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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.” References 1 Verder H, Albertsen P, Ebbesen F, Greisen G, Robertson B, Bertelsen A et al. Nasal continuous positive airway pressure and early surfactant therapy for respiratory distress syndrome in newborns of less than 30 weeks’ gestation. Pediatrics 1999; 103(2): E24. 2 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. 3 Neonatal Resuscitation Textbook. 6th edn. American Heart Association and American Academy of Pediatrics: Elk Grove Village, IL, USA, 2011. 4 Dempsey EM, Al Hazzani F, Faucher D, Barrington KJ. Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2006; 91(4): F279–F282. 5 Friesen RH, Honda AT, Thieme RE. Changes in anterior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg 1987; 66(9): 874–878. 6 Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL. Physiologic changes associated with endotracheal intubation in preterm infants. Crit Care Med 1984; 12(6): 501–503. 7 Barrington K. Canadian Paediatric Society Fetus and Newborn Committee. Premedication for endotracheal intubation in the newborn infant. Paediatr Child Health 2011; 16(3): 159–171. 8 Kumar P, Denson SE, Mancuso TJ. American Academy of Pediatrics Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics 2010; 125(3): 608–615. 9 Byrne E, MacKinnon R. Should premedication be used for semi-urgent or elective intubation in neonates? Arch Dis Child 2006; 91(1): 79–83. 10 Carbajal R, Eble B, Anand KJ. Premedication for tracheal intubation in neonates: confusion or controversy? Semin Perinatol 2007; 31(5): 309–317. 11 Kingma PS. Is premedication for intubation of preterm infants the right choice? J Pediatr 2011; 159(6): 883–884. 12 Oei J, Hari R, Butha T, Lui K. Facilitation of neonatal nasotracheal intubation with premedication: a randomized controlled trial. J Paediatr Child Health 2002; 38(2): 146–150. 13 Bohlin K, Gudmundsdottir T, Katz-Salamon M, Jonsson B, Blennow M. Implementation of surfactant treatment during continuous positive airway pressure. J Perinatol 2007; 27(7): 422–427. 14 Verder H, Robertson B, Greisen G, Ebbesen F, Albertsen P, Lundstrom K et al. Surfactant therapy and nasal continuous positive airway pressure for newborns with respiratory distress syndrome. Danish-Swedish Multicenter Study Group. N Engl J Med 1994; 331(16): 1051–1055. 15 Trevisanuto D, Grazzina N, Ferrarese P, Micaglio M, Verghese C, Zanardo V. Laryngeal mask airway used as a delivery conduit for the administration of surfactant to preterm infants with respiratory distress syndrome. Biol Neonate 2005; 87(4): 217–220. 16 Chen L, Hsiao AL. Randomized trial of endotracheal tube versus laryngeal mask airway in simulated prehospital pediatric arrest. Pediatrics 2008; 122(2): e294–e297. 17 Brimacombe J, Gandini D, Keller C. The laryngeal mask airway for administration of surfactant in two neonates with respiratory distress syndrome. Paediatr Anaesth 2004; 14(2): 188–190. 18 Brimacombe J, Gandini D. Airway rescue and drug delivery in an 800 g neonate with the laryngeal mask airway. Paediatr Anaesth 1999; 9(2): 178. 19 Micaglio M, Zanardo V, Ori C, Parotto M, Doglioni N, Trevisanuto D, ProSeal LMA. for surfactant administration. Paediatr Anaesth 2008; 18(1): 91–92. 20 Attridge J, Stewart C, Stukenborg G, Kattwinkel J. Administration of rescue surfactant by laryngeal mask airway: lessons from a pilot trial. Am J Perinatol 2013; 30(3): 201–206. 21 Roberts KD, Lampland AL, Meyers PA, Worwa CT, Plumm 26 neonatal INTENSIVE CARE Vol. 29 No. 4 • Fall 2016
BJ, Mammel MC. Laryngeal mask airway for surfactant administration in a newborn animal model. Pediatr Res 2010; 68(5): 414–418. 22 Abdel-Latif ME, Osborn DA. Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev 2011; CD008309. 24 Abdi W, Amathieu R, Adhoum A, Poncelet C, Slavov V, Kamoun W et al. Sparing the larynx during gynecological laparoscopy: a randomized trial comparing the LMA Supreme(TM) and the ETT. Acta Anaesthesiol Scand 2010; 54(2): 141–146. 25 Zimmert M, Zwirner P, Kruse E, Braun U. Effects on vocal function and incidence of laryngeal disorder when using a laryngeal mask airway in comparison with an endotracheal tube. Eur j Anaesthesiol 1999; 16(8): 511–515. 26 Akbar AN, Muzi M, Lopatka CW, Ebert TJ. Neurocirculatory responses to intubation with either an endotracheal tube or a laryngeal mask airway in humans. J Clin Anesth 1996; 8(3): 194–197. 27 Blanchard N, Jezraoui P, Milazzo S, Daelman F, Rajaonarivony D, Ossart M. Changes in intraocular pressure with the use of an endotracheal tube or laryngeal mask airway for anesthesia [Variations de la pression intraoculaire selon l’utilisation d’une sonde d’intubation ou d’un masque laryngé en cours d’anesthésie]. Annales Françaises d’Anesthésie et de Réanimation 1996; 15(7): 1008-1012. 28 Kirsten GF, Kirsten CL, Henning PA, Smith J, Holgate SL, Bekker A et al. The outcome of ELBW infants treated with NCPAP and InSurE in a resource-limited institution. Pediatrics 2012; 129(4): e952–e959. 29 Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics 2003; 112(6 Pt 1): 1242– 1247. 30 Dani C, Corsini I, Poggi C. Risk factors for intubationsurfactant-extubation (INSURE) failure and multiple INSURE strategy in preterm infants. Early Hum Dev 2012; 88(Supplement 1): S3–S4. 31 Cherif A, Hachani C, Khrouf N. Risk factors of the failure of surfactant treatment by transient intubation during nasal continuous positive airway pressure in preterm infants. Am J Perinatol 2008; 25(10): 647–652. 32 Göpel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C et al. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an openlabel, randomised, controlled trial. Lancet 2011; 378 (9803): 1627–1634. 33 Dargaville PA, Aiyappan A, Cornelius A, Williams C, De Paoli AG. Preliminary evaluation of a new technique of minimally invasive surfactant therapy. Arch Dis Child Fetal Neonatal Ed 2011; 96(4): F243–F248. 34 Dargaville PA, Aiyappan A, De Paoli AG, Kuschel CA, Kamlin CO, Carlin JB et al. Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 2013; 98(2): F122–F126. neonatal INTENSIVE CARE Vol. 29 No. 4 • Fall 2016 27
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