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Pichler K, Kuehne B, Dekker J, Stummer S, Giordano V, Berger A, Kribs A, Klebermass-Schrehof K. Assessment of Comfort during Less Invasive Surfactant Administration in Very Preterm Infants: A Multicenter Study. Neonatology 2023; 120:473-481. [PMID: 37311430 PMCID: PMC10614453 DOI: 10.1159/000530333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/10/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study was set up to investigate if and to what extent non-pharmacological analgesia is able to provide comfort to very preterm infants (VPI) during less invasive surfactant administration (LISA). METHODS This was a prospective non-randomized multicenter observational study performed in level IV NICUs. Inborn VPI with a gestational age between 220/7 and 316/7 weeks, signs of respiratory distress syndrome, and the need for surfactant replacement were included. Non-pharmacological analgesia was performed in all infants during LISA. In case of failure of the first LISA attempt, additional analgosedation could be administered. COMFORTneo scores during LISA were assessed. RESULTS 113 VPI with a mean gestational age of 27 weeks (+/- 2.3 weeks) and mean birth weight of 946 g (+/- 33 g) were included. LISA was successful at the first laryngoscopy attempt in 81%. COMFORTneo scores were highest during laryngoscopy. At this time point, non-pharmacological analgesia provided adequate comfort in 61% of the infants. 74.4% of lower gestational aged infants (i.e., 220-266 weeks) were within the comfort zone during laryngoscopy compared to 51.6% of higher gestational aged infants (i.e., 270-320 weeks) (p = 0.016). The time point of surfactant administration did not influence the COMFORTneo scores during the LISA procedure. CONCLUSION Non-pharmacological analgesia provided comfort in as much as 61% of the included VPI during LISA. Further research is needed to both develop strategies to identify infants who, despite receiving non-pharmacological analgesia, are at high risk for experiencing discomfort during LISA and define patient-tailored dosage and choice of analgosedative drugs.
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Affiliation(s)
- Karin Pichler
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria,
| | - Benjamin Kuehne
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Stummer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Katrin Klebermass-Schrehof
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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Xu CC, Bao YY, Zhao JX, Cheng K, Sun L, Wu JY, Wu MY, Zhu JJ. Effects of less invasive surfactant administration versus intubation-surfactant-extubation on bronchopulmonary dysplasia in preterm infants with respiratory distress syndrome: a single-center, retrospective study from China. BMC Pulm Med 2022; 22:462. [PMID: 36471386 PMCID: PMC9724250 DOI: 10.1186/s12890-022-02270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study evaluated the effects of less invasive surfactant administration (LISA) and intubation-surfactant-extubation (InSurE) on bronchopulmonary dysplasia (BPD) in preterm infants with respiratory distress syndrome (RDS). METHODS Neonates with respiratory distress syndrome requiring surfactant, with gestational age < 32 weeks and birth weight < 1500 g admitted to our neonatal intensive care unit from January 2018 to December 2019, were retrospectively analyzed. LISA and InSurE were used independently. The incidence of BPD at 36 weeks postmenstrual age, pre-discharge mortality, and need for mechanical ventilation (MV) within 72 h of birth were compared between LISA and InSurE group. Secondary outcomes including necrotizing enterocolitis requiring surgery, retinopathy of prematurity ≥ stage 3, patent ductus arteriosus requiring medical therapy or surgery, and length of hospitalization were analyzed. RESULTS Among the 148 included neonates, there were 46 and 102 infants in LISA group and InSurE group, respectively. There were no significant differences in BPD incidence, the severity of BPD at 36 weeks postmenstrual age, and the rate of MV within the first 72 h after birth between the two groups (P > 0.05, respectively). The incidences of necrotizing enterocolitis requiring surgery, retinopathy of prematurity ≥ stage 3, patent ductus arteriosus requiring medical therapy or surgery, and length of hospitalization did not differ significantly between the two groups (P > 0.05, respectively). CONCLUSIONS For surfactant administration among preterm infants with respiratory distress syndrome, LISA did not decrease bronchopulmonary dysplasia and severity of BPD at 36 weeks postmenstrual age. The benefits of LISA would require further evaluations.
