PICOT Literature Review
Mia Fisher
Grand Canyon University
EBP
325
Wendy Cockron

PICOT Literature Review
This literature review examines the available research on the topic of the administration of natural surfactant vs synthetic surfactant in neonates with respiratory distress syndrome. Respiratory distress syndrome is caused by a deficiency, dysfunction, or inactivation of pulmonary surfactant and is a significant cause of morbidity or mortality of preterm infants.
The literature reviewed, highlights the differences in extracted natural surfactants and synthetic surfactants and whether one proves to be more beneficial over the other.

Pfister RH, Soll R, Wiswell TE. Protein-containing synthetic surfactant versus protein-free synthetic surfactant for the prevention and treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006180. DOI: 10.1002/14651858.CD006180.pub2.
In the above article the use of synthetic surfactant is discussed with regards to protein containing or non-protein containing synthetics. The synthetics that contain proteins have shown a higher efficacy in preventing respiratory distress syndrome than those without. The research suggests the reasoning for this is due to the synthetic containing proteins acting like naturally occurring surfactant proteins. This research lends to the rationale that the synthetic containing protein surfactants effectiveness being like that of a natural surfactant could be more readily available than natural surfactant. (Pfister RH, Soll R, Wiswell TE, Cochrane Database of Systematic Reviews, Issue 4)

Soll R, Blanco F. Natural surfactant extract versus synthetic surfactant for neonatal respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD000144. DOI: 10.1002/14651858.CD000144.
The above article discusses the administration of natural calf lung surfactant to synthetic surfactant in premature neonates at twenty-nine weeks gestation. In the randomized controlled trials conducted, the compared natural surfactant extract to synthetic surfactant demonstrated similar improvement in immediate need for ventilator support in infants who receive natural surfactant extracts. Although similar improvements were found, fewer deaths associated with natural surfactant extract treatment were found. With these findings the research lends to natural surfactant being a more desirable choice between the two. (Soll R, Blanco F., Cochrane Database of Systematic Reviews, Issue 2)

Seger N, Soll R. Animal derived surfactant extract for treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD007836. DOI: 10.1002/14651858.CD007836.
In the above article natural (animal) derived surfactant is discussed regarding modified and unmodified surfactants. The modified natural derived surfactant is supplemented with phospholipids, whereas the unmodified natural derived surfactant only contains the remaining components after the extraction process. Thirteen randomized controlled trials demonstrated that both modified and unmodified natural derived surfactants showed a significant decrease in the risk of neonatal mortality. The findings of the trials lead to there being no differences in the outcomes of either being more significant than the other for the treatment of respiratory distress syndrome in premature neonates. (Seger N, Soll R., Cochrane Database of Systematic Reviews, Issue 2)

Pfister RH, Soll R, Wiswell TE. Protein containing synthetic surfactant versus animal derived surfactant extract for the prevention and treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006069. DOI: 10.1002/14651858.CD006069.pub3.
The above article discusses surfactants derived from bovine or porcine and non-protein containing synthetic surfactants. Both synthetic and animal derived surfactants have shown to be beneficial, however, the comparison of animal derived surfactant to non-protein containing synthetic surfactants have demonstrated improvement in immediate ventilator support and decreased risk of mortality in neonates receiving the animal derived products. It has been shown that the increased efficacy of animal derived surfactants might be due to the protein content. The evaluation of protein containing surfactant was reviewed. While there was a common efficacy in animal derived vs protein containing surfactant, there was insufficient evidence to justify choosing the animal derived over the synthetic for respiratory distress syndrome in neonates. Pfister RH, Soll R, Wiswell TE, Cochrane Database of Systematic Reviews, Issue 4)

Soll R. Synthetic surfactant for respiratory distress syndrome in preterm infants. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD001149. DOI: 10.1002/14651858.CD001149.
In the above article the use of synthetic surfactant was discussed in the treatment of neonates with established respiratory distress syndrome vs prophylactic treatment of respiratory distress syndrome. There was a significant improvement in the clinical outcome of those treated with synthetic surfactant in established RDS as well as a reduction in neonatal mortality and late mortality. However, there was an increased risk for pneumothorax in neonates treated with synthetic surfactant, therefor, a natural surfactant may be the preferred treatment as it has decreased risk for pneumothorax. (Soll R., Cochrane Database of Systematic Reviews, Issue 3)

In reviewing all of the above articles regarding the administration of natural vs synthetic surfactants in neonates with respiratory distress syndrome, I found that there were definitive correlations showing that both types have positive outcomes. With that being said, most of the literature showed that the natural surfactant was predominately the better choice due to the surfactant containing the natural protein peptides and the decrease of secondary complications post surfactant therapy. The use of synthetic surfactants was not discounted as a positive therapy, however, there was a common preference of what type of synthetic had a more therapeutic effect. In the literature reviewed above synthetic protein modified and synthetic non-protein modified surfactants were discussed. The common preference for therapy was the protein modified surfactant due to its similar makeup to natural surfactant in that it contains proteins. The protein modified surfactants were preferred over the unmodified in the same manner that the natural were preferred over the synthetic. The literature showed that there were significant positive outcomes with less secondary complications in the administration of protein modified surfactants vs unmodified. The literature also discussed the importance of synthetic protein modified surfactant vs natural surfactants being more readily available, however, that information did not change the degree of desired therapy in the use of natural surfactants. The concluding literature overall, was that the surfactant of choice for the treatment of respiratory distress syndrome in neonates was the use of the natural derived over all types of synthetics. The primary reasoning was due to the overwhelming positive outcomes that came with the natural surfactant therapy, as well as the decreased post-secondary complications that were far more promising as an end result.

References
Pfister RH, Soll R, Wiswell TE. Protein-containing synthetic surfactant versus protein-free synthetic surfactant for the prevention and treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006180. DOI: 10.1002/14651858.CD006180.pub2.

Soll R, Blanco F. Natural surfactant extract versus synthetic surfactant for neonatal respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD000144. DOI: 10.1002/14651858.CD000144.

Seger N, Soll R. Animal derived surfactant extract for treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD007836. DOI: 10.1002/14651858.CD007836.

Pfister RH, Soll R, Wiswell TE. Protein containing synthetic surfactant versus animal derived surfactant extract for the prevention and treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006069. DOI: 10.1002/14651858.CD006069.pub3.

Soll R. Synthetic surfactant for respiratory distress syndrome in preterm infants. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD001149. DOI: 10.1002/14651858.CD001149.