Surfactant Therapy for Newborns
Canberra Health ServicesClinical Guideline Surfactant Therapy for NewbornsContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc23335041 \h 1Guideline Statement PAGEREF _Toc23335042 \h 2Background PAGEREF _Toc23335043 \h 2Key Objective PAGEREF _Toc23335044 \h 2Alerts PAGEREF _Toc23335045 \h 2Scope PAGEREF _Toc23335046 \h 2Section 1 – Indications for surfactant administration PAGEREF _Toc23335047 \h 3Respiratory distress syndrome (RDS) PAGEREF _Toc23335048 \h 3Meconium aspiration syndrome (MAS) PAGEREF _Toc23335049 \h 4Pulmonary haemorrhage and Pneumonia PAGEREF _Toc23335050 \h 4Section 2 – Which surfactant PAGEREF _Toc23335051 \h 4Section 3 – Method of administration PAGEREF _Toc23335052 \h 5Intubation and ventilation PAGEREF _Toc23335053 \h 5Intubation, surfactant treatment then rapid extubation (INSURE) PAGEREF _Toc23335054 \h 5Surfactant administration via a thin catheter (LISA/MIST) PAGEREF _Toc23335055 \h 6Section 4 – Respiratory management after surfactant administration PAGEREF _Toc23335056 \h 6Implementation PAGEREF _Toc23335057 \h 7Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc23335058 \h 7References PAGEREF _Toc23335059 \h 7Search Terms PAGEREF _Toc23335060 \h 9Attachments PAGEREF _Toc23335061 \h 9Attachment 1: Surfactant administration via an endotracheal tube (ETT) in a ventilated newborn PAGEREF _Toc23335062 \h 11Attachment 2: INSURE technique PAGEREF _Toc23335063 \h 12Attachment 3: Thin catheter technique PAGEREF _Toc23335064 \h 14Guideline StatementBackgroundThere is variation in international, national and state guidelines relating to surfactant use in newborn infants. This guideline outlines Canberra Hospital consensus, relating to the use of surfactant in newborns.Key ObjectiveThe purpose of this procedure is to provide clinicians with information on the safe and effective management of newborns requiring surfactant at Canberra Hospital. Alerts Aim to stabilise newborns with respiratory distress syndrome on Continuous Positive Airway Pressure (CPAP) in the delivery room and provide them with early rescue surfactant if required.Newborns <28 weeks gestation with respiratory distress syndrome and increased work of breathing, may be treated with poractant (curosurf) once they require a Positive End-Expiratory Pressure (PEEP) of 7cmH20 or greater and require any oxygen therapy in the first 24 hours of life. Newborns >/=28 weeks gestation with respiratory distress syndrome and increased work of breathing, may be treated with beractant (survanta) once they require a PEEP of 7cmH20 or greater and requiring >/=30% oxygen therapy in the first 24-48 hours of life Consider treating any ventilated newborn with severe respiratory failure secondary to meconium aspiration, pneumonia or pulmonary haemorrhage with beractant (survanta) Use less invasive methods of surfactant administration, such as INSURE (INtubation, Surfactant treatment then Rapid Extubation) or Minimally Invasive Surfactant Administration (MIST)/ Less Invasive Surfactant Administration (LISA) where able.Take cultural considerations into account when using beractant (derived from a bovine source) or poractant (derived from porcine lung extract) Back to Table of ContentsScopeThis document pertains to newborns cared for by CHS staff in the Neonatal Intensive Care Unit (NICU).This document applies to the following CSH staff working within their scope of practice:Medical Officers Nurses MidwivesBack to Table of ContentsSection 1 – Indications for surfactant administrationPulmonary surfactant is naturally produced by the body. It lines the alveoli reducing surface tension and preventing alveolar collapse at end expiration. It is made up of a mixture of proteins and lipids. There are several clinical scenarios in which surfactant is either not being produced by the newborn in adequate quantities (respiratory distress syndrome) or has been inactivated (meconium aspiration syndrome/pulmonary haemorrhage) in which exogenous surfactant administration is indicated.Respiratory distress syndrome (RDS)Surfactant has been shown to improve short term outcomes in newborns with respiratory distress syndrome by reducing the need for mechanical ventilation, decreasing the incidence of pneumothorax and pulmonary interstitial emphysema, death and the combined outcome of death or chronic lung disease ADDIN EN.CITE <EndNote><Cite><Author>Seger</Author><Year>2009</Year><RecNum>2</RecNum><DisplayText>[1]</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553564399">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Seger, N.</author><author>Soll, R.