Late surfactant replacement therapy and its efficacy on severe bronchopulmonary dysplasia in National Children Hospital

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that is most commonly seen in premature infants who require prolonged mechanical ventilation and oxygen therapy. 75% of intubated infants have episodes of dysfunctional surfactants associated with lower levels of surfactant proteins. This study aims to evaluate the effectiveness of late surfactant therapy in treating BPD in premature infants. Nineteen preterm infants diagnosed with severe BPD requiring mechanic ventilation, according to Jobe and Bancalari, were treated with surfactant (Poractant alpha 100mg/kg intra-tracheal). Patients were observed for change in oxygen requirement before and at 1-h, 6-h, 12-h, 24-h, and 48-h after treatment. There were 13 boys and 6 girls; boy to girl ratio was 2.16/1. The mean gestation age was 28.3 ± 2 weeks; the mean birth weight was 1134.7 ± 314 gram. There was an increase in SpO2 (saturation of peripheral oxygen), PaO2 (the partial pressure of oxygen in arterial blood) and reduction in FiO2 (fraction of inspired oxygen), PaCO2 (the partial pressure of carbon dioxide in arterial blood), OI (oxygen index), MAP (mean airway pressure) and AaDO2 (Alveolar-to-arterial oxygen gradient) after surfactant (p < 0.05). Conclusion: In patients with severe BPD, late surfactant therapy has shown initial benefits in lung functions and reducing oxygen requirement.

A study on the comparison of minimally invasive surfactant therapy with insure technique of surfactant therapy in preterm babies with respiratory distress in a tertiary care hospital – A prospective cohort study

Background: Respiratory distress syndrome (RDS) is a common problem in preterm babies due to surfactant deficiency. Initially, babies were given surfactant therapy by intubation, surfactant administration, and extubation (INSURE) method. Minimally invasive surfactant therapy (MIST) is a novel method of surfactant administration without intubation to spontaneously breathing preterm babies with RDS without the removal of continuous positive airway pressure (CPAP). Aim: This study aims to compare the surfactant therapy in preterm babies with RDS through MIST and INSURE technique. Methods: This prospective, observational cohort study was conducted in the neonatology unit of Calcutta National Medical College and Hospital. A total of 212 preterm babies of <37 weeks of gestation with features of RDS, who require surfactant are taken and divided into two groups. Very sick babies with congenital anomalies are excluded from the study. In MIST group (n=102), 8 Fr feeding tube is used to deliver surfactant while the baby is on CPAP. In INSURE group (n=102), surfactant is given by intubation through endotracheal tube without CPAP and extubated. Results: Mean birth weight was 1.26 kg in MIST and 1.22 kg in INSURE. Mean gestational age was 31.33 weeks in MIST and 31.11 weeks in INSURE. It was observed that there is a significant difference in terms of duration of oxygen requirement, neonatal intensive care unit stay, and surfactant spillage during administration in MIST group compared to INSURE group. However, duration of mechanical ventilation, CPAP, number of doses of surfactant, sepsis, intraventricular hemorrhage, retinopathy of prematurity, pneumothorax, bronchopulmonary dysplasia, and mortality did not show significant difference in both the groups. Conclusion: MIST is safe, feasible, and more beneficial than INSURE technique.

Clinical case of nebulized surfactant therapy for severe COVID-19-associated pneumonia at the 2nd stage of rehabilitation treatment

The development of an effective and safe drug for the treatment of patients with COVID-19 is currently an urgent task for the global medical community. Given that lung damage remains the predominant syndrome in COVID-19, and the development of acute respiratory distress syndrome (ARDS) is the most common reason for transfer to intensive care unit and connection to artificial lung ventilation, it seems promising to study the effectiveness and safety of surfactant therapy, successfully proven in practice in the treatment of adult and preterm infants ARDS. Despite the fact that most studies are devoted to the use of this method in patients in the acute stage, we present a case from our own practice of Surfactant-BL inhalation in a patient with COVID-19-associated pneumonia at the 2nd stage of rehabilitation treatment. Clinical signs of respiratory failure (RR 22 per minute, Sa O2 86% on atmospheric air, 95% on insufflation of humidified oxygen 7 L/min), high percentage of lung tissue damage according to thoracic CT (55% – CT3) on admission to the Medical Rehabilitation Unit, as well as a score of 6 on the NEWS2 scale served as a basis for the patient to receive Surfactant-BL inhalation for the indication «prevention of the development of acute respiratory distress syndrome» in a dosage of 75 mg twice a day for 5 days. Positive dynamics of clinical data at the end of the course of inhalations (decrease of RR to 16 per minute, increase of Sa O2 to 90% on atmospheric air and to 95% on insufflation of humidified oxygen 5 l/min, improvement of auscultatory picture), as well as the control thoracic CT scan, which showed a decrease of lung parenchyma damage to 45.2% (CT-2), indicated the effectiveness and safety of this method in the complex rehabilitation of COVID-19 patient, being a basis for further investigation of this issue

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

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&lt;0.001) than the MAC group. The procedural success was 91% in the Angiocath group and 89% in the MAC group (p &gt;.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

Objective 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). Study Design 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. Results 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. Conclusion 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. Key Points

Ten-year trend of care practices, morbidities and survival of very preterm neonates in the Malaysian National Neonatal Registry: a retrospective cohort study

ObjectivesTo determine a 10-year trend of survival, morbidities and care practices, and predictors of in-hospital mortality in very preterm neonates (VPTN, gestation 22 to <32 weeks) in the Malaysian National Neonatal Registry.DesignRetrospective cohort study.Setting43 Malaysian neonatal intensive care units.Patients29 010 VPTN (without major malformations) admitted between 1 January 2009 and 31 December 2018.Main outcome measuresCare practices, survival, admission hypothermia (AH, <36.5°C), late-onset sepsis (LOS), pneumothorax, necrotising enterocolitis grade 2 or 3 (NEC), severe intraventricular haemorrhage (sIVH, grade 3 or 4) and bronchopulmonary dysplasia (BPD).ResultsDuring this 10-year period, there was increased use of antenatal steroid (ANS), lower segment caesarean section (LSCS) and early continuous positive airway pressure (eCPAP); but decreased use of surfactant therapy. Survival had increased from 72% to -83.9%. The following morbidities had decreased: LOS (from 27.9% to 7.1%), pneumothorax (from 6.0% to 2.7%), NEC (from 8.1% to 4.7%) and sIVH (from 12.2% to 7.5%). However, moderately severe AH (32.0°C–35.9°C) and BPD had increased. Multiple logistic regression analyses showed that lower birth weight, no ANS, no LSCS, admission to neonatal intensive care unit with <100 VPTN admissions/year, no surfactant therapy, no eCPAP, moderate and severe AH, LOS, pneumothorax, NEC and sIVH were significant predictors of mortality.ConclusionSurvival and major morbidities had improved modestly. Failure to use ANS, LSCS, eCPAP and surfactant therapy, and failure to prevent AH and LOS increased risk of mortality.