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Surfactant treatment of newborn infants with respiratory distress syndrome primarily treated with nasal continuous positive air pressure. A pilot study
Abstract
In this pilot study, Curosurf (200 mg/kg) was administrated to 34 patients with the respiratory distress syndrome in nasal-CPAP therapy with FiO2 requirements greater than 0.60 and/or TcPCO2 greater than 8 kPa. The surfactant was instilled during a short period of intubation or in a few cases via an intratracheal catheter (Ch. 6). The age of the patients on surfactant treatment ranged from two to 72 hours. Eighteen patients could be maintained on nasal-CPAP after treatment with Curosurf and only a few complications were seen in these infants. The other 16 patients subsequently required artificial ventilation and had a higher incidence of pulmonary and extrapulmonary complications. On the basis of these observations, we plan a randomized trial to investigate whether, administration of surfactant reduces the need for ventilator treatment and improves the odds for uneventful recovery in this category of patients.
... anterior, en la cual se reemplazaba la sonda nasogástrica por un angiocatéter y se prescindía de la pinza de Magill; surgió así el denominado método MIST (sus siglas en inglés, Minimal Invasive Surfactant Therapy). (7,8,9,10) Los principales métodos mínimamente invasivos descritos en la literatura para la administración del surfactante incluyeron la instilación nasofaríngea, la administración mediante una máscara laríngea, la aerosolización y la cateterización traqueal; esta última resultó una de las técnicas más empleadas en la actualidad en diferentes regiones de Europa. (4,11) En Cuba, el surfactante empleado se denomina Surfacen®, un tensioactivo natural de origen porcino producido por el Centro Nacional de Sanidad Agropecuaria (CENSA), La Habana, Cuba, desde 1990, (12) y cuya instilación se realizó de forma tradicional a través de un tubo endotraqueal en unidades de cuidados intensivos neonatales. ...
... (17) Las principales complicaciones que se pueden presentar con la utilización de los métodos LISA o MIST son: apnea, bradicardia, eventos de hipoxia con desaturación de oxígeno, reflujo de surfactante, mala distribución del surfactante, necesidad de ventilación manual, fallo de la técnica con necesidad de intubación endotraqueal, hemorragia pulmonar, nauseas y tos. (4,8,11,14) En la casuística presentada solo un paciente mostró como complicación desaturación de oxígeno hasta 80 % al inicio de la instilación, sin que constituyera una limitante para continuar con el procedimiento, pues la recuperación de neonato fue instantánea con el incremento de la FiO2 y, una vez que se continuó la administración del surfactante, mejoró notablemente la oxigenación del neonato. En los otros dos casos no se presentaron eventos adversos. ...
Introducción:
La administración de surfactante pulmonar tradicionalmente se realiza mediante un tubo endotraqueal, pero desde hace años existen técnicas menos invasivas como la administración mediante másscara laríngea, aerosolización y cateterización traqueal.
Objetivos:
Demostrar la evolución de tres neonatos que recibieron surfactante pulmonar mediante una cateterización traqueal y describir la técnica empleada para su administración.
Presentación de casos:
Se atendieron tres recién nacidos de muy bajo peso al nacer, que ingresaron en la unidad de cuidados intensivos neonatales del Hospital General Docente “Iván Portuondo”, San Antonio de los Baños, con síndrome de dificultad respiratoria del prematuro. Todos se trataron con surfactante pulmonar exógeno, Surfacen®, el cual se administró mediante cateterización traqueal empleando un catéter umbilical. Se trata de una técnica mínimamente invasiva que se realizó sin dificultades y siempre en el primer intento. Los tres pacientes mostraron mejoría clínica, gasométrica y radiográfica con esta forma de administración y solo uno de ellos tuvo una complicación durante el proceder, que no constituyó una limitante para su realización. Este método permitió mantener una ventilación no invasiva, y fue innecesaria la intubación endotraqueal en los neonatos. Los profesionales encargados de la ejecución de esta técnica recibieron entrenamiento previo.