</author></authors></contributors><auth-address>Department of Pediatrics, University of Vermont College of Medicine, McClure 7, Fletcher Allen Health Care, 111 Colchester Avenue, Burlington, Vermont 05401, USA. nadineseger@</auth-address><titles><title>Animal derived surfactant extract for treatment of respiratory distress syndrome</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD007836</pages><number>2</number><keywords><keyword>Amniotic Fluid/chemistry</keyword><keyword>Animals</keyword><keyword>Biological Products/therapeutic use</keyword><keyword>Bronchopulmonary Dysplasia/mortality/prevention & control</keyword><keyword>Cattle</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Pneumothorax/prevention & control</keyword><keyword>Pulmonary Emphysema/prevention & control</keyword><keyword>Pulmonary Surfactants/chemistry/*therapeutic use</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Respiratory Distress Syndrome, Newborn/mortality/*therapy</keyword><keyword>Swine</keyword></keywords><dates><year>2009</year><pub-dates><date>Apr 15</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>19370695</accession-num><urls><related-urls><url>;[1].Respiratory distress syndrome in preterm newborns <28 weeks gestationStabilising newborns on CPAP and then providing those who need it with early rescue surfactant, has been shown to improve survival and reduce chronic lung disease when compared to electively intubating to provide prophylactic surfactant at birth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EdW5uPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [2-4]. Newborns who require surfactant, benefit from receiving this at <2 hours of age, resulting in less air leak from lungs, reduced chronic lung disease and likelihood of death ADDIN EN.CITE <EndNote><Cite><Author>Bahadue</Author><Year>2012</Year><RecNum>6</RecNum><DisplayText>[5]</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553565041">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bahadue, F. L.</author><author>Soll, R.</author></authors></contributors><auth-address>University of Vermont, Burlington, Vermont, USA.</auth-address><titles><title>Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD001456</pages><volume>11</volume><keywords><keyword>Acute Disease</keyword><keyword>Acute Lung Injury/prevention & control</keyword><keyword>Chronic Disease</keyword><keyword>Drug Combinations</keyword><keyword>Fatty Alcohols/therapeutic use</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Lung Diseases/prevention & control</keyword><keyword>Phosphorylcholine/therapeutic use</keyword><keyword>Polyethylene Glycols/therapeutic use</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Respiratory Distress Syndrome, Newborn/*drug therapy</keyword><keyword>Time Factors</keyword></keywords><dates><year>2012</year><pub-dates><date>Nov 14</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>23152207</accession-num><urls><related-urls><url>;[5]. An Australian study demonstrated that newborns requiring >30% oxygen at 2 hours of age is predictive of CPAP failure [6]. There is little evidence to guide practice around optimal timing of surfactant administration. Taking the current evidence into account it is recommended at CHS:Whenever possible stabilise preterm newborns on CPAP in the delivery room. Avoid intubating newborns for the purpose of surfactant administration at birth, unless this is unavoidable (i.e. unable to achieve appropriate saturation levels with standard resuscitation). Newborns who are intubated for the purpose of resuscitation should be given surfactant as soon as possible after intubation.Have a low threshold for providing surfactant to newborns, with clinically significant respiratory distress syndrome. Newborns <28 weeks gestationGive surfactant to newborns with RDS who require >/= 30% oxygen in the first 24-48 hours of life.Surfactant may be given (ideally using a less/minimally invasive technique or INSURE – see section 3) to newborns <28 weeks gestation requiring a PEEP of 7cmH20 or greater with increased work of breathing and chest X-ray evidence of moderate to severe respiratory distress syndrome requiring any amount of oxygen therapy in the first 24 hours of life. RDS in newborns >/= 28 weeks gestationAs outlined above, providing surfactant to those who require it as early as possible reduces the risk of pneumothorax ADDIN EN.CITE <EndNote><Cite><Author>Bahadue</Author><Year>2012</Year><RecNum>6</RecNum><DisplayText>[5]</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553565041">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bahadue, F. L.</author><author>Soll, R.</author></authors></contributors><auth-address>University of Vermont, Burlington, Vermont, USA.</auth-address><titles><title>Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD001456</pages><volume>11</volume><keywords><keyword>Acute Disease</keyword><keyword>Acute Lung Injury/prevention & control</keyword><keyword>Chronic Disease</keyword><keyword>Drug Combinations</keyword><keyword>Fatty Alcohols/therapeutic use</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Lung Diseases/prevention & control</keyword><keyword>Phosphorylcholine/therapeutic use</keyword><keyword>Polyethylene Glycols/therapeutic use</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Respiratory Distress Syndrome, Newborn/*drug therapy</keyword><keyword>Time Factors</keyword></keywords><dates><year>2012</year><pub-dates><date>Nov 14</date></pub-dates></dates><isbn>1469-493X (Electronic)
