Ellen de Kort

11 General introduction 1 The last decades there has been a tremendous increase in the use of non-invasive ventilatory strategies in preterm newborns. In accordance with these developments, lesser invasive methods of surfactant administration limiting the period of mechanical ventilation have emerged. The first technique used in clinical practice, was the INtubation – SURfactant – Extubation (INSURE) method. In this method, patients were intubated for the sole purpose of surfactant administration and were extubated as soon as possible thereafter. 40 Compared to surfactant administration during mechanical ventilation, INSURE decreased the need for mechanical ventilation, and the incidence of BPD and air leak syndromes. 41 INSURE, however, still requires a short period of mechanical ventilation and even these brief periods have the possibility of causing lung injury. 39,42 After that, several techniques to administer surfactant without the need for mechanical ventilation were developed. One of these techniques is the use of a thin catheter to administer surfactant to spontaneously breathing infants on nasal Continuous Positive Airway Pressure (nCPAP), a technique known as ‘Less Invasive Surfactant Administration’ (LISA) or ‘Minimally Invasive Surfactant Therapy’ (MIST). 43,44 This thin catheter technique has been shown to reduce the incidence of death or BPD, lower the need for mechanical ventilation, and shorten the duration of mechanical ventilation, oxygen therapy and different kinds of respiratory support. 45-51 In the past decade, LISA has made its way into clinical practice to a more or less extent. 52-56 The characteristics of the INSURE and LISA procedures and their differences with surfactant therapy during mechanical ventilation are outlined in Figure 1. •Premedication for intubation: always. •Intubation and start mechanical ventilation (ventilator). •Surfactant administration through endotracheal tube. •Continuing mechanical ventilation for (at least) several hours. Surfactant during mechanical ventilation •Premedication for intubation: commonly. •Intubation and start mechanical ventilation (ventilator, T piece or comparable device). •Surfactant administration through endotracheal tube. •Immediate extubation (ideally within minutes). INtubation-SURfactant-Extubation (INSURE) •Premedication for catheter placement: occasionally. •Patient spontaneously breathing on nCPAP. •Placement of thin catheter through vocal cords. •Administration of surfactant through catheter. •Removal of the catheter, continuation of nCPAP. Less Invasive Surfactant Administration (LISA) Figure 1. Characteristics of different techniques to administer surfactant