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Song ES, Jeon GW. Updates in neonatal resuscitation: routine use of laryngeal masks as an alternative to face masks. Clin Exp Pediatr 2024; 67:240-246. [PMID: 37448129 PMCID: PMC11065637 DOI: 10.3345/cep.2023.00619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/17/2023] [Accepted: 07/10/2023] [Indexed: 07/15/2023] Open
Abstract
Although positive-pressure ventilation (PPV) has traditionally been performed using a face mask in neonatal resuscitation, face mask ventilation for delivering PPV has a high failure rate due to mask leaks, airway obstruction, or gastric inflation. Furthermore, face mask ventilation is compromised during chest compressions. Endotracheal intubation in neonates requires a high skill level, with a first-attempt success rate of <50%. Laryngeal masks can transfer positive pressure more effectively even during chest compressions, resulting in a lower PPV failure rate compared to that of face masks in neonatal resuscitation. In addition, inserting a laryngeal mask is easier and more accessible than endotracheal intubation, and mortality rates do not differ between the 2 methods. Therefore, in neonatal resuscitation, laryngeal masks are recommended in infants with gestational age >34 weeks and/or with a birth weight >2 kg, in cases of unsuccessful face mask ventilation (as a primary airway device) or endotracheal intubation (as a secondary airway device, alternative airway). In other words, laryngeal masks are recommended when endotracheal intubation fails as well as when PPV cannot be achieved. Although laryngeal masks are commonly used in anesthetized pediatric patients, they are infrequently used in neonatal resuscitation due to limited experience, a preference for endotracheal tubes, or a lack of awareness among the healthcare providers. Thus, healthcare providers must be aware of the usefulness of laryngeal masks in depressed neonates requiring PPV or endotracheal intubation, which can promptly resuscitate these infants and improve their outcomes, resulting in decreased morbidity and mortality rates.
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Affiliation(s)
- Eun Song Song
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Ga Won Jeon
- Department of Pediatrics, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
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2
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Guthrie SO, Roberts KD. Less invasive surfactant administration methods: Who, what and how. J Perinatol 2024; 44:472-477. [PMID: 37737494 DOI: 10.1038/s41372-023-01778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/14/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
Surfactant administration via an endotracheal tube (ETT) has been the standard of care for infants with respiratory distress syndrome for decades. As non-invasive ventilation has become commonplace in the NICU, methods for administering surfactant without use of an ETT have been developed. These methods include thin catheter techniques (LISA, MIST), aerosolization/ nebulization, and surfactant administration through laryngeal (LMA) or supraglottic airways (SALSA). This review will describe these methods and discuss considerations and implementation into clinical practice.
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Affiliation(s)
- S O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - K D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA.
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3
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Abdel-Latif ME, Walker E, Osborn DA. Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2024; 1:CD008309. [PMID: 38270182 PMCID: PMC10809312 DOI: 10.1002/14651858.cd008309.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Laryngeal mask airway surfactant administration (S-LMA) has the potential benefit of surfactant administration whilst avoiding endotracheal intubation and ventilation, ventilator-induced lung injury and bronchopulmonary dysplasia (BPD). OBJECTIVES To evaluate the benefits and harms of S-LMA either as prophylaxis or treatment (rescue) compared to placebo, no treatment, or intratracheal surfactant administration via an endotracheal tube (ETT) with the intent to rapidly extubate (InSurE) or extubate at standard criteria (S-ETT) or via other less-invasive surfactant administration (LISA) methods on morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome (RDS). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and three trial registries in December 2022. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster- or quasi-RCTs of S-LMA compared to placebo, no treatment, or other routes of administration (nebulised, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and extracted data. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included eight trials (seven new to this update) recruiting 510 newborns. Five trials (333 infants) compared S-LMA with surfactant administration via ETT with InSurE. One trial (48 infants) compared S-LMA with surfactant administration via ETT with S-ETT, and two trials (129 infants) compared S-LMA with no surfactant administration. We found no studies comparing S-LMA with LISA techniques or prophylactic or early S-LMA. S-LMA versus surfactant administration via InSurE S-LMA may have little or no effect on the composite outcome of death or BPD at 36 weeks' postmenstrual age (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.27 to 8.34, I 2 = not applicable (NA) as 1 study had 0 events; risk difference (RD) 0.02, 95% CI -0.07 to 0.10; I 2 = 0%; 2 studies, 110 infants; low-certainty evidence). There may be a reduction in the need for mechanical ventilation at any time (RR 0.53, 95% CI 0.36 to 0.78; I 2 = 27%; RD -0.14, 95% CI -0.22 to -0.06, I 2 = 89%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 17; 5 studies, 333 infants; low-certainty evidence). However, this was limited to four studies (236 infants) using analgesia or sedation for the InSurE group. There was little or no difference for air leak during first hospitalisation (RR 1.39, 95% CI 0.65 to 2.98; I 2 = 0%; 5 studies, 333 infants (based on 3 studies as 2 studies had 0 events); low-certainty evidence); BPD among survivors to 36 weeks' PMA (RR 1.28, 95% CI 0.47 to 3.52; I 2 = 0%; 4 studies, 264 infants (based on 3 studies as 1 study had 0 events); low-certainty evidence); or death (all causes) during the first hospitalisation (RR 0.28, 95% CI 0.01 to 6.60; I 2 = NA as 2 studies had 0 events; 3 studies, 203 infants; low-certainty evidence). Neurosensory disability was not reported. Intraventricular haemorrhage ( IVH) grades III and IV were reported among the study groups (1 study, 50 infants). S-LMA versus surfactant administration via S-ETT No study reported death or BPD at 36 weeks' PMA. S-LMA may reduce the use of mechanical ventilation at any time compared with S-ETT (RR 0.47, 95% CI 0.31 to 0.71; RD -0.54, 95% CI -0.74 to -0.34; NNTB 2, 95% CI 2 to 3; 1 study, 48 infants; low-certainty evidence). We are very uncertain whether S-LMA compared with S-ETT reduces air leak during first hospitalisation (RR 2.56, 95% CI 0.11 to 59.75), IVH grade III or IV (RR 2.56, 95% CI 0.11 to 59.75) and death (all causes) during the first hospitalisation (RR 0.17, 95% CI 0.01 to 3.37) (1 study, 48 infants; very low-certainty evidence). No study reported BPD to 36 weeks' PMA or neurosensory disability. S-LMA versus no surfactant administration Rescue surfactant could be used in both groups. There may be little or no difference in death or BPD at 36 weeks (RR 1.65, 95% CI 0.85 to 3.22; I 2 = 58%; RD 0.08, 95% CI -0.03 to 0.19; I 2 = 0%; 2 studies, 129 infants; low-certainty evidence). There was probably a reduction in the need for mechanical ventilation at any time with S-LMA compared with nasal continuous positive airway pressure without surfactant (RR 0.57, 95% CI 0.38 to 0.85; I 2 = 0%; RD -0.24, 95% CI -0.40 to -0.08; I 2 = 0%; NNTB 4, 95% CI 3 to 13; 2 studies, 129 infants; moderate-certainty evidence). There was little or no difference in air leak during first hospitalisation (RR 0.65, 95% CI 0.23 to 1.88; I 2 = 0%; 2 studies, 129 infants; low-certainty evidence) or BPD to 36 weeks' PMA (RR 1.65, 95% CI 0.85 to 3.22; I 2 = 58%; 2 studies, 129 infants; low-certainty evidence). There were no events in either group for death during the first hospitalisation (1 study, 103 infants) or IVH grade III and IV (1 study, 103 infants). No study reported neurosensory disability. AUTHORS' CONCLUSIONS In preterm infants less than 36 weeks' PMA, rescue S-LMA may have little or no effect on the composite outcome of death or BPD at 36 weeks' PMA. However, it may reduce the need for mechanical ventilation at any time. This benefit is limited to trials reporting the use of analgesia or sedation in the InSurE and S-ETT groups. There is low- to very-low certainty evidence for no or little difference in neonatal morbidities and mortality. Long-term outcomes are largely unreported. In preterm infants less than 32 weeks' PMA or less than 1500 g, there are insufficient data to support or refute the use of S-LMA in clinical practice. Adequately powered trials are required to determine the effect of S-LMA for prevention or early treatment of RDS in extremely preterm infants. S-LMA use should be limited to clinical trials in this group of infants.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Discipline of Neonatology, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, ACT, Australia