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ADDIN EN.CITE.DATA [6]. A reduction in pneumothorax was also demonstrated in a small Canadian randomised control trial (RCT), randomising newborns 32 weeks and older to minimally invasive surfactant once they were requiring a PEEP of >6cmH20 and >35% oxygen ADDIN EN.CITE <EndNote><Cite><Author>Olivier</Author><Year>2017</Year><RecNum>8</RecNum><DisplayText>[7]</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553570846">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Olivier, F.</author><author>Nadeau, S.</author><author>Belanger, S.</author><author>Julien, A. S.</author><author>Masse, E.</author><author>Ali, N.</author><author>Caouette, G.</author><author>Piedboeuf, B.</author></authors></contributors><auth-address>Department of Pediatrics, CHU de Quebec - Universite Laval, Quebec City, Quebec.
Plateforme de la recherche clinique, Centre de recherche du CHU de Quebec - Universite Laval, Hopital Saint-Francois d'Assise, Quebec City, Quebec.
Department of Pediatrics, Universite de Sherbrooke, Hopital Fleurimont, Sherbrooke, Quebec.
Department of Pediatrics, Universite de Montreal, Hopital Maisonneuve-Rosemont, Montreal, Quebec.</auth-address><titles><title>Efficacy of minimally invasive surfactant therapy in moderate and late preterm infants: A multicentre randomized control trial</title><secondary-title>Paediatr Child Health</secondary-title></titles><periodical><full-title>Paediatr Child Health</full-title></periodical><pages>120-124</pages><volume>22</volume><number>3</number><keywords><keyword>Hyaline membrane disease</keyword><keyword>Infant</keyword><keyword>Premature</keyword><keyword>Pulmonary surfactants</keyword><keyword>Respiratory distress syndrome</keyword><keyword>Spontaneous breathing.</keyword></keywords><dates><year>2017</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1205-7088 (Print)
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ADDIN EN.CITE.DATA [8] and the other showing a reduction in the need for extra-corporeal membrane oxygenation ADDIN EN.CITE <EndNote><Cite><Author>El Shahed</Author><Year>2014</Year><RecNum>14</RecNum><DisplayText>[9]</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553576366">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>El Shahed, A. I.</author><author>Dargaville, P. A.</author><author>Ohlsson, A.</author><author>Soll, R.</author></authors></contributors><auth-address>The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, Canada. Egyptian Neonatal Network (EGNN),Mansoura, Egypt. amr.elshahed@sickkids.ca. amrshahed@.</auth-address><titles><title>Surfactant for meconium aspiration syndrome in term and late preterm infants</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD002054</pages><number>12</number><keywords><keyword>Extracorporeal Membrane Oxygenation/statistics & numerical data</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Meconium Aspiration Syndrome/*drug therapy/mortality</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2014</year><pub-dates><date>Dec 14</date></pub-dates></dates><isbn>1469-493X (Electronic)
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ADDIN EN.CITE.DATA [10, 11]. In a small trial, surfactant administration was shown to improve oxygenation in newborns with pneumonia ADDIN EN.CITE <EndNote><Cite><Author>Tan</Author><Year>2012</Year><RecNum>16</RecNum><DisplayText>[12]</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553643252">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tan, K.</author><author>Lai, N. M.</author><author>Sharma, A.</author></authors></contributors><auth-address>Monash Newborn, Monash Medical Centre/Monash University, Clayton, Australia. kenneth.tan@.au.