Impact of surfactant administration through a thin catheter in the delivery room: A quality control chart analysis coupled with a propensity score matched cohort study in preterm infants

Developing a Respiratory Quality Improvement Program to Prevent and Treat Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit

Improvements in respiratory care have resulted in improved outcomes for preterm infants over the past three decades. To target the multifactorial nature of neonatal lung diseases, neonatal intensive care units (NICUs) should consider developing comprehensive respiratory quality improvement programs that address all drivers of neonatal respiratory disease. This article presents a potential framework for developing a quality improvement program to prevent bronchopulmonary dysplasia in the NICU. Drawing on available research and quality improvement reports, the authors discuss key components, measures, drivers, and interventions that should be considered when building a respiratory quality improvement program devoted to preventing and treating bronchopulmonary dysplasia.

Clinical impact of less invasive surfactant administration using video laryngoscopy in extremely preterm infants

BACKGROUND

Examine the real-world clinical impact of adopting less invasive surfactant administration (LISA) as the primary surfactant administration method in extremely preterm infants.

METHODS

Single-center pre-post cohort study conducted over a 4-year period comparing outcomes of spontaneously breathing inborn infants 24⁺⁰-28⁺⁶ weeks gestational age (GA) receiving surfactant via endotracheal tube (pre-cohort, n = 154) or LISA via thin catheter (post-cohort, n = 70). Primary outcome was need for invasive mechanical ventilation (IMV, ≥2 h) ≤72 h of age. Secondary outcomes were a composite of mortality, bronchopulmonary dysplasia, intraventricular hemorrhage ≥grade 3 or necrotizing enterocolitis, and its individual components. Groups were compared using propensity score methods, including covariates: GA, birth weight, sex, small for GA, SNAP II ≥20, premature rupture of membranes, maternal hypertension/diabetes, and C-section.

RESULTS

GA and birth weight were 27.1 (26, 28.1) weeks and 914 (230) g, and 27.1 (26.1, 28.1) weeks and 920 (236) g for pre- and post-cohorts, respectively. Pre-cohort had higher C-section rates, (67% vs. 51%, p = 0.03). After adjustment for covariates, LISA was associated with reduced IMV exposure [AOR (95% CI) 0.07 (0.04, 0.11)], lower odds of the composite clinical outcome [0.49 (0.33, 0.73)], and most of its individual components.

CONCLUSION

Real-world experience favors LISA as the primary method in extremely preterm infants with established spontaneous respiration.

IMPACT

Less invasive surfactant administration (LISA) is associated with a reduction in respiratory morbidity, but real-world data of routine use among extremely preterm infants are limited. LISA is associated with reduced frequency of exposure to and duration of IMV in both ≤72 h after birth and during hospital stay. LISA is associated with a reduction in mortality, and most other major morbidities including bronchopulmonary dysplasia, and interventricular hemorrhage. Data from a large North American center providing real-world clinical outcomes following LISA as the primary method of surfactant administration.

Quality improvement for neonatal resuscitation and delivery room care

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

New modes of surfactant delivery

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.

Quality Improvement for Neonatal Resuscitation and Delivery Room Care

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

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.

Comparative efficacy of methods for surfactant administration: a network meta-analysis

OBJECTIVES

To compare surfactant administration via thin catheters, laryngeal mask, nebulisation, pharyngeal instillation, intubation and surfactant administration followed by immediate extubation (InSurE) and no surfactant administration.

DESIGN

Network meta-analysis.

SETTING

Medline, Scopus, CENTRAL, Web of Science, Google-scholar and Clinicaltrials.gov databases were systematically searched from inception to 15 February 2020.

PATIENTS

Preterm neonates with respiratory distress syndrome.

INTERVENTIONS

Less invasive surfactant administration.

MAIN OUTCOME MEASURES

The primary outcomes were mortality, mechanical ventilation and bronchopulmonary dysplasia.

RESULTS

Overall, 16 randomised controlled trials (RCTs) and 20 observational studies were included (N=13 234). For the InSurE group, the median risk of mortality, mechanical ventilation and bronchopulmonary dysplasia were 7.8%, 42.1% and 10%, respectively. Compared with InSurE, administration via thin catheter was associated with significantly lower rates of mortality (OR: 0.64, 95% CI: 0.54 to 0.76), mechanical ventilation (OR: 0.43, 95% CI: 0.29 to 0.63), bronchopulmonary dysplasia (OR: 0.57, 95% CI: 0.44 to 0.73), periventricular leukomalacia (OR: 0.66, 95% CI: 0.53 to 0.82) with moderate quality of evidence and necrotising enterocolitis (OR: 0.67, 95% CI: 0.41 to 0.9, low quality of evidence). No significant differences were observed by comparing InSurE with administration via laryngeal mask, nebulisation or pharyngeal instillation. In RCTs, thin catheter administration lowered the rates of mechanical ventilation (OR: 0.39, 95% CI: 0.26 to 0.60) but not the incidence of the remaining outcomes.

