Article Text

other Versions

Download PDFPDF
Comparative efficacy of methods for surfactant administration: a network meta-analysis
  1. Ioannis Bellos1,
  2. Georgia Fitrou1,
  3. Raffaella Panza2,
  4. Aakash Pandita3
  1. 1 Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece, Greece
  2. 2 Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Section, Policlinico Hospital, University of Bari Aldo Moro, Bari, Italy
  3. 3 Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
  1. Correspondence to Dr Aakash Pandita, Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India; aakash.pandita{at}


Objectives To compare surfactant administration via thin catheters, laryngeal mask, nebulisation, pharyngeal instillation, intubation and surfactant administration followed by immediate extubation (InSurE) and no surfactant administration.

Design Network meta-analysis.

Setting Medline, Scopus, CENTRAL, Web of Science, Google-scholar and databases were systematically searched from inception to 15 February 2020.

Patients Preterm neonates with respiratory distress syndrome.

Interventions Less invasive surfactant administration.

Main outcome measures The primary outcomes were mortality, mechanical ventilation and bronchopulmonary dysplasia.

Results Overall, 16 randomised controlled trials (RCTs) and 20 observational studies were included (N=13 234). For the InSurE group, the median risk of mortality, mechanical ventilation and bronchopulmonary dysplasia were 7.8%, 42.1% and 10%, respectively. Compared with InSurE, administration via thin catheter was associated with significantly lower rates of mortality (OR: 0.64, 95% CI: 0.54 to 0.76), mechanical ventilation (OR: 0.43, 95% CI: 0.29 to 0.63), bronchopulmonary dysplasia (OR: 0.57, 95% CI: 0.44 to 0.73), periventricular leukomalacia (OR: 0.66, 95% CI: 0.53 to 0.82) with moderate quality of evidence and necrotising enterocolitis (OR: 0.67, 95% CI: 0.41 to 0.9, low quality of evidence). No significant differences were observed by comparing InSurE with administration via laryngeal mask, nebulisation or pharyngeal instillation. In RCTs, thin catheter administration lowered the rates of mechanical ventilation (OR: 0.39, 95% CI: 0.26 to 0.60) but not the incidence of the remaining outcomes.

Conclusion Among preterm infants, surfactant administration via thin catheters was associated with lower likelihood of mortality, need for mechanical ventilation and bronchopulmonary dysplasia compared with InSurE. Further research is needed to reach firm conclusions about the efficacy of alternative minimally invasive techniques of surfactant administration.

  • neonatology
  • resuscitation
  • mortality

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors IB, GF, RP and AP wrote the manuscript. IB and GF did the literature review and data collection. IB,GF and AP did the statistical evaluation and interpretation. IB and AP did the critical appraisal and final corrections. All authors have read the final manuscript and approve it.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. All the required data is available with the manuscript.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Linked Articles

  • Fantoms
    Ben J Stenson