New techniques, new challenges—The dilemma of pain management for less invasive surfactant administration?

Abstract

Recent years have seen the increasing use of noninvasive respiratory support in preterm infants with the aim of minimizing the risk of mechanical ventilation and subsequent bronchopulmonary dysplasia. Respiratory distress syndrome is the most common respiratory diagnosis in preterm infants, and is best treated by administration of surfactant. Until recently, this has been performed via an endotracheal tube using premedication, which has often included opiate analgesia; subsequently, the infant has been ventilated. Avoidance of mechanical ventilation, however, does not negate the need for surfactant therapy. Less invasive surfactant administration (LISA) in spontaneously breathing infants is increasing in popularity, and appears to have beneficial effects. However, laryngoscopy is necessary, which carries adverse effects and is painful for the infant. Conventional methods of premedication for intubation tend to reduce respiratory drive, which increases the likelihood of ventilation being required. This has led to intense debate about the best strategy for providing appropriate treatment, taking into account both the respiratory needs of the infant and the need to alleviate procedural pain. Currently, clinical practice varies considerably and there is no consensus with respect to optimal management. This review seeks to summarize the benefits, risks, and challenges associated with this new approach.

A survey of minimally invasive surfactant therapy in Canada

“…While our group had published the local use of higher volume surfactant [ 1 ], this national data support that the MIST procedure may be successfully used regardless of the surfactant volume. Similar to previous survey-based studies, premedication prescription in MIST use remains a highly variable practice and future research exploring ideal agents is needed [ 18 ]. Furthermore, the relative popularity of video laryngoscope use was a notable finding.…”

Analgosedation before Less-Invasive Surfactant Administration: A Systematic Review

“…The ideal drug would suppress pain and discomfort, while maintaining cardiorespiratory stability and having a minimal impact on the respiratory drive. Moreover, it would allow a rapid onset and offset and be safe in the long term [6, 14, 33]. To optimize the effect of the chosen drug, the time interval before procedure varies according to its pharmacokinetics properties.…”

“…An important limit is the need to maintain cardiorespiratory stability and to have a minimal impact on the respiratory drive centres. Spontaneous breathing is considered important during LISA procedure to assure the surfactant dispersion from the trachea and to allow the infant to stay on CPAP [5, 6]. The first large RCT, the Avoidance of Mechanical Ventilation study [18], investigating LISA allowed for sedation at the discretion of the caregiver.…”

Surfactant Replacement Therapy: What’s the New Future?

“…Neonatal exposure to painful stimuli at a critical time of brain development in preterm infants is known to be associated with long-term problems such as the decreased development of white matter and subcortical gray matter and chronic pain states in graduates of neonatal intensive care. 71, 122-126 Perlman 126 and Volpe 127 showed that routine endotracheal suctioning changes cerebral blood flow, suggesting that this is a stressful procedure for the infant. Grunau 128 suggests that pain and stress may not only hinder body and head growth but may also cause poor brain development, reduced pain thresholds, and disruption of the set points of biological circuits.…”

“…And since respiratory depression is an indication for tracheal intubation, usage of sedation can prove to be counterproductive. 122…”