CONCLUSION

Among preterm infants, surfactant administration via thin catheters was associated with lower likelihood of mortality, need for mechanical ventilation and bronchopulmonary dysplasia compared with InSurE. Further research is needed to reach firm conclusions about the efficacy of alternative minimally invasive techniques of surfactant administration.

Using a Bundle Approach to Prevent Bronchopulmonary Dysplasia in Very Premature Infants

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that affects about 20% to 30% of infants born at less than 32 weeks of gestation. Diagnosis is made if an infant requires oxygen therapy at 36 weeks' corrected age or discharge home. BPD increases healthcare costs, mortality rates, and risk of long-term respiratory complications and neurosensory impairments.

PURPOSE

The purpose of this project was to improve rates and severity of BPD in very premature infants without increasing length of hospitalization.

METHODS

A multidisciplinary care bundle involving respiratory support and medication use guidelines was created and implemented along with a noninvasive ventilation algorithm for the delivery room. This bundle was utilized for infants born in a Midwest hospital in 2019 at less than 32 weeks of gestation and the outcomes were compared to infants born in 2017.

RESULTS

Implementation of this BPD prevention bundle contributed to a decrease in the use of oxygen at discharge for very premature infants without increasing length of hospitalization. Use of invasive mechanical ventilation and the severity of BPD also decreased.

IMPLICATIONS FOR PRACTICE AND RESEARCH

A multidisciplinary bundle approach can be successful in decreasing the rates of BPD for very premature infants. Future quality improvement projects should focus on improving delivery room management of extremely premature infants, with an emphasis on optimizing noninvasive ventilation strategies. More research is still needed to determine the best method of ventilation for premature infants and the best utilization of surfactant and corticosteroids.

Introducing Less-Invasive Surfactant Administration into a Level IV NICU: A Quality Improvement Initiative

Less-invasive surfactant administration (LISA), a newer technique of delivering surfactant via a thin catheter, avoids mechanical ventilation. LISA has been widely adopted in Europe but less so in the US. Our goal was to increase the percentage of surfactant delivered via LISA from 0% to 51% by 12/2020. Project planning and literature review started 12/2019, and included a standardized equipment kit and simulation training sessions. We began Plan–Do–Study–Act (PDSA) cycles in 6/2020. Initial exclusions for LISA were gestational age (GA) <28 weeks (w) or ≥36 w, intubation in the delivery room, or PCO2 >70 if known; GA exclusion is now <25 w. From 6 to 12/2020, 97 patients received surfactant, 35 (36%) via LISA. When non-LISA-eligible patients were excluded, 35/42 (83%) received LISA successfully. There were only 2/37 patients for whom LISA was not able to be performed. Three LISA infants required mechanical ventilation in the first week of life. Sedation remained an initial challenge but improved when sucrose was used routinely. LISA was safely and successfully introduced in our NICU.

Respiratory distress management in moderate and late preterm infants: The NEOBS Study

OBJECTIVE

To investigate the characteristics and management of respiratory failure (RF) in moderate-to-late preterm infants.

METHODS

NEOBS was a prospective, multicenter, observational study conducted in 46 neonatal intensive care units caring for preterm infants (30+^0/7 to 36+^6/7 weeks of gestation [WG]) in France in 2018. The cohort was stratified into two groups: 30-33 WG (group 1) and 34-36 WG (group 2). Infants with early neonatal RF were included and the outcomes assessed were maternal, pregnancy, and delivery characteristics and how RF was managed.

RESULTS

Of the 560 infants analyzed, 279 were in group 1 and 281 were in group 2. Most pregnancies were singleton (64.1%), and 67.4% of women received prenatal corticosteroids (mostly two doses). Infants were delivered by cesarean section in 59.6% of cases; 91.7% of the infants had an Apgar score ≥7 at 5min. More than 90% of infants were hospitalized post-birth (median duration, 36 and 15 days for groups 1 and 2, respectively). Medical intervention was required for 95.7% and 90.4% of the infants in group 1 and group 2, respectively, and included noninvasive ventilation (continuous positive airway pressure [CPAP]: 88.5% and 82.9%; high-flow nasal cannula: 55.0% and 44.7%, or other) and invasive ventilation (19.7% and 13.2%). The two main diagnoses of RF were respiratory distress syndrome (39.8%) and transient tachypnea of the newborn (57.3%). Surfactant was administered to 22.5% of the infants, using the less invasive surfactant administration (LISA) method for 34.4% of the patients. In the overall population, 8.6% of the infants had respiratory and/or hemodynamic complications.

