Hospital link gets affordable pre-natal drug

By Janet Hefler - June 28, 2007

A creative "swap" program between healthcare providers at Martha's Vineyard Hospital (MVH) and Boston's Brigham and Women's Hospital (BWH), both Partners Healthcare member hospitals, will ensure the cost-effective availability of an important drug to help premature infants born on the Island.

Last Friday, Dr. Steven Ringer, BWH chief of newborn medicine, and Christine Pantano, BWH clinical supervisor of neonatal respiratory care, met with about a dozen MVH medical professionals to work out the details of an exchange program between the two hospitals for Curosurf, a drug used to treat respiratory distress syndrome (RDS) in premature newborn infants.

While physicians at BWH may use 15 to 20 doses of Curosurf a week, Island physicians may only need to use it a few times a year. By setting up a drug exchange program, the two hospitals can rotate stock.

"Martha's Vineyard runs the risk of buying three or four thousand dollars' worth of the drug and having it expire," Dr. Ringer said. "We have enough frequency of use that a month or two before the drug expires, we'll use it up."

Brigham and Women's Hospital registered respiratory therapist Christine Pantano, second from left, demonstrates the technique for administering a drug for premature infants to registered nurses Sandy Ciciora (left), Nancy Hugger, and Lauren Hoehn from Martha's Vineyard Hospital. Photos by Janet Hefler

In treating premature infants with RDS, Dr. Ringer told the MVH staff, "Within the first hour or two of life, Curosurf makes such a truly profound difference for babies, I wouldn't think of not having it here."

Although available in Europe since 1992, the drug has only been on the U.S. market since 2000. As Dr. Ringer described, Curosurf can provide a critical component in treating RDS in the first hours of a premature baby's life. RDS occurs in almost all infants born at 28 to 29 weeks and in about one-third of those born at 32 to 33 weeks, he said.

RDS, which used to be known as hyaline membrane disease, was a common cause of infant deaths in the 1950's and 1960's. The condition gained notoriety when Patrick Bouvier Kennedy, the infant son of President John F. and Jacquelyn Kennedy, died of it two days after he was born five and a half weeks prematurely. If Curosurf had been available, Patrick would have been better in a day, Dr. Ringer said.

RDS occurs when there is not enough surfactant in a baby's lungs, a substance produced by lung cells in insufficient amounts under 32 weeks' gestation and not fully until after 34 weeks. Without surfactant, an infant's lungs lack elasticity and cannot inflate, making breathing difficult and the use of a mechanical ventilator necessary.

Dr. Steven A. Ringer.

Curosurf, which contains a surfactant from pigs' lungs, acts as a lubricant to keep the air sacs in an infant's lungs open, allowing them to inflate.

The most dramatic effects occur in the first half hour after it is given. "It's really a miracle drug," Dr. Ringer marveled. "I've been standing next to a respiratory therapist at times when it was administered to an infant, and immediately turned the oxygen down."

Ms. Pantano agreed, adding that most infants treated with the surfactant are weaned to room air in 30 minutes.

In cases when a premature delivery cannot be prevented, giving a mother medications called corticosteroids before delivery may lower the risk and severity of RSD in the baby, Dr. Ringer said. The steroids often are given between 24 and 34 weeks' gestation to women who are at risk of early delivery.

In a rural and tourist area like the Vineyard, however, a pregnant woman may go into premature labor while vacationing with her family, far from home and the physician who has been regularly following her care. If there are complications, the mother or her infant may be transported by helicopter to a larger medical facility in Boston, aided by either a delivery transport team or newborn transport team from MedFlight or Children's Hospital.

Dr. Melanie Miller, an MVH staff pediatrician who also practices at Vineyard Pediatrics, said in the last seven years, about 10 premature infants were born at the hospital and had RDS. "Sometimes we know about a premature delivery, and the newborn transport team gets here in time and gives the drug - I've given it here only once," she said. Having Curosurf available at the hospital will provide a safeguard in case a transport team is delayed by weather or other factors.

In addition to Dr. Ringer's presentation, Ms. Pantano demonstrated the intubation procedure used to administer the drug and provided hands-on training session for the respiratory therapists, nurses, and doctors in attendance. The drug must be delivered in a single liquid dose directly into an infant's lungs via a tube.

Lung surfactant drugs used in the past were much more difficult to administer and less effective, Dr. Miller said. "We had to use what I nicknamed the 'shake and bake' technique, giving a small dose of the drug while the baby was in one position, waiting 30 seconds, then rotating the baby into a different position and giving another dose. The new drug is much simpler," she said.

Dr. Miller and Dr. Ringer, who have known each other since they met at Children's Hospital in 1985, had an informal exchange program for a similar drug about four years ago. In January this year, Dr. Miller enlisted Dr. Ringer to teach a neonatal resuscitation program at MVH. Talking afterwards, they brainstormed the idea of the Curosurf exchange.

Under the new arrangement, Dr. Miller said, "The willingness of both the pharmaceutical staff here and at Brigham and Women's to coordinate and oversee that exchange makes it a win-win situation." She also expressed her appreciation for the involvement of medical professionals from many MVH departments at Friday's program.

The Curosurf program exemplifies how Vineyard hospital personnel foster professional collaboration with their colleagues in Boston healthcare facilities, in addition to the hospital recently becoming an affiliate of MassGeneral Hospital and a member of Partners HealthCare.

Dr. Ringer also serves as an assistant professor of pediatrics at Harvard Medical School. A preeminent neonatal specialist, he participates in medical missions with Project Vietnam and on an advisory group to the World Health Organization.

At the conclusion of last week's seminar, Dr. Ringer spoke highly of the MVH staff's quality of care and dedication. "One of the greatest things here is everybody really works together; at a bigger hospital, everybody has their own territory," he said.