A Clinical Trial of Nebulized Surfactant for the Treatment of Moderate to Severe COVID-19 (COVSurf)

Lung surfactant is present in the lungs. It covers the alveolar surface where it reduces the work of breathing and prevents the lungs from collapsing. In some respiratory diseases and in patients that require ventilation this substance does not function normally. This study will introduce surfactant to the patients lungs via the COVSurf Drug Delivery System

The hypothesis behind the proposed trial of surfactant therapy for COVID-19 infected patients requiring ventilator support is that endogenous surfactant is dysfunctional. This could be due to decreased concentration of surfactant phospholipid and protein, altered surfactant phospholipid composition, surfactant protein proteolysis and/or oedema protein inhibition of surfactant surface tension function and/or oxidative inactivation of surfactant proteins. Variations of these dysfunctional mechanisms have been reported in a range of lung diseases, including cystic fibrosis and severe asthma, and in child and adult patients with ARDS. Our studies of surfactant metabolism in adult ARDS patients showed altered percentage composition of surfactant PC, with decreased DPPC and increased surface tension-inactive unsaturated species, and decreased concentrations of both total PC and phosphatidylglycerol (PG) The SARS-CoV-2 virus binds to the angiotensin converting enzyme-2 (ACE2) receptor, which is preferentially expressed in the peripheral lung ATII cells. Consequent viral infection of ATII cells could reduce cell number and impair the capacity of the lungs to synthesise and secrete surfactant. This, however, has not yet been demonstrated empirically in COVID-19 patients. If this is the case, then exogenous surfactant administration to the lungs is potential one treatment option to mitigate disease severity in these patients.

To assess the improvement in oxygenation as determined by the PaO2/FiO2 ratio after treatment with study treatment

To assess the improvement in pulmonary ventilation as determined by the Ventilation Index (VI), where VI = (Respiratory rate X PIP X PaCo2 (mmHg)/ 1000 after study treatment.

To assess safety as judged by the frequency and severity of adverse events and severe adverse events (SAEs).

Mean change in pulmonary compliance (L/cmH2O) at 24 and 48 hours after study initiation in the IMV arm

Mean change in PEEP (Positive End-Expiratory Pressure) requirement at 24 and 48 hours after study initiation

To evaluate clinical improvement defined by time to one improvement point on an ordinal scale, as described in the WHO master protocol (2020) daily while hospitalised and on days 15 and 28

Inclusion Criteria: Age ≥18 years old Confirmed COVID-19 positive by PCR Within 24 hours of mechanical ventilation (ETI arm) or within 24 hours of needing either CPAP or NIV (CPAP/NIV arm) Assent or professional assent obtained Exclusion Criteria: Imminent expected death within 24 hours Specific contraindications to surfactant administration (e.g. known allergy, pneumothorax, pulmonary haemorrhage) Known or suspected pregnancy Stage 4 severe chronic kidney disease or requiring dialysis (i.e., eGFR < 30) Liver failure Anticipated transfer to another hospital, which is not a study site within 72 hours. Current participation or participation in another study within the last month that in the opinion of the investigator would prevent enrollment for safety purposes. Consent Declined

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https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200301-sitrep-41-covid-19.pdf?sfvrsn=6768306d_2