Prophylactic Surfactant Administration Research Articles

Neonatal Resuscitation Practices in Portuguese Delivery Rooms: A Cross-Sectional Study.

Data from previous studies have demonstrated inconsistency between current evidence and delivery room resuscitation practices in developed countries. The primary aim of this study was to assess the quality of newborn healthcare and resuscitation practices in Portuguese delivery rooms, comparing current practices with the 2021 European Resuscitation Council guidelines. The secondary aim was to compare the consistency of practices between tertiary and non-tertiary centers across Portugal. An 87-question survey concerning neonatal care was sent to all physicians registered with the Portuguese Neonatal Society via email. In order to compare practices between centers, participants were divided into two groups: Group A (level III and level IIb centers) and Group B (level IIa and I centers). A descriptive analysis of variables was performed in order to compare the two groups. In total, 130 physicians responded to the survey. Group A included 91 (70%) and Group B 39 (30%) respondents. More than 80% of participants reported the presence of a healthcare professional with basic newborn resuscitation training in all deliveries, essential equipment in the delivery room, such as a resuscitator with a light and heat source, a pulse oximeter, and an O2 blender, and performing delayed cord clamping for all neonates born without complications. Less than 60% reported performing team briefing before deliveries, the presence of electrocardiogram sensors, end-tidal CO2 detector, and continuous positive airway pressure in the delivery room, and monitoring the neonate's temperature. Major differences between groups were found regarding staff attending deliveries, education, equipment, thermal control, umbilical cord management, vital signs monitoring, prophylactic surfactant administration, and the neonate's transportation out of the delivery room. Overall, adherence to neonatal resuscitation international guidelines was high among Portuguese physicians. However, differences between guidelines and current practices, as well as between centers with different levels of care, were identified. Areas for improvement include team briefing, ethics, education, available equipment in delivery rooms, temperature control, and airway management. The authors emphasize the importance of continuous education to ensure compliance with the most recent guidelines and ultimately improve neonatal health outcomes.

Management Practices During Perinatal Respiratory Transition of Very Premature Infants.

The present review considers some controversial management practices during extremely premature perinatal transition. We focus on perinatal prevention and treatment of respiratory distress syndrome (RDS) in immature infants. New concerns regarding antenatal corticosteroid management have been raised. Many fetuses are only exposed to potential adverse effects of the drug. Hence, the formulation and the dosage may need to be modified. Another challenge is to increase the fraction of the high-risk fetuses that benefit from the drug and to minimize the harmful effects of the drug. On the other hand, boosting anti-inflammatory and anti-microbial properties of surfactant requires further attention. Techniques of prophylactic surfactant administration to extremely immature infants at birth may be further refined. Also, new findings suggest that prophylactic treatment of patent ductus arteriosus (PDA) of a high-risk population rather than later selective closure of PDA may be preferred. The TREOCAPA trial (Prophylactic treatment of the ductus arteriosus in preterm infants by acetaminophen) evaluates, whether early intravenous paracetamol decreases the serious cardiorespiratory consequences following extremely premature birth. Lastly, is inhaled nitric oxide (iNO) used in excess? According to current evidence, iNO treatment of uncomplicated RDS is not indicated. Considerably less than 10% of all very premature infants are affected by early persistence of pulmonary hypertension (PPHN). According to observational studies, effective ventilation combined with early iNO treatment are effective in management of this previously fatal disease. PPHN is associated with prolonged rupture of fetal membranes and birth asphyxia. The lipopolysaccharide (LPS)-induced immunotolerance and hypoxia-reperfusion-induced oxidant stress may inactivate NO-synthetases in pulmonary arterioles and terminal airways. Prospective trials on iNO in the management of PPHN are indicated. Other pulmonary vasodilators may be considered as comparison drugs or adjunctive drugs. The multidisciplinary challenge is to understand the regulation of pregnancy duration and the factors participating the onset of extremely premature preterm deliveries and respiratory adaptation. Basic research aims to identify deficiencies in maternal and fetal tissues that predispose to very preterm births and deteriorate the respiratory adaptation of immature infants. Better understanding on causes and prevention of extremely preterm births would eventually provide effective antenatal and neonatal management practices required for the intact survival.