</auth-address><titles><title>Surfactant for bacterial pneumonia in late preterm and term infants</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD008155</pages><number>2</number><keywords><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Premature</keyword><keyword>Infant, Premature, Diseases/*drug therapy</keyword><keyword>Pneumonia, Bacterial/*drug therapy</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Term Birth</keyword></keywords><dates><year>2012</year><pub-dates><date>Feb 15</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>22336836</accession-num><urls><related-urls><url>;[12]. There is limited evidence for the use of surfactant in newborns with pulmonary haemorrhage, although some observations studies have reported an apparent short term clinical benefit in ventilatory index ADDIN EN.CITE <EndNote><Cite><Author>Amizuka</Author><Year>2003</Year><RecNum>17</RecNum><DisplayText>[13]</DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553643644">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Amizuka, T.</author><author>Shimizu, H.</author><author>Niida, Y.</author><author>Ogawa, Y.</author></authors></contributors><auth-address>Department of Paediatrics, Saitama Medical Centre, Saitama Medical School, 1981 Kamoda-Tsujido, 350-8550 Kawagoe, Japan.</auth-address><titles><title>Surfactant therapy in neonates with respiratory failure due to haemorrhagic pulmonary oedema</title><secondary-title>Eur J Pediatr</secondary-title></titles><periodical><full-title>Eur J Pediatr</full-title></periodical><pages>697-702</pages><volume>162</volume><number>10</number><keywords><keyword>Albumins/analysis</keyword><keyword>Biological Products/*therapeutic use</keyword><keyword>Female</keyword><keyword>Hemothorax/*complications</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Phosphatidylcholines/analysis</keyword><keyword>Pulmonary Edema/*complications</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Regression Analysis</keyword><keyword>Respiratory Distress Syndrome, Newborn/*drug therapy/etiology</keyword><keyword>Retrospective Studies</keyword></keywords><dates><year>2003</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0340-6199 (Print)
0340-6199 (Linking)</isbn><accession-num>12898240</accession-num><urls><related-urls><url>;[13].Consider giving surfactant to ventilated newborns with severe respiratory failure in the context of pulmonary haemorrhage or pneumonia, recognising there is limited evidence to support this practice.Back to Table of Contents Section 2 – Which surfactantWhen the initial dose of poractant is >100mg/kg, there is some evidence that the use of poractant results in less death or chronic lung disease and a reduction in the requirement for a second dose of surfactant when compared to beractant ADDIN EN.CITE <EndNote><Cite><Author>Singh</Author><Year>2015</Year><RecNum>18</RecNum><DisplayText>[14]</DisplayText><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553644618">18</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Singh, N.</author><author>Halliday, H. L.</author><author>Stevens, T. P.</author><author>Suresh, G.</author><author>Soll, R.</author><author>Rojas-Reyes, M. X.</author></authors></contributors><auth-address>Department of Pediatrics, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, USA, 03784.</auth-address><titles><title>Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD010249</pages><number>12</number><keywords><keyword>Animals</keyword><keyword>Cattle</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Premature</keyword><keyword>Oxygen Inhalation Therapy</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Respiratory Distress Syndrome, Newborn/*drug therapy/mortality</keyword><keyword>Swine</keyword></keywords><dates><year>2015</year><pub-dates><date>Dec 21</date></pub-dates></dates><isbn>1469-493X (Electronic)
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ADDIN EN.CITE.DATA [15]. Consider the cultural values of families when choosing which surfactant to administer (Curosurf is porcine and Survanta is bovine).For infants <28 weeks use poractant (Curosurf) For infants >/=28 weeks use beractant (Survanta)Repeated dosing in respiratory distress syndromeConsider giving repeated doses (second or third dose) ADDIN EN.CITE <EndNote><Cite><Author>Sweet</Author><Year>2017</Year><RecNum>10</RecNum><DisplayText>[16]</DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553573541">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sweet, D. G.</author><author>Carnielli, V.</author><author>Greisen, G.</author><author>Hallman, M.</author><author>Ozek, E.</author><author>Plavka, R.</author><author>Saugstad, O. D.</author><author>Simeoni, U.</author><author>Speer, C. P.</author><author>Vento, M.</author><author>Visser, G. H.</author><author>Halliday, H. L.</author></authors></contributors><auth-address>Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK.</auth-address><titles><title>European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update</title><secondary-title>Neonatology</secondary-title></titles><periodical><full-title>Neonatology</full-title></periodical><pages>107-125</pages><volume>111</volume><number>2</number><keywords><keyword>Consensus</keyword><keyword>Continuous Positive Airway Pressure/*methods</keyword><keyword>Disease Management</keyword><keyword>Europe</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Premature</keyword><keyword>Neonatologists</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Respiratory Distress Syndrome, Newborn/*therapy</keyword></keywords><dates><year>2017</year></dates><isbn>1661-7819 (Electronic)
