Surfactant administration via thin catheter during spontaneous breathing: randomized controlled trial

Evaluation of a respiratory care protocol including less invasive surfactant administration in preterm infants

BACKGROUND

Respiratory care protocol including less invasive śsurfactant administration (LISA) in ≤29 weeks' gestational age (GA) infants introduced in October 2018.

METHODS

Retrospective study of infants admitted on continuous positive airway pressure (CPAP) October 2018 to December 2021. Maternal and neonatal variables were compared between infants managed on CPAP with and without LISA. Infants who received LISA and subsequently required mechanical ventilation (MV) within 72 h of life (HOL) [LISA failure (LF)] were compared with those who required no MV [LISA success (LS)].

RESULTS

249 infants were admitted on CPAP, 5 were intubated prior to LISA, 143 required LISA and 101 remained on CPAP without surfactant. Of those receiving LISA, 108 were LS and 35 were LF. Compared to LS, LF infants were of lower GA and birth weight, required higher fractional inspired oxygen (FiO2), and CPAP level at birth, admission, one HOL, and an hour after LISA. Moreover, LF infants had higher mortality and morbidity. Together GA ≤ 25 weeks' and FiO2 ≥ 0.3 an hour after LISA best predicted LF.

CONCLUSIONS

Over 80% of infants admitted on CPAP avoided MV within 72 HOL. Early predictors of LF provide targets for future interventions to decrease need for MV in preterm infants.

IMPACT

Less invasive surfactant administration (LISA) decreases the need for mechanical ventilation (MV) and improves outcomes. However, some infants require MV within 72 h of life (HOL) despite LISA (LISA failure). Over 80% of ≤29 weeks' gestational age (GA) infants can be successfully managed on CPAP with or without surfactant in the first 72 HOL. A combination of factors including ≤25 weeks' GA and fraction of inspired oxygen ≥0.3 an hour after LISA predict LISA failure. Evaluation of a noninvasive respiratory support strategy including LISA provides targets for intervention to decrease need for MV in preterm infants.

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.

Noninvasive Ventilation

Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk of bronchopulmonary dysplasia and or mortality. Most commonly used NIV modes include nasal continuous positive airway pressure, bi-phasic modes, such as, bi-level positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula, noninvasive neurally adjusted ventilatory assist, and nasal high frequency ventilation are discussed in this review.

Minimal invasive surfactant therapy in preterm infants with respiratory distress syndrome: a single-center experience

BACKGROUND

Minimal invasive surfactant therapy (MIST) includes the tracheal instillation of surfactant via a thin catheter for the treatment of preterm infants with respiratory distress syndrome (RDS). We aimed to evaluate the impact of MIST compared to intubation, surfactant, extubation (INSURE) technique on respiratory outcomes.

METHODS

A prospectively recruited cohort of preterm infants ≤32 weeks with RDS was compared against a historical cohort of infants treated with INSURE. The primary outcome was the need for mechanical ventilation within 72 hours of age and secondary outcomes the overall need and duration of mechanical ventilation, the development of bronchopulmonary dysplasia, common morbidities, and survival.

RESULTS

Thirty-six infants treated with MIST of 29.1±2.2 weeks' gestation and 1219±238 g birthweight compared against 37 infants of 28.8±2.3 weeks' gestation and 1195±336 g birthweight treated with INSURE. A lower proportion of infants treated with MIST required mechanical ventilation within 72 hours of age compared to those treated with INSURE (11% compared 32%, P=0.042). However, no significant differences were noted regarding the overall intubation incidence, bronchopulmonary dysplasia, other morbidities, or survival.

CONCLUSIONS

In spontaneously breathing infants ≤32 weeks with RDS, the MIST technique was associated with a lower need for intubation within 72 hours of age, but otherwise with no significant differences regarding BPD or other neonatal morbidities.

Prophylactic Oropharyngeal Surfactant for Preterm Newborns at Birth: A Randomized Clinical Trial

Importance

Preterm newborns at risk of respiratory distress syndrome are supported with continuous positive airway pressure (CPAP). Many newborns worsen despite CPAP and are intubated for surfactant administration, an effective therapy for treatment of respiratory distress syndrome. Endotracheal intubation is associated with adverse effects. Pharyngeal administration of surfactant to preterm animals and humans has been reported as an alternative.

Objective

To assess whether giving prophylactic oropharyngeal surfactant to preterm newborns at birth would reduce the rate of intubation for respiratory failure.

Design, Setting, and Participants

This unblinded, parallel-group randomized clinical trial (Prophylactic Oropharyngeal Surfactant for Preterm Infants [POPART]) was conducted from December 17, 2017, to September 11, 2020, at 9 tertiary neonatal intensive care units in 6 European countries. Newborns born before 29 weeks of gestation without severe congenital anomalies, for whom intensive care was planned, were eligible for inclusion. The data were analyzed from July 27, 2022, to June 20, 2023.

Intervention

Newborns were randomly assigned to receive oropharyngeal surfactant at birth in addition to CPAP or CPAP alone. Randomization was stratified by center and gestational age (GA).

Main Outcomes and Measures

The primary outcome was intubation in the delivery room for bradycardia and/or apnea or in the neonatal intensive care unit for prespecified respiratory failure criteria within 120 hours of birth. Caregivers were not masked to group assignment.

Results

Among 251 participants (mean [SD] GA, 26 [1.5] weeks) who were well matched at study entry, 126 (69 [54.8%] male) with a mean (SD) birth weight of 858 (261) grams were assigned to the oropharyngeal surfactant group, and 125 (63 [50.4%] male) with a mean (SD) birth weight of 829 (253) grams were assigned to the control group. The proportion of newborns intubated within 120 hours was not different between the groups (80 [63.5%) in the oropharyngeal surfactant group and 81 [64.8%] in the control group; relative risk, 0.98 [95% CI, 0.81-1.18]). More newborns assigned to the oropharyngeal surfactant group were diagnosed with and treated for pneumothorax (21 [16.6%] vs 8 [6.4%]; P = .04).

Conclusions and Relevance

This randomized clinical trial found that administration of prophylactic oropharyngeal surfactant to newborns born before 29 weeks' GA did not reduce the rate of intubation in the first 120 hours of life. These findings suggest that administration of surfactant into the oropharynx immediately after birth in addition to CPAP should not be routinely used.

Trial Registration

EudraCT: 2016-004198-41.

