Minimally Invasive Surfactant Therapy Research Articles

Update of minimally invasive surfactant therapy.

To date, preterm infants with respiratory distress syndrome (RDS) after birth have been managed with a combination of endotracheal intubation, surfactant instillation, and mechanical ventilation. It is now recognized that noninvasive ventilation (NIV) such as nasal continuous positive airway pressure (CPAP) in preterm infants is a reasonable alternative to elective intubation after birth. Recently, a meta-analysis of large controlled trials comparing conventional methods and nasal CPAP suggested that CPAP decreased the risk of the combined outcome of bronchopulmonary dysplasia or death. Since then, the use of NIV as primary therapy for preterm infants has increased, but when and how to give exogenous surfactant remains unclear. Overcoming this problem, minimally invasive surfactant therapy (MIST) allows spontaneously breathing neonates to remain on CPAP in the first week after birth. MIST has included administration of exogenous surfactant by intrapharyngeal instillation, nebulization, a laryngeal mask, and a thin catheter. In recent clinical trials, surfactant delivery via a thin catheter was found to reduce the need for subsequent endotracheal intubation and mechanical ventilation, and improves short-term respiratory outcomes. There is also growing evidence for MIST as an alternative to the INSURE (intubation-surfactant-extubation) procedure in spontaneously breathing preterm infants with RDS. In conclusion, MIST is gentle, safe, feasible, and effective in preterm infants, and is widely used for surfactant administration with noninvasive respiratory support by neonatologists. However, further studies are needed to resolve uncertainties in the MIST method, including infant selection, optimal surfactant dosage and administration method, and need for sedation.

Effect of surfactant therapy using an orogastric tube for tracheal catheterization in preterm newborns with respiratory distress

Introduction: Respiratory distress syndrome (RDS) due to surfactant deficiency requires surfactant therapy for which InSurE method (Intubate, Surfactant, Extubate) has been widely used. However this method requires intubation and positive pressure ventilation, even for a short time which is enough to initiate significant lung injury. Recently, surfactant administration by Minimally Invasive Surfactant Therapy (MIST) using a fine catheter under direct laryngoscopy in spontaneously breathing preterms while on nCPAP has reported good outcomes. We prospectively assessed the outcome of a modified MIST method of surfactant administration using an orogastric tube in preterms with RDS. Materials & Methods: A single centre, prospective observational study was conducted where all consecutive eligible inborn preterm neonates with gestation age more than 24 weeks but less than 34 weeks and suffering from RDS were enrolled to receive surfactant using MIST. Results were compared with a historical cohort of preterm who received surfactant with INSURE techniques. Results: Sixty four cases in the modified MIST group were compared with a historic cohort of 68 cases in INSURE group. There were no differences in the requirement of intubation and mechanical ventilation in the first 72 hours but the duration of MV and CPAP were significantly less in modified MIST group. Other neonatal morbidities and mortality rates were similar in either of the groups. Conclusion: The modified MIST technique is an effective method for the treatment of RDS in preterms with better clinical efficacy and comparable outcomes than the more invasive INSURE procedure and deserves further evaluation.

Sedation during Minimal Invasive Surfactant Therapy in Preterm Infants

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.

Surfactant replacement therapy with a minimally invasive technique: Experience in a tertiary hospital

Abstract Introduction The minimally invasive technique known as MIST (Minimally Invasive Surfactant Therapy), is a method which allows surfactant to be administered to a patient connected to non-invasive respiratory support. Use of this therapy is growing in Neonatal Units, as it reduces the intubation rate and the pathology associated with intubation and allows surfactant to be administered to patients in need. Patients and methods In 2013 and 2014 in the Hospital General Universitario de Elche surfactant was delivered using this method to 19 patients, 5 of whom had a gestational age of 28 or less weeks. Data were compared with a historical cohort consisting of 28 patients with Respiratory Distress Syndrome treated initially with non-invasive respiratory support. Results No incidents were recorded that caused interruption of administration. A reduction in the fraction of inspired oxygen was observed in all cases after surfactant administration. Fewer intubations in the first 72 h of life were found in the treatment group compared to the control group (42% vs. 54%). Discussion The experience in the Hospital General Universitario de Elche shows that administration of surfactant using the MIST technique is a reproducible method of treatment, which allows surfactant distribution during spontaneous breathing with non-invasive respiratory support.