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Affiliation(s)
- Chun-cai Xu
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Ying-ying Bao
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Jing-xin Zhao
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Ke Cheng
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Ling Sun
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Jing-yuan Wu
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-yuan Wu
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia-jun Zhu
- grid.13402.340000 0004 1759 700XDepartment of Neonatology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou, China
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Cavallin F, Bua B, Pasta E, Savio F, Villani PE, Trevisanuto D. Device positioning with LISA vs. INSURE: a crossover randomized controlled manikin trial. J Matern Fetal Neonatal Med 2022; 35:10577-10583. [PMID: 36261132 DOI: 10.1080/14767058.2022.2134774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We aimed to compare time of device positioning, success of procedure and operator's opinion with LISA vs. INSURE in a manikin simulating an extremely low birthweight infant. METHODS A randomized controlled crossover (AB/BA) trial of surfactant administration with LISA vs. INSURE in a preterm manikin. Forty-two tertiary hospital consultants and pediatric residents with previous experience with LISA and INSURE participated. The primary outcome measure was the time of device positioning. The secondary outcome measures were: success of the first attempt, number of attempts, correct depth, and participant's opinion on difficulty in using the device. RESULTS Median time of device positioning was shorter with LISA vs. INSURE (median difference -8 s, 95% confidence interval -16 to -1 s; p = .04). Success at first attempt was 35/40 with LISA (83%) and 31/40 with INSURE (74%) (p = .42). Median number of attempts was 1 (IQR 1-1) with LISA and 1 (IQR 1-2) with INSURE (p = .08). Correct depth was achieved in 30/40 with LISA (71%) and 37/40 with INSURE (88%) (p = .12). Participants found LISA easier to insert in the trachea (p = .002) but INSURE easier to place at the correct depth (p = .008). Handling the device (p = .43), visualizing the glottis (p = .17) and overall difficulty in using the device (p = .13) were not statistically different. CONCLUSIONS In a preterm manikin model, positioning a thin catheter (LISA) was quicker and easier than a tracheal tube (INSURE), but the magnitude of the difference was unlikely to be clinically relevant and the tracheal tube was easier to place at the correct depth. REGISTRATION clinicaltrial.gov NCT04944108.
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Affiliation(s)
| | - Benedetta Bua
- Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Elisa Pasta
- Department of Woman and Child Health, Fondazione Poliambulanza, Brescia, Italy
| | - Federica Savio
- Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | | | - Daniele Trevisanuto
- Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
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Abstract
The provision of exogenous surfactant to premature infants with respiratory distress syndrome has revolutionized the way we care for these patients, significantly improving survival and decreasing morbidity. Currently, the Intubate-SURfactant-Extubate (INSURE) to non-invasive ventilation method remains the standard method for surfactant delivery in the United States. However, the INSURE method requires intubation via direct visualization with a laryngoscope and possible need for sedation. Both carry significant risk to the patients, prompting the development of less invasive ways of safely and efficaciously providing surfactant to newborn infants. The present article reviews and describes the benefits and limitations of several of these alternative methods, including Less Invasive Surfactant Administration (LISA), Minimally Invasive Surfactant Therapy (MIST), via aerosolization, laryngeal mask airway (LMA), and direct nasopharyngeal deposition, focusing on assessment of clinical benefits and the level/risk of invasiveness.
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Affiliation(s)
- Nayef Chahin
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University and School of Medicine, Virginia Commonwealth University, P.O. Box 980276, Richmond, VA 23298-0276, USA.
