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Treating preterm infants with Surfactant: an overview of application techniques and results Angela Kribs, Children‘s Ho

Treating preterm infants with Surfactant: an overview of application techniques and results Angela Kribs, Children‘s Hospital, University of Cologne. Classical way: endotracheal intubation and application of surfactant via endotracheal tube

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Treating preterm infants with Surfactant: an overview of application techniques and results Angela Kribs, Children‘s Ho

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  1. Treating preterm infants with Surfactant: an overview of application techniques and results Angela Kribs, Children‘s Hospital, University of Cologne

  2. 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 Application techniques

  3. 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 !!!! Background

  4. 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 Application of surfactant into the nasopharynx immediately after birth - Data

  5. Pros Avoidance of intubation Avoidance of any positive pressure ventilation Active inspiration of surfactant Cons Failure after cesarian section Application of surfactant into the nasopharynx immediately after birth – potential Pros and Cons

  6. 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) Application of surfactant via a laryngeal mask - Data

  7. 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. Application of surfactant via a laryngeal mask - Data

  8. 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 Application of surfactant via a laryngeal mask – potential Pros and Cons

  9. Nebulization of surfactant - Data Mazela et al. Curr Opin Pediatr 19:155-162

  10. Nebulization of surfactant - Data Mazela et al. Curr Opin Pediatr 19:155-162

  11. 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 Nebulization of surfactant – potential Pros and Cons

  12. 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. Application of surfactant via a thin endotracheal catheter during spontaneous breathing - Data

  13. 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. ) Standard of delivery room management

  14. Persistent apnea and bradycardia with need for resuscition Prenatal diagnosis of severe malformation with imminent respiratory failure (need for transport over a long distance) Indications for endotracheal intubation in the delivery room

  15. 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 Indications for surfactant administration

  16. 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 Indications for endotracheal intubation during the first 72 hours of live

  17. Respiratory management of RDS (n=155) %

  18. Outcome of preterm infants </= 1000 g and </=27 weeks (data are given in %)

  19. Mechanical ventilation vs. CPAP as initial respiratory supportDemographic data and prenatal risks

  20. CPAP + Surfactant: Responder vs Non ResponderDemographic data and prenatal risks

  21. Outcome of preterm infants </= 1000 g and </=27 weeks (data are given in %)

  22. 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 Application of surfactant via a thin endotracheal catheter during spontaneous breathing – potential Pros and Cons

  23. 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 Summary

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