Treating preterm infants with Surfactant:
an overview of application techniques and
results
Angela Kribs, Children‘s Hospital, University of Cologne
Neonatologie
Application techniques
Classical way: endotracheal intubation and application of surfactant
via endotracheal tube
Intubation, surfactant application and rapid extubation (INSURE)
Application of surfactant into the nasopharynx immediately after birth
Application of surfactant via a laryngeal mask
Nebulization of surfactant
Application of surfactant via a thin endotracheal catheter during
spontaneous breathing
Neonatologie
Background
Association of surfactant administration and mechanical ventilation is
meanly a historical phenomena.
Outcome of ELBW infants treated with CPAP as primary respiratory
support is comparable to that of infants treated with primary intubation,
mechanical ventilation and surfactant administration.
Mechanical ventilation has the risk to induce lung injury and may
perhaps influence the development of brain lesions.
But: Surfactant usually related to intubation and mechanical ventilation
has improved the prognosis of preterm infants more than any other
therapy.
>>>>> Surfactant without any mechanical ventilation but
with CPAP could be the combination of two effective
principles !!!!
Neonatologie
Application of surfactant into the nasopharynx immediately
after birth - Data
Kattwinkel et al.
Technique for intrapartum administration of surfactant without
requirement for an endotracheal tube. J Perinatol. 2004;24:360-365.
23 infants enrolled (560-1804 g, 27-30 w)
Instillation of 3,0-4,5 ml Infrasurf into the nasopharynx before birth of
the shoulders
CPAP of 10 cmH2O after birth, than reduced to 6 cmH2O
No further treatment of RDS in 13 of 15 vaginally delivered infants
Need for endotracheal intubation and endotracheal surfactant in 5 of
8 infants delivered by cesarian section
Neonatologie
Application of surfactant into the nasopharynx immediately
after birth – potential Pros and Cons
Pros
Avoidance of intubation
Avoidance of any positive pressure ventilation
Active inspiration of surfactant
Cons
Failure after cesarian section
Neonatologie
Application of surfactant via a laryngeal mask - Data
Brimacombe et al. The laryngeal mask airway for administration of
surfactant in two neonates with respiratory distress syndrome.
Paediatr Anaesth. 2004;14:188-190.
Two case reports of successfull use of this technique in two infants with
RDS (1360g and 3200g)
Neonatologie
Application of surfactant via a laryngeal mask - Data
Trevisanuto D et al. Laryngeal mask airway used as a delivery conduit
for the administration of surfactant to preterm infants with respiratory
distress syndrome. Biol Neonate. 2005;87:217-220.
Neonatologie
Application of surfactant via a laryngeal mask – potential
Pros and Cons
Pros
Avoidance of intubation
In some cases avoidance of any positive pressure ventilation
In some cease active inspiration of surfactant
Cons
Technical limitations in the smallest infants
Neonatologie
Nebulization of surfactant - Data
Mazela et al. Curr Opin Pediatr 19:155-162
Neonatologie
Nebulization of surfactant - Data
Mazela et al. Curr Opin Pediatr 19:155-162
Neonatologie
Nebulization of surfactant – potential Pros and Cons
Pros
Avoidance of intubation
Avoidance of any positive pressure ventilation
Active inspiration of surfactant
Cons
Technical problems (particle size, stability of the substance)
High loss of substance >>>
expensive
Neonatologie
Application of surfactant via a thin endotracheal catheter
during spontaneous breathing - Data
Kribs A et al. Early administration of surfactant in spontaneous
breathing with nCPAP: feasibility and outcome in extremely premature
infants (postmenstrual age </=27 weeks). Paediatr Anaesth.
2007;17:364-369.
Kribs A et al. Early surfactant in spontaneously breathing with nCPAP in
ELBW infants--a single centre four year experience.Acta Paediatr.
2008;97(3):293-298.