Does nebulised surfactant benefit neonates with respiratory distress syndrome on noninvasive respiratory support?

Commentary on: Minocchieri S, Berry CA, Pillow JJ on behalf of the CureNeb Study Team Nebulised surfactant to reduce severity of respiratory distress: a blinded, parallel, randomised controlled trial. Archives of Disease in Childhood – Fetal and Neonatal Edition Published Online First: July 26, 2018. https://doi.org/10.1136/archdischild-2018-315051 Nasal continuous positive airway pressure (CPAP) is the primary mode of respiratory support in the preterm neonates with respiratory distress syndrome (RDS). In comparison with intubation, use of nCPAP is associated with reduced need of surfactant administration, intubation and bronchopulmonary dysplasia in extremely preterm neonates 1, 2. Furthermore, prophylactic surfactant administration has not been found to be superior to early selective surfactant administration if nCPAP fails 3. If surfactant administration is needed, administration by minimally invasive technique (MIST) using a thin catheter while baby is supported with nCPAP may be associated with better respiratory outcomes when compared to administration via an endotracheal tube, as in the INSURE approach 4. With this background, the study reviewed here evaluates the role of a noninvasive approach of surfactant administration – by aerosolisation. This randomised controlled trial recruited moderately and very preterm neonates with mild RDS who needed FiO2 of less than 30% to maintain normoxia when supported by nCPAP 5. Neonates in the intervention group received aerosolised surfactant while neonates in the control group received sham nebulisation. The primary outcome of need of intubation was significantly reduced in the intervention group. Duration of ventilation and incidence of air leaks were similar in the two groups. This study presents an attractive noninvasive method of surfactant administration which can also potentially improve the ease of administration. The study had higher than expected rates of intubation and surfactant use in both 29–31 weeks and 32–33 weeks of gestation study subgroups. This may be due to lower threshold of surfactant administration not only as defined in the study protocol but also on discretion of the clinical team. As a result, the reduced need of intubation in the intervention group observed in this study may not be applicable to other healthcare settings which follow a selective surfactant administration strategy. An important limitation of study is low rate of recruitment due to nonavailability of study personnel (17.7% of eligible neonates recruited) which also led to early stopping of the study. Although the effect size of the study intervention reaches significance, the confidence interval is wide with upper margin of relative risk nearing the point of no effect. Furthermore, the numbers presented for the primary outcome vary when presented at different places throughout the manuscript (Table 1, see full review on the EBNEO website). It is clear that even a small change in numbers can alter the effect size and its confidence interval for such a small study. Minimally invasive technique without need of endotracheal intubation is an attractive proposition. Of many methods of minimally invasive surfactant administration (including thin catheter, laryngeal mask airway and pharyngeal deposition), the aerosolised administration is least invasive. However, many questions including dose, timing and frequency of administration, method of aerosolisation and target patient group most likely to be benefitted remain unanswered. Further research is warranted in investigating the use of different methods of minimally invasive or noninvasive methods of surfactant therapy. Such a research should be conducted in neonates in whom surfactant therapy is warranted as a standard practice. https://ebneo.org/2019/01/nebulized-surfactant/ None. None.

Novel approaches in the delivery room care of term and preterm newborns

While optimal antenatal care is provided for the mother to improve survival of newborn babies, appropriate should be given to the babies. The most important time period in delivery room management is the first minute which is named as “first golden minute”. Within this period, body temperature of the baby should be checked , patency of its airway, its respiratory and heart rate should be assesed, first breath should be initiated in case of need, and saturation must be measured objectively using a pulse oximeter. Excessive and unnecessary use of oxygen should be prevented by considering targeted saturation values which are determined according to the time passed after birth. Recent studies showed that 30-60 seconds delay in umbilical cord clamping time will lead to higher hemoglobin concentrations and iron stores in newborns. Preterm babies who may need ventilatory support should be put on continuous positive airway pressure (CPAP) even from the first breath which will decrease the need for intubation and surfactant administration. Prophylactic administration of surfactant in preterm newborns is being abandoned today, surfactant should only be given to preterm newborns in need. Nowadays, less invasive administration of surfactant (LISA) is being tested. If resuscitation is needed oxygen support should be started with 21% saturated oxygen in newborns at or above 35th gestational age. If the gestational age is less than 35th weeks, 21-30% saturated oxygen should be given at the beginning then, oxygen support should be increased up to targeted saturation levels in a controlled manner.

