Less invasive surfactant administration as a means to facilitate gentler transition for preterm infants? A narrative review

Neonatal respiratory distress syndrome (RDS) is a common challenge for those caring for preterm infants. In RDS, the underlying cause is pulmonary surfactant deficiency or inactivity. Exogenous surfactant administration is the standard treatment. Conventionally, surfactant is delivered to the lungs via an endotracheal tube, usually followed by a period of mechanical ventilation. Alternatives to endotracheal intubation and prolonged ventilation include the intubation-surfactant-extubation approach (INSURE) and the less invasive surfactant application methods (LISA) or minimally invasive surfactant treatment (MIST). In this narrative review, we summarise studies and meta-analyses regarding surfactant treatment in RDS. We also compared different modes of surfactant administration, namely the conventional method via an endotracheal tube, INSURE and LISA/MIST. Several studies have compared the conventional method of surfactant delivery to INSURE, LISA or MIST. Meta-Analyses of these studies, comparing all combinations of surfactant delivery indicate that in preterm infants, LISA may be most effective in reducing the incidence of death or bronchopulmonary dysplasia (BPD), intraventricular haemorrhage (IVH) and retinopathy of prematurity (ROP). We conclude that the LISA technique should be considered as part of a gentler form of supporting transition of preterm infants. To obtain the best result from LISA, it is recommended that LISA is performed by experienced neonatologists with appropriate equipment, as outlined in published guidelines. Further research is needed to assess the short- and long-term impact on neurodevelopment of infants treated with LISA.