A clinical study evaluating the combination of LISA and SNIPPV for the treatment of respiratory distress syndrome in preterm infants

To compare the therapeutic effect of less invasive surfactant administration (LISA) followed by synchronized nasal intermittent positive pressure ventilation (SNIPPV) and traditional intubate-Surfactant-Extubate (InSurE) strategy for the treatment of neonatal respiratory distress syndrome (NRDS). A single-center, non-randomized and single- blinded study Tertiary neonatal intensive care unit 89 infants enrolled were preterm with gestational age < 366/7 weeks and clinically diagnosed with neonatal RDS (NRDS) Interventions: 32 infants were assigned to the LISA + SNIPPV group and 57 infants to the InSurE + nCPAP group. No statistically significant differences were noted in the baseline characteristics of the enrolled infants. A lower proportion of infants developed BPD in the LISA + SNIPPV group compared to the InSurE + CPAP group [10 (31.25%) vs. 21 (36.84%), P > 0.05]; however, there was no statistically significant difference. The number needed to treat (NNT) with LISA + SNIPPV to prevent BPD development is 18. The mortality rate was not significant between our study arms [1 (3.13%) vs 2 (3.51%), P > 0.05]. There were no statistically significant differences in the durations (days) of MV [(12.18 ± 13.89) vs. (11.35 ± 11.61), P > 0.05], oxygen therapy [(35.03 ± 19.13) vs. (39.75 ± 17.91), P > 0.05] and re-intubation rates [(0.19 ± 0.40) vs. (0.21 ± 0.45), P > 0.05] between the two study groups. In terms of complications, the incidence of patent ductus arteriosus (PDA) [24 (75.00%) vs. 27 (47.37%), P < 0.05] was higher and a lower rate of disturbed liver function [1 (3.23%) vs. 19 (33.33%), P < 0.05] were observed in the LISA + SNIPPV group. Acid-base imbalances were reportedly significantly higher in the InSurE group (P < 0.05). No significant differences in other complications were noted. In the interventional group, FiO2 requirements were significantly lower up until the 3rd week of treatment [FiO2 at day 0, (30.75 ± 4.78) vs. (34.66 ± 9.83), P < 0.05; FiO2 at day 21, (25.32 ± 3.74) vs. (29.11 ± 8.17), P < 0.05], as was RSS on days 2 [(0.77 ± 0.38) vs. (1.94 ± 0.75), P < 0.05] and 3 [(0.66 ± 0.33) vs. (1.89 ± 0.82), P < 0.05] after treatment. Additionally, infants in the standard group had a significantly prolonged hospital stay (days) [(45.97 ± 16.93) vs. (54.40 ± 16.26), P < 0.05]. The combination of LISA and SNIPPV for NRDS can potentially lower the rate of BPD, FiO2 demand and shorten the length of hospitalization.

Less invasive surfactant administration versus intubation-surfactant-extubation in the treatment of neonatal respiratory distress syndrome: a systematic review and meta-analyses

OBJECTIVES

To compare LISA with INSURE technique for surfactant administration in preterm with gestational age (GA) < 36 weeks with RDS in respect to the incidence of pneumothorax, bronchopulmonary dysplasia (BPD), need for mechanical ventilation (MV), regional cerebral oxygen saturation (rSO2), peri‑intraventricular hemorrhage (PIVH) and mortality.

METHODS

A systematic search in PubMed, Embase, Lilacs, CINAHL, SciELO databases, Brazilian Registry of Randomized Clinical Trials (ReBEC), Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. RCTs evaluating the effects of the LISA technique versus INSURE in preterm infants with gestational age < 36 weeks and that had as outcomes evaluation of the rates of pneumothorax, BPD, need for MV, rSO2, PIVH, and mortality were included in the meta-analysis. Random effects and hazard ratio models were used to combine all study results. Inter-study heterogeneity was assessed using Cochrane Q statistics and Higgin's I2 statistics.

RESULTS

Sixteen RCTs published between 2012 and 2020 met the inclusion criteria, a total of 1,944 preterms. Eleven studies showed a shorter duration of MV and CPAP in the LISA group than in INSURE group. Two studies evaluated rSO2 and suggested that LISA and INSURE transiently affect brain autoregulation during surfactant administration. INSURE group had a higher risk for MV in the first 72 h of life, pneumothorax, PIVH and mortality in comparison to the LISA group.

CONCLUSION

This systematic review and meta-analyses provided evidence for the benefits of the LISA technique in the treatment of RDS, decreasing CPAP time, need for MV, BPD, pneumothorax, PIVH, and mortality when compared to INSURE.

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.

Less Invasive Surfactant Administration: A Viewpoint

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..

Surfactant administration methods for premature newborns: LISA vs. INSURE comparative analysis

INTRODUCTION

Respiratory Distress Syndrome (RDS) is the most common respiratory disorder among premature infants. The use of surfactant has significantly reduced respiratory complications and mortality. There are two conventional methods for administering surfactant: Intubate-Surfactant-Extubate (INSURE) and Less Invasive Surfactant Administration (LISA). This study aims to compare the effects of surfactant administration using these two methods on the treatment outcomes of premature newborns.

MATERIALS AND METHODS

In this retrospective cohort study, we included 100 premature newborns with RDS and spontaneous breathing who were admitted to the Neonatal Intensive Care Unit of Besat Hospital in Sanandaj city in 2021. Exclusion criteria comprised congenital anomalies and the needing for intubation for resuscitation at birth. The outcomes of epmericaly trated with two methods were compared: the LISA (50 neonates) and the INSURE (50 neonates). Our interesting outcomes were needing for mechanical ventilation, duration of ventilation, pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia. Finally, we entered the data into STATA-14 statistical software and analyzed it using chi-square and t-tests.

RESULTS

In this study, 69% of the neonates were boys. The LISA group exhibited significantly lower rates of need for mechanical ventilation (P = 0.003) and ventilation duration (P < 0.001) compared to the INSURE group. Conversely, there were no significant differences between the two groups (P > 0.05) in terms of pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia rates.

CONCLUSION

The results of this study suggest that the LISA method is a safe and non-invasive approach for surfactant administration. Notably, it resulted in a reduced need for mechanical ventilation and decreased ventilation duration compared to the INSURE method.

Timing of surfactant treatment in respiratory distress syndrome

The introduction of exogenous surfactant in the 1980s has resulted in an improved survival of very preterm infants with respiratory distress syndrome (RDS). Randomized controlled trials conducted before 2000 have shown that the magnitude of this beneficial effect strongly depends on the timing of surfactant treatment, i.e. the earlier surfactant is administered after birth the better. However, the initial mode of respiratory support in infants with RDS has changed dramatically over the last decades, moving from invasive to non-invasive support. Furthermore, new, less invasive techniques to administer surfactant have been introduced to match this non-invasive approach. This review summarizes the evidence on how these practice changes impacted the effect of surfactant timing on mortality and morbidity in preterm infants with RDS.

Alternative routes of surfactant application - An update

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.

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.

Effect of Nasal Continuous Airway Pressure With and Without Surfactant Administration for the Treatment of Respiratory Distress Syndrome in Preterm Neonates

