Ellen de Kort

53 Less Invasive Surfactant Administration without sedation 4 INTRODUCTION Respiratory distress syndrome (RDS) is one of the major causes of neonatal respiratory morbidity and mortality. 1 Although the early use of nasal continuous positive airway pressure (CPAP) significantly reduced the need for surfactant replacement therapy in RDS, still over half of all preterm neonates with RDS require surfactant. 2 Historically, surfactant was administered via an endotracheal tube during a period of mechanical ventilation. As mechanical ventilation may cause ventilator-induced lung injury and increases the risk of bronchopulmonary dysplasia (BPD), 3 the technique of less invasive surfactant administration (LISA) was developed. In this technique, surfactant is administered via a thin catheter in spontaneously breathing infants on nasal CPAP. 4 A systematic review including six randomized controlled trials with a total of 895 patients showed a significantly reduced incidence of BPD and death and a lesser need of mechanical ventilation in infants treated with LISA compared to infants treated with surfactant via an endotracheal tube during mechanical ventilation. 5 Fromendotracheal intubation studies in neonates it is long known that awake laryngoscopy is distressing and painful, and is frequently complicated by a series of serious adverse physiological events. 6-16 Also, awake intubation increases the time and the number of attempts necessary for successful intubation and increases the risk of traumatic injury to the airway. 12,13,17 Therefore, in a consensus statement on the prevention and management of pain in the newborn in 2001 and again by the American Academy of Pediatrics in 2010, it was stated that nonemergency intubation should always be performed with the use of premedication. 18,19 There is no consensus about the optimal premedication strategy. 19 Similar to endotracheal intubation, LISA involves the use of a laryngoscope to place the thin catheter through the vocal cords. However, most of the published randomized controlled trials did not use any premedication before LISA. 5,20,21 Also, in studies investigating LISA practices in different countries, apart from the Nordic countries, LISA is often performed in awake patients. 22-24 Only in the last 3 years, reports started to appear in the literature using different kinds of premedication prior to LISA. 25-28 The performance of LISA in awake patients might be considered a relapse in neonatal medicine. 20 We performed this observational cohort study to assess the success rate and quality of the technical conditions, and the vital parameter response in preterm newborns undergoing a LISA procedure without sedative premedication.