Prophylactic Oropharyngeal Surfactant for Preterm Newborns at Birth- An Overview

Introduction

Respiratory Distress Syndrome (RDS) in newborns is characterized by having deficient surfactants. Exogenously administered surfactant with an endotracheal tube is essential for caring for immature infants. Intubation, laryngoscope, and mechanical ventilation in infants are associated with poor results. Treating the newborn or infant with Continuous Positive Airway Pressure (CPAP) getting intubated, using a surfactant, and maintaining ventilation in infants suffering from respiratory distress despite using CPAP may have good results with intubation surfactant.

Injecting the surfactant into the pharynx is an easy and simple procedure, not requiring any new or expensive instruments or equipment, and the infants do not require laryngoscopy. Prematurely born infants who received pharyngeal surfactant could not breathe for some time, resulting in greater pulmonary thoracic compliance than conventional air, and almost half surfactant reached the lungs. Compared with normal saline the use of surfactant reduced the mortality rate and the need for any support for respiration.

What Are the Methods of Delivering Surfactant for Respiratory Distress?

The desire to use surfactant for treating respiratory distress in infants without complications has led to several routes and methods of administering surfactant. Using the intubation surfactant extubation method, surfactant administration is performed during intubation with CPAP. Intubation and laryngoscopy are not avoided with the use of this technique, and babies may be challenging to extubate.

Babies receiving CPAP may also receive surfactant with the help of a small tube inside the main tube. It can not preclude laryngoscopy use although this technique prevents the usage of a positive airway. Using a thin catheter to administer surfactant reduces the mortality rate or chances of bronchopulmonary dysplasia. This reduced the chances of intubation and mortality. The use of atomized surfactant has given good results. Using prophylactic aerosols as a surfactant with the use of CPAP in the room where the baby is delivered has not proven to be effective. The supraglottic system of the body was used for delivering the surfactant.

Currently, no effective tool is available for infants with low birth weight who are diagnosed with respiratory distress syndrome.

What Are the Clinical Indications for the Use of Surfactant for Respiratory Distress?

The use of surfactant for respiratory distress in prematurely born infants is indicated in the following conditions:

• Newborn showing respiratory distress clinically and radiographically.

• Newborns who are at risk of developing respiratory distress syndrome

• Newborns who are intubated regardless of gestation and infants who require the use of FiO2> 40 percent.

• Severe aspiration of muconium causing respiratory distress. This may improve the body's oxygenation and reduce the chances of need for extracorporeal membrane oxygenation.

• Clinically deteriorating condition because of pulmonary hemorrhage.

• Severe respiratory failure because of respiratory syncytial virus. This improves the exchange of gas and respiration and also lessens the time of using invasive mechanical ventilation.

What Is the Method of Delivering Surfactant to Newborns?

Preparing

• This is a two-person procedure. It should involve a medical professional or a nurse practitioner who can administer the surfactant and one nurse who acts as an assistant.

• The baseline vitals such as heart rate, respiratory rate, oxygen saturation, and blood gas are recorded.

• First, confirm the position of the endotracheal tube with the help of a chest radiograph for administering surfactant. Auscultation of the chest for bilateral air entry and confirming the tube placement.

• If the baby is not intubated, in-out intubation is required for surfactant administration.

• Emergency equipment should be kept ready—intubation drugs and equipment for laryngoscopy.

• A patient endotracheal tube is necessary.

• Start mixing the surfactant before administering it and see if there is any discoloration in the suspension. It should be at least creamy to white. Obtain a uniform solution by turning the vial. Remove the cap and clean the top with an alcohol swab.

Administering

• Keep all instruments ready on a sterilized surface.

• Do not forget to perform the hand hygiene procedure.

• Use sterile gloves for the procedure.

• Using an aseptic technique for surgery, but the tube in the kit to a length that the tip of the tube is 1cm above the endotracheal tube. This helps deliver surfactant intra tracheally.

• Draw the surfactant above the required dose into the syringe with a needle-free device. Attach a pure-cut tube to the syringe or fill this tube using the surfactant. Discard any excess of surfactant.

• Ensure the bed of the infant is flat and the neonate is in the supine position.

• The assistant then may disconnect the endotracheal tube from the ventilator.

• The doctor or the nurse administered this surfactant through the pre-cut tube in a single shot dose or two doses quickly. The total surfactant should be administered in less than one minute.

• After the delivery of the surfactant, positive pressure ventilation is delivered by the assistant using a Neopuff or endotracheal tube connected again to the ventilator after the administration of surfactant. If CPAP was used, then positive pressure may be given with Neopuff. Upright endotracheal tube facilitates drainage of surfactant and minimizes the risk of reflux.

• If surfactant occludes the endotracheal tube, the administration should be stopped until the tube is cleared and chest wall movements resumed.

• Ventilator support is temporarily increased.

• A nurse practitioner or doctor should be at the bedside until the neonate is stable.

• Surfaces should be cleaned, and hand hygiene performed.

• Electronic health records should be updated with information on surfactant administration.

What Are the Complications Associated With Surfactant Delivery?

• Transient bradycardia may occur during the administration of surfactant. There can be oxygen desaturation and endotracheal tube blockage. The administration should be stopped temporarily, ventilation should be provided, or oxygen should be used if necessary.

• There may be obstruction of the endotracheal tube. Chest wash movements and saturation should be monitored. Medical assistance should be called if ventilation doesn’t improve.

• Chances of pneumothorax are present. This may occur because of sudden changes in the pulmonary compliance. Ventilation settings should be changed.

• Incidence of pulmonary hemorrhage is seen. Medical officers should be informed as soon as possible.

Conclusion

The use of surfactant in neonates with respiratory distress has proven effective. This procedure should be done under the supervision of a medical officer and a registered nurse practitioner. Studies show best results are seen within 29 weeks of delivery. Using CPAP along with surfactant administration has reduced the mortality rate in premature neonates with respiratory distress syndrome.