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
- Department of Public Health, College of Science Health and Engineering, La Trobe University, Bundoora, VIC, Australia
| | - Elizabeth Walker
- Canberra Health Services Library and Multimedia, Canberra Health Services, Canberra, ACT, Australia
| | - David A Osborn
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
- Department of Neonatology, Royal Prince Alfred Hospital, Camperdown, Australia
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Mani S, Rawat M. Less Invasive Surfactant Administration: A Viewpoint. Am J Perinatol 2024; 41:211-227. [PMID: 36539205 PMCID: PMC10791155 DOI: 10.1055/a-2001-9139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
The standard of care in treating respiratory distress syndrome in preterm infants is respiratory support with nasal continuous positive airway pressure or a combination of continuous positive airway pressure and exogenous surfactant replacement. Endotracheal intubation, the conventional method for surfactant administration, is an invasive procedure associated with procedural and mechanical ventilation complications. The INSURE (intubation, surfactant administration, and extubation soon after) technique is an accepted method aimed at reducing the short-term complications and long-term morbidities related to mechanical ventilation but does not eliminate risks associated with endotracheal intubation and mechanical ventilation. Alternative methods of surfactant delivery that can overcome the problems associated with the INSURE technique are surfactant through a laryngeal mask, surfactant through a thin intratracheal catheter, and aerosolized surfactant delivered using nebulizers. The three alternative methods of surfactant delivery studied in the last two decades have advantages and limitations. More than a dozen randomized controlled trials have aimed to study the benefits of the three alternative techniques of surfactant delivery compared with INSURE as the control arm, with promising results in terms of reduction in mortality, need for mechanical ventilation, and bronchopulmonary dysplasia. The need to find a less invasive surfactant administration technique is a clinically relevant problem. Before broader adoption in routine clinical practice, the most beneficial technique among the three alternative strategies should be identified. This review aims to summarize the current evidence for using the three alternative techniques of surfactant administration in neonates, compare the three techniques, highlight the knowledge gaps, and suggest future directions. KEY POINTS: · The need to find a less invasive alternative method of surfactant delivery is a clinically relevant problem.. · Clinical trials that have studied alternative surfactant delivery methods have shown promising results but are inconclusive for broader adoption into clinical practice.. · Future studies should explore novel clinical trial methodologies and select clinically significant long term outcomes for comparison..
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Affiliation(s)
- Srinivasan Mani
- Department of Pediatrics, University of Toledo, Toledo, Ohio
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, New York
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5
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Kribs A, Roberts KD, Trevisanuto D, O' Donnell C, Dargaville PA. Alternative routes of surfactant application - An update. Semin Fetal Neonatal Med 2023; 28:101496. [PMID: 38040586 DOI: 10.1016/j.siny.2023.101496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Non-invasive modes of respiratory support have been shown to be the preferable way of primary respiratory support of preterm infants with respiratory distress syndrome (RDS). The avoidance of invasive mechanical ventilation can be beneficial for preterm infants in reduction of morbidity and even mortality. However, it is well-established that some infants managed with non-invasive respiratory support from the outset have symptomatic RDS to a degree that warrants surfactant administration. Infants for whom non-invasive respiratory support ultimately fails are prone to adverse outcomes, occurring at a frequency on par with the group intubated primarily. This raises the question how to combine non-invasive respiratory support with surfactant therapy. Several methods of less or minimally invasive surfactant therapy have been developed to address the dilemma between avoidance of mechanical ventilation and administration of surfactant. This paper describes the different methods of less invasive surfactant application, reports the existing evidence from clinical studies, discusses the limitations of each of the methods and the open and future research questions.
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Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of Medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O' Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland.
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
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6
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Glaser K, Bamat NA, Wright CJ. Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature. Arch Dis Child Fetal Neonatal Ed 2023; 108:554-560. [PMID: 36600473 PMCID: PMC10246486 DOI: 10.1136/archdischild-2022-324530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today's neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicolas A Bamat
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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7
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Kribs A, Roberts KD, Trevisanuto D, O'Donnell C, Dargaville PA. Surfactant delivery strategies to prevent bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151813. [PMID: 37805275 DOI: 10.1016/j.semperi.2023.151813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/09/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.
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Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O'Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
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8
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Budh HP, Nimbalkar S. Surfactant Replacement Therapy: What’s the New Future? JOURNAL OF NEONATOLOGY 2022; 36:331-347. [DOI: 10.1177/09732179221136963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Surfactant replacement therapy (SRT) can be lifesaving for preterm babies with respiratory distress because of surfactant deficiency. Attempts have been made over the last two decades to make surfactant administration as smooth and as nontraumatic as possible. Lesser invasive techniques, such as less invasive surfactant administration, minimally invasive surfactant therapy, intrapartum pharyngeal surfactant therapy, and the laryngeal mask airway, are preferred over invasive techniques like intubate surfactant extubation to reduce trauma and peridosing adverse effects. However, at present, aerosolized surfactant (AS) via nebulization remains the only truly noninvasive method of SRT. Many animal and human studies have shown promising results with the use of AS with similar clinical effects to an instilled surfactant with greater safety potential. But still AS has not been adapted to routine neonatal care. There is still scope for studies to further strengthen the role of AS. Also, SRT is a constantly changing field with new innovations revolutionizing and replacing old techniques.
