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Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
Minimally invasive  surfactant therapy in preterm
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Minimally invasive surfactant therapy in preterm

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  • 1. BMJ– FETAL & NEONATAL MEDICINEMARCH 2013
  • 2. Ojective : to evaluate the applicability& potential effectiveness of atechnique of minimal invasivesurfactant therapy in preterm infantson cpap
  • 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. 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. Outcomes for infants commencing on CPAP coud befurther improved if those with significant RDS were toreceive exogenous surfactant at an early stage
  • 6. INSURE limitations has prompted the pursuit ofalternative less invasive means of giving surfactanttherapy to preterm infants on CPAP
  • 7. MISTDirect tracheal catherizationFlexible feeding tube positioned in trachea withMagills forceps
  • 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. 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. MethodsSiteNICU of ROYAL HOBART HOSPITAL&NICU OF ROYALWOMEN HOSPITALBOTH UNITS USED cpap as initial respiratory support
  • 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. ControlData were collected frm infants managed on CPAP intime period immediately before beginning the study(2006-2009)
  • 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. Catheter withdrawn CPAP recommencedCare after MIST included monitoring &treatment ofPDA &screening of IVH &ROP
  • 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. 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. 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. MIST well tolerated by infants on CPAP , despitereceiving no premedicationSurfactant administration via MIST was associatedwitha more rapid and pronounced improvement inoxygenation
  • 19. Based on these results large scale RCT OF MIST ISREQUIRED
  • 20. SURFACTANT REPLACEMENTONE OF THE BEST STUDIED THERAPIES INNEONATESurfactants of human,bovine or porcine origin havebeen studied
  • 21. TimingProphylactic treatment of deficiency before lung injuryoccurs ,results in better distributon and less lunginjury than supplementation once respiratory failurebis severe
  • 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. 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. retreatment infants on mechanical ventilation&Pressure >7 Fio2>0.3
  • 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. Infasurf (calfactant)3 ml/kg for prophylaxis or rescue therapyMax 3 doses
  • 27. Curosurf (poractant)Intial dose 2.5 ml/kg2 susequent doses 1.25ml/kg administered 12hrs apart
  • 28. complicationsPulmonary hemorrageOccurs in extremely LBW babiesMalesWho have clinical evidence of PDA

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