Severe airway obstruction during surfactant administration using a standardized protocol: a prospective, observational study

Abstract

Objective: The objective of this study was to evaluate the occurrence of adverse effects during surfactant delivery, using a standardized protocol for administration and management of complications.Study Design: The protocol was developed, implemented and used for 6 months. Vital signs and ventilatory parameters were prospectively recorded during the procedure. Infants were classified into three groups, based on the occurrence and severity of complications: no, minor or major.Result: A total of 39 infants received surfactant and 19 presented some complication: 11 minor and 8 major. Six of the major complications were episodes of severe airway obstruction (SAO) and five occurred in extreme low birth weight (ELBW) infants that had more severe lung disease before surfactant delivery. Two cases of persistent pulmonary hypertension occurred in infants with birth weight>1000 g. Conclusion:This study identified a high rate of SAO and provides data to support changes in the protocol, which should include faster and more robust increases in positive inspiratory pressures in ELBW infants presenting with SAO.

Acute and sustained effects of aerosolized vs. bolus surfactant therapy in premature lambs with respiratory distress syndrome

“…It is known there are substantial structural and functional differences between the mature cardiovascular system (adult rabbit) and that of the premature cardiovascular system (premature lamb), particularly during the early period of transition to extrauterine life (e.g., ductus arteriosus, foramen ovale, premature myocardium, autonomic nervous system) (24). Therefore, it seems reasonable to suppose that the SF instillation in preterm lambs more accurately reflects the sequence of events that occurs in preterm infants because hypercapnia and CBF increases following SF therapy have often been reported in very preterm infants linked to a transient airway obstruction by instilled SF (15,25). Therefore, a transient airway obstruction following bolus instillation would have produced high CO 2 levels and led to an increase in CBF (25).…”

“…Therefore, it seems reasonable to suppose that the SF instillation in preterm lambs more accurately reflects the sequence of events that occurs in preterm infants because hypercapnia and CBF increases following SF therapy have often been reported in very preterm infants linked to a transient airway obstruction by instilled SF (15,25). Therefore, a transient airway obstruction following bolus instillation would have produced high CO 2 levels and led to an increase in CBF (25). Because brain injury has been associated with CBF fluctuations, a new therapeutic approach based on SF-aero could represent an important clinical advance.…”

The Role of Surfactant in Lung Disease and Host Defense against Pulmonary Infections

“…Endotracheal instillation remains a widely accepted technique of surfactant administration (103). However, this technique may be complicated by episodes of severe airway obstruction (104). Noninvasive or less-invasive techniques, including aerosolized surfactant, laryngeal mask airway-aided delivery, pharyngeal instillation, and the use of thin intratracheal catheters, are being evaluated (105)(106)(107)(108)(109).…”

Respiratory Care Protocols in Neonatal Intensive Care

“…In a further study, the implementation of a nurse-driven comfort protocol in ventilated preterm infants significantly reduced the amount of morphine used which translated in fewer days on MV and a shorter course of hospitalization [70]. Lastly, the use of a standardized surfactant protocol allowed clinicians to audit their practice and identify strategies to reduce adverse events associated with surfactant administration [71]. The results of this quality control initiative led to later modifications of the surfactant protocol, which has recently been published [72].…”