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Affiliation(s)
- Hetal Pramod Budh
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
| | - Somashekhar Nimbalkar
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
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Al Ali RA, Gautam B, Miller MR, Coulson S, Yuen D. Laryngeal Mask Airway for Surfactant Administration Versus Standard Treatment Methods in Preterm Neonates with Respiratory Distress Syndrome: A Systematic Review and Meta-analysis. Am J Perinatol 2022; 39:1433-1440. [PMID: 33517565 DOI: 10.1055/s-0041-1722953] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Laryngeal mask airway (LMA) has emerged as an alternative surfactant delivery method. The effectiveness of this method for the delivery of surfactant is uncertain. A meta-analysis of randomized control trials (RCTs) comparing LMA with standard methods of surfactant delivery for the outcomes of surfactant dose repetition, oxygen requirement, mechanical ventilation, intubation, mortality, bronchopulmonary dysplasia (BPD), and pneumothorax. STUDY DESIGN Systematic review and meta-analysis of RCTs. Homogeneity between studies was analyzed by using I2 statistics. Risk ratio or mean difference of outcomes was assessed from random effects models. Subgroup analyses were conducted when necessary. Data sources are as follows: Ovid Medline, Embase, and the Cochrane Central Register of Controlled trials from inception till December 2018, bibliographies of identified reviews and trial registries for ongoing studies. RCTs comparing short-term respiratory outcomes in neonates with respiratory distress syndrome who were administered surfactant through an LMA versus standard method of care. RESULTS Six RCTs were identified, enrolling a total of 357 infants. Administering surfactant via LMA was associated with decreased FiO2 requirement (mean difference = 1.82 (95% confidence interval [CI]: -6.01-9.66), decreased intubation (risk ratio [RR] = 0.17; 95% CI: 0.05-0.57), and decreased mechanical ventilation (RR = 0.44; 95% CI: 0.31-0.61). There were no significant differences between groups for death, BPD, or pneumothorax. CONCLUSION LMA might be an effective alternative method of surfactant delivery; however, further high-quality RCTs with larger sample size and including extreme preterm infants are needed to establish LMA as an alternative technique for surfactant delivery. KEY POINTS · Pulmonary surfactants reduce mortality and pulmonary air leaks in newborns with respiratory distress syndrome.. · Preterm lungs are at risk of volutrauma by mechanical ventilation; laryngoscopy is still traumatic.. · Surfactant administration via LMA to avoid mechanical ventilation and intubation might be feasible..
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Affiliation(s)
- Roqaia Ayesh Al Ali
- Neonatal Division, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia.,Neonatal Division, Department of Pediatrics, Western University, London, Canada
| | - Bishal Gautam
- Neonatal Division, Department of Pediatrics, Western University, London, Canada.,Neonatal Division, Royal Alexandria Hospital, Edmonton, Canada
| | - Michael R Miller
- Neonatal Division, Department of Pediatrics, Western University, London, Canada.,Children's Health Research Institute, Western University, London, Canada
| | - Sherry Coulson
- Children's Health Research Institute, Western University, London, Canada
| | - Doris Yuen
- Neonatal Division, Department of Pediatrics, Western University, London, Canada
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Abstract
The provision of exogenous surfactant to premature infants with respiratory distress syndrome has revolutionized the way we care for these patients, significantly improving survival and decreasing morbidity. Currently, the Intubate-SURfactant-Extubate (INSURE) to non-invasive ventilation method remains the standard method for surfactant delivery in the United States. However, the INSURE method requires intubation via direct visualization with a laryngoscope and possible need for sedation. Both carry significant risk to the patients, prompting the development of less invasive ways of safely and efficaciously providing surfactant to newborn infants. The present article reviews and describes the benefits and limitations of several of these alternative methods, including Less Invasive Surfactant Administration (LISA), Minimally Invasive Surfactant Therapy (MIST), via aerosolization, laryngeal mask airway (LMA), and direct nasopharyngeal deposition, focusing on assessment of clinical benefits and the level/risk of invasiveness.
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Affiliation(s)
- Nayef Chahin
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University and School of Medicine, Virginia Commonwealth University, P.O. Box 980276, Richmond, VA 23298-0276, USA.
| | - Henry J Rozycki
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University and School of Medicine, Virginia Commonwealth University, P.O. Box 980276, Richmond, VA 23298-0276, USA
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11
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Should less invasive surfactant administration (LISA) become routine practice in US neonatal units? Pediatr Res 2022; 93:1188-1198. [PMID: 35986148 PMCID: PMC9389478 DOI: 10.1038/s41390-022-02265-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. Although preterm infants are increasingly being admitted to the neonatal intensive care unit on CPAP, centers differ in the ability to manage infants primarily on CPAP. Over the last decade, less invasive surfactant administration (LISA), a method of administering surfactant with a thin catheter, has been devised and has been shown to decrease the need for MV and improve outcomes compared to surfactant administration via an endotracheal tube following intubation. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States. This article provides a summary of the existing evidence on LISA, and practical guidance for US units choosing to implement a change of practice incorporating optimization of CPAP and LISA. IMPACT: The accumulated body of evidence for less invasive surfactant administration (LISA), a widespread practice in other countries, justifies its use as an alternative to intubation and surfactant administration in US neonatal units. This article summarizes the current evidence for LISA, identifies gaps in knowledge, and offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy. This article will help neonatal units in the US develop guidelines for LISA, provide optimal respiratory support for infants with respiratory distress syndrome, improve short- and long-term outcomes of preterm infants, and potentially decrease costs of NICU care.
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12
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O'Shea JE, Scrivens A, Edwards G, Roehr CC. Safe emergency neonatal airway management: current challenges and potential approaches. Arch Dis Child Fetal Neonatal Ed 2022; 107:236-241. [PMID: 33883207 DOI: 10.1136/archdischild-2020-319398] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/21/2021] [Accepted: 03/30/2021] [Indexed: 11/03/2022]
Abstract
This review examines the airway adjuncts currently used to acutely manage the neonatal airway. It describes the challenges encountered with facemask ventilation and intubation. Evidence is presented on how to optimise intubation safety and success rates with the use of videolaryngoscopy and attention to the intubation environment. The supraglottic airway (laryngeal mask airway) is emerging as a promising neonatal airway adjunct. It can be used effectively with little training to provide a viable alternative to facemask ventilation and intubation in neonatal resuscitation and be used as an alternative conduit for the administration of surfactant.
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Affiliation(s)
- Joyce E O'Shea
- Neonatology, Royal Hospital for Children, Glasgow, UK joyce.o'.,Neonatal Transport, Scotstar, Glasgow, UK
| | - Alexandra Scrivens
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gemma Edwards
- Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford, UK.,Department of Population Health, National Perinatal Epidemiology Unit Clinical Trials Unit, Oxford, UK
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13
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Erdeve Ö, Okulu E, Roberts KD, Guthrie SO, Fort P, Kanmaz Kutman HG, Dargaville PA. Alternative Methods of Surfactant Administration in Preterm Infants with Respiratory Distress Syndrome: State of the Art. Turk Arch Pediatr 2022; 56:553-562. [PMID: 35110053 PMCID: PMC8849067 DOI: 10.5152/turkarchpediatr.2021.21240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
For preterm infants with respiratory distress syndrome, delivery of surfactant via brief intubation (INtubate, SURfactant, Extubate; InSurE) has been the standard technique of surfactant administration. However, this method requires intubation and positive pressure ventilation. It is thought that even the short exposure to positive pressure inflations may be enough to initiate the cascade of events that lead to lung injury in the smallest neonates. In an effort to avoid tracheal intubation and positive pressure ventilation, several alternative and less invasive techniques of exogenous surfactant administration have been developed over the years. These have been investigated in clinical studies, including randomized clinical trials, and have demonstrated advantages such as a decrease in the need for mechanical ventilation and incidence of bronchopulmonary dysplasia. These newer techniques of surfactant delivery also have the benefit of being easier to perform. Surfactant delivery via pharyngeal instillation, laryngeal mask, aerosolization, and placement of a thin catheter are being actively pursued in research. We present a contemporary review of surfactant administration for respiratory distress syndrome via these alternative methods in the hope of guiding physicians in their choices for surfactant application in the neonatal intensive care unit.