| | - Henry J Rozycki
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University and School of Medicine, Virginia Commonwealth University, P.O. Box 980276, Richmond, VA 23298-0276, USA
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Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
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Kleijkers LMP, Van Der Spil J, Janssen LCE, Dieleman JP, Andriessen P, van Kaam AH, Onland W, Niemarkt HJ. Short-Term Outcome after Repeated Less Invasive Surfactant Administration: A Retrospective Cohort Study. Neonatology 2022; 119:719-726. [PMID: 36126636 DOI: 10.1159/000526493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Less invasive surfactant administration (LISA) to preterm infants is associated with decreased risk for death or BPD. After LISA, a considerable proportion requires a second dose of surfactant because of ongoing respiratory distress syndrome, raising a clinical dilemma between intubation or performing a repeated LISA (re-LISA) procedure. We aim to assess efficacy of re-LISA in avoiding subsequent nasal continuous positive airway pressure failure (need for intubation in the first 72 h of life; CPAP-F), to identify factors associated with subsequent CPAP-F, and to compare short-term outcomes following re-LISA to surfactant retreatment by endotracheal intubation and mechanical ventilation. METHODS This was an observational retrospective study in two Dutch NICUs. Inclusion criterion was infants with gestational age <32 0/7 weeks requiring a second surfactant dose. Multivariate logistic regression analysis was performed. RESULTS Of 209 infants requiring second surfactant dose, 132 received re-LISA. Subsequent CPAP-F was observed in 56 (42%) infants and was associated with extreme prematurity (OR 2.6, 95% CI: 1.2-5.8) and FiO2>0.5 (OR 5.4, 95% CI: 2.0-14.7). Infants receiving re-LISA had a lower risk of death or BPD compared to infants intubated for the second surfactant dose (OR 0.4, 95% CI: 0.2-0.9). Infants with CPAP-F after re-LISA had similar outcomes compared to those intubated for second surfactant dose. CONCLUSION Re-LISA is effective in reducing CPAP-F and is associated with lower risk of death or BPD compared to retreatment via an endotracheal tube. Infants failing CPAP after re-LISA have similar outcomes compared to intubated infants. These findings support the use of re-LISA in preterm infants with ongoing RDS.
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Affiliation(s)
- Lina M P Kleijkers
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Jooske Van Der Spil
- Department of Neonatology, Emma's Children Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Lobke C E Janssen
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, The Netherlands
| | | | - Peter Andriessen
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma's Children Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma's Children Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Hendrik J Niemarkt
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, The Netherlands
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Altamimi T, Read B, da Silva O, Bhattacharya S. Airway injury and pneumomediastinum associated with less invasive surfactant administration in a premature neonate: a case report. BMC Pediatr 2021; 21:500. [PMID: 34758781 PMCID: PMC8579620 DOI: 10.1186/s12887-021-02981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Talal Altamimi
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada.
| | - Brooke Read
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| | - Orlando da Silva
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| | - Soume Bhattacharya
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
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Brotelande C, Milési C, Combes C, Durand S, Badr M, Cambonie G. Premedication with ketamine or propofol for less invasive surfactant administration (LISA): observational study in the delivery room. Eur J Pediatr 2021; 180:3053-3058. [PMID: 33954805 DOI: 10.1007/s00431-021-04103-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
Less invasive surfactant administration (LISA) has become increasingly popular in neonatal intensive care units (NICUs), but there are currently no guidelines for the premedication prior to this procedure. The aim of this observational study was to compare the efficacy and tolerance of intravenous administrations of ketamine and propofol before LISA in neonates born before 30 weeks of gestational age (GA). The primary outcome was requirement of intubation within 2 h of the procedure. One hundred and fourteen infants, with respective GA and birthweight of 27.6 (26.4, 28.7) weeks and 940 (805, 1140) g, were prospectively included from January 2016 to December 2019. Drug doses were 1 (0.5, 1) mg/kg for ketamine and 1 (1, 1.9) mg/kg for propofol, providing comparable comfort during LISA (p = 0.61). Rates of intubation within 2 h were 5/52 after ketamine, and 5/62 after propofol [aOR 0.54 (0.11-2.68)]. No difference was observed for rates of intubation at 24 h and 72 h following LISA, mortality, or severe morbidity.Conclusion: Pending results from prospective trials, these findings suggest that ketamine or propofol can be used for premedication before LISA, as they show comparable efficacy and tolerance.Trial registration: This study was recorded on the National Library of Medicine registry (https:// clinicaltrials.gov / Identifier: NCT03705468). What is Known? • Less invasive surfactant administration (LISA) is increasingly used in spontaneously breathing premature infants supported with continuous positive airway pressure, but few data are available to guide adequate premedication for this procedure. What is New? • This observational study of 114 neonates, all less than 30-week gestational age and requiring surfactant without endotracheal tube in the delivery room, suggested that ketamine or propofol can be used for premedication before LISA with comparable efficacy and tolerance.
