Thin Endotracheal Catheter Research Articles

70 Purpose-built Catheters for Minimally Invasive Surfactant Therapy – Experience from a Canadian Tertiary Level Neonatal Intensive Care Unit

Abstract Background Surfactant delivery via a thin endotracheal catheter during spontaneous breathing (a technique called minimally invasive surfactant therapy [MIST]), is an increasingly popular alternative to intubation and surfactant administration. Procedural details among different centres vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multiaccess catheters and vascular catheters for this purpose. Recently, purpose-built catheters for MIST received regulatory approval in Canada and became available for use. Procedural differences and user experiences between such catheters have not been described. Objectives The aim of this study was to describe procedural success, procedural adverse effects and user experience pertaining to two different types of purpose-build catheters (BLEScath™ and Surfcath™) for surfactant administration. Design/Methods This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit (NICU) in Southwestern Ontario. Neonates who received MIST using purpose-built catheters between January 1, 2021 and March 31, 2022 were included. Two types of purpose-built catheters were used in this time period: Surfcath™ and BLEScath™. Relevant baseline characteristics and data on procedural details (premedication, type of catheter) were collected. The procedural success, number of attempts and adverse effects among neonates who received MIST via Surfcath™ and those who received surfactant via BLEScath™ were compared, using chi-square tests or Fisher’s tests, as appropriate. User experience was described using an ease-of-use scale. Descriptive reports of user experience were collected and explored for themes/patterns. P-values <0.05 were considered statistically significant. Results 37 neonates met eligibility criteria; 22 received MIST via Surfcath™, whereas 15 received MIST via BLEScath™. Success rates were 91% in SurfCath™ and 93% in BLES-Cath (P> 0.994). Failed attempts were lower in Surfcath™ (23%) compared with BLEScath™ (33%), but the difference was not statistically significant (p=0.708). Upon analyzing ease-of-use by operators, we found that 90% of operators found Surfcath™ very easy or relatively easy to use, compared with 43% of users reflecting the same degree of use with BLEScath™ (P=.021). Users described difficulty in ‘maneuvering’ the BLEScath™ and reported it to be ‘pliable/ flimsy’. There was no difference in adverse events between groups. Conclusion This is the first study in Canada to report the experience of MIST with purpose-built catheters. Overall success rate was equally high for both catheters. Users subjectively reported higher ease of use with SurfCath™. Commercially available purpose-built catheters should facilitate universal adaptation of the MIST method. Our reports regarding operator experience may help with optimizing future product design to improve ease-of-use.

Surfactant delivery strategies to prevent bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.

13 Impact of Catheter Choice on Procedural Success of Minimally Invasive Surfactant Therapy

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Surfactant delivery via a thin endotracheal catheter during spontaneous breathing, a technique called minimally invasive surfactant therapy (MIST), is an alternative to intubation and surfactant administration. Procedural details among different centres vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multi-access catheters, vascular catheters and, recently, custom-designed catheters for this purpose. The impact of choice of catheter on procedural success and adverse effects has not been reported. Objectives The objective of the present study was to compare the procedural success and adverse effects of MIST, using a semi-rigid vascular catheter (16G Angiocath-Hobart Method) versus a flexible multi-access catheter (MAC). Design/Methods This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit in southwestern Ontario. All neonates who received surfactant via MIST between May 1, 2016 and September 30, 2020 were included in the study. Relevant baseline characteristics, data on procedural details (premedication, type of catheter) were collected. The procedural success, number of attempts, and adverse effects between neonates who received MIST via MAC and 16G Angiocath were compared using a Chi Square test or Fisher’s test, as appropriate. A P value of less than 0.05 was considered significant. Results A total of 139 neonates received surfactant via MIST method during the study period. 93 neonates received the surfactant via MAC, while 46 received it via Angiocath. The baseline demographic characteristics in the two groups were similar (Table 1). A higher proportion of neonates in the Angiocath group received atropine (100% vs. 76%, P =.002] and fentanyl (98% vs. 36%; p<0.001) than the MAC group. The procedural success was 91% in the Angiocath group and 89% in the MAC group (p >.99). Multiple attempts were needed in 24% of neonates in the Angiocath group, and 37% in the MAC group (p=0.158). More episodes of desaturations were noted in the Angiocath group (89%) than the MAC group (69%) (P=0.012). Other rates of common adverse effects were similar between the two groups (Table 2). Conclusion The overall procedural success of MIST was similar in both catheter groups. The proportion of neonates requiring multiple attempts was lower with Angiocath use, though this difference was not statistically significant. Desaturation episodes were seen more frequently in the Angiocath group, possibly related to higher use of procedural sedation in this group.