1661-7800 (Linking)</isbn><accession-num>27649091</accession-num><urls><related-urls><url>;[16] of surfactant in newborns with ongoing increased work of breathing and an oxygen requirement of >/= 30% oxygen.6-12 hours - Consider repeated dosing 6 hours after the first dose in newborns who require continued mechanical ventilation and are unable to be extubated secondary to respiratory distress syndrome12 hours - Consider repeated dosing after 12 hours in newborns who remain on CPAP in >30% oxygen.Dosing of surfactant:Please refer to NICU drug manual (Curosurf (poractant) and Survanta (beractant))Back to Table of Contents Section 3 – Method of administrationIntubation and ventilationNewborns who require intubation and ventilation for the purposes of: resuscitation, apnoea, sepsis, hydrops, severe anaemia or severe respiratory acidosis, should receive surfactant via an endotracheal tube (ETT) and remain ventilated until they demonstrate that they can be extubated based on clinical parameters.Refer to Attachment 1 for a step by step guide to performing this procedure.Intubation, surfactant treatment then rapid extubation (INSURE)The INSURE method aims to keep newborns on non-invasive support and has been shown to reduce the need for mechanical ventilation when compared to intubation and ventilation and showed a trend towards less air leak and chronic lung disease ADDIN EN.CITE <EndNote><Cite><Author>Stevens</Author><Year>2007</Year><RecNum>24</RecNum><DisplayText>[17]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553659594">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stevens, T. P.</author><author>Harrington, E. W.</author><author>Blennow, M.</author><author>Soll, R. F.</author></authors></contributors><auth-address>University of Rochester, Pediatrics, Dept of Pediatrics (Neonatology), Box 651, 601 Elmwood Ave, Rochester, NY 14642, USA. timothy_stevens@urmc.rochester.edu</auth-address><titles><title>Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD003063</pages><number>4</number><keywords><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Premature</keyword><keyword>Pulmonary Surfactants/*therapeutic use</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>*Respiration, Artificial</keyword><keyword>Respiratory Distress Syndrome, Newborn/drug therapy/*therapy</keyword><keyword>Risk</keyword></keywords><dates><year>2007</year><pub-dates><date>Oct 17</date></pub-dates></dates><isbn>1469-493X (Electronic)
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ADDIN EN.CITE.DATA [18] and reduce the need for mechanical ventilation ADDIN EN.CITE <EndNote><Cite><Author>Lau</Author><Year>2017</Year><RecNum>21</RecNum><DisplayText>[19]</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="9ra0tp22os5rrueea9d5vxarvw2vdwwdpsxw" timestamp="1553647446">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lau, C. S. M.</author><author>Chamberlain, R. S.</author><author>Sun, S.</author></authors></contributors><auth-address>Saint Barnabas Medical Center, Livingston, NJ, USA.
Saint George's University, Grenada, West Indies.
New Jersey Medical School, Rutgers University, Newark, NJ, USA.
Banner MD Anderson Cancer Center, Gilbert, AZ, USA.</auth-address><titles><title>Less Invasive Surfactant Administration Reduces the Need for Mechanical Ventilation in Preterm Infants: A Meta-Analysis</title><secondary-title>Glob Pediatr Health</secondary-title></titles><periodical><full-title>Glob Pediatr Health</full-title></periodical><pages>2333794X17696683</pages><volume>4</volume><keywords><keyword>bronchopulmonary dysplasia</keyword><keyword>less invasive surfactant administration</keyword><keyword>meta-analysis</keyword><keyword>minimally invasive</keyword><keyword>neonatal respiratory distress syndrome</keyword><keyword>preterm</keyword><keyword>surfactant</keyword><keyword>thin catheter</keyword><keyword>conflicts of interest with respect to the research, authorship, and/or</keyword><keyword>publication of this article.</keyword></keywords><dates><year>2017</year></dates><isbn>2333-794X (Print)
