Less Invasive Surfactant Administration Reduces the Need for Mechanical Ventilation in Preterm Infants: A Meta-Analysis

Less Invasive Surfactant Administration Compared to Intubation, Surfactant, Rapid Extubation Method in Preterm Neonates: An Umbrella Review

INTRODUCTION

In spontaneously breathing neonates, surfactant can be administered via thin catheter while enabling the own breathing (less invasive surfactant administration [LISA]). Alternatively, the neonate is intubated for surfactant delivery (intubation, surfactant, rapid extubation [INSURE]). Thus, the aim was to provide an overview of the efficacy of the LISA compared to INSURE.

METHODS

We performed an umbrella review of previous meta-analyses including randomized controlled trials. We searched PubMed, Scopus, and Web of Science in July 2023. Two authors screened the search results, and systematic reviews with meta-analyses that focused on LISA versus INSURE were included. One author extracted, and another author validated the extracted data. AMSTAR-2 and ROBIS evaluations were performed by two authors independently.

RESULTS

A total of 9 systematic reviews with meta-analyses were included. The quality according to AMSTAR-2 was high in one, moderate in one, low in three, and critically low in four. According to ROBIS, the risk of bias was low in three and high in six of the reviews. LISA was more effective than INSURE in preventing mechanical ventilation (8/8 reviews), death or BPD (4/4 reviews), death (3/9 reviews), and BPD (3/9 reviews).

CONCLUSIONS

All the included systematic reviews and meta-analyses reported LISA to be more effective than INSURE in terms of need for mechanical ventilation and death or BPD. However, the quality of the published systematic reviews has been mostly deficient. Future systematic reviews should focus on reporting quality.

Less Invasive Surfactant Administration (LISA) Versus INSURE Method in Preterm Infants: a Retrospective Study

Background

Respiratory distress syndrome (RDS) is a major cause of morbidity and mortality in preterm infants. Early nasal CPAP and selective administration of surfactant via the endotracheal tube are widely used in the treatment of RDS in preterm infants.

Objective

The aim of this study was to compare the need for intubation and mechanical ventilation after surfactant delivery between LISA-treated and INSURE-treated premature infants with respiratory distress syndrome (RDS).

Methods

Retrospective registry-based cohort study enrolled 36 newborns admitted to the neonatal intensive care unit of the "Santa Maria" Hospital of Terni between 2016 and 2023. As a primary outcome, we followed the need for intubation and mechanical ventilation within 72 hours of life, while the secondary outcomes were major neonatal morbidities and death before discharge.

Results

The LISA group and the INSURE group included 13 and 23 newborns respectively. Demographic features showed no significant differences between the two groups. The need for mechanical ventilation in the first 72 hours of life was similar in both groups (p >0.99). There were no significant differences in morbidities.

Conclusion

LISA and INSURE are equally effective modalities for surfactant administration for the treatment of RDS in preterm infants.

Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative

OBJECTIVE

To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support.

SETTING

Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA).

STUDY POPULATION

Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration.

RESULTS

LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation.

CONCLUSIONS

Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.

Sedation for less invasive surfactant administration in preterm infants: a systematic review and meta-analysis

BACKGROUND

Sedation to preterm neonates receiving less invasive surfactant administration (LISA) for respiratory distress syndrome is controversial.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies (OS) to evaluate the effect of sedative drugs for LISA on respiratory outcomes and adverse effects.

RESULTS

One RCT (78 neonates) and two OS (519 neonates) were analyzed in pairwise meta-analysis and 30 studies (2164 neonates) in proportion-based meta-analysis. Sedative drugs might not affect the duration of the procedure [RCT: mean difference (MD) (95% CI); -11 (-90; 67) s; OS: MD 95% CI: -60 (-178; 58) s; low certainty of evidence (CoE)]. Evidence for success at the first attempt and rescue intubation was uncertain (very low CoE). The risk of nasal intermittent positive pressure ventilation [RCT: 1.97 (1.38-2.81); OS: RR, 95% CI: 2.96 (1.46; 6.00), low CoE], desaturation [RCT: RR, 95% CI: 1.30 (1.03; 1.65), low CoE], and apnea [OS: RR, 95% CI: 3.13 (1.35; 7.24), very low CoE] might be increased with sedation. Bradycardia, hypotension, and mechanical ventilation were comparable between groups (low CoE).

CONCLUSIONS

Use of sedative drugs for LISA temporarily affects the newborn's breathing. Further trials are warranted to explore the use of sedation for LISA.

IMPACT

The effect of sedative drugs (analgesics, sedatives, anesthetics) compared to the effect of no-sedation for LISA in preterm infants with RDS is underexplored. This systematic review and meta-analysis assesses the impact of sedative drugs compared to no-sedation for LISA on short-term pulmonary outcomes and potential adverse events. Sedative drugs for LISA temporarily affect the newborn's breathing (desaturation, apnea) and increase the need for nasal intermittent positive pressure ventilation. For most outcomes, certainty of evidence is low/very low.