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Affiliation(s)
- Ömer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Emel Okulu
- Division of Neonatology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Kari D Roberts
- Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis, USA
| | - Scott O Guthrie
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Prem Fort
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA; Johns Hopkins All Children's Maternal Fetal and Neonatal Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - H Gözde Kanmaz Kutman
- Division of Neonatology, Department of Pediatrics, Health Sciences University, Ankara, Turkey
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
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14
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Guthrie SO, Fort P, Roberts KD. Surfactant Administration Through Laryngeal or Supraglottic Airways. Neoreviews 2021; 22:e673-e688. [PMID: 34599065 DOI: 10.1542/neo.22-10-e673] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Noninvasive ventilation is frequently used in the treatment of infants with respiratory distress syndrome. This practice is often effective in higher gestational age neonates, but can be difficult in those with lower gestational ages as surfactant deficiency can be severe. While noninvasive ventilation avoids the negative effects of intubation and ventilator-induced lung injury, failure of this mode of support does occur with relative frequency and is primarily caused by the poorly compliant, surfactant-deficient lung. Because of the potential problems associated with laryngoscopy and intubation, neonatologists have developed various methods to deliver surfactant in minimally invasive ways with the aim of improving the success of noninvasive ventilation. Methods of minimally invasive surfactant administration include various thin catheter techniques, aerosolization/nebulization, and the use of a laryngeal mask airway/supraglottic airway device. The clinician should recognize that currently the only US Food and Drug Administration-approved device to deliver surfactant is an endotracheal tube and all methods reviewed here are considered off-label use. This review will focus primarily on surfactant administration through laryngeal or supraglottic airways, providing a review of the history of this technique, animal and human trials, and comparison with other minimally invasive techniques. In addition, this review provides a step-by-step instruction guide on how to perform this procedure, including a multimedia tutorial to facilitate learning.
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Affiliation(s)
- Scott O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN.,Co-first authors
| | - Prem Fort
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD.,Johns Hopkins All Children's Maternal Fetal and Neonatal Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL.,Co-first authors
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN
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15
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Roberts CT, Manley BJ, O'Shea JE, Stark M, Andersen C, Davis PG, Buckmaster A. Supraglottic airway devices for administration of surfactant to newborn infants with respiratory distress syndrome: a narrative review. Arch Dis Child Fetal Neonatal Ed 2021; 106:336-341. [PMID: 32989046 DOI: 10.1136/archdischild-2020-319804] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/03/2022]
Abstract
Surfactant is an effective treatment for respiratory distress syndrome, being particularly important for infants in whom continuous positive airway pressure (CPAP) provides insufficient support. Supraglottic airway devices present an attractive option for surfactant delivery, particularly as an alternative to methods dependent on direct laryngoscopy, a procedural skill that is both difficult to learn and in which to maintain competence. Published studies provide encouraging data that surfactant administration by supraglottic airway device can be performed with a high rate of success and may reduce the need for subsequent intubation compared with either continued CPAP or surfactant administration via endotracheal tube. However, existing randomised controlled trials (RCTs) are heterogeneous in design and include just over 350 infants in total. To date, all RCT evidence has been generated in tertiary units, whereas the greatest potential for benefit from the use of these devices is likely to be in non-tertiary settings. Future research should investigate choice and utility of device in addition to safety and effectiveness of procedure. Importantly, studies conducted in non-tertiary settings should evaluate feasibility, meaningful clinical outcomes and the impact that this approach might have on infants and their families. Supraglottic airway devices may represent a simple and effective mode of surfactant administration that can be widely used by a variety of clinicians. However, further well-designed RCTs are required to determine their role, safety and effectiveness in both tertiary and non-tertiary settings before introduction into routine clinical practice.
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Affiliation(s)
- Calum T Roberts
- Department of Paediatrics, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia .,Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Joyce E O'Shea
- Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
| | - Michael Stark
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hsopital, Adelaide, South Australia, Australia
| | - Chad Andersen
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hsopital, Adelaide, South Australia, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Adam Buckmaster
- Women, Children and Families, Central Coast Local Health District, Gosford, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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16
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Ng EH, Shah V. Guidelines for surfactant replacement therapy in neonates. Paediatr Child Health 2021; 26:35-49. [PMID: 33552321 DOI: 10.1093/pch/pxaa116] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/18/2019] [Indexed: 11/12/2022] Open
Abstract
Surfactant replacement therapy (SRT) plays a pivotal role in the management of neonates with respiratory distress syndrome (RDS) because it improves survival and reduces respiratory morbidities. With the increasing use of noninvasive ventilation as the primary mode of respiratory support for preterm infants at delivery, prophylactic surfactant is no longer beneficial. For infants with worsening RDS, early rescue surfactant should be provided. While the strategy to intubate, give surfactant, and extubate (INSURE) has been widely accepted in clinical practice, newer methods of noninvasive surfactant administration, using thin catheter, laryngeal mask airway, or nebulization, are being adopted or investigated. Use of SRT as an adjunct for conditions other than RDS, such as meconium aspiration syndrome, may be effective based on limited evidence.
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Affiliation(s)
- Eugene H Ng
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Vibhuti Shah
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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17
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Ng EH, Shah V. Les directives pour le traitement par surfactant exogène chez le nouveau-né. Paediatr Child Health 2021. [DOI: 10.1093/pch/pxaa117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Résumé
Le traitement par surfactant exogène joue un rôle essentiel dans la prise en charge des nouveau-nés atteints du syndrome de détresse respiratoire (maladie des membranes hyalines) parce qu’il améliore la survie et limite les troubles respiratoires. Puisque la ventilation non invasive est de plus en plus utilisée comme principal mode d’assistance respiratoire chez le nouveau-né prématuré à la naissance, l’administration prophylactique de surfactant n’est plus bénéfique. L’administration précoce de surfactant sous forme de traitement de rattrapage est préconisée chez les nouveau-nés dont le syndrome de détresse respiratoire s’aggrave. La stratégie qui consiste à intuber, administrer du surfactant, puis extuber (INSURE) est largement acceptée en pratique clinique, mais des méthodes non invasives plus récentes à l’aide d’un cathéter fin, d’un masque laryngé ou d’un nébuliseur sont en cours d’adoption ou d’exploration. Selon des données limitées, un traitement d’appoint par surfactant exogène pourrait être efficace pour traiter d’autres affections que le syndrome de détresse respiratoire, telles que le syndrome d’aspiration méconiale.
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Affiliation(s)
- Eugene H Ng
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Vibhuti Shah
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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18
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Guthrie SO, Cummings JJ. Not sure? How should we give exogenous surfactant to newborns with RDS? Pediatr Pulmonol 2020; 55:14-16. [PMID: 31599066 DOI: 10.1002/ppul.24543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Scott Osborn Guthrie
- Department of Pediatrics, Associate Professor of Clinical Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James J Cummings
- Department of Pediatrics and Alden March Bioethics Institute, Clinical Professor of Pediatrics and Bioethics, Albany Medical College, Albany, New York
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19
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Kurepa D, Perveen S, Lipener Y, Kakkilaya V. The use of less invasive surfactant administration (LISA) in the United States with review of the literature. J Perinatol 2019; 39:426-432. [PMID: 30635595 DOI: 10.1038/s41372-018-0302-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/17/2018] [Accepted: 12/06/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND The majority of extremely low gestational age neonates undergo intubation for surfactant therapy. Less invasive surfactant administration (LISA) uses a thin catheter inserted into the trachea to deliver the surfactant. During the procedure, the infant is breathing spontaneously while supported with continuous positive airway pressure. Although LISA is widely adapted in Europe and Australia, the rate of LISA use in the United States is unknown. STUDY DESIGN The aim of this study is to evaluate the use of LISA in the US. A web-based survey was distributed via SurveyMonkey to 2550 neonatologists from AAP's SoNPM mailing list. RESULTS Of the 472 neonatologists who answered the survey, 15% used LISA either as a part of routine care (8%) or as part of research (7%). CONCLUSION Unlike several regions of Europe, LISA is not widely used in the US. Future studies should address ambiguities regarding infant selection, procedure training and "roadblocks" to its broader application.