Neonatologie
Standard of delivery room management
Covering the baby with a polyurethrane wrap
Suction of the mouth
Positioning of a face mask with high- flow- CPAP
(Benveniste valve), FiO2 0,4, PEEP 8-14 cmH2O
Positioning of a pulsoxymeter
Observation of:
SO2 (<80% after 10 min. >>increase FiO2)
Silverman- Score (5 min.) (> 5 after 10 min. >> increase PEEP)
Heart rate (no increase within 2 min. >> ventilation with mask and
bag using PEEP- ventil and a pressure limitation. )
Neonatologie
Indications for endotracheal intubation in the
delivery room
Persistent apnea and bradycardia with need
for resuscition
Prenatal diagnosis of severe malformation
with imminent respiratory failure
(need for transport over a long distance)
Neonatologie
Indications for surfactant administration
FiO2 > 0,3 for SO2 > 80% after optimization
of CPAP for infants with a gestational age <26
completed weeks or FiO2 >0,4 for infants with a
gestational age >26 weeks
Silverman Score > 5 after optimization of
CPAP
Neonatologie
Indications for endotracheal intubation during
the first 72 hours of live
FiO2 > 0,5 for SO2 > 80% for more than two
hours after optimization of CPAP and after
appplication of surfactant
Persistant Silverman Score > 5
More than one apnea with need for
intervention within 2 hours
Resp. acidosis with pH < 7,15
Neonatologie
period 0
period 1
period 2
period 3
period 4
(N=38)
(N=47)
(N=45)
(N=28)
(N=35)
Gestational age
(weeks)
25,7
25,7
25,2
25,3
25,1
(23+2-27+6)
(23+0-27+6)
(23+0-27+6)
(23+0-27+6)
(23+0-27+6)
Birth weight
714
667
705
690
668
(gramm)
(347-1000)
(350-1000)
(430-1000)
(430-1000)
(400-990)
Apgar 5‘
7 (2-9)
7 (3-10)
8 (2-9)
8 (3-9)
8 (1-9)
Gender male / female
23/15
23/24
26/19
16/12
16/19
SGA (<10.Perc.)
9 (23,7%)
10 (21,3%)
10 (22,2%)
6 (21,4%)
11 (31,4%)
Sepsis at birth
12 (31,6%)
13 (27,7%)
17 (37,8%)
12 (42,9%)
15 (42,9%)
PPROM < 23 weeks
3 (7,9%)
10 (21,3%)
10 (22,2%)
6 (21,4%)
11 (31,4%)
Twin to twin
transfusion
2 (5,3%)
6 (12,8%)
5 (11,1%)
2 (7,1%)
1 (2,9%)
Any antenatal steroids
32 (84,2%)
44 (93,6%)
45 (100%)
27 (96,4%)
30 (85,7%)
Neonatologie
Respiratory management of RDS (n=155)
100
% 90
80
70
60
50
40
30
20
10
0
CPAP
CPAP + Surf
mech. Ventilation
CPAP failure as %
of CPAP starters
mech. vent. due to
RDS
period 0 period 1 period 2 period 3 period 4
Neonatologie
Outcome of preterm infants </= 1000 g and
</=27 weeks (data are given in %)
100
90
80
70
60
50
40
30
20
10
0
survival
survival without
BPD
survival without
BPD, IVH>II°, PVL
period period period period period
0
1
2
3
4
survival without
BPD, IVH>II°, PVL,
ROP>II°
Neonatologie
Mechanical ventilation vs. CPAP as initial respiratory support
Demographic data and prenatal risks
Ventilation
CPAP
N=23
N=132
Gestational Age (weeks)
24,8
25,4
P=0,038
Birth weight (gramm)
662
686
n.s.
Apgar 5 min.
4,7
7,6
P<0,001
11/12
63/69
n.s.
Any antenatal steroids
21 (91,3%)
125 (94,7%)
n.s.
SGA < 10. Perc.
4 (17,4%)
40 (30,3%)
n.s.
Sepsis at birth
15 (65,2%)
43 (32,6%)
P=0.004
PPROM < 23 weeks of
gestational age
10 (43,5%)
27 (20,5%)
P=0.031
Twin to twin transfusion
5 (21,8%)
9 (6,8%)
P=0.037
gender male / female
Significance
Neonatologie
CPAP + Surfactant: Responder vs Non Responder
Demographic data and prenatal risks
Responder
Non Responder Significance
N=90
N=38
Gestational Age (weeks)
25,5
25,2
n.s.
Birth weight (gramm)
691
666
n.s.
Apgar 5 min.
7,7
7,4
n.s.
44/46
19/19
n.s.
Any antenatal steroids
87
35
n.s.
SGA < 10. Perc.
26
14
n.s.
Sepsis at birth
26
15
n.s.
PPROM < 23 weeks of
gestational age
20
7
n.s.
Twin to twin transfusion
4
5
n.s.
gender male / female
Neonatologie
Outcome of preterm infants </= 1000 g and </=27 weeks
(data are given in %)
100
90
80
70
60
50
40
30
20
10
0
survival
survival without BPD
survival without
BPD, IVH>II°, PVL
23
24
25
26
survival without
BPD, IVH>II°, PVL,
ROP>II
Neonatologie
Application of surfactant via a thin endotracheal catheter
during spontaneous breathing – potential Pros and Cons
Pros
Minimization of trauma by intubation
Avoidance of any positive pressure ventilation
Active inspiration of surfactant
Cons
New procedure with „learning curve“
Still need for laryngoskopie
Neonatologie
Summary
There is an obvious need for alternative ways to administer surfactant
to premature infants with RDS
With this alternative ways it should be possible to:
Avoid intubation
Avoid mechanical ventilation
Allow active inspiration of surfactant
Data from feasibility studies are available and promising but large
prospective randomized trials are needed