Evaluation of the Need for Prophylactic Surfactant at 27-28 Weeks Gestation

Objective: Evaluate outcomes in 27-28 week gestation infants before and after a change in prophylactic surfactant guidelines. Materials and Methods: This retrospective chart review followed a change in NICU guidelines (January 2013) in which recommendations for prophylactic surfactant target population were changed from all infants under 29 weeks' to those under 27 weeks'. All 27-28 week infants born 24 months before (PRE) and 24 months after (POST) the guideline change were searched by database. Demographic data and outcomes were evaluated using non-parametric ANOVA and Dunn's multiple comparisons test. Results : In a NICU where 92% of its 27-28 week neonates receive at least one dose of prenatal steroids, the groups differed in only two outcome measures: surfactant doses and ventilator days after discontinuing prophylactic surfactant. Conclusions : This study suggests that there is no clear benefit and potential risk to prophylactic surfactant administration in 27-28 week gestation neonates. More studies may be useful to redefine criteria (or need) for prophylactic surfactant. Relevance: As prenatal steroids for prevention of respiratory distress syndrome has become more prevalent, we may need to reassess the routine use of surfactant in extremely and very low birthweight infants.

The survival of extremely and very preterm infants and advance in respiratory support

Extremely and very preterm infants(EPI and VPI) have high mortality and morbidity mainly caused by their lung immaturity and easy to develop bronchopulmonary dysplasia.Antenatal and postnatal respiratory management strategies are associated with their survival and long term outcomes.Antenatal steroids, surfactant therapy and ventilation strategies have shown the potential to improving the outcomes of EPI and VPI.Non-invasive ventilation especially continuous positive airway pressure started at or soon after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in such preterm infants.New strategies of ventilation such as high frequency oscillatory ventilation, neutrally adjusted ventilator assist and volume targeted ventilation will be explored. Key words: Extremely preterm infants; Very preterm infants; Mortality; Respiratory management

Bovine Surfactant Replacement Therapy in Neonates of Less than 32 Weeks' Gestation: A Multicenter Controlled Trial of Prophylaxis versus Early Treatment in China — a Pilot Study

A domestic surfactant preparation has been used in China for a number of years. However, as for other surfactant preparations, there is debate among neonatologists regarding the optimal dose, mode of administration, and the best time of intervention. To evaluate whether prophylactic administration of surfactant is superior to early treatment in preterm infants < 32 weeks with a high risk of respiratory distress syndrome (RDS). We prospectively compared small premature infants (< 32 weeks) receiving 70mg/kg bovine surfactant within 30 minutes after birth (prophylactic group, N=116) with infants who received surfactant therapy for established RDS (early treatment group, N=91). The primary outcome assessed was the incidence of RDS. The secondary outcomes assessed were severity of RDS, mortality, and bronchopulmonary dysplasia morbidity. Compared with the early treatment group, the prophylactic group had a significantly better PaO2 (at 1 hour, 4 hours, and 12 hours postdose, respectively), better a/APO2 (at 1 hour, 4 hours, 12 hours, and 24 hours postdose, respectively), lower PaCO2 (at 1 hour postdose), and a significantly decreased need for mean airway pressure (MAP) and FiO2 on ventilation (p<0.05). The prophylactic group had shorter durations for mechanical ventilation and supplemental oxygen compared with the early treatment group (p<0.01 and p<0.05, respectively). The incidence of RDS was comparable between the groups; however, the prophylactic group had a significantly lower incidence of severe RDS and significantly lower rate of repeated doses of surfactant than the early treatment group (p<0.05). The incidences of bronchopulmonary dysplasia and patent ductus arteriosus were also lower in the prophylactic group than the early treatment group (p<0.05). The two groups were comparable in mortality rate. In preterm infants under 32 weeks' gestation, prophylactic use of a domestic surfactant preparation is better than early surfactant treatment in improving pulmonary status and in decreasing the incidence of severe RDS and duration on mechanical ventilation.