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Affiliation(s)
- Dalibor Kurepa
- Cohen Children's Medical Center, New Hyde Park, NY, USA.
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20
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Calevo MG, Veronese N, Cavallin F, Paola C, Micaglio M, Trevisanuto D. Supraglottic airway devices for surfactant treatment: systematic review and meta-analysis. J Perinatol 2019; 39:173-183. [PMID: 30518796 DOI: 10.1038/s41372-018-0281-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/26/2018] [Accepted: 10/24/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare surfactant administration via supraglottic airway device (SAD) vs. nasal CPAP alone or INSURE. STUDY DESIGN A systematic search of PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials and Clinicaltrials.gov was performed. Articles meeting inclusion criteria (RCT, surfactant administration via SAD, laryngeal mask, I-gel) were assessed RESULTS: Five RCTs were eligible. Surfactant administration via SAD reduced the need for intubation/mechanical ventilation (RR 0.57, 95%CI 0.38-0.85) and short-term oxygen requirements (MD -8.00, 95%CI -11.09 to -4.91) compared to nCPAP alone. Surfactant administration via SAD reduced the need for intubation/mechanical ventilation (RR 0.43, 95%CI 0.31-0.61), but increased short-term oxygen requirements (MD 3.10, 95%CI 0.51-5.69) compared to INSURE approach. CONCLUSIONS In preterm infants with RDS, surfactant administration via SAD reduces the need for intubation/mechanical ventilation. Overall, available literature includes few, small, poor-quality studies. Surfactant administration via SAD should be limited to clinical trials.
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Affiliation(s)
- Maria Grazia Calevo
- Epidemiology, Biostatistics and Committees Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padua, Italy
| | | | | | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy.
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21
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Qureshi MJ, Kumar M. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev 2018. [PMID: 29542112 PMCID: PMC6494187 DOI: 10.1002/14651858.cd003314.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation. OBJECTIVES Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation? SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates. MAIN RESULTS We included seven trials that involved a total of 794 infants. Five studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events. AUTHORS' CONCLUSIONS LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.
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Affiliation(s)
- Mosarrat J Qureshi
- Northern Alberta Neonatal Program, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, AB, Canada, T5H 3V9
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22
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Roberts KD, Brown R, Lampland AL, Leone TA, Rudser KD, Finer NN, Rich WD, Merritt TA, Czynski AJ, Kessel JM, Tipnis SM, Stepka EC, Mammel MC. Laryngeal Mask Airway for Surfactant Administration in Neonates: A Randomized, Controlled Trial. J Pediatr 2018; 193:40-46.e1. [PMID: 29174079 DOI: 10.1016/j.jpeds.2017.09.068] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 09/01/2017] [Accepted: 09/26/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine if preterm infants with moderate respiratory distress syndrome on continuous positive airway pressure (CPAP) who received surfactant via a laryngeal mask airway (LMA) would have a decreased rate of intubation and mechanical ventilation compared with those on CPAP who did not receive surfactant. STUDY DESIGN In this prospective, multicenter, randomized controlled trial, 103 premature infants 280/7-356/7 weeks gestation, ≥1250 g and ≤36 hours old on CPAP requiring fraction of inspired oxygen 0.30-0.40 were assigned to receive surfactant administered through an LMA then placed back on CPAP (LMA group) or maintained on CPAP with no surfactant administered (control group). The primary outcome was treatment failure necessitating intubation and mechanical ventilation in the first 7 days of life. RESULTS Surfactant administration through an LMA (n = 50) significantly decreased the rate of intubation and mechanical ventilation compared with controls (n = 53): 38% vs 64%, respectively, OR 0.30 (95% CI 0.13, 0.70), P = .006, number needed to treat: 4). There were no serious adverse events associated with placement of the LMA or surfactant administration. CONCLUSIONS In premature neonates with moderate respiratory distress syndrome, surfactant administered through an LMA decreased the rate of intubation and mechanical ventilation. This intervention may have significant impact on clinical care in both high and low resource settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT01116921.
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Affiliation(s)
- Kari D Roberts
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.
| | - Roland Brown
- Department of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Andrea L Lampland
- Department of Pediatrics, University of Minnesota, Minneapolis, MN; Department of Pediatrics, Children's Minnesota, St. Paul, MN
| | - Tina A Leone
- Department of Pediatrics, Columbia University, New York, NY
| | - Kyle D Rudser
- Department of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Neil N Finer
- Department of Pediatrics, University of California-San Diego, San Diego, CA
| | - Wade D Rich
- Department of Pediatrics, Sharp Mary Birch, San Diego, CA
| | - T Allen Merritt
- Department of Pediatrics, Loma Linda University, Loma Linda, CA
| | - Adam J Czynski
- Department of Pediatrics, Loma Linda University, Loma Linda, CA
| | - Julie M Kessel
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI
| | - Sajani M Tipnis
- Department of Pediatrics, University of Mississippi, Jackson, MS
| | - Erin C Stepka
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Mark C Mammel
- Department of Pediatrics, University of Minnesota, Minneapolis, MN; Department of Pediatrics, Children's Minnesota, St. Paul, MN
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23
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Bansal SC, Caoci S, Dempsey E, Trevisanuto D, Roehr CC. The Laryngeal Mask Airway and Its Use in Neonatal Resuscitation: A Critical Review of Where We Are in 2017/2018. Neonatology 2018; 113:152-161. [PMID: 29232665 DOI: 10.1159/000481979] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/05/2017] [Indexed: 11/19/2022]
Abstract
Studies using videotape recordings and respiratory function monitoring have shown that both face mask (FM) application and endotracheal tube (ETT) placement represent a challenge for resuscitators. Hence, there is a strong need for devices that can largely be used independently of individual operator training levels, in order to ensure more reliable support in time-critical situations, such as neonatal resuscitation. The laryngeal mask airway device (LMA) has evolved as a potentially very valuable tool. We conducted a systematic review of studies evaluating the use of the LMA in neonatal resuscitation. An electronic literature search of large medical databases was performed to identify relevant publications on the use of an LMA during neonatal delivery room (DR) resuscitation. Following a rigorous systematic review, we identified a total of 7 randomized controlled trials with results indicating that initial respiratory management of newborn infants with an LMA is feasible for a defined subgroup of infants, but the evidence is still insufficient to recommend the LMA instead of FM ventilation in the DR. There is, in particular, a dearth of evidence of the use of LMA in neonates born before 34 weeks' gestational age or weighing <1,500 g at birth. There were no reports on significant complications following the use of LMA; however, evidence is still limited regarding short- and long-term outcomes. We conclude that the limited currently available evidence suggests that the use of the LMA is a feasible and safe alternative to mask ventilation of late preterm and term infants in the DR. The potential use of LMA resuscitation, in particular for low-gestation and low-birth-weight infants, needs further study.