Effect of Minimally Invasive Surfactant Therapy on Lung Volume and Ventilation in Preterm Infants

To assess the changes in (regional) lung volume and gas exchange during minimally invasive surfactant therapy (MIST) in preterm infants with respiratory distress syndrome. In this prospective observational study, infants requiring a fraction of inspired oxygen (FiO2) ≥ 0.30 during nasal continuous positive airway pressure of 6 cmH2O were eligible for MIST. Surfactant (160-240 mg/kg) was administered in supine position in 1-3 minutes via an umbilical catheter placed 2 cm below the vocal cords. Changes in end-expiratory lung volume (EELV), tidal volume, and its distribution were recorded continuously with electrical impedance tomography before and up to 60 minutes after MIST. Changes in transcutaneous oxygen saturation (SpO2) and partial carbon dioxide pressure, FiO2, respiratory rate, and minute ventilation were recorded. A total of 16 preterm infants were included. One patient did not finish study protocol because of severe apnea 10 minutes after MIST. In the remaining infants (gestational age 29.8 ± 2.8 weeks, body weight 1545 ± 481 g) EELV showed a rapid and sustained increase, starting in the dependent lung regions, followed by the nondependent regions approximately 5 minutes later. Oxygenation, expressed as the SpO2/FiO2 ratio, increased from 233 (IQR 206-257) to 418 (IQR 356-446) after 60 minutes (P < .001). This change was significantly correlated with the change in EELV (ρ = 0.70, P < .01). Tidal volume and minute volume decreased significantly after MIST, but transcutaneous partial carbon dioxide pressure was comparable with pre-MIST values. Ventilation distribution remained unchanged. MIST results in a rapid and homogeneous increase in EELV, which is associated with an improvement in oxygenation.

Nasal continuous positive airway pressure versus nasal intermittent positive-pressure ventilation within the minimally invasive surfactant therapy approach in preterm infants: a randomised controlled trial

ObjectiveTo compare the effectiveness of nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive-pressure ventilation (NIPPV) as the initial respiratory support within the minimally invasive surfactant therapy (MIST) approach...

Terapia con surfactante con técnica mínimamente invasiva: experiencia en un hospital terciario

IntroductionSurfactant delivered using a minimally invasive technique, known as MIST (Minimally Invasive Surfactant Therapy) is a method which allows surfactant to be adminstered to a patient connected to non-invasive respiratory support. This is an increasingly used therapy in Neonatal Units that reduces the intubation rate and the pathology associated with intubation and allows the surfactant to be administered to the patients who clinically need it. Patients and methodsIn years 2013 and 2014 in the Hospital General Universitario de Elche surfactant was delivered using this method to 19 patients, five of whom were 28 or less weeks of gestation age at birth. A comparison is made with a historical cohort consisting of 28 patients with Respiratory Distress Syndrome treated initially with non-invasive respiratory support. ResultsNo incidents were recorded that caused the interruption of the administration. A reduction in the fraction of inspired oxygen was observed in all cases after surfactant administration. Fewer intubations in the first 72hours of life were found in the treatment group compared to the control group (42% vs. 54%). DiscussionThe experience recorded in the Hospital General Universitario de Elche shows that the administration of surfactant using a MIST technique is a reproducible method of treatment, which allows the surfactant distribution during spontaneous breathing with non invasive respiratory support.

Minimally Invasive Surfactant Therapy

For many years preterm infants with respiratory distress syndrome have been managed with a combination of intubation and surfactant replacement therapy. It is now recognized that applying noninvasive ventilation (NIV) such as nasal continuous positive airway pressure (CPAP) in preterm infants is a reasonable alternative to early intubation after birth. Recently, nasal CPAP has shown a benefit with a small reduction in the risk of the combined outcome of death or bronchopulmonary dysplasia. There has been an upsurge in the use of NIV as primary therapy for preterm infants, bringing with it the dilemma of when and how to give exogenous surfactant. In an effort to overcome this problem, minimally invasive surfactant therapy (MIST) to spontaneously breathing infants, allows them to remain on CPAP in first days after birth. MIST has included administration of exogenous surfactant by brief tracheal catheterization, aerosolization, laryngeal mask, and intrapharyngeal instillation. In recent clinical trials, surfactant delivery via brief tracheal catheterization was found to reduce the need for subsequent intubation and mechanical ventilation and to improve short-term respiratory outcomes. In conclusion, MIST is gentle, safe, feasible and effective to perform in preterm infants and will also be used commonly in Korea.

