Minimally invasive surfactant therapy in preterm

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Minimally invasive surfactant therapy in preterm

  1. 1. BMJ– FETAL & NEONATAL MEDICINEMARCH 2013
  2. 2. Ojective : to evaluate the applicability& potential effectiveness of atechnique of minimal invasivesurfactant therapy in preterm infantson cpap
  3. 3. Already known on this topicPreterm infants managed intially on cpap will go onto require intubation because of respiratory distressrelated to surfactant defeciency
  4. 4. What this study addsA technique of MIST using narrow bore vascularcatheter inserted into trachea was successfully appliedby neonatal physicians at two sitesAdministration of surfactantb via MIST resulted insustained reduction in o2 requirement &decrease inthe need in intubation for 25-28 weeks gestation
  5. 5. Outcomes for infants commencing on CPAP coud befurther improved if those with significant RDS were toreceive exogenous surfactant at an early stage
  6. 6. INSURE limitations has prompted the pursuit ofalternative less invasive means of giving surfactanttherapy to preterm infants on CPAP
  7. 7. MISTDirect tracheal catherizationFlexible feeding tube positioned in trachea withMagills forceps
  8. 8. A new alternative method of surfactant delivery viatracheal catherization using a semirigid vascularcatheterWhich was found to be practicable with nosignificant procedural complication s
  9. 9. aiimsTo evaluate the applicability & apparent safety of thetechniqueDocument the physiologic response to surfactantadministrationComare outcomes of infants receiving MIST with likegestation historical controls
  10. 10. MethodsSiteNICU of ROYAL HOBART HOSPITAL&NICU OF ROYALWOMEN HOSPITALBOTH UNITS USED cpap as initial respiratory support
  11. 11. Study groupsInfants receiving MISTSTUDY conducted b/w june 2009-2011 mayPreterm infants b/w 25 &32 completed weeks ofgestation were eligible for inclusion with CPAP &,24hrs age required cpap pressure of ≥7
  12. 12. ControlData were collected frm infants managed on CPAP intime period immediately before beginning the study(2006-2009)
  13. 13. Mist procedureSurfactant instilled via tracheal catheterizationOn stable babies with HR>120 SPO2>85%A 16 gauge vascular catheter was marked to indicatedesired depth of ninsedtion (25-26 – 1cm )(27-28 wks1.5 cm)Direct larygoscopy performed tracheal catheter wasinserted beyond vocal cords surfactant given at dose of100 or 200 mg/kg
  14. 14. Catheter withdrawn CPAP recommencedCare after MIST included monitoring &treatment ofPDA &screening of IVH &ROP
  15. 15. RESULTSTOTAL 61 infants were enrolledInfants at 25-28 weeks gestation received surfactant viaMIST at early age (3hrs)Those at 29 32 weeks gestation (9hrs)A modest decrease in CPAP pressure was notedafterMIST sustained at least 24 hrs of lifeOxygenation improved after MIST in both gestationalages with reduction in Fio2
  16. 16. Comparedb with historical controls the need forintubation before 72h was considerably reduced afterMIST in 25-28 wksIn this study the narrow bore semirigid design ofcatheter means that, unlike a standard endotrachealtube
  17. 17. It can be passed down the eyeline without obscuringthe view of the glottis , with an external diameter lessthan half that of a 2.5 mm endotracheal tubeMist catheter passes easily through vocal cords
  18. 18. MIST well tolerated by infants on CPAP , despitereceiving no premedicationSurfactant administration via MIST was associatedwitha more rapid and pronounced improvement inoxygenation
  19. 19. Based on these results large scale RCT OF MIST ISREQUIRED
  20. 20. SURFACTANT REPLACEMENTONE OF THE BEST STUDIED THERAPIES INNEONATESurfactants of human,bovine or porcine origin havebeen studied
  21. 21. TimingProphylactic treatment of deficiency before lung injuryoccurs ,results in better distributon and less lunginjury than supplementation once respiratory failurebis severe
  22. 22. ResponseResponse variesThe reasons include timing of treatment & patientfactors such as concurrent illness & degree of of lungmaturityDelayed resuscitationExcessive fluid administrationImproper ventilator stratagies
  23. 23. Combined use of antenatal steroids& post natalsurfactant therapy improves neonatal outcomeIn established RDS repeated surfactant treatmentresults in greater improvement in oxygenation&ventilation decreased risk of pneumothorax &improve d survival when compared to single dosetherapy
  24. 24. retreatment infants on mechanical ventilation&Pressure >7 Fio2>0.3
  25. 25. administrationSurvanta-beractant bovinedose 4ml/kg(100m/kg) divided in 4 quater dosesProphylaxis : give with in 15 min of birth in infats at risk4 doses can be given no more frequently than every6hrs
  26. 26. Infasurf (calfactant)3 ml/kg for prophylaxis or rescue therapyMax 3 doses
  27. 27. Curosurf (poractant)Intial dose 2.5 ml/kg2 susequent doses 1.25ml/kg administered 12hrs apart
  28. 28. complicationsPulmonary hemorrageOccurs in extremely LBW babiesMalesWho have clinical evidence of PDA

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