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Affiliation(s)
- Satvik Chaitanya Bansal
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Trust, Headley Way, Oxford, UK
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24
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Shim GH. Update of minimally invasive surfactant therapy. KOREAN JOURNAL OF PEDIATRICS 2017; 60:273-281. [PMID: 29042870 PMCID: PMC5638833 DOI: 10.3345/kjp.2017.60.9.273] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/10/2017] [Accepted: 08/18/2017] [Indexed: 11/27/2022]
Abstract
To date, preterm infants with respiratory distress syndrome (RDS) after birth have been managed with a combination of endotracheal intubation, surfactant instillation, and mechanical ventilation. It is now recognized that noninvasive ventilation (NIV) such as nasal continuous positive airway pressure (CPAP) in preterm infants is a reasonable alternative to elective intubation after birth. Recently, a meta-analysis of large controlled trials comparing conventional methods and nasal CPAP suggested that CPAP decreased the risk of the combined outcome of bronchopulmonary dysplasia or death. Since then, the use of NIV as primary therapy for preterm infants has increased, but when and how to give exogenous surfactant remains unclear. Overcoming this problem, minimally invasive surfactant therapy (MIST) allows spontaneously breathing neonates to remain on CPAP in the first week after birth. MIST has included administration of exogenous surfactant by intrapharyngeal instillation, nebulization, a laryngeal mask, and a thin catheter. In recent clinical trials, surfactant delivery via a thin catheter was found to reduce the need for subsequent endotracheal intubation and mechanical ventilation, and improves short-term respiratory outcomes. There is also growing evidence for MIST as an alternative to the INSURE (intubation-surfactant-extubation) procedure in spontaneously breathing preterm infants with RDS. In conclusion, MIST is gentle, safe, feasible, and effective in preterm infants, and is widely used for surfactant administration with noninvasive respiratory support by neonatologists. However, further studies are needed to resolve uncertainties in the MIST method, including infant selection, optimal surfactant dosage and administration method, and need for sedation.
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Affiliation(s)
- Gyu-Hong Shim
- Department of Pediatrics, Inje University Busan Paik Hospital, Busan, Korea
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25
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Barbosa RF, Simões E Silva AC, Silva YP. A randomized controlled trial of the laryngeal mask airway for surfactant administration in neonates. J Pediatr (Rio J) 2017; 93:343-350. [PMID: 28130967 DOI: 10.1016/j.jped.2016.08.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To compare the short-term efficacy of surfactant administration by laryngeal mask airway versus endotracheal tube. METHODS Preterm infants (28-35 weeks of gestational age), weighing 1kg or more, with respiratory distress syndrome, requiring nasal continuous positive airway pressure, with increased respiratory effort and/or fraction of inspired oxygen (FiO2)≥0.40 to maintain oxygen saturation 91-95%, were randomized to receive surfactant by LMA following nCPAP or by ETT following mechanical ventilation (MV). The primary outcome was a clinical response defined as FiO2≤0.30 three hours after surfactant. Secondary outcomes for LMA group were: need of surfactant retreatment during the first 24h, MV requirement, and presence of surfactant in gastric content. RESULTS Forty-eight patients were randomized; 26 in the LMA group and 22 in the ETT group. Six of 26 patients (23%) in the LMA group and five of 22 patients (22.7%) in the ETT group did not meet the primary outcome (p=0.977). Fourteen (53.8%) of the LMA patients were not intubated nor ventilated; 12 (46.1%) were ventilated: for surfactant failure (23%), for nCPAP failure (11.5%), and for late complications (11.5%). Groups were similar regarding prenatal status, birth conditions, and adverse events. No significant gastric content was found in 61.5% of the LMA patients. Oxygen and second dose surfactant requirements, arterial/alveolar ratio, and morbidities were similar among groups. CONCLUSIONS Surfactant administration by LMA showed short-term efficacy, with similar supplementary oxygen need compared to surfactant by ETT, and lower MV requirement. Further studies with larger sample size are necessary to confirm these results.
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Affiliation(s)
- Rosilu F Barbosa
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Laboratório Interdisciplinar de Investigação Médica, Belo Horizonte, MG, Brazil; Maternidade UNIMED-BH, Unidade de Terapia Intensiva Neonatal, Belo Horizonte, MG, Brazil.
| | - Ana C Simões E Silva
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Laboratório Interdisciplinar de Investigação Médica, Belo Horizonte, MG, Brazil
| | - Yerkes P Silva
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Laboratório Interdisciplinar de Investigação Médica, Belo Horizonte, MG, Brazil; Hospital Lifecenter, Departamento de Anestesia, Belo Horizonte, MG, Brazil
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Barbosa RF, Simões e Silva AC, Silva YP. A randomized controlled trial of the laryngeal mask airway for surfactant administration in neonates. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Niemarkt H, Hütten M, Kramer BW. Surfactant for Respiratory Distress Syndrome: New Ideas on a Familiar Drug with Innovative Applications. Neonatology 2017; 111:408-414. [PMID: 28538236 PMCID: PMC5516408 DOI: 10.1159/000458466] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the last 4 decades, advances in neonatology have led to a significant increase in the survival of preterm infants. One of the biggest advances was the introduction of surfactant replacement therapy for the treatment of respiratory distress syndrome. This is the main cause of respiratory insufficiency in preterm infants and is one of the major causes of perinatal morbidity and mortality. Surfactant replacement therapy is already a well-investigated and established therapy in neonatology. However, surfactant replacement therapy has progressed and been refined over recent decades, especially with the increasing care for preterm infants born before 26 weeks' gestational age and the recent clinical focus on avoiding mechanical ventilation. Clinical evidence is evolving on new types of surfactant, surfactant dosages, co-medication given before, with, or after surfactant replacement, and new technical advances regarding the mode of administration.
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Affiliation(s)
- H.J. Niemarkt
- Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - M.C. Hütten
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
- *Prof. Boris W. Kramer, Department of Pediatrics, Maastricht University Medical Center, PO Box 5800, NL-6202 AZ Maastricht (The Netherlands), E-Mail
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Abstract
Respiratory distress syndrome (RDS) caused by surfactant deficiency is major cause for neonatal mortality and short- and long-term morbidity of preterm infants. Continuous positive airway pressure and other modes of noninvasive respiratory support and intubation and positive pressure ventilation with surfactant therapy are efficient therapies for RDS. Because continuous positive airway pressure can fail in severe surfactant deficiency, and because traditional surfactant therapy requires intubation and positive pressure ventilation, this entails a risk of lung injury. Several strategies to combine noninvasive respiratory therapy with minimally invasive surfactant therapy have been described. Available data suggest that those strategies may improve outcome of premature infants with RDS.
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Affiliation(s)
- Angela Kribs
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Cologne, Kerpener Str 62, Cologne 50937, Germany.