Impact of Catheter Choice on Procedural Success of Minimally Invasive Surfactant Therapy.

Surfactant delivery via a thin endotracheal catheter during spontaneous breathing; a technique called minimally invasive surfactant therapy (MIST) is an alternative to intubation and surfactant administration. Procedural details among different centers vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multiaccess suction catheters, vascular catheters, and more recently custom-built catheters for this purpose. The impact of choice of catheter on procedural success and procedural adverse effects has not been reported. Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart Method) versus a flexible multiaccess catheter (MAC). This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit in Southwestern Ontario. All neonates who received surfactant via MIST between May 1, 2016 and September 30, 2020 were included in the study. Relevant baseline characteristics and data on procedural details (premedication, type of catheter, etc.) were collected. The procedural success, number of attempts, and adverse effects between neonates who received MIST via MAC and 16G Angiocath was compared by using Chi-square test or Fisher's test as appropriate. A p-value of less that 0.05 was considered significant. A total of 139 neonates received surfactant via MIST method during the study period. Moreover, 93 neonates received the surfactant via MAC, while 46 received it via Angiocath. The baseline demographic characteristics in the two group were similar. A higher proportion of neonates in Angiocath group received Atropine (100 vs. 76%, p = 0.002) and Fentanyl (98 vs. 36%, p < 0.001) than the MAC group.The procedural success was 91% in the Angiocath group and 89% in the MAC group (p > 0.99). Multiple attempts were needed in 24% of neonates in the Angiocath group and 37% in the MAC group (p = 0.158). More episodes of desaturations were noted in the Angiocath group (89%) than the MAC group (69%; p = 0.012). Other rates of common adverse effects were similar between the two groups. On exploratory analysis fentanyl use held significant association with less success, more desaturation, apneic episodes, and need of positive pressure ventilation /intubation. The overall procedural success of MIST is similar in both catheter groups. The proportion of neonates requiring multiple attempts was lower with the Angiocath, though difference was not statistically significant. Desaturation episodes were seen more frequently in the Angiocath group, which was related to higher use of procedural sedation in this group. · MIST is emerging as a less invasive method of surfactant delivery that has proven clinical benefits.. · Considerable, procedural variation is reported, particularly regarding choice of catheter.. · Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart method) versus a flexible MAC.. · High and comparable procedural success was seen in both groups..

Research progress of less invasive surfactant application in premature infants with respiratory distress syndrome

Intratracheal surfactant administration is the only specific treatment for respiratory distress syndrome and usually requires endotracheal intubation, positive pressure and/or mechanical ventilation which are harmful to the immature lung.One of these alternative methods is less invasive surfactant application (LISA) via a thin endotracheal catheter during spontaneous breathing with continuous positive airway pressure.Use of LISA allows administration of surfactant while avoiding intubation and positive pressure.Observational studies have fostered expectations of a positive effect of LISA on serious complications of preterm infants and the need for mechanical ventilation.However, there is still a controversy about indications, premedication and serious complications of preterm infants while using LISA.This article reviews the controversies of LISA technology in preterm infants with respiratory distress syndrome. Key words: Less invasive surfactant application; Respiratory distress syndrome; Pulmonary surfactant; Endotracheal intubation; Infant, premature; Mechanical ventilation; Serious complications

Comparative study of the effect of the administration of surfactant through a thin endotracheal catheter into trachea during spontaneous breathing with intubation (intubation-surfactant-extubation method)

Introduction: The main reason for respiratory distress syndrome (RDS) is surfactant deficiency. One of the methods for surfactant administration is through a thin endotracheal catheter (TEC) during the spontaneous breathing of an infant. To identify the clinical effects of this method, we decided to compare the effect of surfactant administration through a TEC during spontaneous breathing through the intubation-surfactant-extubation (INSURE) method. Methodology: In a single-blind clinical trial, we randomly divided 40 premature infants with a gestational age of 0.05). The mechanical ventilation requirement in the infants of the control group was significantly higher compared to the intervention group (P = 0.027). The duration of NCPAP requirement and duration of hospitalization in the groups did not significantly differ (P > 0.05). Conclusion: Based on our results, the TEC method decreases mechanical ventilation requirement, but NCPAP requirement and duration of stay did not differ from the normal method, therefore, TEC can be an acceptable alternative to INSURE.

High-volume surfactant administration using a minimally invasive technique: Experience from a Canadian Neonatal Intensive Care Unit.