CONCLUSIONS

The NEOBS study demonstrated that CPAP was widely used in the delivery room and the LISA method was chosen for 34.4% of the surfactant administrations for the management of RF in moderate-to-late preterm infants. The incidence of RF-related complications was low.

Respiratory monitoring during less invasive surfactant administration in the delivery suite

BACKGROUND

On the neonatal unit less invasive surfactant administration (LISA) reduces BPD and the need for mechanical ventilation.

AIMS

To evaluate the feasibility of LISA in the delivery suite and to undertake respiratory function physiological monitoring before and after LISA.

STUDY DESIGN

A prospective, observational cohort study was undertaken. A LISA simulation training programme was delivered. Then, LISA was undertaken in infants with respiratory distress maintained on continuous positive airway pressure (CPAP) in the delivery suite using videolaryngoscopic guidance without sedation.

SUBJECTS

Thirty-eight infants with a median (IQR) gestational age of 31 + ⁵ weeks (30⁺³-33⁺⁴) and birth weight of 1.61 (1.42-1.90) kg had LISA in the delivery suite.

OUTCOME MEASURES

Adverse effects of LISA and whether LISA resulted in changes in tidal and minute volumes, end tidal carbon dioxide (EtCO₂) levels and the inspired oxygen concentration (FiO₂).

RESULTS

Respiratory function monitoring was available for 34 of the infants. LISA occurred at a median (IQR) interval of 18 (15-29) minutes after birth. The most common adverse events were desaturation (44.7%) and surfactant reflux (39.5%), both responded to either temporary suspension of LISA or slowing the speed of surfactant administration. Following LISA, there was a significant reduction in respiratory rate 2 min later (p < 0.001) and in the FiO₂ 2 h later (p < 0.001).

CONCLUSIONS

LISA is feasible in the delivery suite after appropriate training of staff. It can be undertaken without serious adverse effects and results in a reduction in respiratory distress and improvement in oxygenation.

A systematic review of reports of quality improvement for bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is the most common morbidity of preterm infants, and its incidence has not responded to research and intervention efforts to the same degree as other major morbidities associated with prematurity. The complexity of neonatal respiratory care as well as persistent inter-institutional variability in BPD rates suggest that BPD may be amenable to quality improvement (QI) efforts. We present a systematic review of QI for BPD in preterm infants. We identified 22 reports from single centers and seven from collaborative efforts published over the past two decades. In almost all of the reports, respiratory QI interventions successfully reduced BPD or other key respiratory measures, particularly for infants with birth weight over 1000 g. Several themes and lessons from existing reports may help inform future efforts in both research and QI to impact the burden of BPD.

Less invasive surfactant administration: best practices and unanswered questions

PURPOSE OF REVIEW

The purpose of this review is to describe current concepts in the field of Less Invasive Surfactant Administration (LISA). The use of continuous positive airway pressure (CPAP) has become standard for the treatment of premature infants with respiratory problems throughout the world. However, if CPAP fails, technologies like LISA are needed that can combine surfactant delivery and spontaneous breathing with the support of noninvasive modes of ventilation.

RECENT FINDINGS

LISA with thin catheters has been in use in Germany for more than 15 years. In the last 5 years, there was substantial interest in this method around the world. Randomized studies and recent metaanalyses indicate that the LISA technique helps to avoid mechanical ventilation especially in emerging respiratory distress syndrome (RDS). LISA is also associated with improved outcomes of preterm infants, specifically in the prevention of bronchopulmonary dysplasia (BPD) and intracranial hemorrhage (ICH). By now, a variety of different LISA catheters, devices and techniques have been described. However, most of the technologies are still connected with the unpleasant experience of laryngoscopy for the affected infants, so that the search for even less invasive techniques, for example, surfactant application by nebulization, goes on.

SUMMARY

Maintenance of spontaneous breathing with support by the LISA technique holds big promise in the care of preterm infants. Patient comfort and lower complication rates are strong arguments to further investigate and promote the LISA approach. Open questions include exact indications for different patient groups, the usefulness of devices/catheters that have recently been built for the LISA technique and -- perhaps most urgently -- the issue of analgesia/sedation during the procedure. Studies on long-term outcome after LISA are under way.