Less invasive surfactant administration via infant feeding tube versus InSurE method in preterm infants: a randomized control trial

There is growing evidence that less invasive surfactant administration (LISA) is a better alternative to the standard Intubate-surfactant-extubate (InSurE) procedure in spontaneously breathing preterm infants with RDS. The infant feeding tube is easily available and cost-effective in comparison to special catheters used for surfactant administration in various studies on LISA and cost-effective health care is the need of the hour for countries like ours which are Low and middle-income countries(LMICs).The present study was planned to compare the total duration of respiratory support in preterm babies between 26 to 34 weeks of gestation with RDS requiring surfactant therapy administered by LISA technique using an infant feeding tube or InSurE method. In this unblinded randomised controlled trial, 150 infants were allocated to LISA (n = 74) or InSurE group (n = 76). An 8F feeding tube was used for surfactant delivery in the LISA group. The primary outcome was the total duration of respiratory support required and secondary outcomes included the proportion of babies developing BPD, IVH, PDA, NEC, ROP, air leaks, CPAP failure, and those requiring a repeat dose of surfactant along with the duration of hospitalization, time to regain birth weight and Death. The baseline variables including birth weight and gestation age were similar in the two groups. Nearly 27% of the mothers did not receive any dose of antenatal steroids (ANS) while around 37% of the mothers received complete course of ANS. A high proportion of babies (57%) were delivered by cesarean section. Intrapharyngeal reflux was significantly more in babies who received surfactant with the LISA method in comparison to InSurE technique (32% v/s 3%, p < 0.001). There was no statistically significant difference in the primary outcome of the total duration of respiratory support in both groups with a median duration of 120 h, 95% CI (69-235), and p = 0.618. The need for invasive mechanical ventilation was significantly lower in the LISA group (p = 0.017) with RR (95% CI) 0.498 (0.259-0.958). The rate of CPAP failure was significantly lower in the LISA group (p = 0.005) with RR (95% CI) 0.55 (0.34-0.89). In this study, the total duration of hospital stay was reduced in the LISA group (19 days) compared to InSurE group (26 days), although the same was not statistically significant. LISA with an 8F feeding tube is feasible and an effective strategy for surfactant administration which resulted in a significant reduction in CPAP failure and the need for invasive mechanical ventilation.Trial registration: www.ctri.nic.in id CTRI/2020/05/025360. Trial was registered at CTRI on 26/05/2020. First case of trial was enrolled on 28/05/2020.

Less Invasive Surfactant Administration: A Review of Current Evidence of Clinical Outcomes With Beractant

Evidence supporting clinical recommendations or approval for less invasive surfactant administration (LISA) has primarily examined heterogeneous or small-volume (e.g., 1.25-2.5 mL/kg) animal-derived surfactant regimens. To address the evidence gap for larger-volume (e.g., 4-5 mL/kg) animal-derived surfactants, the aim of this review was to evaluate and summarize LISA literature for widely used larger-volume beractant. Surfactant treatment and the LISA technique were initially summarized. The available literature on beractant with LISA was thoroughly assessed and reviewed, including a recent systematic analysis, studies from regions where access or preferences may influence reliance on larger-volume surfactants, and investigations of short- and long-term outcomes. The available literature indicated improved short-term outcomes, including less need for mechanical ventilation, death, or bronchopulmonary dysplasia, and no negative long-term developmental outcomes when beractant was administered via LISA compared with older, more invasive techniques. The rates of short-term outcomes were similar to those previously observed in examinations of LISA with small-volume surfactants, including in populations reflecting very preterm infants. As uptake of LISA is expected to increase, future research directions for larger-volume surfactants include cost-effectiveness evaluations and robust examinations of repeat dosing and surfactant reflux to further inform clinical practice. This review provides a detailed assessment of the literature describing surfactant and LISA, with a focus on studies of beractant. Collectively, the available evidence supports the use of beractant with LISA based both on short-term and long-term outcomes relative to more invasive techniques and comparability of outcomes with small-volume surfactants and may be valuable in guiding clinical decision-making.

Poractant alfa versus bovine lipid extract surfactant: prospective comparative effectiveness study

OBJECTIVE

To compare short term respiratory outcomes in preterm infants treated with bovine lipid extract surfactant or poractant alfa.

STUDY DESIGN

Prospective comparative effectiveness cohort study of infants <32 weeks' gestational age requiring surfactant in thirteen centers. Each center provided bovine lipid extract surfactant for a set period of time in the year 2019 and then changed to poractant alfa for the remainder of the year. The primary outcome was total duration of respiratory support.

RESULT

968 infants were included. 494 received bovine lipid extract surfactant and 474 received poractant alfa. No difference was observed in the total duration of respiratory support (mechanical ventilation or non-invasive) (median 38 vs 40.5 days), need to re-dose surfactant, bronchopulmonary dysplasia, survival to discharge, or length of admission.

CONCLUSION

In this pragmatic study, we did not identify any difference in short term outcomes between the groups based on the type of surfactant received.

A systematic review of surfactant delivery via laryngeal mask airway, pharyngeal instillation, and aerosolization: Methods, limitations, and outcomes

Less invasive surfactant administration methods without laryngoscopy and endotracheal catheterization include delivery via laryngeal mask airway, pharyngeal instillation, and aerosolization. These less invasive techniques are promising and have several advantages over INSURE (Intubation-Surfactant-Extubation) and thin catheter techniques. The objective of this review is to discuss the requisites, techniques, short-term outcomes, and adverse events associated with these methods.

Surfactant delivery via thin catheters: Methods, limitations, and outcomes

Various less invasive surfactant administration strategies like surfactant replacement therapy via thin catheters, laryngeal mask airway, pharyngeal instillation, and nebulized surfactant are increasingly being practiced to avoid the harmful effects of endotracheal intubation and ventilation. Numerous studies have been done to study surfactant replacement via thin catheters whereas little data is available for other methods. However, there are variations in premedication policies, type of respiratory support used in these studies. Surfactant delivery using thin catheters has been reported to be associated with decrease in the need for mechanical ventilation (MV), duration of MV, bronchopulmonary dysplasia and neonatal mortality. With the current evidence, among all the available surfactant delivery methods, the one using thin catheters appears to be the most feasible and beneficial to improve clinical neonatal outcomes.