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Affiliation(s)
- Camille Brotelande
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Christophe Milési
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Clémentine Combes
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Sabine Durand
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Maliha Badr
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France.
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Härtel C, Glaser K, Speer CP. The Miracles of Surfactant: Less Invasive Surfactant Administration, Nebulization, and Carrier of Topical Drugs. Neonatology 2021; 118:225-234. [PMID: 33971657 DOI: 10.1159/000516106] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
Surfactant replacement therapy (SRT) has long become the standard of care in the treatment of neonatal respiratory distress syndrome (RDS), significantly decreasing acute pulmonary morbidity and mortality in preterm infants. For decades, this beneficial replacement therapy has been administered via endotracheal tube. Despite significantly improving the outcome of RDS, however, the burden of bronchopulmonary dysplasia remains, in particular, in very immature preterm infants. Acknowledging the direct relationship between exposure to and duration of invasive mechanical ventilation and chronic lung disease, the latter has been gradually replaced by noninvasive ventilation strategies in neonatal RDS. This replacement is strongly related to the demand for similarly noninvasive modes of surfactant administration. Alternative techniques in spontaneously breathing infants have evolved, including less invasive techniques using thin catheters (less invasive surfactant administration and minimally invasive surfactant treatment) as well as nebulization of surfactant, although the latter is not ready for clinical application yet. In addition, given their therapeutic delivery to the lungs and subsequent alveolar distribution, surfactant preparations represent an attractive vehicle for pulmonary deposition of drugs in preterm infants. Further improvement of SRT and expansion of the field of application of lung surfactant may hold additional benefits, especially in the treatment of the most immature preterm infants.
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Affiliation(s)
- Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
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Chevallier M, Durrmeyer X, Ego A, Debillon T. Propofol versus placebo (with rescue with ketamine) before less invasive surfactant administration: study protocol for a multicenter, double-blind, placebo controlled trial (PROLISA). BMC Pediatr 2020; 20:199. [PMID: 32384914 PMCID: PMC7206779 DOI: 10.1186/s12887-020-02112-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/29/2020] [Indexed: 01/05/2023] Open
Abstract
Background One major limitation for less invasive surfactant administration (LISA) is the difficulty in providing sedation before this procedure and the competitive risk of respiratory depression versus avoidance of intubation for most sedative or analgesic drugs used in this context. The objective of this study is to compare the need for mechanical ventilation within 72 h of life following premedication with propofol, versus placebo (rescue with ketamine), for the LISA procedure in preterm neonates born before 32 weeks gestational age (wGA). Methods ProLISA is a phase III, non-inferiority, multicenter, double blind, randomized, placebo controlled trial designed according to the SPIRIT Statement. Neonates born before 32 wGA in 12 geographically dispersed Neonatal Intensive Care Units in France needing surfactant will be included from September 2019 to September 2022. A sample of 542 patients is needed. The neonate is randomized to the intervention (propofol) or control placebo group. Open label rescue treatment with ketamine is possible in both groups if FANS (Faceless Acute Neonatal pain Scale) is ≥6. To guide drug administration, FANS is scored before attempting laryngoscopy. Once an adequate score has been obtained, LISA is performed according to a standardized protocol. The primary outcome is the need for mechanical ventilation within 72 h of life. Secondary outcomes are tolerance of the procedure, pain evaluation, hemodynamic and neurologic parameters after the intervention, morbidities before discharge and neurodevelopmental assessment at 2 years of age. Discussion This paper describes the first multicenter, double-blind, randomized, placebo-controlled trial on this topic and will provide crucial information to support implementation of the LISA procedure. Trial registration ClinicalTrials.gov: NCT04016246. Registered 06 June 2019, N°EUDRACT: 2018–002876-41.
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Affiliation(s)
- Marie Chevallier
- UMR 5525 ThEMAS, CNRS, TIMC-IMAG, Grenoble Alps University, Grenoble, France. .,Neonatal Intensive Care Unit, Grenoble Alps University Hospital, Grenoble, France.
