Minimally Invasive Surfactant Administration in Preterm Infants

More, Kiran; Sakhuja, Pankaj; Shah, Prakesh S.

doi:10.1001/jamapediatrics.2014.1148

Cited by 97 publications

(79 citation statements)

References 42 publications

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“…The published evidence in relation to minimally invasive surfactant therapy is characterised by a paucity of clinical trials [9,11,12,13,14,15] and a surfeit of meta-analyses [18,19,20,21,22], with the overall impression being that surfactant is more effective when delivered via a thin catheter to a spontaneously breathing infant, rather than via an endotracheal tube with positive pressure ventilation. Only around 250 of the 895 infants thus far studied have been in the gestation range of 29-32 weeks [9,12,13,14], and none of the trials including infants at this gestation have compared surfactant administration using a minimally invasive approach with continuation of CPAP.…”

Section: Discussionmentioning

confidence: 99%

Impact of Minimally Invasive Surfactant Therapy in Preterm Infants at 29-32 Weeks Gestation

et al. 2017

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Background: Most preterm infants born at 29-32 weeks gestation now avoid intubation in early life, and thus lack the usual conduit through which exogenous surfactant is given if needed. Objective: The aim of this work was to examine whether a technique of minimally invasive surfactant therapy used selectively at 29-32 weeks gestation would improve outcomes. Methods: We studied the impact of selective administration of surfactant (poractant alfa 100-200 mg/kg) by thin catheter in infants with respiratory distress syndrome on continuous positive airway pressure (CPAP). The threshold for consideration of treatment was CPAP ≥7 cm H₂O and FiO₂ ≥0.35 prior to 24 h of life. In-hospital outcomes were compared before and after introducing minimally invasive surfactant therapy (epochs 1 and 2, respectively). Results: During epoch 2, of 266 infants commencing CPAP, 51 (19%) reached the treatment threshold. Thirty-seven infants received surfactant via thin catheter, and CPAP failure was avoided in 34 of these (92%). For the overall cohort of infants at 29-32 weeks gestation, after the introduction of minimally invasive surfactant therapy, there were reductions in CPAP failure (epoch 1: 14%, epoch 2: 7.2%) and average days of intubation, with equivalent surfactant use and days of respiratory support (intubation + CPAP). Pneumothorax was substantially reduced (from 8.0 to 2.4%). These findings were mirrored within the subgroups reaching the severity threshold in each epoch. The incidence of bronchopulmonary dysplasia was low in both epochs. Conclusions: Selective use of minimally invasive surfactant therapy at 29-32 weeks gestation permits a primary CPAP strategy to be pursued with a high rate of success, and a low risk of pneumothorax.

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Section: Discussionmentioning

confidence: 99%

Impact of Minimally Invasive Surfactant Therapy in Preterm Infants at 29-32 Weeks Gestation

et al. 2017

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“…Administration of surfactant without intubation and mechanical ventilation, using procedures such as MIST, has recently received increased attention and many neonatal units have adopted the method [4,7,9,21]. There is, however, no consensus on whether the procedure should be performed with or without the use of premedication, which has been a hot topic for debate.…”

Section: Discussionmentioning

confidence: 99%

Sedation during Minimal Invasive Surfactant Therapy in Preterm Infants

et al. 2016

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Background: There is no data available whether sedation should be given during minimally invasive surfactant therapy (MIST). Objective: To compare the level of comfort of preterm infants receiving sedation versus no sedation for MIST. Methods: A retrospective study of preterm infants receiving MIST was performed in Leiden University Medical Center in 2014. Sedation (propofol 1 mg/kg) was optional and left to the discretion of the caregiver. Standardized COMFORTneo scores were compared, and COMFORTneo <14 was considered comfortable. Basic characteristics and complications were noted. Results: In 38 infants receiving MIST, 23 received propofol and 15 were not sedated. Mean (SD) gestational age [29 (2) vs. 29 (3) weeks] and birth weight [1,312 (483) vs. 1,469 (588) g] were not different. Median (IQR) COMFORTneo was not different between the groups before [11 (9-15) vs. 10 (8-12)] and after MIST [10 (8-12) vs. 9 (8-10)], but lower in the sedated group during MIST [12 (9-17) vs. 20 (15-23)] with more often COMFORTneo <14 (56 vs. 11%). Duration of MIST [2 (2-4) vs. 3 (2-7) min] and occurrence of bradycardia (13 vs. 33%) and hypotension (21 vs. 18%) were not different. Although not significant, intubation occurred more often in the sedated group (during MIST: 9 vs. 0%, <24 h after MIST: 26 vs. 13%). During MIST, oxygen saturation <80% lasted longer in the sedated group [3 (2-4) vs. 1 (0-2) min], and nasal intermittent positive pressure ventilation was applied more (100 vs. 33%). Conclusions: Preterm infants receiving MIST were more comfortable when sedation was given, but needed ventilation more often. A randomized controlled trial is warranted to test whether the benefit of sedation outweighs the risks of complications.

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“…However, nearly 75% of the intervention group eventually needed MV, and the rate of desaturations was significantly higher in this group [51]. Although direct comparison with INSURE reported improved outcomes in one study [52], reanalysis of the data could not reproduce statistical significance when included in a meta-analysis, and therefore to date this is still uncertain [53]. Nebulization to deliver surfactant has not yet reached a stage where it can be recommended for routine clinical use [54].…”

Section: Surfactant Therapymentioning

confidence: 99%

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update

et al. 2016

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Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

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Minimally Invasive Surfactant Administration in Preterm Infants

Abstract: Surfactant administration via a thin catheter may be an efficacious and potentially safe method; however, further studies are needed. Further studies are also needed for other methods of minimally invasive surfactant administration.

Cited by 97 publications

References 42 publications

Impact of Minimally Invasive Surfactant Therapy in Preterm Infants at 29-32 Weeks Gestation

Impact of Minimally Invasive Surfactant Therapy in Preterm Infants at 29-32 Weeks Gestation

Sedation during Minimal Invasive Surfactant Therapy in Preterm Infants

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update

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