Impact of Catheter Choice on Procedural Success of Minimally Invasive Surfactant Therapy

OBJECTIVE

 Surfactant delivery via a thin endotracheal catheter during spontaneous breathing; a technique called minimally invasive surfactant therapy (MIST) is an alternative to intubation and surfactant administration. Procedural details among different centers vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multiaccess suction catheters, vascular catheters, and more recently custom-built catheters for this purpose. The impact of choice of catheter on procedural success and procedural adverse effects has not been reported. Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart Method) versus a flexible multiaccess catheter (MAC).

STUDY DESIGN

 This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit in Southwestern Ontario. All neonates who received surfactant via MIST between May 1, 2016 and September 30, 2020 were included in the study. Relevant baseline characteristics and data on procedural details (premedication, type of catheter, etc.) were collected. The procedural success, number of attempts, and adverse effects between neonates who received MIST via MAC and 16G Angiocath was compared by using Chi-square test or Fisher's test as appropriate. A p-value of less that 0.05 was considered significant.

RESULTS

 A total of 139 neonates received surfactant via MIST method during the study period. Moreover, 93 neonates received the surfactant via MAC, while 46 received it via Angiocath. The baseline demographic characteristics in the two group were similar. A higher proportion of neonates in Angiocath group received Atropine (100 vs. 76%, p = 0.002) and Fentanyl (98 vs. 36%, p < 0.001) than the MAC group.The procedural success was 91% in the Angiocath group and 89% in the MAC group (p > 0.99). Multiple attempts were needed in 24% of neonates in the Angiocath group and 37% in the MAC group (p = 0.158). More episodes of desaturations were noted in the Angiocath group (89%) than the MAC group (69%; p = 0.012). Other rates of common adverse effects were similar between the two groups. On exploratory analysis fentanyl use held significant association with less success, more desaturation, apneic episodes, and need of positive pressure ventilation /intubation.

CONCLUSION

 The overall procedural success of MIST is similar in both catheter groups. The proportion of neonates requiring multiple attempts was lower with the Angiocath, though difference was not statistically significant. Desaturation episodes were seen more frequently in the Angiocath group, which was related to higher use of procedural sedation in this group.

KEY POINTS

· MIST is emerging as a less invasive method of surfactant delivery that has proven clinical benefits.. · Considerable, procedural variation is reported, particularly regarding choice of catheter.. · Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart method) versus a flexible MAC.. · High and comparable procedural success was seen in both groups..

Pulmonary surfactant: a unique biomaterial with life-saving therapeutic applications

Pulmonary surfactant is a complex lipoprotein mixture secreted into the alveolar lumen by type 2 pneumocytes, which is composed by tens of different lipids (approximately 90% of its entire mass) and surfactant proteins (approximately 10% of the mass). It is crucially involved in maintaining lung homeostasis by reducing the values of alveolar liquid surface tension close to zero at end-expiration, thereby avoiding the alveolar collapse, and assembling a chemical and physical barrier against inhaled pathogens. A deficient amount of surfactant or its functional inactivation is directly linked to a wide range of lung pathologies, including the neonatal respiratory distress syndrome. This paper reviews the main biophysical concepts of surfactant activity and its inactivation mechanisms, and describes the past, present and future roles of surfactant replacement therapy, focusing on the exogenous surfactant preparations marketed worldwide and new formulations under development. The closing section describes the pulmonary surfactant in the context of drug delivery. Thanks to its peculiar composition, biocompatibility, and alveolar spreading capability, the surfactant may work not only as a shuttle to the branched anatomy of the lung for other drugs but also as a modulator for their release, opening to innovative therapeutic avenues for the treatment of several respiratory diseases.

Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome

BACKGROUND

Non-invasive respiratory support is increasingly used for the management of respiratory dysfunction in preterm infants. This approach runs the risk of under-treating those with respiratory distress syndrome (RDS), for whom surfactant administration is of paramount importance. Several techniques of minimally invasive surfactant therapy have been described. This review focuses on surfactant administration to spontaneously breathing infants via a thin catheter briefly inserted into the trachea.

OBJECTIVES

Primary objectives In non-intubated preterm infants with established RDS or at risk of developing RDS to compare surfactant administration via thin catheter with: 1. intubation and surfactant administration through an endotracheal tube (ETT); or 2. continuation of non-invasive respiratory support without surfactant administration or intubation. Secondary objective 1. To compare different methods of surfactant administration via thin catheter Planned subgroup analyses included gestational age, timing of intervention, and use of sedating pre-medication during the intervention.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 30 September 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials.