Conclusiones:
La administración mínimamente invasiva de surfactante pulmonar resultó un método eficaz con el que se consiguió la resolución total del cuadro de dificultad respiratoria en los neonatos. El procedimiento empleado permitió una administración rápida y segura del Surfacen®.
... In 1992, Verder et al. [1] The main challenge in applying LISA is the lack of a reliable method of confirming the placement of the thin catheter into the airway [3]. ...
... Az exogén surfactant pótlás napjainkban is az RDS kezelésének alapját képezi, melynek alkalmazása évtizedeken át csak invazív lélegeztetés mellett volt kivitelezhető 14 . 1992-ben Verder és munkatársai alkalmaztak először vékonykatéteres technikát felületaktív anyag adására RDS-ben szenvedő koraszülöttekben 15 . A módszert mintegy egy évtizeddel később újra felfedezve Kribs és csapata tökéletesítette 16 . ...
... The main advantage of this method is that it avoids intubation and all the associated risks [6]. The LISA procedure reduces the median days on mechanical ventilation, intubation-related lung injury, and oxygen requirement at 28 days of life compared to the INSURE method (Intubation SURfactant Extubation), which is a less invasive method [7,8]. The LISA method also reduces the composite score for death and/or bronchopulmonary dysplasia. ...
Background
Simulation-based training is gaining increasing prominence in neonatology training. The Less Invasive Surfactant Administration (LISA) method is starting to be taught in simulation. The aim of this educational study was to develop and validate a rating scale for teaching the LISA method in simulation.
Methods
The Downing framework was used to create this performance-rating scale. A first version of the scale was submitted to 12 French and Belgian experts to obtain their opinions. Consensus was reached using a modified Delphi method. The performance of 40 pediatricians was then evaluated with this scale on a preterm neonate manikin simulating a neonatal respiratory distress syndrome. Each run was evaluated using the scale by two independent observers based on video recordings.
Results
The Cronbach alpha score of the rating scale was 0.72. The intraclass correlation coefficient (ICC) was 0.91 and the scores between raters were not significantly different. Finally, this rating scale correctly distinguished the experienced from the inexperienced learners (p < 0.01).
Conclusions
This rating scale is one of the first rating scales for the evaluation and teaching of the LISA method in simulation. This tool has ample potential for use in clinical practice to evaluate the performance of surfactant administration in preterm neonates.
... Los resultados del ensayo OPTIMIST-A muestran que LISA es el único enfoque entre las estrategias alternativas de administración de surfactantes con evidencia existente para prevenir la DBP, con una reducción en la incidencia de DBP en sobrevivientes a la edad postmenstrual de 36 semanas (24)(25)(26). Sin embargo, INSURE (intubar, surfactante, extubar) se presenta como la segunda opción para evitar una mayor necesidad de uso de ventilación mecánica y oxígeno suplementario (21,27,28,29). No obstante, no hay datos concluyentes que demuestren que el uso clínico de rutina de esta técnica, con el objetivo de disminuir la displasia broncopulmonar, sea superior a otras opciones (24). ...
Introducción: La displasia broncopulmonar es una patología que afecta especialmente a los recién nacidos prematuros. Aunque esta enfermedad se manifiesta durante el período neonatal, su impacto en la calidad de vida posterior puede ser significativo. Por ende, resulta esencial comprender sus factores asociados. Objetivo: Analizar la evidencia disponible sobre los factores de riesgo para la displasia broncopulmonar en recién nacidos pretérmino. Métodos: Se realizó una revisión exploratoria en la que se incluyeron estudios sobre displasia broncopulmonar publicados en cualquier idioma entre 2015 y 2020. La búsqueda se llevó a cabo en las bases de datos LILACS, Scopus, Science Direct, PubMed, ProQuest y Google Scholar, con inclusión de estudios publicados entre septiembre y diciembre de 2020.Resultados: Se identificaron 63.096 artículos, de los cuales 13 fueron incluidos en esta revisión. Entre los factores descritos por los estudios se encuentran un patrón metabólico fetal alterado, niveles reducidos de hemoglobina fetal, bajo peso al nacer y sepsis neonatal tardía. Conclusiones: Los estudios analizados permitieron reconocer factores del individuo que inciden en el desarrollo de la displasia broncopulmonar, así como factores ambientales. Algunos de ellos han sido ampliamente estudiados y continúan repercutiendo en la presencia de la enfermedad, proporcionando datos importantes para el abordaje terapéutico. A pesar de lo anterior, la evidencia no es concluyente.