Background Neonatal respiratory distress syndrome is a common cause of respiratory distress in newborns, often resulting from a lack of surfactant production or premature lung breakdown. The objective of this study was to compare the effect of nasal continuous airway pressure with and without surfactant administration for the treatment of respiratory distress syndrome in preterm neonates. Methodology A comparative analytical study was conducted on 100 neonates (group A continuous positive airway pressure (CPAP) with surfactant = 50 vs. group B CPAP only= 50 ). The group was allocated to the patient according to sequence. In group A, the neonates were given surfactant by the INSURE (intubation, surfactant, extubation) technique via an endotracheal tube with a single dose of 100 mg/kg/dose within the first hours of life followed by CPAP. In group B, the neonates were given only CPAP after birth. At follow-up after 24 hours, pH, pCO2, pO2, positive end-expiratory pressure (PEEP), and FiO2 were documented. All information was recorded on a predesigned questionnaire and results were subjected to statistical analysis to determine the significance of observed differences. Collected data were entered and analyzed using SPSS version 22 (IBM Corp., Armonk, NY, USA). Both groups were compared for mean pH, pCO2, pO2, PEEP, and FiO2 using an independent-sample t-test and effectiveness using a chi-square test. A significant difference was considered when the p-value was ≤0.05. Results Group A had a mean age of 4.84 ± 0.95 hours, while group B had a mean age of 5.5 ± 1.26 hours (p = 0.04). Gender distribution was similar in both groups, with 46.0% males and 54.0% females in group A, and 48.0% males and 52.0% females in group B (p = 0.841). Regarding post-treatment blood gas analysis, group A had a mean pH of 7.30 ± 0.05, and group B had a mean pH of 7.302 ± 0.07. While there was no significant difference in pO2 levels (p = 0.38), there was a substantial difference in pCO2 levels, with group A at 38.26 ± 4.35 and group B at 35.45 ± 4.36 (p = 0.02).CPAP parameters also showed a statistically significant difference in PEEP pCO2, with group A at 4.5 ± 0.73 and group B at 4.16 ± 0.37 (p = 0.004). After treatment, group A exhibited significant improvements in blood gas analysis and CPAP parameters compared to group B. Conclusions The study revealed that both CPAP with and without surfactant treatment effectively treat respiratory distress syndrome in preterm infants, with both being safe, effective, secure, and reducing side effects. However, CPAP treatment without surfactant is a non-invasive and cost-effective option.

Comparison of mortality and short-term outcomes between classic, intubation-surfactant-extubation, and less invasive surfactant administration methods of surfactant replacement therapy

Background

Intubation-Surfactant-Extubation (InSurE) and less invasive surfactant administration (LISA) are alternative surfactant replacement therapy methods for reducing the complications associated with invasive mechanical ventilation. This study aimed to compare the Classic, InSurE, and LISA methods in Very-Low-Birth-Weight infants (VLBWIs) in South Korea.

Methods

The Korean Neonatal Network (KNN) enrolled VLBWIs born between January 1, 2019 and December 31, 2020. They were analyzed retrospectively to compare the duration of respiratory support, length of hospitalization, mortality, and short-term outcomes of the three groups.

Results

The duration of invasive ventilator support was shorter in the following order: InSurE (3.99 ± 11.93 days), LISA (8.78 ± 29.32 days), and the Classic group (22.36 ± 29.94 days) (p = 0.014, p < 0.01) and InSurE had the shortest hospitalization (64.91 ± 24.07 days, p < 0.05) although the results couldn't adjust for confounding factor because of irregular distribution. InSurE had the lower risk of intraventricular hemorrhage (IVH) grade II-IV [odds ratio (OR) 0.524 [95% confidence interval (CI): 0.287-0.956], p = 0.035] than in the Classic group. Mortality was lower in the InSurE [OR 0.377 (95% CI: 0.146-0.978), p = 0.045] and LISA [OR 0.296 (95% CI: 0.102-0.862), p = 0.026] groups than in the Classic group. There was a reduced risk of moderate to severe bronchopulmonary dysplasia (BPD) [OR 0.691 (95% CI: 0.479-0.998, p = 0.049), OR 0.544 (95% CI: 0.355-0.831, p = 0.005), respectively], pulmonary hypertension [OR 0.350 (95% CI: 0.150-0.817, p = 0.015), OR 0.276 (95% CI: 0.107-0.713, p = 0.008), respectively], periventricular leukomalacia (PVL) [OR 0.382 (95% CI: 0.187-0.780, p = 0.008), OR 0.246 (95% CI: 0.096-0.627, p = 0.003), respectively], and patent ductus arteriosus (PDA) with treatment [OR 0.628 (95% CI: 0.454-0.868, p = 0.005), OR 0.467 (95% CI: 0.313-0.696, p < 0.001) respectively] in the InSurE and LISA groups compared to the Classic group.

Conclusion

InSurE showed the lowest duration of invasive ventilator support, length of hospitalization. InSurE and LISA exhibited reduced mortality and decreased risks of moderate to severe BPD, pulmonary hypertension, PVL, and PDA with treatment compared to the Classic group.

Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis

Background

The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS.

Methods

The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life.

Findings

58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) <0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low.

Interpretation

Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound.

Funding

None.

Purpose Built Catheters for Minimally Invasive Surfactant Therapy: Experience from a Canadian Tertiary Level Neonatal Intensive Care Unit

Background

Minimally invasive surfactant therapy (MIST), a method of surfactant delivery via a thin catheter during spontaneous breathing, is an increasingly popular alternative to intubation and surfactant administration. Recently, purpose-built catheters for MIST received regulatory approval in Canada and became available for use. However, procedural success and user experience with such catheters have not been described.

Methods

This retrospective cohort study included neonates who received MIST using purpose-built catheters between January 1, 2021, and March 31, 2022. Two types of purpose-built catheters were used in this period - SurfCath™ and BLEScath™. Procedural success, number of attempts, and adverse events in neonates receiving MIST via the two catheters were compared using chi-square or Fisher's tests. User experience was described using an ease-of-use scale.

Results

Thirty-seven neonates met eligibility criteria; 22 received MIST via SurfCath™, whereas 15 received MIST via BLEScath™. Success rates were 91% in SurfCath™ and 93% in BLEScath™ (P> 0.994). Failed attempts were lower in SurfCath™ (23%) in comparison to BLEScath™ (33%), but the difference was not statistically significant (P=0.708). Among operators, 90% found SurfCath™ very easy/relatively easy to use compared to 43% of users reflecting the same degree of use with BLEScath™ (P=.021). There was no difference in adverse events.

Conclusion

This is the first study in Canada to report MIST with purpose-built catheters. Overall, the success rate was equally high with both catheters. Users subjectively reported higher ease of use with SurfCath™. Commercially available purpose-built catheters should facilitate universal adaptation of the MIST method.

Prevention of Chronic Morbidities in Extremely Premature Newborns with LISA-nCPAP Respiratory Therapy and Adjuvant Perinatal Strategies

Less invasive surfactant administration techniques, together with nasal continuous airway pressure (LISA-nCPAP) ventilation, an emerging noninvasive ventilation (NIV) technique in neonatology, are gaining more significance, even in extremely premature newborns (ELBW), under 27 weeks of gestational age. In this review, studies on LISA-nCPAP are compiled with an emphasis on short- and long-term morbidities associated with prematurity. Several perinatal preventative and therapeutic investigations are also discussed in order to start integrated therapies as numerous organ-saving techniques in addition to lung-protective ventilations. Two thirds of immature newborns can start their lives on NIV, and one third of them never need mechanical ventilation. With adjuvant intervention, these ratios are expected to be increased, resulting in better outcomes. Optimized cardiopulmonary transition, especially physiologic cord clamping, could have an additively beneficial effect on patient outcomes gained from NIV. Organ development and angiogenesis are strictly linked not only in the immature lung and retina, but also possibly in the kidney, and optimized interventions using angiogenic growth factors could lead to better morbidity-free survival. Corticosteroids, caffeine, insulin, thyroid hormones, antioxidants, N-acetylcysteine, and, moreover, the immunomodulatory components of mother's milk are also discussed as adjuvant treatments, since immature newborns deserve more complex neonatal interventions.

Changes in ventilation modes in the last decade and their impact on the prevalence of bronchopulmonary dysplasia in preterm infants

BACKGROUND

Less invasive forms of ventilation have evolved aiming to decrease bronchopulmonary dysplasia (BPD) morbidity. It is unclear whether changes in ventilation practices have been associated with improvements in respiratory outcomes.

