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Original Investigation |

Minimally Invasive Surfactant Administration in Preterm Infants:  A Meta-narrative Review

Kiran More, MD, FRACP1; Pankaj Sakhuja, MD2; Prakesh S. Shah, MSc, MD, FRCPC3,4,5
[+] Author Affiliations
1Department of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
2Department of Paediatrics, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
3Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
4Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
5Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
JAMA Pediatr. 2014;168(10):901-908. doi:10.1001/jamapediatrics.2014.1148.
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Importance  Surfactant administration by minimally invasive methods that allow for spontaneous breathing might be safer and more effective than administration with endotracheal intubation and mechanical ventilation; however, the efficacy and safety of minimally invasive methods have not been reviewed.

Objective  To conduct a meta-narrative review of the efficacy and safety of minimally invasive surfactant administration using a thin catheter, aerosolization, a laryngeal mask airway, and pharyngeal administration in preterm infants with or at risk for respiratory distress syndrome.

Data Sources  We searched the PubMed, EMBASE, Cochrane, and CINAHL databases, published journals, and conference proceedings from inception to June 30, 2013.

Study Selection  Randomized clinical trials or observational studies of preterm infants who were given surfactant for respiratory distress syndrome by minimally invasive methods.

Data Extraction and Synthesis  An overall meta-narrative review was conducted encompassing the evolution of noninvasive surfactant therapy. Risk ratios and 95% confidence intervals are reported when appropriate.

Main Outcomes and Measures  Chronic lung disease diagnosed by the need for oxygen therapy at a postmenstrual age of 36 weeks, need for mechanical ventilation within the first 72 hours of birth, need for mechanical ventilation any time during the hospital stay, and adverse events associated with administration of surfactant by various methods.

Results  We included 10 studies (6 randomized and 4 observational) of 3081 neonates. Thin catheter administration was evaluated in 6 studies (2 randomized and 4 observational); aerosolization, in 2 randomized studies; and laryngeal mask and pharyngeal administration, in 1 observational study each. The meta-narrative review confirmed the slow evolution and challenges of the different modes of administration, with thin catheter administration being the most studied intervention. Two randomized studies of surfactant administration using a thin catheter revealed no significant difference in the outcome of bronchopulmonary dysplasia but a potential reduction in the need for mechanical ventilation within 72 hours of birth when compared with standard care.

Conclusions and Relevance  Surfactant administration via a thin catheter may be an efficacious and potentially safe method; however, further studies are needed. Further studies are also needed for other methods of minimally invasive surfactant administration.

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Figure 1.
Flow Diagram Describing Study Selection for Inclusion in Meta-narrative Review

LMA indicates laryngeal mask airway; NG, nasogastric; and RCT, randomized clinical trial.

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Figure 2.
Timeline for Evolution of Techniques for Surfactant Administration While Maintaining Spontaneous Breathing

LMA indicates laryngeal mask airway.

aIndicates randomized clinical trial.

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