... When radiographic findings were ambiguous, the stable microbubble test of the gastric fluid (medium to zero) was performed [11]. While surfactant was administered as promptly as possible following the diagnosis of RDS, the intubation-surfactantextubation method and less-invasive surfactant administration were not adopted in the unit [12]. In our unit, during the study period, weaning from invasive mechanical ventilation was considered with a peak inspiratory pressure of <15 cm H 2 O, mandatory respiratory rate of ≤30/min, and FiO 2 of <0.3 on synchronized intermittent mandatory ventilation; early extubation was encouraged with the use of nasal continuous positive airway pressure. ...
Introduction:
Respiratory morbidities in neonates are often progressive and life-threatening, and its early prediction is crucial. Intrauterine inflammation is one of the key control variables of respiratory morbidities in both very preterm and term neonates; however, little is known about its effects in the remaining group of moderate-to-late preterm neonates born between 32+0 and 36+6 weeks of gestation. This study aimed to confirm whether intrauterine inflammation is associated with respiratory morbidities in moderate-to-late preterm neonates.
Methods:
A single-center retrospective observational study was conducted in neonates born between 32+0 and 34+6 weeks of gestation between April 2013 and March 2018. The correlation between respiratory morbidities (defined as a requirement for invasive mechanical ventilation longer than the median duration of 3 days) and intrauterine inflammation was assessed using multivariable logistic regression analysis.
Results:
The study population comprised 242 neonates born at 33.7 ± 0.8 weeks of gestation and weighing 1,936 ± 381 g. The multivariable model to predict the outcome comprised respiratory distress syndrome (odds ratio [OR]: 9.1; 95% confidence interval [CI]: 3.7-22.5; p < 0.001), lower gestational age (per week; OR: 0.5; 95% CI: 0.3-0.8; p < 0.005), higher birth-weight z-score (OR: 1.6; 95% CI: 1.2-2.2; p < 0.005), lower cord blood pH (per 0.10; OR: 0.5; 95% CI: 0.3-0.7; p < 0.005), and chorioamnionitis (OR: 2.8; 95% CI: 1.1-7.2; p < 0.05).
Conclusion:
Together with the incidence of respiratory distress syndrome and gestational age, chorioamnionitis and high birth-weight z-scores were associated with an increased incidence of respiratory morbidities in moderate-to-late preterm neonates. The deleterious impact of intrauterine inflammation on the lungs may be common in neonates of virtually all gestational ages. Traditional admission policy of neonatal intensive care units based on a threshold birth-weight, may leave a group of neonates without close observation despite their increased risks for respiratory morbidities.
... Less invasive surfactant administration (LISA) has recently been introduced to treat preterm infants with respiratory distress syndrome (RDS). With this method exogenous surfactant is administered with a small catheter placed in the trachea while keeping the infants on continuous positive airway pressure (CPAP) support (Verder et al 1992, Kribs et al 2007, Herting et al 2019. In this way mechanical ventilation and its damaging effects are avoided (Aldana-Aguirre et al 2017). ...
Objective: Less invasive surfactant administration (LISA) has been introduced to preterm infants with respiratory distress syndrome (RDS) on continuous positive airway pressure (CPAP) support in order to avoid intubation and mechanical ventilation. However, after this LISA procedure, a significant part of infants fails CPAP treatment (CPAP-F) and requires intubation in the first 72h of life, which is associated with worse complication free survival chances. The aim of this study was to predict CPAP-F after LISA, based on machine learning (ML) analysis of high resolution vital parameter monitoring data surrounding the LISA procedure.