OBJECTIVE

To examine the changes in ventilation modes in preterm neonates between two periods during the last decade and their impact on BPD prevalence.

METHODS

A retrospective chart review of very low birth weight infants and those born at less than 32 weeks gestation hospitalized during two periods: the years 2012-2013 and 2018-2019. The primary outcome was the prevalence of BPD. Study variables included the mode and duration of ventilation, duration of oxygen need, and perinatal clinical parameters.

RESULTS

Four hundred eighty-one infants were enrolled. Between the two study periods, a significant increase was observed in invasive (33%-47%, p = 0.002), and noninvasive ventilation rates (44%-72%, p < 0.001). The average duration of noninvasive ventilation increased significantly (from 9.24 to 14.08 days, p = 0.016). The total duration of respiratory support remained unchanged. The overall prevalence of moderate and severe BPD at 36 weeks corrected age remained approximately 40% in preterm infants born at less than 28 weeks gestation.

CONCLUSION

The increasing use of non-invasive ventilation was not accompanied by a reduction in the use of invasive ventilation, nor by a reduced prevalence of BPD. The high prevalence of BPD remains a significant problem in extreme prematurity. Other interventions, in addition to less aggressive ventilation, need to be explored.

Surfactant administration in preterm babies (28-36 weeks) with respiratory distress syndrome: LISA versus InSurE, an open-label randomized controlled trial

INTRODUCTION

INtubate-SURfactant-Extubate (InSurE) approach is traditional method of surfactant delivery in preterm neonates with respiratory distress syndrome (RDS). Newer, less invasive surfactant administration (LISA) techniques lessen the need for mechanical ventilation and its adverse consequences. Evidence on the favorable effects of LISA can't be extrapolated from developed to developing countries. Aim of study is to compare the effectiveness of InSurE and LISA.

OBJECTIVES

Primary outcome was to find need of intubation and mechanical ventilation within 72 h of birth. Neonates were followed until discharge/death for adverse events and complications. MATERIALS AND METHODS: Open-label randomized controlled trial (RCT) was conducted at tertiary neonatal intensive care unit. Preterm neonates with diagnosis of RDS were randomized in two groups (InSurE or LISA) to receive surfactant soon after birth. Nasal intermittent positive pressure ventilation (NIPPV) was used as primary mode of respiratory support.

RESULTS

A total of 150 neonates were analyzed (75 in each group). Insignificant statistical difference was seen in the need for intubation and mechanical ventilation within 72 h of birth between the two groups (InSurE, 30 [40%] and LISA, 30 [40%], relative risk 1.0, 95% confidence interval 0.68-1.48). Twelve percent (n = 9, LISA group) and 14.6% (n = 11 InSurE group) had adverse events during the procedure. Also, we observed insignificant statistical difference in the rates of major complications or duration of respiratory support, hospital stay, and mortality.

CONCLUSION

LISA and InSurE are equally effectiSpontaneously breathing pretermve for surfactant administration in the treatment of RDS, when NIPPV is the primary mode of respiratory support. More RCTs are required to compare the efficacy and long-term outcomes of LISA with InSurE.

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.

Randomized Trial of Surfactant Therapy via Laryngeal Mask Airway Versus Brief Tracheal Intubation in Neonates Born Preterm

OBJECTIVE

To evaluate the possible noninferiority of surfactant administration via laryngeal mask airway (LMA) vs endotracheal tube (ETT) in avoiding the requirement for mechanical ventilation in preterm neonates with respiratory distress syndrome (RDS).

STUDY DESIGN

This was a randomized controlled trial including infants born at 27 to 36 weeks of gestation, >800 g, diagnosed with RDS and receiving fraction of inspired oxygen 0.30-0.60 via noninvasive respiratory support. Infants were randomized to surfactant via LMA (with atropine premedication) or ETT (InSuRE approach with atropine and remifentanil premedication). Primary outcome was failure of surfactant treatment to prevent the need for mechanical ventilation.

RESULTS

Patients were randomized, 51 to LMA and 42 to the ETT group. Both groups had similar baseline characteristics, with birth weights ranging from 810 to 3560 g. Failure rate was 29% in the ETT group and 20% in the LMA group (P = .311). This difference was due to early failures (within 1 hour), with 12.5% in the ETT group and 2% in the LMA group (P = .044). Surfactant therapy via LMA was non-inferior to administration via ETT; failure risk difference -9.0% (CI -∞ to 5.7%). Efficacy in decreasing fraction of inspired oxygen, number of surfactant doses administered, time to wean off all respiratory support, rates of adverse events, and outcomes including pneumothorax and BPD diagnosis did not differ between groups.

CONCLUSIONS

Surfactant therapy via LMA was noninferior to administration via ETT and it decreased early failures, possibly by avoiding adverse effects of premedication, laryngoscopy, and intubation. These characteristics make LMA a desirable conduit for surfactant administration.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02164734.

Early Surfactant Therapy for Respiratory Distress Syndrome in Very Preterm Infants

BACKGROUND

It is currently considered that early initiation of nasal continuous positive airway pressure, using a less invasive exogenous surfactant administration and avoiding mechanical ventilation as much as possible to minimize lung damage, may reduce mortality and/or the risk of morbidities in preterm infants. The aim of our study was to quantify our experience and compare different strategies of surfactant administration, to investigate which method is associated with less morbidity.

MATERIALS AND METHODS

A total of 135 preterm infants with early rescue surfactant administration for respiratory distress syndrome were included in the study. The infants were treated in an academic, Level III Neonatal Intensive Care Unit over a 3-year period between 1 December 2018 and 1 December 2021. Patients were separated into three groups: those with standard surfactant administration; those with Less Invasive Surfactant Administration-LISA; and those with Intubation Surfactant Administration Extubation-INSURE. As a primary outcome, we followed the need for intubation and mechanical ventilation within 72 h, while the secondary outcomes were major neonatal morbidities and death before discharge.

RESULTS

The surfactant administration method was significantly associated with the need for mechanical ventilation within 72 h after the procedure (p < 0.001). LISA group infants needed less MV (OR = 0.538, p = 0.019) than INSURE group infants. We found less morbidities (OR = 0.492, p = 0.015) and deaths before discharge (OR = 0.640, p = 0.035) in the LISA group compared with the INSURE group. The analysis of morbidities found in infants who were given the surfactant by the LISA method compared with the INSURE method showed lower incidence of pneumothorax (3.9% vs. 8.8%), intraventricular hemorrhage (17.3% vs. 23.5%), intraventricular hemorrhage grade 3 and 4 (3.9% vs. 5.9%), sepsis/probable sepsis (11.5% vs. 17.7%) retinopathy of prematurity (16.7% vs. 26.7%) and deaths (3.9% vs. 5.9%). There were no significant differences between groups in frequencies of bronchopulmonary dysplasia, necrotizing enterocolitis and patent ductus arteriosus.

CONCLUSIONS

Less invasive surfactant administration methods seem to have advantages regarding early need for mechanical ventilation, decreasing morbidities and death rate. In our opinion, the LISA procedure may be a good choice in spontaneously breathing infants regardless of gestational age.

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.