Respiratory support in preterm infants with respiratory distress syndrome

Neonatal respiratory distress syndrome (RDS) is most common in premature infants, the smaller the gestational age, the higher the incidence. Continuous positive airway pressure (CPAP) started in the delivery room has been shown in multicentre randomized controlled trials to reduce the need for mechanical ventilation (MV) and surfactant. The European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants–2013 Update recommended that CPAP should be started from birth in all babies at risk of RDS and a starting pressure of at least 6 cmH2O (1 cmH2O=0.098 kPa) should be applied. CPAP with early rescue surfactant should be considered the optimal management for babies with RDS. Using CPAP immediately after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants. If endotracheal intubation is needed, early administration of surfactant is preferable. Nasal intermittent positive pressure ventilation may reduce the risk of extubation failure in babies failing on CPAP. Several strategies have been employed specifically to improve the success of noninvasive ventilation and shorten the duration of MV. Caffeine should be used to facilitate weaning from MV and to reduce bronchopulmonary dysplasia. A short tapering course of low- or very low-dose dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1~2 weeks. Very early steroid treatment and treatment with high doses cannot be recommended. Key words: Neonatal respiratory distress syndrome; Continuous positive airway pressure; Premature infant

Prophylactic and selective surfactant administration in preterm infants with 28 weeks and lower: a single center experience

Prophylactic and selective surfactant administration in preterm infants with 28 weeks and lower: a single center experience

Respiratory Support in Preterm Infants at Birth

Current practice guidelines recommend administration of surfactant at or soon after birth in preterm infants with respiratory distress syndrome. However, recent multicenter randomized controlled trials indicate that early use of continuous positive airway pressure with subsequent selective surfactant administration in extremely preterm infants results in lower rates of bronchopulmonary dysplasia/death when compared with treatment with prophylactic or early surfactant therapy. Continuous positive airway pressure started at or soon after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants.

Exogenous surfactant therapy in 2013: what is next? who, when and how should we treat newborn infants in the future?

BackgroundSurfactant therapy is one of the few treatments that have dramatically changed clinical practice in neonatology. In addition to respiratory distress syndrome (RDS), surfactant deficiency is observed in many other clinical situations in term and preterm infants, raising several questions regarding the use of surfactant therapy.ObjectivesThis review focuses on several points of interest, including some controversial or confusing topics being faced by clinicians together with emerging or innovative concepts and techniques, according to the state of the art and the published literature as of 2013. Surfactant therapy has primarily focused on RDS in the preterm newborn. However, whether this treatment would be of benefit to a more heterogeneous population of infants with lung diseases other than RDS needs to be determined. Early trials have highlighted the benefits of prophylactic surfactant administration to newborns judged to be at risk of developing RDS. In preterm newborns that have undergone prenatal lung maturation with steroids and early treatment with continuous positive airway pressure (CPAP), the criteria for surfactant administration, including the optimal time and the severity of RDS, are still under discussion. Tracheal intubation is no longer systematically done for surfactant administration to newborns. Alternative modes of surfactant administration, including minimally-invasive and aerosolized delivery, could thus allow this treatment to be used in cases of RDS in unstable preterm newborns, in whom the tracheal intubation procedure still poses an ethical and medical challenge.ConclusionThe optimization of the uses and methods of surfactant administration will be one of the most important challenges in neonatal intensive care in the years to come.