Minimally Invasive Surfactant Therapy: New Age

For many years preterm infants with respiratory distress syndrome (RDS) have been managed with intubation and surfactant administration, but advances in Neonatology have allowed a softer therapy in newborns. The use of non-invasive respiratory support has been widespread. This has implied that surfactant administration, linked to mechanical ventilation, is just used in cases of non-invasive respiratory support failure. Nowadays Minimally Invasive Surfactant Therapy (MIST) allows neonatologists to use surfactant administration with non-invasive respiratory support. MIST techniques by tracheal catheterization have shown good results reducing the need of mechanical ventilation, bronchopulmonary dysplasia and improved oxygenation. These techniques are safe, effective, gentle and feasible to perform in all level NICUs.

PO-0733 Minimal Invasive Surfactant Therapy: Cui Bono?

Background Minimal invasive surfactant therapy (MIST) is associated with a diminished need for mechanical ventilation. Insufficient insight exists in predictive success factors. Aim Defining success factors for MIST. Methods From 2011–2013 preterm infants admitted to the NICU with respiratory distress and radiographically established IRDS with FiO2 Results 40 neonates (GA 24 +2 –37 +1 weeks [30 weeks], birth weight 600–3330 gram [1375 gram], IRDS grade I-III) were eligible. In 38 patients MIST was performed (2/40 were nonetheless intubated due to unrest). Tube insertion caused bradycardia with spontaneous recovery in one patient. Surfactant administration caused desaturation with spontaneous recovery in all patients and apnea in one patient. There were no complications. Therapeutic success was reached in 24/38 (63,2%) patients. In 6/24 (25%) respiratory adjustments were necessary; increasing PEEP in 2/24, starting nIPPV in 4/24. Causes for intubation 14/38 (27,8%) were rebound IRDS (6/14), sepsis (5/14) and insufficient drive to breath 2/14. Gestational age, birth weight, FiO2/IRDS degree, timing of MIST and gastric tube route (nasal/oral) were not correlated with success. Conclusion Success factors for MIST are a calm patient, an adequate drive to breathe and the absence of sepsis.

The OPTIMIST-A trial: evaluation of minimally-invasive surfactant therapy in preterm infants 25-28 weeks gestation.

BackgroundIt is now recognized that preterm infants ≤28 weeks gestation can be effectively supported from the outset with nasal continuous positive airway pressure. However, this form of respiratory therapy may fail to adequately support those infants with significant surfactant deficiency, with the result that intubation and delayed surfactant therapy are then required. Infants following this path are known to have a higher risk of adverse outcomes, including death, bronchopulmonary dysplasia and other morbidities. In an effort to circumvent this problem, techniques of minimally-invasive surfactant therapy have been developed, in which exogenous surfactant is administered to a spontaneously breathing infant who can then remain on continuous positive airway pressure. A method of surfactant delivery using a semi-rigid surfactant instillation catheter briefly passed into the trachea (the “Hobart method”) has been shown to be feasible and potentially effective, and now requires evaluation in a randomised controlled trial.Methods/designThis is a multicentre, randomised, masked, controlled trial in preterm infants 25–28 weeks gestation. Infants are eligible if managed on continuous positive airway pressure without prior intubation, and requiring FiO2 ≥ 0.30 at an age ≤6 hours. Randomisation will be to receive exogenous surfactant (200 mg/kg poractant alfa) via the Hobart method, or sham treatment. Infants in both groups will thereafter remain on continuous positive airway pressure unless intubation criteria are reached (FiO2 ≥ 0.45, unremitting apnoea or persistent acidosis). Primary outcome is the composite of death or physiological bronchopulmonary dysplasia, with secondary outcomes including incidence of death; major neonatal morbidities; durations of all modes of respiratory support and hospitalisation; safety of the Hobart method; and outcome at 2 years. A total of 606 infants will be enrolled. The trial will be conducted in >30 centres worldwide, and is expected to be completed by end-2017.DiscussionMinimally-invasive surfactant therapy has the potential to ease the burden of respiratory morbidity in preterm infants. The trial will provide definitive evidence on the effectiveness of this approach in the care of preterm infants born at 25–28 weeks gestation.Trial registrationAustralia and New Zealand Clinical Trial Registry: ACTRN12611000916943; ClinicalTrials.gov: NCT02140580.