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est, IMRB- GRC GEMINI, Créteil, France.,Inserm, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, Paris, France
| | - Anne Ego
- Neonatal Intensive Care Unit, Grenoble Alps University Hospital, Grenoble, France
| | - Thierry Debillon
- UMR 5525 ThEMAS, CNRS, TIMC-IMAG, Grenoble Alps University, Grenoble, France.,Neonatal Intensive Care Unit, Grenoble Alps University Hospital, Grenoble, France
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11
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Buyuktiryaki M, Alarcon-Martinez T, Simsek GK, Canpolat FE, Tayman C, Oguz SS, Kutman HGK. Five-year single center experience on surfactant treatment in preterm infants with respiratory distress syndrome: LISA vs INSURE. Early Hum Dev 2019; 135:32-36. [PMID: 31229792 DOI: 10.1016/j.earlhumdev.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/11/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surfactant administration traditionally involved endotracheal intubation and mechanical ventilation, which is associated with a risk of barotrauma and volutrauma. OBJECTIVE To compare the morbidity and mortality rates between LISA-treated and INSURE-treated premature babies with respiratory distress syndrome (RDS). METHODS We assessed retrospectively the medical records of preterm infants who were born at 250/7 to 296/7 weeks of gestation and were administered surfactant initially either with LISA or INSURE method over a five-year period. RESULTS Analysis of the data of 205 LISA-treated and 178 INSURE-treated infants revealed the mean gestational age as 28.1 ± 1.3 and 28 ± 1.3 weeks and mean birth weight as 1041 ± 205 and 1029 ± 222 g in LISA and INSURE groups, respectively. The mechanical ventilation requirement in the first 72 h of life (%26.8-%42.1, p = 0.002) and the incidence of moderate-severe BPD (%12.2-%21.9, p = 0.01) were lower in LISA-treated infants. LISA method was found as an independent factor in reducing mechanical ventilation requirement in the first 72 h of life and incidence of moderate-severe BPD [RR: -0.49 (%95 CI -0.28 to -0.85), p = 0.01]. CONCLUSION Data obtained from our five-year clinical experience are comparable with the recent literature. LISA is currently the most suitable method of surfactant administration and it should be the first choice in spontaneously breathing infants considering its favorable effects on respiratory morbidities in preterm infants with RDS.
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Affiliation(s)
- Mehmet Buyuktiryaki
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey.
| | - Tugba Alarcon-Martinez
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey
| | - Gulsum Kadioglu Simsek
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey
| | - Fuat Emre Canpolat
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey
| | - Cuneyt Tayman
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey
| | - Serife Suna Oguz
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey
| | - Hayriye Gozde Kanmaz Kutman
- Division of Neonatology, Health Sciences University, Zekai Tahir Burak Maternity Education and Research Hospital, Ankara, Turkey
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Abstract
Non-invasive ventilation is currently the preferred respiratory support for premature infants with respiratory distress. The lung-protective effects of non-invasive ventilation should however not prompt disregard for the possible pain and discomfort it can generate. Non-pharmacological interventions should be used in all premature infants, regardless of their respiratory support, and are not detailed in this review. This review includes currently available evidence and gaps in knowledge regarding three aspects of pain management in premature infants receiving non-invasive ventilation: optimisation of non-invasive ventilation especially through the choice of positive pressure source, appropriate interface and synchronisation; sedative or analgesic drug use for strategies aiming at administering surfactant with reduction or avoidance of tracheal ventilation; risks and benefits of some analgesic and/or sedative drugs used to treat or prevent prolonged pain and discomfort during non-invasive ventilation. In spite of limited robust evidence, this overview should trigger caregivers' reflections on their daily practice.
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13
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Vento M, Bohlin K, Herting E, Roehr CC, Dargaville PA. Surfactant Administration via Thin Catheter: A Practical Guide. Neonatology 2019; 116:211-226. [PMID: 31461712 DOI: 10.1159/000502610] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/06/2019] [Indexed: 11/19/2022]
Abstract
Exogenous surfactant replacement is the most effective evidence-based therapy for respiratory distress syndrome in preterm infants. The mode of administration has evolved in the last decade towards less invasive techniques that aim to effectively provide an adequate dose of surfactant, while allowing spontaneous respiration to continue, and with the support of continuous positive airway pressure. Surfactant delivery via aerosolisation, pharyngeal instillation, and laryngeal mask are being actively pursued in research, but have not yet been adopted to any significant degree in clinical practice. Surfactant administration via thin catheter, on the other hand, is becoming more widely used in neonatal intensive care units worldwide and is now an acknowledged alternative to the standard mode of surfactant delivery. Different devices, including nasogastric tubes, vascular catheters, and purpose-built surfactant instillation catheters are used. We present here a contemporary review of surfactant administration via thin catheter, in a practical guide format that reflects the individual and collective scientific opinions of the clinicians who participated in formulating the guide.