AARC Clinical Practice Guideline. Surfactant Replacement Therapy: 2013

We searched the MEDLINE, CINAHL, and Cochrane Library databases for English-language randomized controlled trials, systematic reviews, and articles investigating surfactant replacement therapy published between January 1990 and July 2012. By inspection of titles, references having no relevance to the clinical practice guideline were eliminated. The update of this clinical practice guideline is based on 253 clinical trials and systematic reviews, and 12 articles investigating surfactant replacement therapy. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation scoring system: 1: Administration of surfactant replacement therapy is strongly recommended in a clinical setting where properly trained personnel and equipment for intubation and resuscitation are readily available. 2: Prophylactic surfactant administration is recommended for neonatal respiratory distress syndrome (RDS) in which surfactant deficiency is suspected. 3: Rescue or therapeutic administration of surfactant after the initiation of mechanical ventilation in infants with clinically confirmed RDS is strongly recommended. 4: A multiple surfactant dose strategy is recommended over a single dose strategy. 5: Natural exogenous surfactant preparations are recommended over laboratory derived synthetic suspensions at this time. 6: We suggest that aerosolized delivery of surfactant not be utilized at this time.

Nebulised surfactant in preterm infants with or at risk of respiratory distress syndrome

Nebulised surfactant has the potential to deliver surfactant to the infant lung with the goal of avoiding endotracheal intubation and ventilation, ventilator-induced lung injury and bronchopulmonary dysplasia (BPD). To determine the effect of nebulised surfactant administration either as prophylaxis or treatment compared to placebo, no treatment or intratracheal surfactant administration on morbidity and mortality in preterm infants with, or at risk of, respiratory distress syndrome (RDS). Searches were performed of CENTRAL (The Cochrane Library, January 2012), MEDLINE and PREMEDLINE (1950 to January 2012), EMBASE (1980 to January 2012) and CINAHL (1982 to January 2012), as well as proceedings of scientific meetings, clinical trial registries, Google Scholar and reference lists of identified studies. Expert informants and surfactant manufacturers were contacted. Randomised, cluster-randomised or quasi-randomised controlled trials of nebulised surfactant administration compared to placebo, no treatment, or other routes of administration (laryngeal, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. Two review authors independently assessed studies for eligibility and quality, and extracted data. No studies of prophylactic or early nebulised surfactant administration were found. A single small study of late rescue nebulised surfactant was included. The study is of moderate risk of bias. The study enrolled 32 preterm infants born < 36 weeks' gestation with RDS on nasal continuous positive airway pressure (nCPAP). The study reported no significant difference between nebulised surfactant administration compared to no treatment groups in chronic lung disease (risk ratio (RR) 5.00; 95% confidence interval (CI) 0.26 to96.59) or other outcomes (oxygenation 1 to 12 hours after randomisation, need for mechanical ventilation, days of mechanical ventilation or continuous positive airways pressure (CPAP) or days of supplemental oxygen). No side effects of the nebulised surfactant therapy or aerosol inhalation were reported. There are insufficient data to support or refute the use of nebulised surfactant in clinical practice. Adequately powered trials are required to determine the effect of nebulised surfactant administration for prevention or early treatment of RDS in preterm infants. Nebulised surfactant administration should be limited to clinical trials.

Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants

Surfactant therapy is effective in improving the outcome of very preterm infants. Trials have studied a wide variety of surfactant preparations used either to prevent or treat respiratory distress syndrome (RDS). In animal models, prophylactic surfactant leads to more homogeneous distribution and less evidence of lung damage. However, administration requires intubation and treatment of infants who will not go on to develop RDS. This is of particular concern with the advent of improved approaches to providing continuous distending pressure, particularly in the form of nasal continuous positive airway pressure (CPAP). To compare the effect of prophylactic surfactant administration to surfactant treatment of established RDS in very preterm infants at risk of RDS. We updated the search of the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and clinical trials.gov register in December 13, 2011. Randomized and quasi-randomized controlled trials that compared the effects of prophylactic surfactant administration to surfactant treatment of established RDS in preterm infants at risk of RDS. Data regarding clinical outcomes were extracted from the reports of the clinical trials by the reviewers. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group. Eleven studies were identified that met inclusion criteria [nine without routine application of continuous positive air way pressure (CPAP) in the selective treatment group; two with routine application of CPAP in the selective treatment group]The meta-analysis of studies conducted prior to the routine application of CPAP demonstrated a decrease in the risk of air leak and neonatal mortality associated with prophylactic administration of surfactant. However, the analyses of studies that allowed for routine stabilization on CPAP demonstrated a decrease in the risk of chronic lung disease or death in infants stabilized on CPAP. When all studies were evaluated together, the benefits of prophylactic surfactant could no longer be demonstrated. Although the early trials of prophylactic surfactant administration to infants judged to be at risk of developing RDS compared to selective use of surfactant in infants with established RDS demonstrated a decreased risk of air leak and mortality, recent large trials that reflect current practice (including greater utilization of maternal steroids and routine post delivery stabilization on CPAP) do not support these differences and demonstrate less risk of chronic lung disease or death when using early stabilization on CPAP with selective surfactant administration to infants requiring intubation.