SELECTION CRITERIA

We included randomised trials comparing surfactant administration via thin catheter (S-TC) with (1) surfactant administration through an ETT (S-ETT), or (2) continuation of non-invasive respiratory support without surfactant administration or intubation. We also included trials comparing different methods/strategies of surfactant administration via thin catheter. We included preterm infants (at < 37 weeks' gestation) with or at risk of RDS.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed study quality and risk of bias and extracted data. Authors of all studies were contacted regarding study design and/or missing or unpublished data. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 16 studies (18 publications; 2164 neonates) in this review. These studies compared surfactant administration via thin catheter with surfactant administration through an ETT with early extubation (Intubate, Surfactant, Extubate technique - InSurE) (12 studies) or with delayed extubation (2 studies), or with continuation of continuous positive airway pressure (CPAP) and rescue surfactant administration at pre-specified criteria (1 study), or compared different strategies of surfactant administration via thin catheter (1 study). Two trials reported neurosensory outcomes of of surviving participants at two years of age. Eight studies were of moderate certainty with low risk of bias, and eight studies were of lower certainty with unclear risk of bias. S-TC versus S-ETT in preterm infants with or at risk of RDS Meta-analyses of 14 studies in which S-TC was compared with S-ETT as a control demonstrated a significant decrease in risk of the composite outcome of death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.48 to 0.73; risk difference (RD) -0.11, 95% CI -0.15 to -0.07; number needed to treat for an additional beneficial outcome (NNTB) 9, 95% CI 7 to 16; 10 studies; 1324 infants; moderate-certainty evidence); the need for intubation within 72 hours (RR 0.63, 95% CI 0.54 to 0.74; RD -0.14, 95% CI -0.18 to -0.09; NNTB 8, 95% CI; 6 to 12; 12 studies, 1422 infants; moderate-certainty evidence); severe intraventricular haemorrhage (RR 0.63, 95% CI 0.42 to 0.96; RD -0.04, 95% CI -0.08 to -0.00; NNTB 22, 95% CI 12 to 193; 5 studies, 857 infants; low-certainty evidence); death during first hospitalisation (RR 0.63, 95% CI 0.47 to 0.84; RD -0.02, 95% CI -0.10 to 0.06; NNTB 20, 95% CI 12 to 58; 11 studies, 1424 infants; low-certainty evidence); and BPD among survivors (RR 0.57, 95% CI 0.45 to 0.74; RD -0.08, 95% CI -0.11 to -0.04; NNTB 13, 95% CI 9 to 24; 11 studies, 1567 infants; moderate-certainty evidence). There was no significant difference in risk of air leak requiring drainage (RR 0.58, 95% CI 0.33 to 1.02; RD -0.03, 95% CI -0.05 to 0.00; 6 studies, 1036 infants; low-certainty evidence). None of the studies reported on the outcome of death or survival with neurosensory disability. Only one trial compared surfactant delivery via thin catheter with continuation of CPAP, and one trial compared different strategies of surfactant delivery via thin catheter, precluding meta-analysis.

AUTHORS' CONCLUSIONS

Administration of surfactant via thin catheter compared with administration via an ETT is associated with reduced risk of death or BPD, less intubation in the first 72 hours, and reduced incidence of major complications and in-hospital mortality. This procedure had a similar rate of adverse effects as surfactant administration through an ETT. Data suggest that treatment with surfactant via thin catheter may be preferable to surfactant therapy by ETT. Further well-designed studies of adequate size and power, as well as ongoing studies, will help confirm and refine these findings, clarify whether surfactant therapy via thin tracheal catheter provides benefits over continuation of non-invasive respiratory support without surfactant, address uncertainties within important subgroups, and clarify the role of sedation.

New BPD-prevalence and risk factors for bronchopulmonary dysplasia/mortality in extremely low gestational age infants ≤28 weeks

OBJECTIVE

To evaluate prevalence and risk factors of moderate-severe Bronchopulmonary dysplasia (BPD)/Death in extremely low gestation age neonates (ELGANs).

STUDY DESIGN

Study of 266 ELGANs born at gestational age (GA) ≤ 28 weeks (w). Primary Outcome measure-composite outcome of moderate-severe BPD/Death using the National Institute of Child Health and Human Development NICHD's (2001) BPD definition.

RESULT

Cohort's mean GA and birth-weight (BW) were 25.3 ± 1.4w and 724 ± 14 g respectively with an overall mortality of 19% and moderate-severe BPD of 67%. Prevalence of moderate-severe BPD/death decreased significantly with increasing GA (86-93%) at 23-24 w; to <60% at 27-28w (OR 0.63; 95% CI; 0.52-0.77). On univariate analysis, other risk factors included BW(OR 1.005; 95% CI; 1.003-1.007), Sepsis (OR 2.9; 95% CI, 1.3-6.4), PDA needing treatment (OR 2.2; 95% CI, 1.3-3.9); air leaks (OR 2.7; 95% CI; 1.02-7.3) FiO₂ requirement >25%(OR 1.06; 95% CI; 1.01-1.11); and mechanical ventilation(MV) on Day7 (OR5.5; 95% CI; 2.8-10.8). Only need for Day7 MV was independently predictive of composite outcome (OR1.97; 95% CI; 1.3-3.1).

CONCLUSION

Risk factor identification will enable initiatives to implement lung protective strategies and develop prospective models for BPD prediction and prognostication.

Introduction of less invasive surfactant administration (LISA), impact on diagnostic and therapeutic procedures in early life: a historical cohort study

Background

In preterm infants with Respiratory Distress Syndrome (RDS), Less Invasive Surfactant Administration (LISA) has been established to reduce the need of mechanical ventilation and might improve survival rates without bronchopulmonary dysplasia. The aim of this study was to investigate whether NICU care has changed after introduction of less invasive surfactant administration (LISA), with regard to diagnostic and therapeutic procedures in the first week of life.

Methods

Infants with gestational age < 32 weeks who received surfactant by LISA (June 2014 – December 2017, n = 169) were retrospectively compared to infants who received surfactant after intubation (January 2012 – May 2014, n = 155). Local protocols on indication for surfactant, early onset sepsis, blood transfusions and enteral feeding did not change between both study periods. Besides, as secondary outcome complications of prematurity were compared. Data was collected from electronic patient files and compared by univariate analysis through Students T-test, Mann Whitney-U test, Pearson Chi-Square test or Linear by Linear Association.

Results

All baseline characteristics of both groups were comparable. Compared to controls, LISA patients received a higher total surfactant dose (208 vs.160 mg/kg; p < 0.001), required redosing more frequently (32.5% vs. 21.3%; p = 0.023), but needed less mechanical ventilation (35.5% vs. 76.8%; p < 0.001). After LISA, infants underwent fewer X-rays (1.0 vs. 3.0, p < 0.001), blood gas examinations (3.0 vs. 5.0, p < 0.001), less inotropic drugs (9.5% vs. 18.1%; p = 0.024), blood transfusions (24.9% vs. 41.9%, p = 0.003) and had shorter duration of antibiotic therapy for suspected early onset sepsis (3.0 vs. 5.0 days, p < 0.001). Moreover, enteral feeding was advanced faster (120 vs. 100 mL/kg/d, p = 0.048) at day seven. There were no differences in complications of prematurity.