Surfactant therapy using a bronchofiberscope in respiratory distress syndrome

BACKGROUND

Avoiding endotracheal intubation and using nasal continuous positive airway pressure as the initial treatment is recommended in infants with respiratory distress syndrome (RDS), and modes of lesser invasive surfactant administration have recently been reported. We report a pilot study assessing the feasibility of surfactant therapy using a bronchofiberscope (STUB) in RDS.

METHODS

Surfactant was administered to 31 preterm infants (gestational age range of 28 weeks 0 days to 36 weeks 6 days) diagnosed with RDS, through the working channel of the bronchofiberscope or endotracheal tubes. Patient characteristics, outcomes, adverse events, and comorbidities were assessed in the two groups.

RESULTS

Twelve infants received STUB. Two of the 12 infants (17%) needed subsequent intubation and additional surfactant administration. Nineteen infants received surfactant through endotracheal tubes. Four of the 19 infants (21%) required additional surfactants. There was no significant difference in the number of infants that needed additional surfactant (p = 1.00). Gestational age, birthweight, length of hospitalization, adverse events, such as desaturations and bradycardias, and comorbidities were similar between the two groups. Days of invasive ventilation were significantly shorter in the STUB group (p = 0.0002).

CONCLUSION

STUB was feasible in this small cohort and reduced the need for intubation to 17%, leading to fewer days of invasive ventilation, without increasing comorbidities and adverse events. To the best of our knowledge, this is the first study to administer surfactants using bronchofiberscopes.

Failure of early non-invasive ventilation in preterm infants with respiratory distress syndrome in current care practice in Spanish level-III neonatal intensive care units - a prospective observational study

Introduction

Despite advances in respiratory distress syndrome (RDS) management over the past decade, non-invasive ventilation (NIV) failure is frequent and associated with adverse outcomes. There are insufficient data on the failure of different NIV strategies currently used in clinical practice in preterm infants.

Methods

This was a prospective, multicenter, observational study of very preterm infants [gestational age (GA) <32 weeks] admitted to the neonatal intensive care unit for RDS that required NIV from the first 30 min after birth. The primary outcome was the incidence of NIV failure, defined as the need for mechanical ventilation for <72 h of life. Secondary outcomes were risk factors associated with NIV failure and complication rates.

Results

The study included 173 preterm infants with a median GA of 28 (IQR 27-30) weeks and a median birth weight of 1,100 (IQR 800-1,333) g. The incidence of NIV failure was 15.6%. In the multivariate analysis, lower GA (OR, 0.728; 95% CI, 0.576-0.920) independently increased the risk of NIV failure. Compared to NIV success, NIV failure was associated with higher rates of unfavorable outcomes, including pneumothorax, intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, and a combined outcome of moderate-to-severe bronchopulmonary dysplasia or death.

Conclusion

NIV failure occurred in 15.6% of the preterm neonates and was associated with adverse outcomes. The use of LISA and newer NIV modalities most likely accounts for the reduced failure rate. Gestational age remains the best predictor of NIV failure and is more reliable than the fraction of inspired oxygen during the first hour of life.

Surfactant Replacement Therapy: What’s the New Future?

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.

A pilot study of evaluation of semi-rigid and flexible catheters for less invasive surfactant administration in preterm infants with respiratory distress syndrome—a randomized controlled trial

Background

In respiratory distress syndrome, many neonatology centers worldwide perform minimal invasive surfactant application in premature infants, using small-diameter catheters for endotracheal intubation and surfactant administration.

Methods

In this single-center, open-label, randomized-controlled trial, preterm infants requiring surfactant administration after birth, using a standardized minimal invasive protocol, were randomized to two different modes of endotracheal catheterization: Flexible charrière-4 feeding tube inserted using Magill forceps (group 1) and semi-rigid catheter (group 2). Primary outcome was duration of laryngoscopy. Secondary outcomes were complication rate (intraventricular hemorrhage, soft-tissue damage in first week of life) and vital parameters during laryngoscopy. Between 2019 and 2020, 31 infants were included in the study. Prior to in-vivo testing, laryngoscopy durations were studied on a neonatal airway mannequin in students, nurses and doctors.

Results

Mean gestational age and birth weight were 27 + 6/7 weeks and 1009 g; and 28 + 0/7 weeks and 1127 g for group 1 and 2, respectively. Length of laryngoscopy was similar in both groups (61.1 s and 64.9 s) overall (p.77) and adjusted for weight (p.70) or gestational age (p.95). Laryngoscopy failed seven times in group 1 (43.8%) and four times (26.7%) in group 2 (p.46). Longer laryngoscopy was associated with lower oxygen saturation with lowest levels occurring after failed laryngoscopy attempts. Secondary outcomes were similar in both groups. In vitro data on 40 students, 40 nurses and 12 neonatologists showed significant faster laryngoscopy in students and nurses group 2 (p < .0001) unlike in neonatologists (p.13).

Conclusion

This study showed no difference in laryngoscopy duration in endotracheal catheterization when comparing semi-rigid and flexible catheters for minimal invasive surfactant application in preterm infants. In accordance with preliminary data and in contrast to published in-vitro trials, experienced neonatologists were able to perform endotracheal catheterization using both semi-rigid and flexible catheters at similar rates and ease, in vitro and in vivo.

Trial registration

ClinicalTrials.gov. NCT05024435 Registered 27 August 2021—Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03714-3.

Surfactant without Endotracheal Tube Intubation (SurE) versus Intubation-Surfactant-Extubation (InSurE) in Neonatal Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

Neonatal respiratory distress syndrome (NRDS) is generally treated with surfactant by intubation-surfactant-extubation (InSurE) technique, an invasive method of surfactant administration. Surfactant without endotracheal tube intubation (SurE) is a noninvasive technique that avoids intubation and has been found to have improved the delivery of exogenous surfactants, thereby decreasing lung damage in neonates. This systematic review aimed to provide insights into the efficacy of SurE over InSurE in neonates who received respiratory support and to evaluate the progression and onset of concurrent diseases after treatment. The CENTRAL, PubMed, and Embase databases were searched for data collection. In all, 21 research articles were eligible, comprising 19,976 study participants. The data showed a significant reduction in the composite outcome of stage 2 necrotizing enterocolitis, bronchopulmonary dysplasia, and onset of hemodynamically significant patent ductus arteriosus when treated with SurE. The trend towards lower pneumothorax rates with SurE was also evident. These findings were robust due to the sensitivity analyses performed. There were no differences in the outcome of death or rates of other neonatal morbidities. Overall, SurE was identified as a better substitute for InSurE to treat neonates with RDS.

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.

Should less invasive surfactant administration (LISA) become routine practice in US neonatal units?

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.

Association of Administration of Surfactant Using Less Invasive Methods With Outcomes in Extremely Preterm Infants Less Than 27 Weeks of Gestation

IMPORTANCE

The inclusion of less invasive surfactant administration (LISA) in the care of preterm infants has been found to be beneficial for respiratory outcomes. Recently, the OPTIMIST trial found higher mortality rates in the subgroup of infants born at 25 to 26 weeks' gestational age (GA) who received surfactant treatment while spontaneously breathing.