Approach: Patients with a gestational age (GA) < 32 weeks receiving LISA were included. Vital parameter data was obtained from a data warehouse. Physiological features (HR, RR, peripheral oxygen saturation (SpO2) and body temperature) were calculated in eight 0.5h windows throughout a period 1.5h before to 2.5h after LISA. First, physiological data was analyzed to investigate differences between the CPAP-F and CPAP-Success (CPAP-S) groups. Next, the performance of two types of ML models (logistic regression: LR, support vector machine: SVM) for the prediction of CPAP-F were evaluated.
Main results: Of 51 included patients, 18 (35%) had CPAP-F. Univariate analysis showed lower SpO2, temperature and heart rate variability (HRV) before and after the LISA procedure. The best performing ML model showed an Area Under the Curve (AUC) of 0.90 and 0.93 for LR and SVM respectively in the 0.5h window directly after LISA, with GA, HRV, respiration rate and SpO2 as most important features. Excluding GA decreased performance in both models.
Significance: In this pilot study we were able to predict CPAP-F with a ML model of patient monitor signals, with best performance in the first 0.5h after LISA. Using ML to predict CPAP-F based on vital signals gains insight in (possibly modifiable) factors that are associated with LISA failure and can help to guide personalized clinical decisions in early respiratory management.
INTRODUCTION: Respiratory Distress Syndrome (RDS) is the most common respiratory disorder among premature infants. The use of surfactant has significantly reduced respiratory complications and mortality. There are two conventional methods for administering surfactant: Intubate-Surfactant-Extubate (INSURE) and Less Invasive Surfactant Administration (LISA). This study aims to compare the effects of surfactant administration using these two methods on the treatment outcomes of premature newborns. MATERIALS AND METHODS: In this retrospective cohort study, we included 100 premature newborns with RDS and spontaneous breathing who were admitted to the Neonatal Intensive Care Unit of Besat Hospital in Sanandaj city in 2021. Exclusion criteria comprised congenital anomalies and the needing for intubation for resuscitation at birth. The outcomes of epmericaly trated with two methods were compared: the LISA (50 neonates) and the INSURE (50 neonates). Our interesting outcomes were needing for mechanical ventilation, duration of ventilation, pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia. Finally, we entered the data into STATA-14 statistical software and analyzed it using chi-square and t-tests. RESULTS: In this study, 69% of the neonates were boys. The LISA group exhibited significantly lower rates of need for mechanical ventilation (P = 0.003) and ventilation duration (P < 0.001) compared to the INSURE group. Conversely, there were no significant differences between the two groups (P > 0.05) in terms of pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia rates. CONCLUSION: The results of this study suggest that the LISA method is a safe and non-invasive approach for surfactant administration. Notably, it resulted in a reduced need for mechanical ventilation and decreased ventilation duration compared to the INSURE method.
Backgroud: Respiratory distress syndrome (RDS) is a major cause of morbidity and mortality in preterm infants. Early nasal CPAP and selective administration of surfactant via the endotracheal tube are widely used in the treatment of RDS in preterm infants. Objective: The aim of this study was to compare the need for intubation and mechanical ventilation after surfactant delivery between LISA-treated and INSURE-treated premature infants with respiratory distress syndrome (RDS). Methods: Retrospective registry-based cohort study enrolled 36 newborns admitted to the neonatal intensive care unit of the “Santa Maria” Hospital of Terni between 2016 and 2023. As a primary outcome, we followed the need for intubation and mechanical ventilation within 72 hours of life, while the secondary outcomes were major neonatal morbidities and death before discharge. Results: The LISA group and the INSURE group included 13 and 23 newborns respectively. Demographic features showed no significant differences between the two groups. The need for mechanical ventilation in the first 72 hours of life was similar in both groups (p >0.99). There were no significant differences in morbidities. Conclusion: LISA and INSURE are equally effective modalities for surfactant administration for the treatment of RDS in preterm infants.
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