Minimally invasive surfactant therapy with a gastric tube is as effective as the intubation, surfactant, and extubation technique in preterm babies

Preterm infants requiring surfactant replacement have been treated using the INSURE technique, which requires sedation and comprises tracheal intubation, surfactant instillation and extubation. However, minimally invasive surfactant therapy (MIST) does not require sedation, minimises airway injury and avoids placing positive pressure ventilation on an immature lung. This study compared the feasibility of the two techniques and the outcomes in preterm babies with respiratory distress syndrome (RDS). Preterm infants with RDS prospectively received surfactant via a gastric tube placed in the trachea by direct laryngoscopy with no sedation. Technique-related complications and respiratory outcomes were analysed. We compared 44 patients who received MIST with a historic cohort of 31 patients who received INSURE. This showed no differences in the rate of intubation and mechanical ventilation in the first 72h, or secondary respiratory outcomes and relevant morbidities, between the babies who received INSURE and those who received MIST. More babies in the MIST group (35%) needed a second dose of surfactant than the INSURE group (6.5%) (p<0.0001). Surfactant administration using MIST, with no sedation, is feasible in preterm infants with RDS. No significant differences in secondary respiratory outcomes were found between the MIST and INSURE techniques.

Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure

ObjectiveTo evaluate the applicability and potential effectiveness of a technique of minimally-invasive surfactant therapy (MIST) in preterm infants on continuous positive airway pressure (CPAP).MethodsAn open feasibility study of MIST was...

Preliminary evaluation of a new technique of minimally invasive surfactant therapy

ObjectiveTo investigate a method of minimally invasive surfactant therapy (MIST) to be used in spontaneously breathing preterm infants on continuous positive airway pressure (CPAP), evaluating the feasibility of the technique...

HPV and Cervical Cancer

<h3>Objective</h3> To investigate a method of minimally invasive surfactant therapy (MIST) to be used in spontaneously breathing preterm infants on continuous positive airway pressure (CPAP), evaluating the feasibility of the technique and the therapeutic benefit after MIST. <h3>Design</h3> Non-randomised feasibility study. <h3>Setting</h3> Tertiary neonatal intensive care unit. <h3>Patients and interventions</h3> Study subjects were preterm infants with respiratory distress supported with CPAP, with early enrolment of 25–28-week infants (n=11) at any CPAP pressure and fractional inspired O₂ concentration (FiO₂), and enrolment of 29–34-week infants (n=14) at CPAP pressure ≥7 cm H₂O and FiO₂ ≥0.35. Without premedication, a 16 gauge vascular catheter was inserted through the vocal cords under direct vision. Porcine surfactant (∼100 mg/kg) was then instilled, followed by reinstitution of CPAP. <h3>Measurements and results</h3> Respiratory indices were documented for 4 h following MIST, and neonatal outcomes ascertained. In all cases, surfactant was successfully administered and CPAP re-established. Coughing (32%) and bradycardia (44%) were transiently noted, and 44% received positive pressure inflations. There was a clear surfactant effect, with lower FiO₂ after MIST (pre-MIST: 0.39±0.092 (mean±SD); 4 h: 0.26±0.093; p&lt;0.01), and a modest reduction in CPAP pressure. Adverse outcomes were few: intubation within 72 h (n=3), pneumothorax (n=1), chronic lung disease (n=3) and death (n=1), all in the 25–28-week group. Outcome was otherwise favourable in both gestation groups, with a trend towards reduction in intubation in the first 72 h in the 25–28-week infants compared with historical controls. <h3>Conclusions</h3> Surfactant can be effectively delivered via a vascular catheter, and this method of MIST deserves further investigation.