Administration of Surfactant Via Supraglottic Airway

Abstract

Background: Exogenous pulmonary surfactant replacement therapy is indicated to treat infants with surfactant deficiency, either congenital or acquired. Common examples include preterm infants with respiratory distress syndrome (RDS) and term infants with meconium aspiratory syndrome (MAS). The main method of surfactant is direct instillation into the lungs through an endotracheal tube. Recently, surfactant administration through a laryngeal or supraglottic airway (SALSA) has become available. We aimed to implement SALSA in our NICU with the goal of decreasing intubations and sedation use for surfactant administration.

Methods: The protocol for surfactant administration through a supraglottic airway included those neonates with birth weight ≥ 1,500 g and less than 48 h of life. The airway can be placed by the provider (MD/NNP) or the RRT. Surfactant is instilled through the airway in one position and two aliquots, which is identical to our endotracheal tube procedure. When delivering surfactant through a supraglottic airway, the RT maintains a noninvasive CPAP interface and device on the patient, and CPAP is resumed immediately after airway removal, preventing significant loss of FRC. The nasogastric tube is aspirated and amount of surfactant in the stomach, if any, quantified. Data is recorded in REDCap by the provider supervising the procedure. Exemption granted by local IRB for initial quality improvement initiative.

Results: In the two years since implementation, we have utilized the SALSA procedure 73 times. Average gestational age is 34 and 5/7 weeks (31 1/7 to 39 4/7) with average birth weight of 2,541 g (1,508 to 4,410 g). Intubation after SALSA was performed in 23 of the 76 subjects (30%). Of those 23 patients, 17 received a second dose of surfactant. Complication rate was low and included desaturation (16.5%) and bradycardia (30.1%). The SALSA procedure was aborted due to complications in 9 cases (12.3%). Patients requiring FIO₂ ≥ 0.4 after the procedure decreased by 44% (25 to 14). In addition, for patients receiving SALSA, use of intravenous sedative medications was completely avoided.

Conclusions: Through multidisciplinary collaboration, we were able to successfully implement a change in approach to giving exogenous surfactant to newborns. In administering surfactant via a supraglottic airway, we avoid known complications of endotracheal intubation, such as airway bleeding, airway trauma, oversedation, and need for mechanical ventilation.