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Affiliation(s)
- Maximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain, .,Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain,
| | - Kajsa Bohlin
- Department of Neonatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Egbert Herting
- Department of Paediatrics, University of Luebeck, Luebeck, Germany
| | - Charles Christoph Roehr
- Newborn Services, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Medical Sciences Division, University of Oxford, Department of Paediatrics, Oxford, United Kingdom
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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14
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Abstract
Traditionally, surfactant has been administered to preterm infants with respiratory distress syndrome via an endotracheal tube and in conjunction with mechanical ventilation. However, negative consequences of mechanical ventilation such as pneumothorax and bronchopulmonary dysplasia are well known. In order to provide the benefits of surfactant administration without the negative effects of mechanical ventilation, several methods of less invasive surfactant administration have been developed. These methods include InSurE (intubate, surfactant, extubate), pharyngeal administration, laryngeal mask administration, aerosolized surfactant administration, and thin catheter administration (TCA). Of these, TCA has been studied most extensively and holds the most promise as a less invasive and effective mode of surfactant administration to preterm infants. Further studies will aid in determining which patients would benefit most from less invasive surfactant administration.
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Affiliation(s)
- Whittney D Barkhuff
- Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA,
| | - Roger F Soll
- Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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15
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Langhammer K, Roth B, Kribs A, Göpel W, Kuntz L, Miedaner F. Treatment and outcome data of very low birth weight infants treated with less invasive surfactant administration in comparison to intubation and mechanical ventilation in the clinical setting of a cross-sectional observational multicenter study. Eur J Pediatr 2018; 177:1207-17. [PMID: 29808237 DOI: 10.1007/s00431-018-3179-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 10/14/2022]
Abstract
UNLABELLED The aim of this study was to contribute further to existing randomized controlled trials and meta-analyses showing advantages in the outcome of less invasive surfactant administration (LISA)-treated infants and add new aspects concerning treatment and outcome data collected in the routine clinical setting. Four hundred seven very low birth weight infants who received surfactant via either LISA or intubation methods were enrolled in the observational cross-sectional multicenter study. To compare infants in terms of surfactant administration, we used an exact matching procedure (the same gestational age, severe perinatal depression (pH < 7.10), birth weight < 10th percentile, antenatal steroid treatment, and the same gender). To check for robustness, we performed repeated matching. LISA-treated infants required significantly less mechanical ventilation during hospital stay (p < 0.001) and days with supplemental oxygen (p = 0.03). Analgesics and sedatives were used less often during the stay (p < 0.001). Infants treated with LISA had significantly lower rates of bronchopulmonary dysplasia (p = 0.003). LISA failure infants were identified as more likely to be small for gestational age and more immature. CONCLUSION Our study complements former results with advantages for LISA-treated infants in mechanical ventilation and bronchopulmonary dysplasia in the clinical routine. TRIAL REGISTRATION DRKS00004589 What is Known: • According to existing literature, LISA-treated infants seem to have some favors in terms of treatment and outcome data. Observational studies in routine clinical setting are missing. What is New: • Data of 407 VLBW infants collected in routine clinical setting showed that LISA-treated infants needed less mechanical ventilation and fewer days with supplemental oxygen and less analgesics and sedatives. A reduced risk of BPD could be showed. SGA infants seem to have higher risks of LISA failure.