Surfactant delivery via a thin endotracheal catheter during spontaneous breathing, a technique called minimally invasive surfactant therapy (MIST), is an alternative to intubation and surfactant administration. There is paucity of data regarding the administration of high-volume surfactant using this technique. We conducted a retrospective cohort study to review the safety, efficacy, and procedural details pertaining to the delivery of 5 mL/kg of BLES® via MIST approach. In 2016, our centre initiated a practice change allowing the use of MIST as an alternative method of surfactant delivery in infants born at ≥28 weeks and/or with a birth weight ≥ 1,000 g with respiratory distress syndrome. In this study, we identified all neonates who received surfactant via MIST between May 1, 2016 and July 30, 2018 and collected relevant procedural data. Since this practice change, MIST technique was attempted in 43 neonates with successful instillation of surfactant in 41 (95.3%) of the neonates. Intubation and positive pressure ventilation was avoided in 35 neonates (85.3%). No serious adverse effect was noted. Our study reports successful use of higher volume surfactant via MIST. This should encourage other similar centres to consider this technique, in order to avoid unnecessary intubation and positive pressure ventilation.

BOVINE LIPID EXTRACT SURFACTANT (BLES®) ADMINISTRATION USING A MINIMALLY INVASIVE APPROACH

Abstract BACKGROUND There is growing evidence that surfactant delivery via a thin endotracheal catheter during spontaneous breathing; a technique called minimally invasive surfactant therapy (MIST) is an alternative to intubation and surfactant administration. The majority of studies evaluating the MIST technique have utilized a higher concentration; lower volume surfactant at a dose of 2.5ml/kg. Little evidence is available describing the feasibility of administering a lower concentration, larger volume surfactant at a dose of 5ml/kg utilizing the MIST technique. OBJECTIVES To describe the feasibility of utilizing Bovine Lipid Extract Surfactant (BLES®) with the MIST technique within a single tertiary centre after a change in practice. DESIGN/METHODS A guideline for surfactant administration (BLES® – 5 ml/kg) using the MIST technique was developed in our centre in 2016. Infants with a birth weight ≥ 1000 g and ≥28 weeks gestation were deemed eligible candidates for this technique if they developed RDS and met criteria for surfactant administration (FiO2 requirement greater than 40% on nasal continuous positive airway pressure (NCPAP) and were clinically well apart from respiratory distress. Surfactant was administered via a thin catheter (KimVent® Multi-Access Catheter) which was inserted into the trachea using Magill forceps, while the baby continued to breathe spontaneously on NCPAP. Depth of catheter insertion was estimated using 6 cm + weight in kg. Surfactant was instilled into the trachea over 1–3 minutes and the delivery was timed to coincide with inspiration. Administration of sucrose was recommended and of atropine was optional prior to laryngoscopy for insertion of the endotracheal catheter. RESULTS Since implementation of the new guidelines, a total of 22 infants received surfactant by the MIST method. The mean gestational age was 32 ± 2.6 weeks and mean birth weight was 1972 ± 788g. Five infants (22.7%) had transient bradycardia and desaturations during the procedure. Five infants (22.7%) required intubation post MIST procedure at variable times (range 6–29 hours), 3 infants (14%) for increasing oxygen requirements and a second dose of surfactant and 2 (9%) infants for hypercapnia and poor respiratory drive. Twenty infants (90%) were successfully weaned to 21% oxygen on NCPAP post procedure at a median duration of 0.5 (range 0.01–29) hours. CONCLUSION The delivery of BLES® using the MIST technique for RDS was overall well tolerated by the patients and shown to be an effective alternative to more invasive methods.

Surfactant administration via a thin endotracheal catheter during spontaneous breathing in preterm infants.

To systematically review the clinical outcomes of surfactant administration via a thin endotracheal catheter during spontaneous breathing compared with conventional administration involving tracheal intubation, mechanical ventilation (MV), and tracheal extubation, in preterm infants. PubMed, EMBASE, and the Cochrane Library were searched to identify relevant clinical trials. Data were analyzed using the Cochrane Collaboration methods. Primary outcome measures included the incidence of MV and bronchopulmonary dysplasia (BPD). Finally, four RCTs, two prospective cohort trials, and six historical controlled trials involving 5,261 preterm infants were analyzed. In RCTs, surfactant administration though a thin catheter reduced the incidence of MV (risk ratio [RR]: 0.74; 95% confidence interval [CI]: 0.66, 0.81) in 72 hr and BPD (RR: 0.69, 95%CI: 0.50, 0.97) compared with conventional administration and in non-RCTs, there was also significant reduction in the incidence of MV (RR: 0.55, 95%CI: 0.45, 0.68) and BPD (RR: 0.70, 95%CI: 0.60, 0.82) in favor of the thin catheter group. There were no significant differences between the two procedures in terms of short-term pulmonary complications, intracranial pathology, necrotizing enterocolitis, retinopathy of prematurity, and mortality. Thus, surfactant administration via a thin endotracheal catheter to preterm infants has promising benefits, including reducing the incidences of MV and BPD, while providing comparable breathing support to conventional administration in MV. Pediatr Pulmonol. 2017; 52:844-854. © 2017 Wiley Periodicals, Inc.

