Minimally Invasive Surfactant Therapy

Gyu Hong Shim

doi:10.14734/kjp.2015.26.4.289

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Shim: Minimally Invasive Surfactant Therapy

Review Article

Korean J Perinatol 2015;26(4):289-298.

Published online: 20 December 2015

DOI: https://doi.org/10.14734/kjp.2015.26.4.289

Minimally Invasive Surfactant Therapy

Gyu Hong Shim, M.D., Ph.D.

Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea

Correspondence to: Gyu Hong Shim, M.D., Ph.D. Department of Pediatrics, Inje University Sanggye Paik Hospital, Dongil-ro 1342, Nowon-gu, Seoul 01757, Korea Tel: +82-2-950-1632, Fax: +82-2-950-1246 E-mail: peddoc@paik.ac.kr

Received 20 December 2015 Revised 26 December 2015 Accepted 29 December 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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.

Keywords: Respiratory distress syndrome, Surfactant, Noninvasive ventilation, Minimally invasive surfactant therapy, Tracheal catheterization

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Fig. 1.

Cologne methods of tracheal catheterization for surfactant replacement therapy. (A) Equipment of Cologne method is shown (feeding tube, 10 mL syringe, Magill's forceps, and laryngoscope with blade). Insertion of the feeding tube (B) and administration of surfactant (C) are shown.

Fig. 2.

Hobart methods of tracheal catheterization for surfactant replacement therapy. (A) Equipment of Hobart method is shown (vascular catheters, 10 mL syringe, and laryngoscope with blade). Insertion of the vascular catheter (B) and administration of surfactant (C) are shown.

Table 1.

Techniques of Tracheal Catheterization for Surfactant Administration¹⁵

Method	Catheter	Magill forceps	Dose and mode of surfactant	Premedication
Cologne method¹⁷	4- to 5-FG feeding tube	Yes	100 mg/kg, Slow push, 1–3 min	Atropine, sedation, and analgesia (optional)
Hobart method^27, ²⁸	16-G angiocatheter	No	100–200 mg/kg, 3–4 boluses, 15–30 sec	Sucrose
Take Care method²⁹	5-FG feeding tube	No	100 mg/kg, Slow bolus, 30–60 sec	None
SONSURE method³⁰	4-FG feeding tube	Yes	100 mg/kg, Slow push, 1–3 min	Atropine

Abbreviation: SONSURE, Sonda Nasogástica Surfactante Extubación.

Table 2.

Clinical Studies of Surfactant Administration via Tracheal Catheterization^15, ³⁸

Author	Design and Population	Control (No.)	Intervention (No.)	Results
Kribs, et al. 2007¹⁷	Nonrandomized feasibility study; ELBW infants with GA, 23–27 wk	ET instillation (n=34)	MIST, FiO₂>0.4: 100 mg/kg surfactant (n=29)	BPD: 14% I vs. 15% C (NS); mortality: 12% I vs. 35% C (P=0.025)
Kribs, et al. 2010³¹	Prospective cohort study; VLBW infants or GA, <31 wks	ET instillation (n= 1,222)	MIST (n=319)	MV in first 72 hr: 29% I vs. 53% C (P<0.001); BPD: 11% I vs. 18% C (P=0.004)
Dargaville, et al. 2011²⁷	Nonrandomized feasibility study, GA 25–34 wks	CPAP, ET instillation (n=173)	MIST (n=25)	Lower FiO₂ after MIST (pre-MIST: 0.39±0.092 (mean±SD); 4 hr: 0.26±0.093;P<0.01
Gopel, et al. 2011³⁸	RCT; VLBW infants or GA, 26–28⁺⁶ wks, age <12 h	CPAP followed by ET instillation (n=112)	MIST (n-=108)	MV on day 2–3: RR, 0.68 (95% CI, 0.42–0.88); MV at any time: RR, 0.42 (95% CI, 0.31–0.59); BPD: RR, 0.62 (95% CI, 0.27–1.40)
Dargaville, et al. 2013²⁸	Nonrandomized study (historical controls); GA, 25–34 wks, age, <24 h	Routine CPAP and ET Instillation (n=41: GA, 25–28 wks; 56: GA, 29–34 wks)	MIST (n=38: GA, 25–28 wks; 23: GA, 29–34 wks)	MV at 72 hr, GA, 25–28 wks: OR, 0.21 (95% CI, 0.08–0.55); MV at 72 hr, GA, 29–34 wks: OR 0.34 (95% CI, 0.11–1.0); BPD: 29% I vs 29% C (P=0.85)
Klebermass-Schrehof, et al. 2013³⁹	Nonrandomized study (historical controls); GA, 23–27 wk, at birth	CPAP, ET Instillation (n=182)	MIST (n=224)	MV need at 3 d: 23% I vs. 52% C (P<0.001); BPD: 16% I vs. 12% C (NS)
Kanmaz, et al. 2013²⁹	RCT; GA, <32 wk; age <72 h	INSURE method (n= 100)	porcine surfactant, 100 mg/kg (n=100)	MV within 72 hr: 30% I vs. 45% C (P=0.02) (reported); MV at any time: 40% I vs. 49% C (P=0.08); BPD: 10% I vs. 20% C (P=0.009)
Aguar, et al. 2014³⁰	Prospective cohort study, GA 24⁺⁰-35⁺⁶ wks, at birth	INSURE method (n= 31)	MIST (n=45)	MV within 72 hr: 34% I vs. 26% C (P=0.44); a second dose of surfactant: 35% I vs. 6.5% C (P< 0.0001).
Kribs, et al. 2015⁴⁰	RCT; GA, <27 wk; age <2 h	CPAP, ET instillation (n=107)	MIST (n=104)	Intubation: 74.8% I vs. 99.0% C (P=0.04); Pneumothorax: 4.8 % I vs. 12.6% C (P=0.02); Severe IVH: 10.3% I vs. 22.1% C (P= 0.02); Survival without major complications: 50.5% I vs. 35.6 % C (P=0.02).
Göpel, et al. 2015⁴¹	Prospective cohort study (German Neonatal Network), GA <32 wks	CPAP, ET instillation (n=1,103)	MIST (n=1,103)	MV: 41% I vs. 62% C (P<0.001); BPD: 12% I vs. 18% C (P=0.001); BPD or death:14% vs. 21% (P <0.001).

Abbreviations: No., number; ELBW, extremely low birth weight; GA, gestational age; ET, endotracheal; MIST, minimally invasive surfactant therapy; FiO₂, fraction of inspired oxygen; BPD, bronchopulmonary dysplasia; NS, not significant; I, intervention; C, control; NS, not significant; VLBW, very low birth weight; MV, mechanical ventilation; CPAP, continuous positive airway pressure; SD, standard deviation; RCT, randomized control trial; RR, relative risk; CI, confidence interval; OR, odd ratio; INSURE, intubation, surfactant administration during brief mechanical ventilation, and Extubation; IVH, intraventricular hemorrhage.

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