatment and pulmonary sur- cluding surfactant A, calfactant extracted from bo- factants. In addition to interventions, other rou- vine lung lavage, poractant extracted from whole tine medical treatments were consistent between lung, and beractant extracted from whole bovine the two groups. The primary outcome of the anal- lung. 2) Containing synthetic protein, including ysis was the mortality rate of infants with NRDS. synthetic SP-B peptide and DPPC phospholipid We excluded documents with incomplete data, in components, called lucinactant, also known as which the research design was defective or the sta- KL-4. 3) Colfosceril, which contains no protein and tistical method was not correct, semi-randomised is widely used, consisting of phospholipids, hexa- controlled trials, non-randomised controlled trials, decanol, and tetrabutanol [7, 8]. observational studies, expert reviews, letters, and Due to the lack of large sample randomised repeated publication studies. controlled studies; NRDS has not yet had an ideal NRDS treatment plan. Multiple randomised con- Data extraction trolled trials (RCTs) were conducted to study exog- Two researchers independently screened the enous PS in the treatment of NRDS, but its quality literature, extracted the data, and cross-checked. and efficacy were not systematically evaluated. If there was any disagreement, a third party was We conducted a network meta-analysis to deter- consulted to assist in the judgment. When reading mine efficacy of PS in NRDS treatment, and to pro- the literature, the questions and abstracts were vide an evidenced-base reference for clinical use. read first. After excluding the clearly unrelated documents, the full text was read to determine Material and methods the final inclusion. The data extraction content Search strategy includes: 1) Basic information for inclusion in the study, including first author and publication MEDLINE, Embase, The Cochrane Library, time. 2) The basic characteristics of the subjects, and Clinical Trials databases were electronically including the number of samples in each group, searched to collect RCT of antihypertensive drugs the average age of the patient, and the disease. and hyperkalaemia events in patients with diabet- 3) Intervention-specific details. 3) Key elements of ic nephropathy from inception to January 2019. In bias risk assessment. 4) Outcome indicators and addition, the reference to the published research outcome measurement data of interest. Lack of was traced back to supplement the relevant liter- information led to contacting the author to sup- ature. Two reviewers independently screened lit- plement the data as much as possible. erature, extracted data, and assessed the risk bias of the included studies. The search was performed Risk of bias assessment by means of a combination of subject words and free words, and appropriate adjustments were Two investigators evaluated the bias risk of made according to different databases. The search inclusion in the study in accordance with the terms included: Neonatal respiratory distress syn- Corchrane Handbook for RCT bias risk assessment drome, NRDS, Infantile respiratory distress syn- tools. drome, Respiratory distress syndrome in infant, Pulmonary surfactant-associated protein A, Pul- Statistical analysis monary surfactant-associated protein B, Pulmo- This study used a Bayesian grade model to per- nary surfactant-associated protein C, Pulmonary form a mesh meta-analysis of outcome measures surfactant-associated protein D, Pulmonary sur- using R software. The count data used the odds factant-associated proteins, Survanta, Alveofact, ratio (OR), and the interval estimate used 95% Infasurf, Curosurf, Surfaxin, Exosurf, Randomized CI as the effect size indicator. P < 0.05 was set controlled trials, RCT. a statistically significant standard. If the P value of Cochran’s Q test statistic was less than 0.05 Inclusion and exclusion criteria or the I2 statistic is larger than 50%, then there We only include randomised controlled trials, was significant heterogeneity among included regardless of whether or not to refer to the allo- studies for each pairwise comparison. As a result, cation of hidden or blinded methods, the publi- the fixed-effect model may not be appropriate for cation time and the study area were not limited. synthesising direct evidence, and the random-ef- 2 Arch Med Sci Comparative efficacy of pulmonary surfactant in respiratory distress syndrome in preterm infants: a Bayesian network meta-analysis Articles identified through literature search: • Medline (n = 698) • Embase (n = 727) • Cochrane Library (n = 1) Identification • Clinical Trials (n = 14) Excluded (n = 15) • Duplicate studies Studies after duplicates removed (n = 712) Screening Articles excluded based on abstracts (n = 671) Full-text articles revieved (n = 41) sequence generation (selection bias) Random Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) bias) (reporting Selective reporting Other bias Baroutis 2003 Eligibility Articles excluded base on (n = 18): Bloom 1997 • No relevant outcome measure (n = 1) Bloom 2005 • Insufficient network connections (n = 12) Bozdag 2015 • Lack of detailed information da Costa 1999 (n = 4) Included Dizdar 2012 Articles included in this meta-analysis (n = 24) Fujii 2010 Figure 1. Flow diagram of the study selection pro- Gharehbaghi 2010 cess Giannakopoulou 2002 fects model should be used instead [9]. After Hammoud 2004 comparing the various interventions, the ranking probability table was used to rank the pros and Hudak 1996 cons of the intervention (the value indicates the probability of the intervention at the nth position). Hudak 1997 R packages (coda, lattice, gemtc, rjags, igraph) Jeon
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