Conclusion

The introduction of LISA is associated with significantly fewer diagnostic and therapeutic procedures in the first week of life, which emphasizes the beneficial effects of LISA.

Minimally invasive surfactant therapy versus InSurE in preterm neonates of 28 to 34 weeks with respiratory distress syndrome on non-invasive positive pressure ventilation-a randomized controlled trial

Preterm neonates with respiratory distress syndrome (RDS) are commonly treated with surfactant by intubate surfactant extubate (InSurE) technique. Mode of surfactant administration has evolved towards less invasive technique in the last few years. We randomised 58 preterm infants of 28-34 weeks of gestation with RDS within 6 h of birth to receive surfactant by InSurE or minimally invasive surfactant therapy (MIST). Non-invasive positive pressure ventilation (NIPPV) was used as primary respiratory support. The main objective was to compare the need of invasive mechanical ventilation (IMV) in first 72 h of life and secondarily hemodynamically significant patent ductus arteriosus (hsPDA), intraventricular haemorrhage (IVH) (> grade 2), bronchopulmonary dysplasia (BPD) and composite outcome of BPD/mortality. We did not find any difference in need of IMV in first 72 h between MIST and InSurE (relative risk with MIST, 0.62; 95% confidence interval, 0.22 to 1.32). No difference was observed in terms of hs PDA, IVH (> grade 2), BPD and composite outcome of BPD/mortality.Conclusion: There is no difference between MIST and InSurE in preterm neonates with RDS with NIPPV as a primary mode of respiratory support. Larger multicentre studies are needed to further explore differences in treatment failure and other secondary outcomes.Trial registration: www.ctri.nic.in id CTRI/2019/03/017992, registration date March 8, 2019. What is Known • InSurE is commonly used for many years for treatment of RDS in preterm neonates. • MIST has been introduced as a newer tool. What is New • MIST with feeding tube is comparable with InSurE in preterm infants with RDS in developing countries. •NIPPV can be used as primary respiratory support for MIST.

Less invasive surfactant administration reduces incidence of severe intraventricular haemorrage in preterms with respiratory distress syndrome: a cohort study

OBJECTIVE

Less invasive surfactant administration (LISA) has proved to safely improve morbidity in extreme preterms with respiratory distress syndrome (RDS). Its effect regarding intraventricular hemorrhage (IVH) remains controversial between most recent systematic reviews. We aimed to evaluate its effect over incidence of severe IVH in this population.

STUDY DESIGN

We compared the incidence of IVH in a prospective cohort of consecutively born preterm infants <34 weeks' gestation receiving LISA (n = 108) with a historical cohort receiving surfactant delivery via tracheal tube and managed with mechanical ventilation (n = 100).

RESULTS

No significant differences regarding perinatal characteristics were observed between both groups. There was a significant reduction in the incidence of severe IVH in LISA group as compared with the historical group [OR = 0.054 (95% CI 0.01-0.2) p = 0.000. NNT 5]. In addition, a significant trend towards decreased mortality was also observed in the study group [OR = 0.2 (95% CI 0.04-0.9) p = 0.027, NNT 9]. Intervention group infants also showed lower oxygenation requirements during the first 72 h post surfactant administration and a reduced incidence of pneumothorax. They were less frequently intubated [31 infants (28.4%) vs. 100 [100%]; P < 0.001] and required fewer days of mechanical ventilation. However, no significant difference in bronchopulmonary dysplasia incidence was observed between both groups.

CONCLUSIONS

LISA approach effectively reduces severe IVH in very low and low birth weight (BW) preterms with RDS. In addition we observe a significant trend towards reduction in both need and duration of MV support, air leak, and overall mortality in the intervention group.

Minimally Invasive Surfactant Therapy: An Analytical Report of Our Prospective Dubai Cohort

Introduction: Type 2 pneumocytes of the respiratory epithelium secrete the endogenous surfactant, a detergent-like substance that lines the alveolar sacs of the lungs. The surfactant facilitates the gas exchange process across the alveolar membrane by preventing the collapse of the alveoli and thereby maintaining their distended state. Respiratory distress syndrome of the premature neonates is characterized by quantitative and/or qualitative defects of endogenous surfactant metabolic pathways. The advent of exogenous surfactant therapy is rightly hailed as the major milestone in advancement of the care of the babies with surfactant-deficient lung disease. The administration of exogenous surfactant traditionally involves endotracheal intubation and mechanical ventilation. Minimally invasive surfactant therapy (MIST) is the technique of delivering surfactant without intubation whilst continuing the baby on noninvasive respiratory support. This author introduced MIST as the default way of administering surfactant in his neonatal units in Dubai and has to his credit the first published report on MIST from the United Arab Emirates in this journal in 2018. 

Objective: To analyze prospectively all our babies in Dubai who received surfactant by MIST.

Design: Prospective descriptive study of all babies receiving surfactant by MIST starting from January 2018.

Setting: Three tertiary care neonatal centers in Dubai.

Patients and methods: Thirteen babies (gestation 27-36 weeks and birth weight 0.95-2.81 kg) were treated with MIST on 15 occasions. Catheterization techniques were by infant feeding tube in 10 babies, LISA (less invasive surfactant administration) catheter in one baby, and 2.0 size endotracheal tube (ETT) with surfactant filled syringe directly attached to its hub two times each in two babies. Curosurf the porcine surfactant at 200 mg/kg was used on nine occasions and Survanta the bovine surfactant at 4 mL/kg on six occasions.