OBJECTIVE

To analyze outcomes among LISA-exposed, highly vulnerable babies born at less than 27 weeks' GA within the large-scale observational cohort of the German Neonatal Network.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study of data from 68 tertiary level neonatal intensive care units in Germany of infants born between 22 weeks 0 days to 26 weeks 6 days of gestation between April 1, 2009, and December 31, 2020, short-term outcomes among infants receiving LISA vs infants not receiving LISA were compared.

EXPOSURE

Use of LISA within the first 72 hours of life.

MAIN OUTCOMES AND MEASURES

The main outcomes were rates of LISA use, use of mechanical ventilation within the first 72 hours (considered failure of LISA), and association of LISA with outcomes, including death from all causes, bronchopulmonary dysplasia (BPD), death and BPD combined, pneumothorax, retinopathy of prematurity, intracerebral hemorrhage, and periventricular leukomalacia. To address potential confounding factors, multivariate logistic regression models were used.

RESULTS

A total of 6542 infants (3030 [46.3%] female and 3512 [53.7%] male; mean [SD] GA, 25.3 (1.1) weeks; mean [SD] birth weight, 715 [180] g) were analyzed; 2534 infants (38.7%) received LISA, which was most frequently given quasi-prophylactically during delivery room management. Among the infants who received LISA, 1357 (53.6%) did not require mechanical ventilation in the first 72 hours compared with 331 infants (8.3%) of 4008 who did not receive LISA. In a multivariate logistic regression model that adjusted for GA, small-for-GA status, sex, multiple birth, inborn status, antenatal steroid use, and maximum fraction of inspired oxygen in the first 12 hours of life, LISA was associated with reduced risks of all-cause death (odds ratio [OR], 0.74; 95% CI, 0.61-0.90; P = .002), BPD (OR, 0.69; 95% CI, 0.62-0.78; P < .001), and BPD or death (OR, 0.64; 95% CI, 0.57-0.72; P < .001) compared with infants without LISA exposure.

CONCLUSIONS AND RELEVANCE

The results of this long-term multicenter cohort study suggest that LISA may be associated with reduced risks of adverse outcomes in extremely preterm infants.

Early surfactant and non-invasive ventilation versus intubation and surfactant: a propensity score-matched national study

OBJECTIVE

To compare outcome after less invasive surfactant administration (LISA) and primary endotracheal intubation (non-LISA) in infants born before gestational age (GA) 28 weeks.

SETTING

All neonatal intensive care units (NICUs) in Norway during 2012-2018.

METHODS

Defined population-based data were prospectively entered into a national registry. We compared LISA infants with all non-LISA infants and with non-LISA infants who received surfactant following intubation. We used propensity score (PS) matching to identify non-LISA infants who were similar regarding potential confounders.

MAIN OUTCOME VARIABLES

Rate and duration of mechanical ventilation (MV), survival, neurological and gastrointestinal morbidity, and need of supplemental oxygen or positive pressure respiratory support at postmenstrual age (PMA) 36 and 40 weeks.

RESULTS

We restricted analyses to GA 25-27 weeks (n=843, 26% LISA) because LISA was rarely used at lower GAs. There was no significant association between NICUs regarding proportions treated with LISA and proportions receiving MV. In the PS-matched datasets, fewer LISA infants received MV (61% vs 78%, p<0.001), and they had fewer days on MV (mean difference 4.1, 95% CI 0.0 to 8.2 days) and lower mortality at PMA 40 weeks (absolute difference 6%, p=0.06) compared with all the non-LISA infants, but only a lower rate of MV (64% vs 97%, p<0.001) and fewer days on MV (mean difference 5.8, 95% CI 0.6 to 10.9 days) compared with non-LISA infants who received surfactant after intubation.

CONCLUSION

LISA reduced the rate and duration of MV but had no other clear benefits.

Comparison of minimally invasive surfactant therapy with intubation surfactant administration and extubation for treating preterm infants with respiratory distress syndrome: a randomized clinical trial

BACKGROUND

Respiratory distress syndrome (RDS) is a common cause of hospitalization and death in preterm infants who require surfactant treatment and respiratory support.

PURPOSE

This study aimed to compare the clinical outcomes of minimally invasive surfactant therapy (MIST) and the INtubation, SURfactant administration, and Extubation (INSURE) technique in preterm infants with RDS.

METHODS

In this clinical trial, 112 preterm infants born at 28-36 weeks of gestation and diagnosed with RDS randomly received 200-mg/kg surfactant by MIST or the INSURE method. In the MIST group, surfactant was administered using a thin catheter (5F feeding tube); in the INSURE group, surfactant was administered after intubation using a feeding tube and the tracheal tube was removed after positive pressure ventilation was started. Nasal continuous positive airway pressure was applied in both groups for respiratory support and the postprocedure clinical outcomes were compared.

RESULTS

The mean hospitalization time was shorter for infants in the MIST group than for those in the INSURE group (9.19± 1.72 days vs. 10.21±2.15 days, P=0.006). Patent ductus arteriosus was less frequent in the MIST group (14.3% vs. 30.4%, P=0.041). Desaturation during surfactant administration occurred less commonly in the MIST group (19.6% vs. 39.3%, P=0.023). There were no significant intergroup differences in other early or late complications.

CONCLUSION

These results suggest that surfactant administration using MIST could be a good replacement for INSURE in preterm infants with RDS since its use reduced the hospitalization time and the number of side effects.

Outcomes following less-invasive-surfactant-administration in the delivery-room

BACKGROUND

Less invasive surfactant administration (LISA) on the neonatal unit reduces the need for mechanical ventilation and bronchopulmonary dysplasia (BPD).

AIMS

To assess the immediate and longer-term efficacy of LISA to prematurely born infants in the delivery-room.

STUDY DESIGN

A case control study with inborn historical controls matched for gestational age, birthweight and gender to each LISA infant.

SUBJECTS

Infants born between 26⁺⁰ weeks and 34⁺⁶ weeks of gestational age.

OUTCOME MEASURES

Respiratory function monitoring before and after LISA and need for mechanical ventilation within 72 h of birth.

RESULTS

Ninety-nine infants, median gestational age of 32⁺⁴(range:27⁺⁰-34⁺⁶) weeks, were prospectively recruited. The respiratory rate and inspired oxygen (FiO₂) decreased two minutes after LISA and there was a reduction in the FiO₂ requirement at two hours post birth. Compared to historical controls, LISA administration was associated with a reduction in the need for mechanical ventilation within 72 h after birth (20.2% versus 56.6% p < 0.001) the incidence of moderate to severe BPD (8.2% versus 20.2%, p = 0.02) and the median costs of neonatal intensive care stay (£1218 versus £2436, p = 0.03) and total neonatal unit stay (£12,888 versus £17,240, p = 0.04). A high FiO₂ in the delivery-room pre-LISA (median 0.75 versus 0.60, p = 0.02) was associated with LISA failure, that is mechanical ventilation within 72 h of birth.

CONCLUSIONS

LISA to prematurely born infants in the delivery-room was associated with reductions in the need for mechanical ventilation and costs of care, but was less successful in those with initial, more severe respiratory disease.

Pharmacotherapy in Bronchopulmonary Dysplasia: What Is the Evidence?

