Curriculum and assessment tool for less invasive surfactant administration: an international Delphi consensus study

Changes in practice of less-invasive surfactant administration (LISA) in United Kingdom neonatal units

AIM

To determine whether the use of less-invasive surfactant administration (LISA) had changed between 2018 and 2024.

METHODS

An online questionnaire was sent to all 191 neonatal units between June 2023 and May 2024. One consultant from each neonatal unit was randomly selected. Follow-up was done by telephone (middle-grade doctor grade and above or alternatively to Advanced Neonatal Nurse Practitioners) for the non-responders.

RESULTS

Response rate was 100%from 191 units neonatal units. LISA was used in 134 (70%) neonatal units in 2024 compared to 35 (18.7%) units in 2018 (p < 0.001). The reason why LISA was not performed was lack of experience/training (51%) or not having a standardised practice/guideline (49%). LISA in the delivery suite (DS) had increased from 2% in 2018 to 16% in 2024, and the use of video laryngoscope for LISA is becoming standard of practice. The oxygen requirement criteria for the use of LISA in both the DS and on neonatal unit had reduced to FiO2 of 0.3 or more.

CONCLUSION

The uptake of LISA had increased in the United Kingdom. There is greater use of LISA in the DS. Lack of training and expertise were the major limiting factors for LISA not being performed.

Less Invasive Surfactant Administration for Preterm Infants - State of the Art

BACKGROUND

Less invasive surfactant administration (LISA) has become the preferred method of surfactant administration for spontaneously breathing babies on continuous positive airway pressure (CPAP).

SUMMARY

The development of LISA followed the need to combine CPAP and surfactant replacement as mainstay treatment options for respiratory distress syndrome, thereby avoided exposure to positive pressure ventilation.

KEY MESSAGES

This review summarises the current knowns and unknowns of LISA including the physiological concept, its relevance for short-term and long-term outcomes and the challenges for practical implementation of LISA as part of a less invasive respiratory care bundle. Further, we provide an update of the evidence on alternatives to LISA, for example, nebulised surfactant administration, pharyngeal deposition of surfactant and delivery via supraglottic airway.

NON-pharmacological Approach Less Invasive Surfactant Administration (NONA-LISA) trial: protocol for a randomised controlled trial

INTRODUCTION

Using pre-procedure analgesia with the risk of apnoea may complicate the Less Invasive Surfactant Administration (LISA) procedure or reduce the effect of LISA.

METHODS

The NONA-LISA trial (ClinicalTrials.gov, NCT05609877) is a multicentre, blinded, randomised controlled trial aiming at including 324 infants born before 30 gestational weeks, meeting the criteria for surfactant treatment by LISA. Infants will be randomised to LISA after administration of fentanyl 0.5-1 mcg/kg intravenously (fentanyl group) or isotonic saline solution intravenously (saline group). All infants will receive standardised non-pharmacological comfort care before and during the LISA procedure. Additional analgesics will be provided at the clinician's discretion. The primary outcome is the need for invasive ventilation, meaning mechanical or manual ventilation via an endotracheal tube, for at least 30 min (cumulated) within 24 h of the procedure. Secondary outcomes include the modified COMFORTneo score during the procedure, bronchopulmonary dysplasia at 36 weeks, and mortality at 36 weeks.

DISCUSSION

The NONA-LISA trial has the potential to provide evidence for a standardised approach to relief from discomfort in preterm infants during LISA and to reduce invasive ventilation. The results may affect future clinical practice.

IMPACT

Pre-procedure analgesia is associated with apnoea and may complicate procedures that rely on regular spontaneous breathing, such as Less Invasive Surfactant Administration (LISA). This randomised controlled trial addresses the effect of analgesic premedication in LISA by comparing fentanyl with a placebo (isotonic saline) in infants undergoing the LISA procedure. All infants will receive standardised non-pharmacological comfort. The NONA-LISA trial has the potential to provide evidence for a standardised approach to relief from discomfort or pain in preterm infants during LISA and to reduce invasive ventilation. The results may affect future clinical practice regarding analgesic treatment associated with the LISA procedure.

Technical Skills Curriculum in Neonatology: A Modified European Delphi Study

INTRODUCTION

Simulation-based training (SBT) aids healthcare providers in acquiring the technical skills necessary to improve patient outcomes and safety. However, since SBT may require significant resources, training all skills to a comparable extent is impractical. Hence, a strategic prioritization of technical skills is necessary. While the European Training Requirements in Neonatology provide guidance on necessary skills, they lack prioritization. We aimed to identify and prioritize technical skills for a SBT curriculum in neonatology.

METHODS

A three-round modified Delphi process of expert neonatologists and neonatal trainees was performed. In round one, the participants listed all the technical skills newly trained neonatologists should master. The content analysis excluded duplicates and non-technical skills. In round two, the Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula (CAMES-NAF) was used to preliminarily prioritize the technical skills according to frequency, importance of competency, SBT impact on patient safety, and feasibility for SBT. In round three, the participants further refined and reprioritized the technical skills. Items achieving consensus (agreement of ≥75%) were included.

RESULTS

We included 168 participants from 10 European countries. The response rates in rounds two and three were 80% (135/168) and 87% (117/135), respectively. In round one, the participants suggested 1964 different items. Content analysis revealed 81 unique technical skills prioritized in round two. In round three, 39 technical skills achieved consensus and were included.

CONCLUSION

We reached a European consensus on a prioritized list of 39 technical skills to be included in a SBT curriculum in neonatology.