Main outcome measures: MIST success defined as the baby not needing intubation and ventilation within 72 hours post MIST. Outcome measures with respect to the different modalities of MIST procedure and surfactant preparations used in this prospective cohort.

Results: Only one of the 13 babies (7.7%) in this cohort needed escalation of support with mechanical ventilation and high frequency oscillation (HFO). MIST using semi-rigid catheters like the LISA catheter or the smallest size ETT was technically easier to perform. No differences were observed with regard to the surfactant preparation used. None had an abnormal neurosonogram and there were no instances of sepsis and necrotizing enterocolitis either. The baby that had an unsuccessful MIST had retinopathy of prematurity that was effectively treated with Laser post discharge from neonatal unit. All the babies in this cohort had age appropriate developmental milestones on subsequent follow up visits ranging from three months to two years.

Conclusions: MIST can be easily mastered and adapted in our neonatal units. MIST by any of the three variations of techniques as described in our cohort at FiO2 thresholds not exceeding 0.4 results in quicker resolution of the surfactant deficient lung disease, reduces the oxygen days in these babies and perhaps thereby insures intact survival of these babies.

Survey of less Invasive Surfactant Administration in England, slow adoption and variable practice

AIM

National survey to evaluate the uptake of Less Invasive Surfactant Administration (LISA) in neonatal units across England.

METHODS

A web-based survey was sent out by email to all 150 neonatal units in England. It consisted of questions regarding indications for LISA, the practicalities of the procedure and reasons for not using this technique.

RESULTS

The response rate was 96% (144/150 units). Only 11% of units are using LISA, but majority (78%) would consider implementing LISA on their unit. 56% would also consider LISA on delivery suite. Challenges identified are having a guideline and staff training. 61% of units have set the target population ≥27 weeks. On sub-analysis, for tertiary units, the trend for LISA is ≥26 weeks. The median FiO₂ threshold for LISA is 0.3 (IQR 0.3-0.4) in less than 28 weeks gestational age (GA), and 0.4 in higher gestations. The most common suggestion for premedication is fentanyl (32%).

CONCLUSION

The uptake of LISA in England is low comparing to the rest of Europe. Even though many units are considering implementing LISA, there is lack of training and national guidelines. There is urgent need for standardisation of practice and clear indications for LISA.

Minimally Invasive Surfactant Administration for the Treatment of Neonatal Respiratory Distress Syndrome: A Multicenter Randomized Study in China

Background/Aims: Nasal continuous positive airway pressure (nCPAP) was recommended as the initial respiratory support for spontaneous breathing in infants with very low birth weight and neonatal respiratory distress syndrome (NRDS). Less invasive surfactant administration (LISA) and minimally invasive surfactant therapy (MIST) have been reported to reduce the incidence of bronchopulmonary dysplasia (BPD). This study aimed to explore the applicability of minimally invasive surfactant administration (MISA) in China. Materials and Methods: MISA was a randomized controlled study conducted at eight level III neonatal intensive care units (NICUs) in China. Spontaneously breathing infants born at 25+0 to 31+6 weeks' gestation who progressively developed respiratory distress during the first 6 h after birth were randomly assigned to receive MISA or endotracheal intubation surfactant administration (EISA). The primary outcome was the difference in the morbidity of BPD between two groups of infants with MISA and EISA at 36 weeks corrected gestational age. Results: Demographic and clinical characteristics of the 151 infants in the MISA group were similar to the 147 infants in the EISA group. The comparison showed no clear benefits in the MISA group in the incidence of BPD, while infants from the EISA group had higher rates of patent ductus arteriosus (PDA) (60.5 vs. 41.1%, p = 0.001). The duration of surfactant infusion and the total time of surfactant administration in the MISA group were significantly longer than in the EISA group. A slightly increased heart rate was noted 1 h post surfactant administration in the EISA group. In subgroup analysis, the comparison of 51 smaller (<30 weeks) preterm infants, named MISAs (n = 31) and EISAs (n = 20), showed a significant reduction of BPD (29.0 vs. 70.0%, p = 0.004) and PDA (29.0 vs. 65.0%, p = 0.011). In the subgroup analysis of blood gas, arterial oxygen saturation (SaO₂) value at 1 and 12 h and partial pressure of arterial oxygen (PaO₂) at 12 h were all higher in the EISA group compared to the MISA group. Conclusion: MISA had no clear benefit on the incidence of BPD, but it was related to a reduction in PDA. It is an appropriate therapy for spontaneous breathing in infants with extremely low birth weight and NRDS.

Optimal Ventilation and Surfactant Therapy in Very-Low-Birth-Weight Infants in Resource-Restricted Regions

In resource-restricted regions, respiratory distress syndrome (RDS) data are often underreported, making the determination of effective interventions and their outcome difficult. The combination of oxygen, nasal continuous positive airway pressure (CPAP) and surfactant therapy has the potential to prevent 42% of RDS-related deaths in sub-Saharan Africa, despite the financial implications. This article provides a brief overview on the status of RDS management, mainly nasal CPAP and surfactant therapy in very-low-birth-weight infants, in resource-restricted regions of sub-Saharan Africa. Data from the public health sector, as compared to the private health sector, of the Western Cape province, South Africa, are used to illustrate what RDS management strategies are able to accomplish in a resource-restricted region. Upscaling of all components (antenatal care, antenatal corticosteroids, prevention of hypothermia and RDS management strategies) are required to decrease premature infant mortality rates in resource-restricted areas.