Surfactant replacement therapy in extremely low gestational age newborns.

There is a growing body of evidence over the last years suggesting continuous positive airway pressure (CPAP) ventilation being the first choice of ventilatory support in newborns with extremely low gestational age, and early rescue surfactant treatment being as effective as prophylactic therapy. The Intubation Surfactant Extubation procedure is discussed as an alternative procedure that may have the potential to combine the positive effects of surfactant and early CPAP. A further mode of surfactant administration, administration via a thin endotracheal catheter during spontaneous breathing with CPAP, has recently come into clinical use. This less invasive surfactant administration technique shows some short-term benefits but still cannot be recommended for general use in this vulnerable population. Long-term follow-up studies are needed to allow new recommendations on surfactant therapy in this high-risk population.

Surfactant administration without intubation in preterm infants with respiratory distress syndrome – our experiences

Background: Surfactant replacement therapy is crucial in the management of respiratory distress syndrome (RDS) in preterm infants. Classic strategies of surfactant administration required intubation. To reduce the need of intubation and mechanical ventilation (MV), we applied surfactant via a thin endotracheal catheter without intubation.Patients and methods: We compared 26 preterm infants threatened by RDS treated with surfactant via a thin endotracheal catheter without intubation (studied group – SG) with a retrospective group of preterm infants managed on MV with early surfactant treatment using INtubation SURfactant Extubation (INSURE) method (control group – CG). Study had an approval from the ethics committee (RNN/6/14/KE).Results: In the SG, 26 preterm infants were treated with one dose of surfactant (Curosurf®) administered via endotracheal catheter without intubation while receiving nasal continuous positive airway pressure (nCPAP)/SiPAP (Infant Flow). After surfactant administration, significantly less patients in SG required intubation and MV (19.2%) versus 65% necessity of second intubation in the CG. The median of time of MV in SG was 5 d versus 3.5 d in CG. Median time spent on nCPAP was 5.5 d versus 4.0 d in CG. The incidence of intraventricular hemorrhage (IVH) in the SG was 53.9%, including 50% with ≥IVH II versus 36.7% (30% ≥IVH II) in CG. The incidence of other complications of prematurity in the SG, such as necrotizing enterocolitis was 11.5% versus 23.3% in CG, the hemodynamically important patent ductus arteriosus was observed in 53.9% in SG versus 45% in CG. Bronchopulmonary dysplasia level in SG was significantly lower (15.4%) than in CG (40%), and the incidence of retinopathy of prematurity in SG was also lower (3.9%) versus 11.7% in MV group.Conclusion: Surfactant application via a thin endotracheal catheter without intubation seems to be a beneficial therapy for preterm infants with slight and mild degree of RDS. This new method of surfactant application was associated with a lower prevalence of intubation and MV and better pulmonary outcome than implementation of traditional surfactant therapy (INSURE) and MV. Prospective randomized controlled trial is required.

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.

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.

Surfactant without Intubation in Preterm Infants with Respiratory Distress: First Multi-center Data

Recently in a report of a single center a method has been described to apply surfactant via a thin endotracheal catheter to very low birth weight infants spontaneously breathing with nasal continuous positive airway pressure. We now analyzed available multicenter data. In a multicenter study investigating genetic risk factors, clinical and outcome data and data of antenatal and postnatal treatment of infants with a birth weight below 1,500 g were prospectively recorded. The measures of infants treated with the new method of surfactant application were compared to those of infants who received standard care. The analysis was restricted to infants with a gestational age below 31 weeks (n=1,541). 319 infants were treated with the new method and 1,222 with standard care. The need for mechanical ventilation during the first 72 h (29% vs. 53%, p<0.001), the rate of bronchopulmonary dysplasia defined as oxygen at 36 weeks of postmenstrual age (10.9 % vs. 17.5%, p=0.004) and the rate of death or bronchopulmonary dysplasia were significantly lower in the treatment group than in the standard care group. Surfactant, theophyllin, caffeine and doxapram were significantly more often and analgetics, catecholamines and dexamethasone were significantly less frequently used in the treatment group. A new method of surfactant application was associated with a lower prevalence of mechanical ventilation and better pulmonary outcome. A prospective controlled trial is required to determine whether this approach is superior to standard care.

Early administration of surfactant in spontaneous breathing with nCPAP through a thin endotracheal catheter—An option in the treatment of RDS in ELBW infants?

Early administration of surfactant in spontaneous breathing with nCPAP through a thin endotracheal catheter—An option in the treatment of RDS in ELBW infants?