Treating preterm infants with Surfactant:

1

• Treating preterm infants with Surfactant
• an overview of application techniques and results
• Angela Kribs, Childrens Hospital, University of
  Cologne

2
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

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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.
• gtgtgtgtgt Surfactant without any mechanical
  ventilation but with CPAP could be the
  combination of two effective principles !!!!

4
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. 200424360-365.
• 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

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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

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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. 200414188-190.
• Two case reports of successfull use of this
  technique in two infants with RDS (1360g and
  3200g)

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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. 200587217-220.
  

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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

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Nebulization of surfactant - Data
Mazela et al. Curr Opin Pediatr 19155-162
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Nebulization of surfactant - Data
Mazela et al. Curr Opin Pediatr 19155-162
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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 gtgtgt
• expensive

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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 lt/27 weeks). Paediatr
  Anaesth. 200717364-369.
• Kribs A et al. Early surfactant in spontaneously
  breathing with nCPAP in ELBW infants--a single
  centre four year experience.Acta Paediatr.
  200897(3)293-298.

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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 (lt80 after 10 min. gtgtincrease FiO2)
• Silverman- Score (5 min.) (gt 5 after 10 min. gtgt
  increase PEEP)
• Heart rate (no increase within 2 min. gtgt
  ventilation with mask and bag using PEEP- ventil
  and a pressure limitation. )

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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)

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Indications for surfactant administration

• FiO2 gt 0,3 for SO2 gt 80 after optimization of
  CPAP for infants with a gestational age lt26
  completed weeks or FiO2 gt0,4 for infants with a
  gestational age gt26 weeks
• Silverman Score gt 5 after optimization of CPAP

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Indications for endotracheal intubation during
the first 72 hours of live

• FiO2 gt 0,5 for SO2 gt 80 for more than two hours
  after optimization of CPAP and after appplication
  of surfactant
• Persistant Silverman Score gt 5
• More than one apnea with need for intervention
  within 2 hours
• Resp. acidosis with pH lt 7,15

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period 0 (N38) period 1 (N47) period 2 (N45) period 3 (N28) period 4 (N35)
Gestational age (weeks) 25,7 (232-276) 25,7 (230-276) 25,2 (230-276) 25,3 (230-276) 25,1 (230-276)
Birth weight (gramm) 714 (347-1000) 667 (350-1000) 705 (430-1000) 690 (430-1000) 668 (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 (lt10.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 lt 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)
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Respiratory management of RDS (n155)

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Outcome of preterm infants lt/ 1000 g and lt/27
weeks (data are given in )
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Mechanical ventilation vs. CPAP as initial
respiratory supportDemographic data and prenatal
risks
Ventilation N23 CPAP N132 Significance
Gestational Age (weeks) 24,8 25,4 P0,038
Birth weight (gramm) 662 686 n.s.
Apgar 5 min. 4,7 7,6 Plt0,001
gender male / female 11/12 63/69 n.s.
Any antenatal steroids 21 (91,3) 125 (94,7) n.s.
SGA lt 10. Perc. 4 (17,4) 40 (30,3) n.s.
Sepsis at birth 15 (65,2) 43 (32,6) P0.004
PPROM lt 23 weeks of gestational age 10 (43,5) 27 (20,5) P0.031
Twin to twin transfusion 5 (21,8) 9 (6,8) P0.037
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CPAP Surfactant Responder vs Non
ResponderDemographic data and prenatal risks
Responder N90 Non Responder N38 Significance
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.
gender male / female 44/46 19/19 n.s.
Any antenatal steroids 87 35 n.s.
SGA lt 10. Perc. 26 14 n.s.
Sepsis at birth 26 15 n.s.
PPROM lt 23 weeks of gestational age 20 7 n.s.
Twin to twin transfusion 4 5 n.s.
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Outcome of preterm infants lt/ 1000 g and lt/27
weeks (data are given in )
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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

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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