Surfactant therapy in premature babies: SurE or InSurE

BACKGROUND

Preterm infants with respiratory distress syndrome (RDS) requiring surfactant therapy have been traditionally receiving surfactant by intubation surfactant and extubation technique (InSurE), which comprises of tracheal intubation, surfactant administration, and extubation. However, more recently noninvasive methods like least invasive surfactant therapy or minimally invasive surfactant therapy have been reported to be successful. These methods, avoid intubation thus minimize airway trauma and avoid barotrauma. The primary aim of this randomized trial was to compare the need for mechanical ventilation (MV) between the administration of surfactant via a thin catheter during spontaneous breathing and the InSurE technique.

METHODS

Preterm infant's ≤34 weeks with RDS requiring continuous positive airway pressure (CPAP) within 6 hours of life were prospectively randomized to receive early surfactant either by SurE (surfactant without endotracheal tube intubation) or InSurE technique. The need for MV within the first 72 hours and other related outcomes were analyzed between the two groups.

RESULTS

One hundred seventy-five infants in each group were analyzed. The need for MV in the first 72 hours of life was significantly lower in the SurE group compared to the InSurE group (19% vs 40%, P < .01). Similarly, duration of oxygen therapy and hospital stay were significantly shorter in the SurE group. Furthermore, bronchopulmonary dysplasia (BPD) rate was significantly lower among the infants administered surfactant by the SurE technique.

CONCLUSION

In preterm neonates with RDS who are stabilized on CPAP, the SurE technique for surfactant delivery results in the reduced need for MV and also may decrease the rate of BPD in some vulnerable subpopulations.

The influence of the technique of surfactant administration (LISA vs INSURE) on the outcomes of respiratory distress syndrome treatment in preterm infants

OBJECTIVE

Intratracheal administration of exogenous surfactant is a well-established therapy for respiratory distress syndrome in preterm infants. The two preferred methods for respiratory support in neonates that contribute to limiting the risk of lung damage associated with mechanical ventilation include nCPAP and non-invasive ventilation. The increasing popularity of surfactant administration techniques is due to the fact they reduce the time of mechanical ventilation until this medication is administered. In some cases a short period of mechanical ventilation follows (INSURE: INtubation-SURfactant-Extubation). There are also methods that make it possible to completely avoid intubation and help maintain spontaneous breathing during surfactant administration (LISA: Less Invasive Surfactant Administration, MIST: Minimal Invasive Surfactant Therapy). Aim: To analyze treatment outcomes in preterm infants who suffer from respiratory distress syndrome and require exogenous surfactant administration depending on the technique used: LISA vs INSURE.

PATIENTS AND METHODS

Material and methods: The present retrospective analysis included 129 infants born at a gestational age of between 24 and 33 weeks who were hospitalized in the Neonatology Department in the years 2014-2016, were administered surfactant and remained on non-invasive ventilation. All the subjects received only proractant alfa. Both study groups: LISA (n=83) and INSURE (n=46) were analyzed in terms of respiratory distress treatment outcomes and the presence of complications of prematurity.

RESULTS

Results: There were no significant differences in patient characteristics between the two study groups (LISA vs INSURE: mean birth body weight was 1210 g vs 1275 g, respectively; mean gestational age at birth was 30 weeks vs 29 6/7 weeks, respectively). The comparison of respiratory support method and FiO2 concentration within the first 72 hours after surfactant administration showed no significant differences between the groups. Similarly, respiratory outcomes did not significantly differ between the LISA and INSURE groups and were: the need for intubation ⎼ 42.2% vs 32.6%, p=0.201, duration of mechanical ventilation - median days 0 vs 0, p=0.377, duration of nCPAP - median days 5 vs 5, p=0.379, duration of oxygen supplementation - median days 1 vs 1, p=0.555, and the incidence of bronchopulmonary dysplasia - 28.9% vs 23.9%, p=0.506. Also, the incidence of complications was similar in both study groups.

CONCLUSION

Conclusions: Our retrospective analysis of preliminary outcomes of surfactant administration involving the use of the LISA technique showed no statistically significant differences as compared with the INSURE method. The randomized, prospective study that is currently being conducted at our Neonatology Department and includes biochemical markers of lung damage, will bring more objective data on the safety and effectiveness of both surfactant administration techniques (LISA vs INSURE).

Long-term outcomes of preterm infants treated with less invasive surfactant technique (LISA)

OBJECTIVE

The aim of this study is to compare the clinical outcomes at 24 months postmenstrual age of two populations receiving beractant replacement therapy using less invasive surfactant administration (LISA) versus intubation, administration of surfactant, and early extubation (INSURE). Hospital admission requirements, psychomotor development, and respiratory and neurological outcomes were studied.

STUDY DESIGN

This was a single-center, retrospective, and descriptive study with a sample of 60 patients (30 for each group) on nasal continuous positive airway pressure during the first 3 days of life, requiring surfactant administration.

RESULTS

We found no significant differences between both groups on psychomotor development and respiratory and neurological outcomes.

CONCLUSION

Compared to INSURE technique, the administration of surfactant by LISA is feasible and safe and reduces invasive mechanical ventilation exposure with no differences in the follow-up neurodevelopmental and respiratory outcomes at 24 postmenstrual age.

The use of less invasive surfactant administration (LISA) in the United States with review of the literature

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.

High-volume surfactant administration using a minimally invasive technique: Experience from a Canadian Neonatal Intensive Care Unit

Background

Surfactant delivery via a thin endotracheal catheter during spontaneous breathing, a technique called minimally invasive surfactant therapy (MIST), is an alternative to intubation and surfactant administration. There is paucity of data regarding the administration of high-volume surfactant using this technique.

