Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature

Abstract

Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today’s neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIVandearly surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.

Substantiating and Adopting Lung Ultrasound Scores to Predict Surfactant Need in Preterm Neonates with Respiratory Distress Syndrome within an Institution

“…22 One may argue that FiO 2 and respiratory effort on clinical exam should be able to predict surfactant need; however, a study has shown that FiO 2 remains a poor predictor for surfactant deficiency. 4 LUS offers additional advantages in predicting surfactant need and is supported by the European consensus guidelines on the management of RDS. 3,8 Quality improvement projects have shown that using LUS can improve the timeliness of surfactant administration and reduce unnecessary oxygen exposure.…”

“…3 However, around 50% of preterm neonates fail on nCPAP alone and need surfactant therapy. 4 Timely and accurately differentiating the preterm neonates who will benefit from surfactant administration remains challenging. The European consensus guidelines recommend surfactant administration threshold as >30% supplemental oxygen for preterm neonates on continuous positive airway pressure 6 cm H 2 O.…”

“…3 However, relying solely on oxygen fraction (FiO 2 ) alone is a poor predictor for surfactant deficiency. 4 Delay in surfactant therapy may impact neonatal outcomes. 5,6 An adjunct diagnostic tool is needed to recognize neonates with significant RDS who will benefit from surfactant therapy.…”

Respiratory Severity Score during the First 3 Hours of Life as a Predictor for Failure of Noninvasive Respiratory Support and Need for Late Rescue Surfactant Administration

“…Dual strategy, early noninvasive respiratory support with early surfactant administration may increase NIV success. 4,5 The ideal time for surfactant administration has been debated. 6 Current guidelines for RDS management suggest early rescue surfactant administration.…”

“…Dual strategy, early noninvasive respiratory support with early surfactant administration may increase NIV success. 4 5…”