Bronchopulmonary Dysplasia (BPD) is a multifactorial disease affecting over 35% of extremely preterm infants born each year. Despite the advances made in understanding the pathogenesis of this disease over the last five decades, BPD remains one of the major causes of morbidity and mortality in this population, and the incidence of the disease increases with decreasing gestational age. As inflammation is one of the key drivers in the pathogenesis, it has been targeted by majority of pharmacological and non-pharmacological methods to prevent BPD. Most extremely premature infants receive a myriad of medications during their stay in the neonatal intensive care unit in an effort to prevent or manage BPD, with corticosteroids, caffeine, and diuretics being the most commonly used medications. However, there is no consensus regarding their use and benefits in this population. This review summarizes the available literature regarding these medications and aims to provide neonatologists and neonatal providers with evidence-based recommendations.

Is Less Invasive Surfactant Administration Better than INtubation-SURfactant-Extubation for Prophylactic Surfactant Replacement Therapy?

Purpose: The study aimed to examine whether prophylactic surfactant replacement therapy (SRT) with less invasive surfactant administration (LISA) by tracheal catheterization in a group of spontaneously breathing preterm infants would improve clinical outcomes compared to prophylactic SRT with the INtubation-SURfactantExtubation (INSURE) method.Methods: We compared 20 spontaneously breathing preterm infants, 25 to 29 weeks of gestation or with a birth weight of less than 1,250 g, treated with prophylactic SRT using a gastric tube (LISA group), to the 20 spontaneously breathing preterm infants matched by gestational age and birth weight, managed with prophylactic SRT via the INSURE method (INSURE group, historical control).Results: The LISA group had lower rates of mechanical ventilation (MV) 72 hours after birth (P=0.019) and at any time (P=0.025), lower frequency of bradycardia during SRT (P=0.031), and lower median duration of MV than the INSURE group (P=0.038). In multivariate analysis, the LISA method was associated with a significantly lower likelihood of receiving invasive ventilation during hospitalization (odds ratio [OR], 0.029; 95% confidence interval [CI], 0.001 to 0.938; P=0.046) and a decreased frequency of bradycardia during SRT (OR, 0.020; 95% CI, 0.001 to 0.535; P=0.020) as compared to the INSURE method.Conclusion: Prophylactic SRT using LISA via tracheal catheterization in preterm infants may significantly reduce exposure to MV during hospitalization and bradycardia during surfactant administration.

Alternative Methods of Surfactant Administration in Preterm Infants with Respiratory Distress Syndrome: State of the Art

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.

Inhaled Medicines: Past, Present, and Future

The purpose of this review is to summarize essential pharmacological, pharmaceutical, and clinical aspects in the field of orally inhaled therapies that may help scientists seeking to develop new products. After general comments on the rationale for inhaled therapies for respiratory disease, the focus is on products approved approximately over the last half a century. The organization of these sections reflects the key pharmacological categories. Products for asthma and chronic obstructive pulmonary disease include β -2 receptor agonists, muscarinic acetylcholine receptor antagonists, glucocorticosteroids, and cromones as well as their combinations. The antiviral and antibacterial inhaled products to treat respiratory tract infections are then presented. Two "mucoactive" products-dornase α and mannitol, which are both approved for patients with cystic fibrosis-are reviewed. These are followed by sections on inhaled prostacyclins for pulmonary arterial hypertension and the challenging field of aerosol surfactant inhalation delivery, especially for prematurely born infants on ventilation support. The approved products for systemic delivery via the lungs for diseases of the central nervous system and insulin for diabetes are also discussed. New technologies for drug delivery by inhalation are analyzed, with the emphasis on those that would likely yield significant improvements over the technologies in current use or would expand the range of drugs and diseases treatable by this route of administration. SIGNIFICANCE STATEMENT: This review of the key aspects of approved orally inhaled drug products for a variety of respiratory diseases and for systemic administration should be helpful in making judicious decisions about the development of new or improved inhaled drugs. These aspects include the choices of the active ingredients, formulations, delivery systems suitable for the target patient populations, and, to some extent, meaningful safety and efficacy endpoints in clinical trials.

Trial of aerosolised surfactant for preterm infants with respiratory distress syndrome

OBJECTIVE

To evaluate the safety of an aerosolised surfactant, SF-RI 1, administered via nasal continuous positive airway pressure (nCPAP) and a prototype breath synchronisation device (AeroFact), to preterm infants with respiratory distress syndrome (RDS).

DESIGN

Multicentre, open-label, dose-escalation study with historical controls.

SETTING

Newborn intensive care units at Mater Mothers' Hospital, Brisbane, and Royal Hospital for Women, Sydney, Australia.

PATIENTS

Infants 26 weeks through 30 weeks gestation who required nCPAP 6-8 cmH₂O and fraction of inspired oxygen (FiO₂) <0.30 at <2 hours of age.

INTERVENTIONS

In part 1, infants received a single dose of 216 mg/kg of aerosolised surfactant. In part 2, infants could receive up to four doses of aerosolised surfactant. Three historical control infants were matched for each enrolled infant.

MAIN OUTCOME MEASURES

Treatment failure was defined as Respiratory Severity Score (FiO₂×cmH₂O nCPAP) >2.4, nCPAP >8 cmH₂O, arterial carbon dioxide >65 mm Hg, pH <7.20 or three severe apnoeas within 6 hours during the first 72 hours of life. Other outcomes included tolerance of the AeroFact treatment and complications of prematurity.

RESULTS

10 infants were enrolled in part 1 and 21 in part 2 and were compared with 93 historical controls. No safety issues were identified. In part 2, 6 of 21 (29%) AeroFact-treated infants compared with 30 of 63 (48%) control infants met failure criteria. Kaplan-Meier analysis of patients in part 2 showed a trend towards decreased rate of study failure in the AeroFact-treated infants compared with historical controls (p=0.10).

CONCLUSION

The AeroFact system can safely deliver aerosolised surfactant to preterm infants with RDS who are on nCPAP.

TRIAL REGISTRATION NUMBER

ACTRN12617001458325.

Teaching fiberoptic-assisted tracheoscopy in very low birth weight infants: A randomized controlled simulator study

OBJECTIVE

We developed a fiberoptic-assisted tracheoscopy (FAST) method to avoid direct laryngoscopy during surfactant replacement therapy and compared two training approaches on a very low birth weight (VLBW) infant simulator.

DESIGN

This prospective randomized controlled study was conducted at the Department of Neonatology and Pediatric Intensive Care Medicine of the University Medical Center Hamburg-Eppendorf, Germany.

PARTICIPANTS

We recruited physicians, trainees, students, and nurses without prior experience in endoscopic techniques.

INTERVENTIONS

Participants were assigned randomly to a group that received instructions according to Peyton's Four-Step Approach and a control group that received standard bedside teaching only.

MAIN OUTCOME MEASURES

Primary endpoints were the total and the component times required to place the bronchoscope and the method success.

RESULTS

We recruited 186 participants. Compared with the control group, the Peyton group had a lower mean (±standard deviation) FAST completion time (33.2 ± 27.5 s vs. 79.5 ± 47.9 s, p < 0.001; d = 1.12) and a higher FAST success rate (95% vs. 84%, p = 0.036, V = 0.18).

CONCLUSION

After standardized training, the vast majority of novices completed FAST successfully. Peyton's four-step approach resulted in faster and more successful performance than standardized training.