Methods

We conducted a retrospective cohort study to review the safety, efficacy, and procedural details pertaining to the delivery of 5 mL/kg of BLES® via MIST approach. In 2016, our centre initiated a practice change allowing the use of MIST as an alternative method of surfactant delivery in infants born at ≥28 weeks and/or with a birth weight ≥ 1,000 g with respiratory distress syndrome. In this study, we identified all neonates who received surfactant via MIST between May 1, 2016 and July 30, 2018 and collected relevant procedural data.

Results

Since this practice change, MIST technique was attempted in 43 neonates with successful instillation of surfactant in 41 (95.3%) of the neonates. Intubation and positive pressure ventilation was avoided in 35 neonates (85.3%). No serious adverse effect was noted.

Conclusions

Our study reports successful use of higher volume surfactant via MIST. This should encourage other similar centres to consider this technique, in order to avoid unnecessary intubation and positive pressure ventilation.

Should Minimally Invasive Surfactant Therapy be a Must in Neonatal Intensive Care Units? Pilot Report of Initial Cases in Dubai

Minimally invasive surfactant therapy (MIST) in neonates without intubation has in recent times become an accepted standard in the neonatal intensive care units (NICU) especially in Europe. We have adapted this novel technique in our clinical practice in the neonatal intensive care units in Dubai since 2018. Herein we report the successful outcome of implementation of this technique in three of our neonates of gestation/weight, 28/1.03 kg, 34/2.0 kg and 28/1.18 kg respectively in our NICU in Dubai, United Arab Emirates.

Sustained lung inflation at birth via short binasal prong in very low birth weight preterm infants: A retrospective study

BACKGROUND AND OBJECTIVES

It is believed, that sustained lung inflation (SLI) at birth in preterm infants reduces the need for mechanical ventilation (MV) and improves respiratory outcomes. The aim of this study was to compare need for MV in preterm infants at high risk for respiratory distress syndrome (RDS) after prophylactic SLI via short binasal prongs at birth combined with early nasal continuous positive airway pressure (nCPAP) versus nCPAP alone.

METHODS

Medical records of infants born at 26^0/7 to 29^6/7 weeks gestation through 2015 and 2017 were retrospectively assessed. Infants who get sustained inflations at 25 cmH₂ O pressure for 15 s following delivery via binasal short prongs comprised the study group. Gestational age matched infants who was supported solely with nCPAP (6 cmH₂ O PEEP) comprised the control group. Early rescue surfactant (200 mg/kg poractant alfa) was delivered using the less invasive surfactant administration technique in infants with established RDS.

RESULTS

A total of 215 infants were analyzed. Fewer infants in the SLI group required MV within the first 72 h of life compared to the control group (25.7% vs 56.9%, P < 0.001). In multiple logistic regression analysis, SLI emerged as an independent factor for reduced MV need. Bronchopulmonary dysplasia (BPD) incidence including mild BPD was significantly lower in the SLI group (31.9% vs 48%, P = 0.01); however, moderate and severe BPD rates did not reach to a statistical significance (11.5% vs 20.6%, P = 0.06).

CONCLUSION

Prophylactic SLI maneuver at birth for preterm infants with impending RDS reduces the need for MV with no adverse effects.

Less invasive surfactant administration and complications of preterm birth

In a large cohort study of the German Neonatal Network (GNN) we aimed to evaluate whether less invasive surfactant administration (LISA) strategy is associated with complications of preterm birth. Within the observational period n = 7533 very-low-birth-weight infants (VLBWI) with gestational age 22 0/7 to 28 6/7 weeks were enrolled in GNN; n = 1214 VLBWI never received surfactant, n = 2624 VLBWI were treated according to LISA procedure, n = 3695 VLBWI had surfactant via endotracheal tube (ETT). LISA was associated with a reduced risk for adverse outcome measures including mortality [odds ratio (OR) 0.66 (95% CI: 0.51-0.84), p < 0.001] bronchopulmonary dysplasia [BPD; OR 0.55 (95% CI: 0.49-0.62), p < 0.001], intracerebral hemorrhage (ICH) grade II-IV [OR 0.55 (95% CI: 0.48-0.64), p < 0.001] and retinopathy of prematurity [ROP; OR 0.62 (95% CI: 0.45-0.85), p < 0.001]. Notably, LISA was associated with an increased risk for focal intestinal perforation [FIP; OR 1.49 (95% CI: 1.14-1.95), p = 0.002]. The differences in FIP rates were primarily observed in VLBWI born <26 weeks (LISA: 10.0 vs. ETT: 7.4%, p = 0.029). Our observational data confirm that LISA is associated with improved outcome. In infants <26 weeks we noted an increased risk for FIP. Future randomized controlled trials including LISA need to integrate safety analyses for this particular subgroup.

Clinical, technological, and economic issues associated with developing new lung surfactant therapeutics

Discovery of lung surfactant deficiency as a main cause of neonatal respiratory distress syndrome (NRDS) has influenced a steep increase in lung surfactant research. Although this has yielded impactful scientific discoveries, much of the basic research on lung surfactants has failed to translate into clinical practices. This is attributed to insufficient information covering the entire lung surfactant ecosystem, from the basic science to economics surrounding the development and clinical practices. In this manuscript, developments related to improving therapeutic lung surfactant as well as the degree of unmet need are analyzed from both technical and economic perspectives. Two potential opportunities are emphasized: (1) aerosolized lung surfactants to treat NRDS infants, and (2) synthetic lung surfactants for acute respiratory distress syndrome (ARDS) patients. Each has a modestly projected US market size of $120 million and $4 billion, well enough to make up for the high development costs associated with investigational drug development. Both opportunities have been pursued in the past, but to date these attempts have met with no success mainly due to technical limitations. With the recent advancements in both fields, technology improvements have created opportunities to solve both decades-old problems.