Ellen de Kort

162 Chapter 9 are often performed without premedication to maintain a spontaneous breathing pattern. 81-88 Since LISA failure is associated with a higher need for mechanical ventilation, a higher incidence of supplemental oxygen at day 28 and a 20% lower survival rate without adverse events, 89 maintaining the respiratory drive to prevent LISA from failing is of utmost importance. There is, however, no evidence that laryngoscopy in the context of LISA is not accompanied with pain, discomfort and harmful effects. In an observational study on LISAwithout sedative premedicationwe showed a relatively low first attempt success rate of 52%, a high rate of inadequate technical quality of 41% and a 54% incidence of oxygen desaturations. 90 These results could indicate patient discomfort and intolerance to the procedure and promotes the use of sedative premedication in LISA. In the past three years, several studies have been published evaluating the effect of different kinds of premedication for LISA procedures. Although patient comfort significantly improved, 91,92 both propofol and ketamine did have important negative effects on the respiratory drive. 91-94 Comparing our findings in non-sedated LISA with studies using premedication, showed that our incidence of oxygen desaturations was lower compared to the premedicated population in those studies. 90,92-94 This is most probably due to respiratory depression caused by the premedication. Also, first attempt success rate of LISAwas comparable between our study and the studies using premedication. 90,92,94 Premedication did, however, provide better intubating conditions. 90,94 These comparisons do not mean performing LISA in awake patients is acceptable and even better than using premedication. These data do indicate we have to do better in premedicating patients for LISA, using drugs with the least effect on the respiratory drive. READY TO TACK – Towards premedication use in less invasive surfactant administration Recommendations for clinical practice • Laryngoscopy for LISA probably causes equal stress, discomfort and physiological disturbances compared to laryngoscopy for intubation. LISA should, therefore, be performed with premedication. • The premedication that is used, should have a very short duration of action and should not influence the respiratory drive. • Results from studies on the use of propofol as premedication for LISA indicate that propofol might have to great an effect on the respiratory drive. Propofol, therefore, seems probably not suitable for this purpose.