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16
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Gortner L, Schüller SS, Herting E. Review demonstrates that less invasive surfactant administration in preterm neonates leads to fewer complications. Acta Paediatr 2018; 107:736-743. [PMID: 29172232 DOI: 10.1111/apa.14161] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/28/2017] [Accepted: 11/21/2017] [Indexed: 11/28/2022]
Abstract
Surfactant treatment of neonatal respiratory distress syndrome (RDS) was introduced in Europe during the 1990s. Meta-analyses have indicated that using less invasive surfactant administration techniques on preterm neonates receiving continuous positive airway pressure (CPAP) results in improved survival rates without bronchopulmonary dysplasia. Surfactant should be administered early and ventilator settings adapted to changing oxygen requirements and lung mechanics. Side effects including initial bradycardia, oxygen desaturation, tube obstruction and isolated cases of pulmonary haemorrhage have been reported. CONCLUSION Less invasive surfactant therapy improves pulmonary outcomes in preterm neonates with RDS and should ideally be administered in combination with CPAP.
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Affiliation(s)
- Ludwig Gortner
- Division of Neonatology, Paediatric Intensive Care Medicine and Neuropaediatrics; Department of Paediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - Simone S. Schüller
- Division of Neonatology, Paediatric Intensive Care Medicine and Neuropaediatrics; Department of Paediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - Egbert Herting
- Department of Paediatrics and Adolescent Medicine; University Hospital of Schleswig Holstein; Lübeck Germany
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17
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Fabbri L, Klebermass-Schrehof K, Aguar M, Harrison C, Gulczyńska E, Santoro D, Di Castri M, Rigo V. Five-country manikin study found that neonatologists preferred using the LISAcath rather than the Angiocath for less invasive surfactant administration. Acta Paediatr 2018; 107:780-783. [PMID: 29315806 PMCID: PMC5947293 DOI: 10.1111/apa.14214] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/20/2017] [Accepted: 01/03/2018] [Indexed: 11/28/2022]
Abstract
Aim Less invasive surfactant administration (LISA) has been shown to decrease the risk of death and bronchopulmonary dysplasia in preterm neonates. The LISAcath is the first catheter to be specifically developed for LISA, and we compared the clinical impressions of neonatologists using the LISAcath and the commonly used Angiocath in a simulated setting. Methods This was a multinational, multicentre study, conducted in October 2016, which involved 39 neonatologists who were recruited by employees of the sponsor from large, well‐recognised neonatal intensive care units across Europe. LISA was not the standard of care in these units in Austria, Belgium, Poland, Spain and the United Kingdom at the time of the study. After training, participants simulated LISA on a neonatal manikin, once with the LISAcath and once with Angiocath, then answered a 10‐item questionnaire. Results The responses to nine of 10 questions showed that 67‐95% of the respondents preferred the LISAcath to the Angiocath, with most of the remainder indicating no preference. The only exception was the luer connection question, with two‐thirds expressing no preference. The LISAcath was considered potentially safer by 33 of 39 participants, with no votes for the Angiocath. Conclusion Overall, neonatologists preferred using the LISAcath rather than the Angiocath on a neonatal manikin.
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Affiliation(s)
- Laura Fabbri
- Research & Development - Neonatology; Chiesi Farmaceutici SpA; Parma Italy
| | - Katrin Klebermass-Schrehof
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
| | - Marta Aguar
- Division of Neonatology; Hospital Universitari i Politècnic la Fe; Valencia Spain
| | | | - Ewa Gulczyńska
- Department of Neonatology; Polish Mother's Memorial Hospital - Research Institute; Łódź Poland
| | - Debora Santoro
- Research & Development - Neonatology; Chiesi Farmaceutici SpA; Parma Italy
| | - Marco Di Castri
- Research & Development - Neonatology; Chiesi Farmaceutici SpA; Parma Italy
| | - Vincent Rigo
- Neonatology Division; CHU de Liège - CHR de la Citadelle; University of Liège; Liège Belgium
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18
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Heiring C, Jonsson B, Andersson S, Björklund LJ. Survey shows large differences between the Nordic countries in the use of less invasive surfactant administration. Acta Paediatr 2017; 106:382-386. [PMID: 27992064 DOI: 10.1111/apa.13694] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/28/2016] [Accepted: 12/05/2016] [Indexed: 02/05/2023]
Abstract
AIM Less invasive surfactant administration (LISA), namely surfactant instillation through a thin catheter in the trachea during spontaneous breathing, is increasingly used for premature infants. We surveyed the use of this technique in the Nordic countries in autumn 2015. METHODS A link to a web-based survey of surfactant administration methods was emailed to the directors of all neonatal units in the Nordic Region, apart from Finland, where only the five university-based departments were invited. RESULTS Of the 73 units (85%) who responded, 23 (32%) said that they used LISA. The country rates were Iceland 100%, Norway 82%, Finland 60%, Denmark, including Faroe Island and Greenland, 11% and Sweden 9%. LISA was used in 62% of level three units, but only 14% of level two units and most commonly in babies with a gestational age of at least 26 weeks. Premedication was always or sometimes used by 78%. The main reasons for not using LISA were lack of familiarity with the technique (61%), no perceived benefit over other methods (22%) and concerns about patient discomfort (26%). CONCLUSION Less invasive surfactant administration was used in 32% of Nordic neonatal units, most commonly in level three units. Premedication was used more often than previously reported.