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Pinheiro JMB, Santana-Rivas Q, Pezzano C. Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery. J Perinatol 2016; 36:196-201. [PMID: 26633145 DOI: 10.1038/jp.2015.177] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 09/01/2015] [Accepted: 10/07/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare the effectiveness of surfactant delivery via endotracheal tube (ETT) using an intubation-surfactant-rapid extubation approach with premedication) vs laryngeal mask airway (LMA) in preventing the need for mechanical ventilation in preterm neonates with moderate respiratory distress syndrome (RDS). STUDY DESIGN Moderately preterm infants diagnosed with RDS, receiving nasal continuous positive airway pressure with FiO2 0.30 to 0.60, were randomized to two groups at age 3 to 48 h. Those in the ETT group were intubated following premedication with atropine and morphine, whereas the LMA group received only atropine. Both groups received calfactant before a planned reinstitution of nasal continuous positive airway pressure, and had equivalent pre-specified criteria for subsequent mechanical ventilation and surfactant retreatment. The primary outcome was failure of surfactant treatment strategy to avoid mechanical ventilation; we differentiated early from late failures to assess the contribution of potential mechanisms such as respiratory depression versus less-effective surfactant delivery. Secondary outcomes addressed efficacy and safety end points. RESULT Sixty-one patients were randomized, one excluded and 30 analyzed in each group, with similar baseline characteristics. Failure rate was 77% in the ETT group and 30% in the LMA group (P<0.001). The difference was related to early failure, as late failure rates did not differ between groups. FiO2 decrease after surfactant and rates of adverse events were similar between groups. CONCLUSION Surfactant therapy through an LMA decreases the proportion of newborns with moderate RDS who require mechanical ventilation, when compared with a standard endotracheal intubation procedure with sedation. The efficacy of surfactant in decreasing RDS severity appears similar with both methods. Morphine premedication likely contributed to early post-surfactant failures.
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Affiliation(s)
- J M B Pinheiro
- Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - Q Santana-Rivas
- Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - C Pezzano
- Department of Pediatrics, Albany Medical College, Albany, NY, USA.,Cardiorespiratory Services, Albany Medical Center, Albany, NY, USA
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Schmölzer GM, Agarwal M, Kamlin COF, Davis PG. Supraglottic airway devices during neonatal resuscitation: An historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation 2013; 84:722-30. [DOI: 10.1016/j.resuscitation.2012.11.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 10/09/2012] [Accepted: 11/04/2012] [Indexed: 10/27/2022]
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Abstract
Modern anaesthesia practice in children was made possible by the invention of the endotracheal tube (ET), which made lengthy and complex surgical procedures feasible without the disastrous complications of airway obstruction, aspiration of gastric contents or asphyxia. For decades, endotracheal intubation or bag-and-mask ventilation were the mainstays of airway management. In 1983, this changed with the invention of the laryngeal mask airway (LMA), the first supraglottic airway device that blended features of the facemask with those of the ET, providing ease of placement and hands-free maintenance along with a relatively secure airway. The invention and development of the LMA by Dr. Archie Brain has had a significant impact on the practice of anaesthesia, management of the difficult airway and cardiopulmonary resuscitation in children and neonates. This review article will be a brief about the clinical applications of supraglottic airways in children.
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Affiliation(s)
- S Ramesh
- Department of Anaesthesia, Senior Consultants, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
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Göpel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C, Siegel J, Avenarius S, von der Wense A, Vochem M, Groneck P, Weller U, Möller J, Härtel C, Haller S, Roth B, Herting E. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011; 378:1627-34. [PMID: 21963186 DOI: 10.1016/s0140-6736(11)60986-0] [Citation(s) in RCA: 298] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Surfactant is usually given to mechanically ventilated preterm infants via an endotracheal tube to treat respiratory distress syndrome. We tested a new method of surfactant application to spontaneously breathing preterm infants to avoid mechanical ventilation. METHOD In a parallel-group, randomised controlled trial, 220 preterm infants with a gestational age between 26 and 28 weeks and a birthweight less than 1·5 kg were enrolled in 12 German neonatal intensive care units. Infants were independently randomised in a 1:1 ratio with variable block sizes, to standard treatment or intervention, and randomisation was stratified according to centre and multiple birth status. Masking was not possible. Infants were stabilised with continuous positive airway pressure and received rescue intubation if necessary. In the intervention group, infants received surfactant treatment during spontaneous breathing via a thin catheter inserted into the trachea by laryngoscopy if they needed a fraction of inspired oxygen more than 0·30. The primary endpoint was need for any mechanical ventilation, or being not ventilated but having a partial pressure of carbon dioxide more than 65 mm Hg (8·6 kPa) or a fraction of inspired oxygen more than 0·60, or both, for more than 2 h between 25 h and 72 h of age. Analysis was by intention to treat. This study is registered, number ISRCTN05025922. FINDINGS 108 infants were assigned to the intervention group and 112 infants to the standard treatment group. All infants were analysed. On day 2 or 3 after birth, 30 (28%) infants in the intervention group were mechanically ventilated versus 51 (46%) in the standard treatment group (number needed to treat 6, 95% CI 3-20, absolute risk reduction 0·18, 95% CI 0·30-0·05, p=0·008). 36 (33%) infants in the intervention group were mechanically ventilated during their stay in the hospital compared with 82 (73%) in the standard treatment group (number needed to treat: 3, 95% CI 2-4, p<0·0001). The intervention group had significantly fewer median days on mechanical ventilation, (0 days. IQR 0-3 vs 2 days, 0-5) and a lower need for oxygen therapy at 28 days (30 infants [30%] vs 49 infants [45%], p=0·032) compared with the standard treatment group. We recorded no differences between groups for mortality (seven deaths in the intervention group vs five in the standard treatment group) and serious adverse events (21 vs 28). INTERPRETATION The application of surfactant via a thin catheter to spontaneously breathing preterm infants receiving continuous positive airway pressure reduces the need for mechanical ventilation. FUNDING German Ministry of Research and Technology, University of Lübeck, and Chiesi Pharmaceuticals.
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Abdel-Latif ME, Osborn DA. Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2011:CD008309. [PMID: 21735428 DOI: 10.1002/14651858.cd008309.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Laryngeal mask airway (LMA) administration is one way of delivering surfactant to the infant lung, with the potential benefit of avoiding endotracheal intubation and ventilation, ventilator induced lung injury and bronchopulmonary dysplasia (BPD). OBJECTIVES To determine the effect of LMA surfactant administration either as prophylaxis or treatment compared to placebo, no treatment, or intratracheal surfactant administration on morbidity and mortality in preterm infants with, or at risk of, respiratory distress syndrome (RDS). SEARCH STRATEGY We searched CENTRAL (The Cochrane Library, October 2010), MEDLINE and PREMEDLINE (1950 to October 2010), EMBASE (1980 to October 2010) and CINAHL (1982 to October 2010). We also searched proceedings of scientific meetings, clinical trial registries, Google Scholar and reference lists of identified studies, as well as contacting expert informants and surfactant manufacturers. SELECTION CRITERIA Randomised, cluster-randomised or quasi-randomised controlled trials of laryngeal mask surfactant administration compared to placebo, no treatment, or other routes of administration (nebulised, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and quality, and extracted data. MAIN RESULTS We found no studies of prophylactic or early LMA surfactant administration. A single small study of late rescue LMA surfactant was identified as eligible for inclusion. The study enrolled 26 preterm infants born ≥ 1200 g with RDS on continuous positive airway pressure (nCPAP). LMA surfactant administration compared to no treatment resulted in a reduction in mean FiO(2) required to maintain oxygen saturation between 88% and 92% for 12 hours after the intervention. No significant difference was reported in subsequent mechanical ventilation and endotracheal surfactant, pneumothorax, days on intermittent positive airway pressure (IPPV), and days on IPPV or oxygen. AUTHORS' CONCLUSIONS There is evidence from a single small trial that LMA surfactant administration in preterm infants ≥ 1200 g with established RDS may have a short term effect in reducing oxygen requirements although the study is underpowered to detect important clinical effects. Adequately powered trials are required to determine the effect of LMA surfactant administration for prevention or treatment of RDS in preterm infants. LMA surfactant administration should be limited to clinical trials.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Department of Neonatology, Australian National University Medical School, PO Box 11, Woden, ACT, Australia, 2606
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Roberts KD, Lampland AL, Meyers PA, Worwa CT, Plumm BJ, Mammel MC. Laryngeal mask airway for surfactant administration in a newborn animal model. Pediatr Res 2010; 68:414-8. [PMID: 20613684 DOI: 10.1203/pdr.0b013e3181ef7619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Premature infants are subjected to adverse effects of intubation to benefit from surfactant. We hypothesized that administration of surfactant through a laryngeal mask airway (LMA) is as effective as administration through an endotracheal tube (ETT) and that time and physiologic changes during instrumentation will be less in the LMA group. This study is a randomized, controlled trial using newborn pigs. Lung injury was induced via surfactant washout. Animals were randomized into groups: 1) LMA placed, no surfactant administered (control; n = 8); 2) surfactant via an LMA (LMA group; n = 8); and 3) surfactant via an ETT (ETT group; n = 8). We demonstrated that partial pressure of oxygen in arterial blood (Pao2) levels of the LMA and ETT groups were not statistically different. Time for successful placement of LMA was 19 ± 1 s versus ETT 123 ± 35 s (mean ± SEM); number of attempts for successful LMA placement was 1.1 (1-2) versus ETT 1.9 (1-7) [mean (range)]. Administration of surfactant via an LMA compared with an ETT resulted in similar improvements in oxygenation. Placement of the device required less time and fewer attempts. These data suggest that further study in human neonates is justified. If proven effective, some infants with respiratory distress may be able to receive surfactant while avoiding intubation.