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ADDIN EN.CITE.DATA [20].Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsis may not be good candidates for thin catheter surfactant.Refer to Attachment 3 for further information.We recommend giving surfactant either via INSURE or thin catheter depending on patient need and clinician preference. We recommend avoiding positive pressure ventilation in a spontaneously breathing newborn, even when administering surfactant via an ETT.Only use INSURE or thin catheter surfactant in a patient who requires surfactant rather than ventilation. Do not use either of these methods in a rapidly deteriorating patient with respiratory failure needing lung recruitment using positive pressure or support on a ventilator. The decision regarding how to administer surfactant should be made in consultation with the fellow/consultant on callBack to Table of ContentsSection 4 – Respiratory management after surfactant administrationSurfactant administration leads to rapid changes in lung compliance. It is common to need a slightly higher peak inspiratory pressure, oxygen and inspiratory time in the minutes following surfactant administration. It’s important to carefully monitor clinical response to a surfactant bolus and modify ventilation settings accordingly. After a few minutes, lung compliance improves, and it becomes necessary to wean peak inspiratory pressure and oxygen in order to maintain normal tidal volumes and saturation targets. Aim to maintain a tidal volume of 4-6ml/kg.Aim to manage newborns with respiratory distress syndrome who require surfactant on volume targeted ventilation when able and review them every 15 minutes in the first hour after surfactant administration.Back to Table of ContentsImplementation This guideline will be discussed at relevant clinical and management meetings. This guideline has previously been discussed and reviewed by our clinician team. Its use will be audited after it has been implemented as part of a clinical practice improvement project aimed at reducing the incidence of pneumothorax and as part of standard benchmarking performed routinely in NICU for preterm infants.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesMedication Handling Consent and TreatmentPatient Identification and Procedure MatchingProceduresNeonatal Routine Care Pulse Oximetry Screening – Neonates Care of the Extremely Preterm and Low Birth Weight Baby – The Golden Hour Patient Identification and Procedure MatchingVital Signs and Early Warning Scores Guidelines Management of Neonatal Pneumothorax Birth Requiring the Presence of a Neonatal Team Member LegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferences1. Seger N, Soll R. Animal derived surfactant extract for treatment of respiratory distress syndrome. Cochrane Database Syst Rev. 2009(2):CD007836. doi:10.1002/14651858.CD007836.2. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics. 2011;128(5):e1069-76. doi:10.1542/peds.2010-3848.3. Network SSGotEKSNNR, Finer NN, Carlo WA, Walsh MC, Rich W, Gantz MG et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med. 2010;362(21):1970-9. doi:10.1056/NEJMoa0911783.4. Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2012(3):CD000510. doi:10.1002/14651858.CD000510.pub2.5. Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev. 2012;11:CD001456. doi:10.1002/14651858.CD001456.pub2.6. Dargaville PA, Ali SKM, Jackson HD, Williams C, De Paoli AG. Impact of Minimally Invasive Surfactant Therapy in Preterm Infants at 29-32 Weeks Gestation. Neonatology. 2018;113(1):7-14. doi:10.1159/000480066.7. Olivier F, Nadeau S, Belanger S, Julien AS, Masse E, Ali N et al. Efficacy of minimally invasive surfactant therapy in moderate and late preterm infants: A multicentre randomized control trial. Paediatr Child Health. 2017;22(3):120-4. doi:10.1093/pch/pxx033.8. Natarajan CK, Sankar MJ, Jain K, Agarwal R, Paul VK. Surfactant therapy and antibiotics in neonates with meconium aspiration syndrome: a systematic review and meta-analysis. J Perinatol. 2016;36 Suppl 1:S49-54. doi:10.1038/jp.2016.32.9. El Shahed AI, Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration syndrome in term and late preterm infants. Cochrane Database Syst Rev. 2014(12):CD002054. doi:10.1002/14651858.CD002054.pub3.10. Jasani B, Kabra N, Nanavati R. Surfactant Replacement Therapy Beyond Respiratory Distress Syndrome in Neonates. Indian Pediatr. 2016;53(3):229-34. 11. Polin RA, Carlo WA, Committee on F, Newborn, American Academy of P. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics. 2014;133(1):156-63. doi:10.1542/peds.2013-3443.12. Tan K, Lai NM, Sharma A. Surfactant for bacterial pneumonia in late preterm and term infants. Cochrane Database Syst Rev. 2012(2):CD008155. doi:10.1002/14651858.CD008155.pub2.13. Amizuka T, Shimizu H, Niida Y, Ogawa Y. Surfactant therapy in neonates with respiratory failure due to haemorrhagic pulmonary oedema. Eur J Pediatr. 