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Affiliation(s)
| | - Baldvin Jonsson
- Department of Neonatology; Karolinska University Hospital; Stockholm Sweden
- Department of Women's and Children's Health; Karolinska Institute; Stockholm Sweden
| | - Sture Andersson
- Children's Hospital; Helsinki University Central Hospital and University of Helsinki; Helsinki Finland
| | - Lars J. Björklund
- Department of Paediatric Surgery and Neonatology; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; University of Lund; Lund Sweden
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19
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Göpel W, Kribs A, Härtel C, Avenarius S, Teig N, Groneck P, Olbertz D, Roll C, Vochem M, Weller U, von der Wense A, Wieg C, Wintgens J, Preuss M, Ziegler A, Roth B, Herting E. Less invasive surfactant administration is associated with improved pulmonary outcomes in spontaneously breathing preterm infants. Acta Paediatr 2015; 104:241-6. [PMID: 25474712 DOI: 10.1111/apa.12883] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 06/21/2014] [Accepted: 11/26/2014] [Indexed: 02/03/2023]
Abstract
AIM Providing less invasive surfactant administration (LISA) to spontaneously breathing preterm infants has been reported to reduce mechanical ventilation and bronchopulmonary dysplasia (BPD) in randomised controlled trials. This large cohort study compared these outcome measures between LISA-treated infants and controls. METHODS Infants receiving LISA, who were born before 32 gestational weeks and enrolled in the German Neonatal Network, were matched to control infants by gestational age, umbilical cord pH, Apgar-score at 5 min, small for gestational age status, antenatal treatment with steroids, gender and highest supplemental oxygen during the first 12 h of life. Outcome data were compared with chi-square and Mann-Whitney U-tests and adjusted for multiple comparisons. RESULTS Between 2009 and 2012, 1103 infants were treated with LISA at 37 centres. LISA infants had lower rates of mechanical ventilation (41% versus 62%, p < 0.001), postnatal dexamethasone treatment (2.5% versus 7%, p < 0.001), BPD (12% versus 18%, p = 0.001) and BPD or death (14% versus 21%, p < 0.001) than the controls. CONCLUSION Surfactant treatment of spontaneously breathing infants was associated with lower rates of mechanical ventilation and BPD. Additional large-scale randomised controlled trials are needed to assess the possible long-term benefits of LISA.
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Affiliation(s)
- Wolfgang Göpel
- Department of Pediatrics; University of Lübeck; Lübeck Germany
| | - Angela Kribs
- Department of Pediatrics; University of Cologne; Cologne Germany
| | | | - Stefan Avenarius
- Department of Pediatrics; University of Magdeburg; Magdeburg Germany
| | - Norbert Teig
- Department of Pediatrics; University of Bochum; Bochum Germany
| | | | | | | | | | | | | | | | | | - Michael Preuss
- Institute for Medical Biometry and Statistics; University of Lübeck; Lübeck Germany
| | - Andreas Ziegler
- Institute for Medical Biometry and Statistics; University of Lübeck; Lübeck Germany
- Center for Clinical Trials; University of Lübeck; Lübeck Germany
| | - Bernhard Roth
- Department of Pediatrics; University of Cologne; Cologne Germany
| | - Egbert Herting
- Department of Pediatrics; University of Lübeck; Lübeck Germany
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