A multicenter, randomized controlled, non-inferiority trial, comparing nasal continuous positive airway pressure with nasal intermittent positive pressure ventilation as primary support before minimally invasive surfactant administration for preterm infants with respiratory distress syndrome (the NIV-MISA-RDS trial): Study protocol

BACKGROUND

Non-invasive ventilation (NIV) treatment has been developed to minimize lung damage and to avoid invasive mechanical ventilation (IMV) in preterm infants, especially in those with a gestational age of <30 weeks. Our hypothesis is that for preterm infants <30 weeks with potential to develop respiratory distress syndrome (RDS), nasal continuous positive airway pressure (NCPAP) is non-inferior to the nasal intermittent positive pressure ventilation (NIPPV) as primary respiratory support before minimal invasive surfactant administration (MISA).

METHODS AND DESIGN

The NIV-MISA-RDS trial is planned as an unblinded, multicenter, randomized, non-inferiority trial at 14 tertiary neonatal intensive care units (NICUs) in China. Eligible infants are preterm infants of 24-29⁺⁶ weeks of gestational age who have spontaneous breaths at birth and require primary NIV support for RDS. Infants are randomized 1:1 to treatment with either NCPAP or NIPPV once admitted into NICUs. If an infant presents progressively aggravated respiratory distress and is clinically diagnosed as having RDS, pulmonary surfactant will be supplemented by MISA in the first 2 h of life. The primary outcome is NIV treatment failure within 72 h after birth. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 80% power, the study requires 480 infants per group (in total 960 infants).

DISCUSSION

Current evidence shows that NIV and MISA may be the most effective strategy for minimizing IMV in preterm infants with RDS. However, there are few large randomized controlled trials to compare the effectiveness of NCPAP and NIPPV as the primary respiratory support after birth and before surfactant administration. We will conduct this trial to test the hypothesis that NCPAP is not inferior to NIPPV as the initial respiratory support in reducing the use of IMV in premature infants who have spontaneous breaths after birth and who do not require intubation in the first 2 h after birth. The study will provide clinical data for the selection of the initial non-invasive ventilation mode in preterm infants with a gestational age of <30 weeks with spontaneous breaths after birth.

CLINICAL TRIAL REGISTRATION

https://register.clinicaltrials.gov, identifier: NCT05137340.

Thin-catheter Surfactant Application for Respiratory Distress Syndrome in Spontaneously Breathing Preterm Infants: A Meta-analysis of Randomized Clinical Trials

BACKGROUND

Surfactant application by a thin catheter represented by the term less invasive surfactant administration (LISA) for respiratory distress syndrome in spontaneously breathing preterm infants was developed as an alternative to endotracheal intubation.

METHODS

We conducted a meta-analysis to assess the effects of LISA when compared to the socalled intubation-surfactant-extubation (INSURE) and the standard endotracheal intubation and mechanical ventilation (MV). The primary outcome was the composite incidence of death or bronchopulmonary dysplasia at a postmenstrual age of 36 weeks. The secondary outcome was the composite incidence of seven other severe adverse events. On 06 October 2021, we searched randomized clinical trials (RCTs) in PubMed, the Cochrane Library, ClinicalTrials.gov, and the ICTRP Registry.

RESULTS

We included 18 RCTs. The pooled data on the primary outcome favored LISA when compared to either INSURE (risk ratio 0.67; 95% CI, 0.51 to 0.88) or MV (risk ratio 0.78; 95% CI, 0.61 to 0.99). The pooled data on the second outcome also favored LISA when compared to INSURE (risk ratio 0.75; 95% CI, 0.60 to 0.94) and MV (risk ratio 0.73; 95% CI, 0.55 to 0.96).

CONCLUSION

The findings showed that surfactant application by non-intubation respiratory support and the use of a thin catheter may decrease the composite risk of death or bronchopulmonary dysplasia. The included data support the view that LISA should be considered the preferred treatment option in eligible infants.

Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review

BACKGROUND

Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required.

METHODS

A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted.

RESULTS

179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions.

CONCLUSIONS

Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.

Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome: The OPTIMIST-A Randomized Clinical Trial

IMPORTANCE

The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain.

OBJECTIVE

To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020.

INTERVENTIONS

Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately.

RESULTS

Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group.

CONCLUSIONS AND RELEVANCE

Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000916943.

Airway injury and pneumomediastinum associated with less invasive surfactant administration in a premature neonate: a case report

Background

The use of less invasive surfactant administration (LISA)/minimally invasive surfactant therapy (MIST) has increased due to its potential advantage over traditional surfactant delivery methods through an endotracheal tube. Known complications for this procedure include failure of the first attempt at insertion, desaturation, and bradycardia. To the best of our knowledge, this is the first reported case of pneumomediastinum and subcutaneous emphysema following LISA.

Case presentation

A preterm newborn born at 27 weeks of gestation presented with respiratory distress syndrome requiring surfactant replacement. LISA using the Hobart method was completed. There was a report of procedural difficulty related to increased resistance to insertion of the 16G angiocath. The newborn was subsequently noted to have subcutaneous emphysema over the anterior aspect of the neck and substantial pneumomediastinum on radiological assessment. Associated complications included hypotension requiring inotropic support. The newborn was successfully managed conservatively, with complete resolution of the air leak.

Conclusions

Upper airway injury leading to air leak syndrome is a rare complication of the Hobart method for LISA. Awareness of such procedural complications is important as the use of the LISA method increases.

Surfactant Nebulization to Prevent Intubation in Preterm Infants: A Systematic Review and Meta-analysis

CONTEXT

Surfactant nebulization (SN) may offer a safe alternative for surfactant administration in respiratory distress syndrome of preterm infants.

OBJECTIVE

To evaluate the efficacy of SN for the prevention of early intubation.

DATA SOURCES

Medline, Embase, The Cochrane Library, clinicaltrials.gov, published abstracts, and references of relevant articles were searched through March 23, 2021.

STUDY SELECTION

Randomized clinical trials of preterm infants <37 weeks' gestation comparing SN with noninvasive respiratory support or intratracheal surfactant application.

DATA EXTRACTION

Two reviewers extracted data and assessed risk of bias from included studies separately and blinded. Data were pooled by using a fixed-effects model. Subgroups (gestational age, type of nebulizer, surfactant type, and dosage) were evaluated. Primary outcome was intubation rate at 72 hours after birth.

RESULTS

Nine studies recruiting 1095 infants met inclusion criteria. SN compared with standard care significantly reduced intubation rate at 72 hours after birth (226 of 565 infants [40.0%] vs 231 of 434 infants [53.2%]; risk ratio [RR]: 0.73, 95% confidence interval [CI]: 0.63-0.84; number needed to treat: 8; 95% CI: 5-14]). Prespecified subgroup analysis identified important heterogeneity: SN was most effective in infants ≥28 weeks' gestation (RR: 0.70, 95% CI: 0.60-0.82), with a pneumatically driven nebulizer (RR: 0.52, 95% CI: 0.40-0.68) and in infants receiving ≥200 mg/kg and animal-derived surfactant (RR: 0.63, 95% CI: 0.52-0.75). No differences in neonatal morbidities or mortality were identified.

LIMITATIONS

Quality of evidence was low owing to risk of bias and imprecision.

CONCLUSIONS

SN reduced the intubation rate in preterm infants with a higher efficacy for specific subgroups. There was no difference in relevant neonatal morbidities or mortality.

Surfactant Administration Through Laryngeal or Supraglottic Airways

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.