Assessment of pulmonary surfactant in COVID-19 patients
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Assessment of pulmonary surfactant in COVID-19 patients Peter Schousboe1, Lothar Wiese2, Christian Heiring3, Henrik Verder1, Porntiva Poorisrisak3, Povl Verder1 and Henning Bay Nielsen4*
Keywords: COVID-19, ARDS, Pulmonary surfactant The clinical presentation of coronavirus 2 (SARS-CoV-2) ranges from asymptomatic to severe respiratory failure, and correspondingly requirement for respiratory support ranging from varying levels of supplementary O2, to non-invasive and invasive ventilation. In a recent editorial by Gattinoni et al. [1], it is proposed that, based on different pathophysiology need for ventilator support, there are two groups of COVID-19 patients: one group that develops acute respiratory distress syndrome (ARDS) with low compliance, and another classified as non-ARDS with normal compliance and hypoxemia caused by a high level of intrapulmonary shunting. Furthermore, non-ARDS type COVID-19 pneumonia may transit to ARDS-type COVID-19 by self-inflicted or ventilator-induced lung injury. We propose that the direct effects on pulmonary tissue by SARS-CoV-2 in COVID-19 pneumonia in ARDS COVID-19 patients resembles neonatal respiratory distress syndrome (NRDS), caused by surfactant deficiency.
COVID-19 patients and pulmonary surfactant SARS-CoV-2 enters and replicates in the alveolar type II cells impacting the production and turnover of pulmonary surfactants. This results in alveolar collapse and inflammation leading to increased capillary permeability, edema, and microvascular thrombosis; where the associated ARDS clinical picture closely resembles NRDS. Of importance, as ARDS progresses, vascular permeability increases and surfactant deactivates making the lung increasingly unstable [2]. Thus, * Correspondence: [email protected] 4 Department of Anesthesia and Intensive Care, Zealand University Hospital Roskilde, Sygehusvej 10, 4000 Roskilde, Denmark Full list of author information is available at the end of the article
clinical studies have provided promising data on the effect of surfactant treatment in patients with ARDS [3]. These pathophysiological findings have prompted several groups to investigate if surfactant administration could improve the COVID19 patient outcome. Interventional trials are currently underway in the UK, USA, and Canada (ClinicalTrials.gov IDs: NCT04375735, NCT04362059, NCT04384731). Treatment of NRDS with rescue surfactant and continuous positive airway pressure (CPAP), when compared to mechanical ventilation, results in reduced development of pulmonary fibrosis; a complication also reported in intubated COVID-19 patients. Antenatal corticosteroid treatment may also accelerate fetal lung maturation in the risk of preterm birth. A multicentre trial evaluates whether surfactant plus budesonide improves survival in NRDS [4]. In COVID-19 patients, dexamethasone seems to improve the outcome. We suggest assessment of surfactant levels should be added to the evaluation of COVID-19 patients. A pointof-care test for fast measuring surfactant at birth in premat
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