Recommendations for neonatal surfactant therapy – addendum

Francais en page 139 How should surfactant be used in preterm infants initially managed with nasal continuous positive airway pressure (CPAP)? Many centres providing neonatal intensive care have increased their use of CPAP as a first-line method of respiratory support for preterm infants. This practice shift started after several descriptive, as well as before/after cohort studies, suggested that avoiding intubation and mechanical ventilation may help to reduce bronchopulmonary dysplasia (BPD) (1,2). There has been concern, however, that adopting this practice might deprive some infants of the proven benefits of expeditiously administered exogenous surfactant, especially those born at the youngest gestational ages who have traditionally been provided with prophylactic treatment. Recent randomized trials comparing elective intubation and prophylactic surfactant to initial management with nasal CPAP and selective surfactant therapy, suggest that the latter approach is safe and reduces the number of infants intubated and given surfactant (3–7). In the largest of these studies, even the infants at highest risk for respiratory distress syndrome (RDS) and its associated complications (ie, those born at 24 to 25 weeks’ gestational age), appeared to fare as well, if not better, when initially managed with nasal CPAP (4). These studies suggest that application of nasal CPAP shortly after birth to very preterm infants is an acceptable alternative strategy to elective intubation and prophylactic surfactant treatment. However, the criteria for surfactant treatment of infants initially supported with nasal CPAP have been inconsistent. A short period of observation on CPAP is necessary to enable clinicians to identify infants with surfactant sufficiency or mild RDS, who may be effectively managed without endotracheal intubation and surfactant treatment. Yet, a delay in treating a newborn with significant surfactant deficiency could result in a suboptimal response and/or an increased risk of complications. Criteria for selective treatment of infants initially managed with CPAP are needed. Verder et al (8), who were early advocates of the INSURE (INtubate, SURfactant, Extubate) approach for infants with RDS, found that preterm infants with RDS initially managed with nasal CPAP had better outcomes when treated with surfactant when reaching a fraction of inspired oxygen (FiO2) of approximately 0.37 to 0.55 versus 0.57 to 0.77. A systematic review examining timing of surfactant administration to preterm infants with RDS initially managed with CPAP also found that earlier treatment was more effective (9). From this review, when a low treatment threshold (FiO2 ≤0.45) for intubation and surfactant administration in the early treatment group was used, protection from air leak and BPD was enhanced. Examining several recent, large randomized trials yields additional useful information that can be used to guide practice (3–7). The two studies that did not allow treatment with surfactant of infants initially managed with nasal CPAP, until the requirement for supplemental oxygen exceeded an FiO2 of 0.60, showed increased rates of pneumothorax compared with the group intubated and given surfactant shortly after birth (3,7). The studies in which selective treatment was provided at lower supplemental oxygen thresholds saw no increase in air leak (4–6). These observations are consistent with a previous systematic review that found that babies with or at high risk for RDS had better outcomes if surfactant was given earlier rather than later in the clinical course (10). However, the prophylactic administration of surfactant with rapid extubation to nasal CPAP for infants at risk of RDS does not appear to convey an additional advantage compared with selective treatment after a short period of nasal CPAP, as long as the threshold for treatment is not too high (5,6).

