INTENSIVE CARE

surfactant treatment strategy to avoid mechanical ventilation; we
differentiated early from late failures to assess the contribution
of potential mechanisms such as respiratory depression versus
less-effective surfactant delivery. Secondary outcomes addressed
efficacy and safety end points.”
Results
It was noted in the study that “with accruing evidence that
the LMA is easier to use than an ETT, 15,16 causes less pain,
trauma and neurocirculatory disturbances than endotracheal
intubation, 24-27 and can be used for surfactant delivery, 15,17,18 we
envisioned a potentially advantageous alternative to INSURE.”
The results of the study backed up what the authors “envisioned”
as out of the patients who were studied, the “failure rate was
77% in the ETT group and 30% in the LMA group (Po0.001). The
difference was related to early failure, as late failure rates did not
differ between groups. FiO2 decrease after surfactant and rates
of adverse events were similar between groups.”
The study authors expanded on these results, saying that “we
found a substantially higher rate of failure to avoid mechanical
ventilation in the ETT group, which was accounted for by early
failures, suggesting that respiratory depression due to morphine
premedication was principally responsible for the apparent
superiority of the LMA strategy.”
The study included one note about how the LMA approach could
also benefit certain types of health care providers that might be
lacking resources: “As our study targeted neonates ≥29 weeks,
the results may not apply to more immature populations. There
is only one reported neonate weighing 1000 g who received
surfactant through an LMA, 18 as a size 1 LMA (the smallest
available) is relatively large for such patients. Still, the LMA
may be an important alternative to intubation for surfactant
administration in settings with low resources 20,28 or limited staff
expertise in intubation.” 29
In conclusion, the study authors wrote that “rescue surfactant
through an LMA in newborns with mild-to-moderate RDS
produces physiological and short-term clinical outcomes similar
to a morphine-based INSURE approach while obviating the need
for laryngoscopy, tracheal intubation and analgesia. As morphine
likely increased post-intubation ventilatory requirements,
optimal premedication strategies for INSURE should avoid
morphine and minimize the duration of respiratory depression—
which might be achievable with a rapid-onset, short-acting agent
such as remifentanil. Larger studies could then evaluate whether
less-invasive surfactant delivery via LMA produces respiratory
outcomes equivalent to those of an optimized INSURE
approach.”
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26 neonatal INTENSIVE CARE Vol. 29 No. 4 • Fall 2016