2003;162(10):697-702. doi:10.1007/s00431-003-1276-x.14. Singh N, Halliday HL, Stevens TP, Suresh G, Soll R, Rojas-Reyes MX. Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2015(12):CD010249. doi:10.1002/14651858.CD010249.pub2.15. Lemyre B, Fusch C, Schmolzer GM, Rouvinez Bouali N, Reddy D, Barrowman N et al. Poractant alfa versus bovine lipid extract surfactant for infants 24+0 to 31+6 weeks gestational age: A randomized controlled trial. PLoS One. 2017;12(5):e0175922. doi:10.1371/journal.pone.0175922.16. Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update. Neonatology. 2017;111(2):107-25. doi:10.1159/000448985.17. Stevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev. 2007(4):CD003063. doi:10.1002/14651858.CD003063.pub3.18. Aldana-Aguirre JC, Pinto M, Featherstone RM, Kumar M. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2017;102(1):F17-F23. doi:10.1136/archdischild-2015-310299.19. Lau CSM, Chamberlain RS, Sun S. Less Invasive Surfactant Administration Reduces the Need for Mechanical Ventilation in Preterm Infants: A Meta-Analysis. Glob Pediatr Health. 2017;4:2333794X17696683. doi:10.1177/2333794X17696683.20. Kribs A, Roll C, Gopel W, Wieg C, Groneck P, Laux R et al. Nonintubated Surfactant Application vs Conventional Therapy in Extremely Preterm Infants: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(8):723-30. doi:10.1001/jamapediatrics.2015.0504.Back to Table of ContentsSearch Terms NICU, Neonatology, Surfactant, MIST, LISA, INSURE, Neonate, Newborn, Pre-term, Baby, Administration, TherapyBack to Table of ContentsAttachmentsAttachment 1: Surfactant administration via an endotracheal tube (ETT) in a ventilated newbornAttachment 2: INSURE techniqueAttachment 3: Thin catheter techniqueDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 30/10/2019New DocumentTina Bracher, ED WY&CCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameAttachment 1: Surfactant administration via an endotracheal tube (ETT) in a ventilated newbornPerson performing procedure:Medical officer and/or nursing staff within their scope of practiceEquipment:Sterile dressing pack and sterile glovesAngiocath 16GA5 or 10 mL sterile syringe, drawing up needle, surfactantWorking Neopuff and suction equipmentCautions:Lung compliance may change rapidly following surfactant administrationWatch for signs of pneumothoraxObserve closely and titrate FiO2/Positive inspiratory pressure (PIP) to maintain normal ventilation targets (oxygen saturations of 90-95% and tidal volume of 4-6mL/kg)Procedure:Ensure the newborn’s parents have had the procedure explained to them if able depending on the acuity of the situation. Confirm the newborn’s identity as per the Patient Identification and Procedure Matching procedure.Warm surfactant prior to administration as this makes it more effective (to body/room temperature) Check the newborn’s neopuff is set appropriately and the suction is workingCheck the ETT position on a recent chest X-ray and ensure that there is equal air entry/ an ETT above the carina both clinically and on X-ray.Suction the newborn airways prior to the procedureOpen dressing pack, sterile angiocath and syringe onto the sterile field, maintaining asepsisWash hands and don sterile glovesRemove the needle from the angiocath and place it in a sharps binright2413000Draw up the surfactant into the syringe, ensuring there is an additional 2mL of air in the syringe (to facilitate flushing all surfactant out of the syringe)Connect the surfactant syringe to the angiocathDisconnect the newborn from the ventilatorPlace the angiocath in the ETTAdminister the surfactant slowly into the angiocath via ETT over 20-30 secondsReconnect the ventilator to the newbornThe medical officer and nurse caring for the newborn will need to carefully monitor the need for increases and decreases in ventilation parameters, as lung compliance changes. Target normal oxygen saturations and a tidal volume of 4-6 mL/kg.Avoid suctioning the newborn for at least 1 hour after the procedure where possible to avoid removing surfactant from the lungs.Document the procedure in the newborns clinical record.Attachment 2: INSURE techniquePerson performing technique:Medical officer within their scope of practiceEquipment:Sterile dressing pack and sterile glovesAngiocath 16GA5 or 10 mL sterile syringe and drawing up needle, surfactantWorking Neopuff and suction equipmentIntubation equipment including ETT and laryngoscope, airway adjuncts, stethoscope, CO2 detectorAtropine availableCautions:Lung compliance may change rapidly following surfactant administrationWatch for signs of pneumothoraxObserve closely and titrate Fio2Intubation may cause a vagal response. Have atropine available.Exclusion criteria:Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsisNewborns who are deteriorating rapidly and have lung de-recruitment requiring invasive ventilation Procedure:Ensure the newborn’s parents have had the procedure explained to them and consent has been obtained for the procedure. Confirm the newborn’s identity as per the Patient Identification and Procedure Matching procedure.Warm surfactant prior to administration as this makes it more effectivePrepare equipment for intubation. Avoid using intubation drugs where possible. If the newborn is distressed during the procedure, they may require analgesia/intubation drugs. Discuss this with the fellow/consultant on call.Set the neopuff to a PIP/PEEP of 20/6 and an FiO2 appropriate to the newborns’ conditionCheck suction equipment is workingRemove the CPAP and place the newborn on the neopuffSwaddle the newborn and provide sucrose Intubate the newborn, ensuring that the ETT is positioned above the carina (good bilateral air entry clinically and an ETT that is at the expected depth of insertion for age/size)right2413000Draw up the surfactant into the syringe, ensuring there is an additional 2mL of air in the syringe (to facilitate flushing all surfactant out of the syringe)Place the angiocath in the ETTAdminister the surfactant slowly into the angiocath via ETT over 20-30 secondsWhere possible allow the newborn to breath in the surfactant over approximately 15-20 secondsPlace newborn directly back on CPAP via the ETT and avoid giving positive pressure ventilation if able. You may need to increase the FiO2 or the PEEP to aid recovery. Only provide positive pressure ventilation if the newborn is apnoeic and desaturating.Aim to extubate within 5 minutes of surfactant administration, if the newborn is breathing spontaneously and has saturations within the target range, without a significantly increased Fio2 >20% from baseline Place the newborn directly back on CPAP and observe their clinical status closely.Document the procedure in the newborns clinical record.Attachment 3: Thin catheter techniquePerson performing technique:Medical officer within their scope of practiceEquipment:Sterile dressing pack and sterile glovesAngiocath 16GALip liner pencil5 or 10 mL sterile syringe, drawing up needle, surfactantWorking neopuff and suction equipmentIntubation equipment including ETT and laryngoscope, airway adjuncts, stethoscope, CO2 detectorHudson CPAP prongs appropriate to newborn size. These are the only brand that allow intubation of the cords without removal of the prongs.Atropine availableCautions:Lung compliance may change rapidly following surfactant administrationWatch for signs of pneumothoraxObserve closely and titrate FiO2Intubation may cause a vagal response. Have atropine available.Exclusion criteria:Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsisNewborns who are deteriorating rapidly and have lung de-recruitment requiring invasive ventilation Procedure:Ensure the newborn’s parents have had the procedure explained to them and consent has been obtained for the procedure. Confirm the newborn’s identity as per the Patient Identification and Procedure Matching procedure.Warm surfactant to body or room temperature prior to administration as this makes it more effectiveSet the Neopuff to a PIP/PEEP of 20/6 and FiO2 appropriate to the newborns ’s conditionCheck the suction equipment is workingEnsure intubation equipment and atropine are available, in case of an acute deterioration during the procedure.Place the newborn on Hudson prong CPAPSwaddle the newborn and provide sucroseOpen dressing pack, sterile angiocath and syringe onto the sterile field, maintaining asepsis 3227998532400Wash hands and don sterile glovesMark the insertion depth, based on the newborns weight, on the thin catheter using a lip liner (distance from the tip to the insertion point):<1000g = 1.5cm5472235877281000-2000g = 2.0 cm2000-3000g = 2.5cm>3000g = 3cmIntroduce a slight curve to the catheter at the desired insertion depthDraw up the surfactant into the syringe, ensuring there is an additional 2mL of air in the syringe (to facilitate flushing all surfactant out of the syringeUsing a laryngoscope, insert the thin catheter to the desired depth (see above).Remove the laryngoscope whilst anchoring the thin catheter in situConnect the surfactant to the catheter and administer the surfactant in 3-4 boluses over 15-20 seconds.Remove the thin catheter and continue CPAPIf catheterisation of the trachea is not possible within 20–30 seconds, remove the laryngoscope and allow recovery on CPAP before attempting tracheal catheterisation again. Consider abandoning the procedure after three unsuccessful attempts Document the procedure in the newborns clinical record. ................
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