Prophylactic Administration of Surfactant with Nasal Continuous Positive Airway Pressure in Preterm Infants with Gestational Age Less than 30 Weeks

Purpose: This study was performed to investigate the effectiveness and safety of the prophylactic administration method of surfactant, followed by rapid extubation to nasal CPAP (nCPAP) in very preterm infants. Methods: Thirty-three preterm infants with 24-29 weeks gestational age (GA) were treated with the method of prophylactic administration of surfactant by a brief intubation within 15 minutes after birth and rapid extubation to nCPAP for the treatment of respiratory distress. The variables and complications related to oxygen therapy and mechanical ventilation (MV) were compared with those of 24 historical control infants with comparable GA, treated with the rescue surfactant administration with prolonged MV for the respiratory distress syndrome (RDS). Results: Prophylactic surfactant with nCPAP did not reduce the total durations of oxygen therapy and MV, compared with the rescue surfactant with MV (P=0.622 P=122, respectively). The incidence of death and BPD at 36 weeks postmenstrual age (PMA) and other complications related to oxygen therapy and MV were not increased in the infants treated with prophylactic surfactant with nCPAP despite the lower GA and birth weight. In the subgroup analysis for infants with 27-29 weeks of GA, the total duration of MV tended to decrease in infants treated with prophylactic surfactant with nCPAP (Odd ratio, 0.93, 95% Confidence interval, 0.87, 1.00, P=0.051). Conclusion: Prophylactic surfactant administration followed by rapid extubation to nCPAP tended to reduce the duration of MV in infants with GA of 27-29 weeks, compared with the rescue surfactant administration with prolonged MV for RDS.

An Audit of Management of Respiratory Distress Syndrome in the Context of the 2007 European Consensus Guidelines

Background and aims: To audit compliance and variation in management of neonatal respiratory distress syndrome (RDS) in an era post publication of the 2007 European Consensus Guidelines. Methodology: Retrospective review of inborn preterms less than (< )37 weeks with RDS for the period from January 1st 2008 to December 31st 2008. Results: Of 197 infants, 29(14.72%) infants were < 27 weeks, 31(15.74%) between 27 to < 30 weeks, 91(46.19%) between 30 to < 34 weeks, and 46(23.35%) between 34 to < 37 weeks. All infants< 27weeks received surfactant, administered before 15mins in 28 of 29 infants. 80.65% infants in the 27 to < 30 weeks age group received surfactant, in comparison to 37.36%of infants between 30 to < 34 weeks, and 15.22% infants between 34 to < 37 weeks. Prophylactic surfactant was administered in 58% of infants between 27 to < 30 weeks age group. This did not correlate with the use or non-use of prenatal steroids. Only 1 of 29 infants < 27 weeks was immediately extubated post-surfactant. Timing of surfactant re-dosing was variable and initiated at a higher mean FiO266% and alveolar-arterial ratio 0.14 in prohylaxed infants < 27 weeks compared to rescue/re-dosing surfactant at mean FiO2 48% in infants between 27 to < 30 weeks. Conclusions: Overall compliance was achieved in prophylactic surfactant administration in infants < 27 weeks. For babies more than 27 weeks, significant variation was demonstrated in management strategies. This practice variation prompts generation of a unit policy of when to intervene with progression of RDS.

Tidal volume delivery during surfactant administration in the delivery room

Reduced mortality for infants born at less than 30 weeks’ gestation after prophylactic surfactant administration has led many to advocate routine intubation and administration of surfactant in all infants at risk of respiratory distress syndrome. However, surfactant administration is associated with adverse events including bradycardia, changes in cerebral blood flow and endotracheal tube obstruction. The aim of this study was to analyse respiratory function immediately before and after surfactant administration in the delivery room. We reviewed video recordings of the initial resuscitation in the delivery room of infants born at less than 32 weeks’ gestation between February 2007 and March 2010. Positive pressure ventilation was delivered with either a Neopuff T-piece or self-inflating bag. Respiratory parameters were recorded with a respiratory function monitor (RFM). Each RFM recording was analysed for 30 s before and 2 min after surfactant administration. Of 230 infants recorded during the study period 16 infants received surfactant in the delivery room. Their mean (standard deviation, SD) gestation and birth weight were 25 (1) weeks and 757 (249) g, respectively. Complete airway obstruction was seen in 4/16 (25%) infants. The median (interquartile range, IQR) duration of this obstruction was 16 (8–27) s. The median (IQR) expired tidal volume before surfactant delivery was 8.0 (5.2–11.2) mL/kg compared to 4.6 (4.1–7.3) mL/kg (p = 0.03) after surfactant administration. Substantial tidal volume changes occur before, during and after surfactant administration in the delivery room. Complete airway obstruction is common. Monitoring respiratory function during this procedure may help to assess the delivered tidal volume and airway pressures after surfactant treatment.

Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome

Laryngeal mask airway (LMA) administration is one way of delivering surfactant to the infant lung, with the potential benefit of avoiding endotracheal intubation and ventilation, ventilator induced lung injury and bronchopulmonary dysplasia (BPD). To determine the effect of LMA surfactant administration either as prophylaxis or treatment compared to placebo, no treatment, or intratracheal surfactant administration on morbidity and mortality in preterm infants with, or at risk of, respiratory distress syndrome (RDS). We searched CENTRAL (The Cochrane Library, October 2010), MEDLINE and PREMEDLINE (1950 to October 2010), EMBASE (1980 to October 2010) and CINAHL (1982 to October 2010). We also searched proceedings of scientific meetings, clinical trial registries, Google Scholar and reference lists of identified studies, as well as contacting expert informants and surfactant manufacturers. Randomised, cluster-randomised or quasi-randomised controlled trials of laryngeal mask surfactant administration compared to placebo, no treatment, or other routes of administration (nebulised, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials. Two review authors independently assessed studies for eligibility and quality, and extracted data. We found no studies of prophylactic or early LMA surfactant administration. A single small study of late rescue LMA surfactant was identified as eligible for inclusion. The study enrolled 26 preterm infants born ≥ 1200 g with RDS on continuous positive airway pressure (nCPAP). LMA surfactant administration compared to no treatment resulted in a reduction in mean FiO(2) required to maintain oxygen saturation between 88% and 92% for 12 hours after the intervention. No significant difference was reported in subsequent mechanical ventilation and endotracheal surfactant, pneumothorax, days on intermittent positive airway pressure (IPPV), and days on IPPV or oxygen. There is evidence from a single small trial that LMA surfactant administration in preterm infants ≥ 1200 g with established RDS may have a short term effect in reducing oxygen requirements although the study is underpowered to detect important clinical effects. Adequately powered trials are required to determine the effect of LMA surfactant administration for prevention or treatment of RDS in preterm infants. LMA surfactant administration should be limited to clinical trials.

Role of prophylactic surfactant in preterm infants

Respiratory distress syndrome (RDS) in preterm neonates is caused by a deficiency or dysfunction of pulmonary surfactant. The physiological function of surfactant includes the ability to lower surface tension, as well as the ability to rapidly adsorb and spread. A wide variety of surfactant products have been formulated and studied in clinical trials. The present study was designed to find out whether prophylactic administration of surfactant leads to a significant decrease in the risk of neonatal mortality and neonatal morbidity. This was an experimental study in which a total of 125 preterm newborns less than 34 weeks gestation were studied. One hundred preterm newborns (controls) less than 34 weeks gestation were managed in the conventional manner as per the existing protocols in the neonatal intensive care unit. Twenty-five consecutively delivered preterm newborns less than 34 weeks gestation were administered surfactant. Data regarding clinical outcomes including mortality and morbidity profile was collected and analysed. The mean duration of ventilation in the ventilated babies in the control group and the surfactant group was 129.8 ± 43 hours and 85.7 ± 46 hours, respectively; the difference being statistically significant. In the surfactant group, four babies (16%) died and in the control group, 27 babies (27%) died. The difference was not statistically significant. The number of babies developing retinopathy of prematurity and needing laser treatment for retinopathy of prematurity was greater in the surfactant group. Prophylactic administration of surfactant in preterm newborns of gestational age < 34 weeks is associated with a significant decrease in mean duration of ventilation and an increase in the incidence of retinopathy of prematurity.