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Affiliation(s)
- Kari D Roberts
- Department of Pediatrics, University of Minnesota, Amplatz Children's Hospital, Minneapolis, Minnesota 55455, USA.
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Micaglio M, Zanardo V, Ori C, Parotto M, Doglioni N, Trevisanuto D. ProSeal LMA for surfactant administration. Paediatr Anaesth 2008; 18:91-2. [PMID: 18095983 DOI: 10.1111/j.1460-9592.2007.02371.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Been JV, Zimmermann LJI. What's new in surfactant? A clinical view on recent developments in neonatology and paediatrics. Eur J Pediatr 2007; 166:889-99. [PMID: 17516084 PMCID: PMC7102086 DOI: 10.1007/s00431-007-0501-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 04/18/2007] [Indexed: 11/29/2022]
Abstract
UNLABELLED Surfactant therapy has significantly changed clinical practice in neonatology over the last 25 years. Recent trials in infants with respiratory distress syndrome (RDS) have not shown superiority of any natural surfactant over another. Advancements in the development of synthetic surfactants are promising, yet to date none has been shown to be superior to natural preparations. Ideally, surfactant would be administered without requiring mechanical ventilation. An increasing number of studies investigate the roles of alternative modes of administration and the use of nasal continuous positive airway pressure to minimise the need for mechanical ventilation. Whether children with other lung diseases benefit from surfactant therapy is less clear. Evidence suggests that infants with meconium aspiration syndrome and children with acute lung injury/acute respiratory distress syndrome may benefit, while no positive effect of surfactant is seen in infants with congenital diaphragmatic hernia. However, more research is needed to establish potential beneficial effects of surfactant administration in children with lung diseases other than RDS. Furthermore, genetic disorders of surfactant metabolism have recently been linked to respiratory diseases of formerly unknown origin. It is important to consider these disorders in the differential diagnosis of unexplained respiratory distress although no established treatment is yet available besides lung transplantation for the most severe cases. CONCLUSION Research around surfactant is evolving and recent developments include further evolution of synthetic surfactants, evaluation of surfactant as a therapeutic option in lung diseases other than RDS and the discovery of genetic disorders of surfactant metabolism. Ongoing research is essential to continue to improve therapeutic prospects for children with serious respiratory disease involving disturbances in surfactant.
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Affiliation(s)
- Jasper V Been
- Department of Paediatrics, Research Institute Growth and Development, Maastricht University Hospital, Maastricht, The Netherlands.
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Abstract
The appropriate role for laryngeal masks during delivery room resuscitation has not been established. The authors systematically reviewed the literature to answer three clinical questions: (1) In newborns requiring positive-pressure ventilation for resuscitation, would a laryngeal mask achieve safe and effective ventilation faster than facemask ventilation? (2) In newborns unable to be ventilated effectively with a facemask during resuscitation, would a laryngeal mask achieve effective ventilation faster than endotracheal intubation? (3) In newborns requiring resuscitation, would a laryngeal mask achieve effective ventilation when facemask ventilation and endotracheal intubation have been unsuccessful?
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Affiliation(s)
- Enrique Udaeta Mora
- Department of Pediatrics, Hospital Angeles Mexico, Agrarismo 208-301 B, Escandon, Mexico City 18000, Mexico
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Grein AJ, Weiner GM. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev 2005:CD003314. [PMID: 15846656 DOI: 10.1002/14651858.cd003314.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Providing effective positive pressure ventilation is the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated with a manual resuscitation bag and face-mask (BMV) followed by endotracheal intubation (ETT) if depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or severe neonatal depression. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation. OBJECTIVES Among newborns requiring positive pressure ventilation for resuscitation, is effective ventilation and successful resuscitation achieved faster with the LMA compared with either BMV or ETT? SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE (1966-November 2004), Pre-MEDLINE (November 15, 2004), CINAHL 1982-November 2004), reference lists of published trials, and Society for Pediatric Research abstracts were searched. Experts were contacted for additional references. SELECTION CRITERIA Randomised and quasi-randomised trials DATA COLLECTION AND ANALYSIS Two reviewers independently evaluated studies, assessed methodologic quality, and extracted data using the Cochrane Neonatal Review Group criteria. Categorical treatment effects were described as relative risks and risk differences and continuous treatment effects were described as the mean difference. There were insufficient data to perform pooled analyses. MAIN RESULTS No eligible studies compared the LMA with BMV. One small randomised controlled trial comparing the LMA with ETT when BMV had been unsuccessful was included. There was no statistically significant difference between the LMA and ETT with the exception of a clinically insignificant difference in time to complete insertion of the device favouring the ETT. AUTHORS' CONCLUSIONS The LMA can achieve effective ventilation during neonatal resuscitation in a time-frame consistent with current guidelines. There is no evidence to evaluate the relative efficacy and safety of the LMA compared with BMV as the primary airway device. A single, small randomised controlled trial found no clinically significant difference between the LMA and ETT when BMV was unsuccessful. Case series and case reports suggest that the LMA can provide an effective rescue airway during resuscitation if both BMV and ETT have been unsuccessful. A well-designed randomised controlled trial comparing the LMA with BMV during neonatal resuscitation is warranted.
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Affiliation(s)
- A J Grein
- Department of Pediatrics, Neonatal-Perinatal Medicine, Indiana University School of Medicine, USA, 699 West Drive, RR 208, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana 46202-5119, USA.
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Abstract
Airway control during interhospital transport may present enormous management difficulties, even for experienced personnel. The laryngeal mask airway is an airway management device that has been established as a safe reliable tool in adult and pediatric practice. We describe 2 cases of successful interhospital transfer of infants with congenital airway malformations with the use of the laryngeal mask airway, and we review the literature.
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