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• Re:Minimally-invasive (and painful?) surfactant therapy.
  Rosilu F. Barbosa
  Published on: 22 March 2016

• Published on: 22 March 2016

  Re:Minimally-invasive (and painful?) surfactant therapy.

  • Rosilu F. Barbosa, medical doctor
  • Other Contributors:
    • Juliana de O. Marcatto, Yerkes P. e Silva

  Sir, we read with interest the article by Dargaville et al., entitled "Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure", in which the authors describe significant results using a semirigid vascular catheter inserted into the trachea by direct laringoscopy for surfactant administration, without analgesia and sedation(1). However, direct laringoscopy and tracheal manipulation...

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  Sir, we read with interest the article by Dargaville et al., entitled "Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure", in which the authors describe significant results using a semirigid vascular catheter inserted into the trachea by direct laringoscopy for surfactant administration, without analgesia and sedation(1). However, direct laringoscopy and tracheal manipulation, is an extremely distressing and painful procedure, with potential for airway and systemic injury. It is well established that direct laringoscopy and tracheal intubation without analgesia should be performed only for urgent resuscitations. Neonatal pain may result in altered systemic and cerebral blood pressure, intracranial hemorrhage, hypersensitive pain perception and long-term sequelaes(2). In their study 36% of the neonates had bradycardia sustained for more than 10s during laryngoscopy or vocal cord manipulation. It is now evident that initial stabilization with CPAP and rescue surfactant administration if necessary, is not worse than intubation, mechanical ventilation and surfactant administration immediately after birth. INSURE procedure is an alternative, combining early surfactant and CPAP. Welzing et al. have shown that INSURE can be performed using remifentanil as premedication for tracheal intubation with excellent neonatal outcome(3). In the same way, our group have shown that remifentanil as premedication allows early awakening and extubation(4). However, the short period of positive pressure ventilation required for INSURE, even if an ultra short acting opioid is used, could compromise the benefit of early surfactant. In this way, some reports have shown that a laryngeal mask airway (LMA) as a conduit for surfactant administration could be a simple and painless procedure(5). Trials of surfactant administration through the LMA are now being conducted. So, finding a noninvasive and painless method of surfactant administration, without laryngoscopy, tracheal manipulation and positive pressure ventilation, will be one of the most important subjects for neonatology research in upcoming years.

  References 1.Dargaville PA, et al. Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 2013;98:F122-F126. 2.Carbajal R, Eble B, Anand KJ. Premedication for tracheal intubation in neonates: confusion or controversy? Semin Perinatol 2007;3:309-17. 3.Welzing L, Kribs A, Huenseler C, Eifinger F, Mehler K, Roth B. Remifentanil for INSURE in preterm infants: a pilot study for evaluation of efficacy and safety aspects. Acta Paediatr 2009;98:1416-20. 4.e Silva YP, Gomez RS, Marcatto JdeO, Maximo TA, Barbosa RF, Silva AC. Early awakening and extubation with remifentanil in ventilated premature neonates. Paediatr Anaesth 2008;18:176-83. 5.Trevisanuto D, Grazzina N, Ferrarese P, Micaglio M, Verghese C, Zanardo V. Laryngeal mask airway used as a delivery conduit for the administration of surfactant to preterm infants with respiratory distress syndrome. Biol Neonate 2005;87:217-20.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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