Abstract
Purpose
To compare five pulmonary surfactant (PS) administration strategies for neonates with respiratory distress syndrome (RDS), including intubation-surfactant-extubation (InSurE), thin catheter administration, laryngeal mask airway (LMA), surfactant nebulization (SN), and usual care, with a particular emphasis on the comparison of the LMA and SN with other strategies.
Methods
We conducted a systematic search of MEDLINE, EMBASE, PUBMED, and Cochrane CENTRAL databases up to November 2023. Two authors independently conducted data extraction, and assessed bias using the Cochrane Risk of Bias Tool. Frequency-based random-effects network meta-analyses were executed.
Results
A total of 36 trials and 4035 infants were included in the analysis. LMA (OR: 0.20, 95%CI: 0.09 to 0.42) and Less Invasive Surfactant Administration (LISA) (OR: 0.17, 95%CI: 0.09 to 0.32) significantly reduced intubation rates compared to usual care. SN had a higher intubation rate compared to LISA (OR: 3.36, 95%CI: 1.46 to 7.71) and LMA (OR: 2.92, 95%CI: 1.10 to 7.71). LMA had a higher incidence of BPD compared to LISA (OR: 2.59, 95%CI: 1.21 to 5.54). SN ranked second to LISA in preventing BPD and death, but its efficacy decreased after excluding high-risk studies. SN and LMA had the lowest incidence of adverse events during administration.SN had the highest likelihood of secondary administration. Most results were rated as low or very low quality, with findings related to SN significantly impacted by high-risk trials.
Conclusions
The thin catheter strategy minimized intubation risk and showed a better composite effect in reducing both mortality and BPD incidence. SN and LMA each showed safety and some clinical benefits in the subpopulations where they were studied, but their efficacy needs further validation through high-quality studies.
Key Points
- Efficacy of LISA: LISA showed the lowest intubation and BPD rates, making it the most effective among the strategies studied.
- Laryngeal Mask Airway (LMA): LMA was associated with reduced intubation rates but had a higher likelihood of BPD compared to LISA.
- Surfactant Nebulization (SN): SN showed reduced BPD and mortality but higher intubation rates and the need for secondary doses compared to LISA and LMA.
- InSurE Method: Though effective, InSurE ranked lower than LISA in preventing BPD and mortality due to its invasiveness and procedural risks.
- Safety Considerations: SN and LMA exhibited fewer adverse events during administration compared to invasive methods.
- Subgroup Variability: The efficacy of LMA and SN varied with gestational age and respiratory maturity, necessitating further stratified studies.
- Limitations of SN: SN’s effectiveness depends on nebulizer type, dose, and delivery settings, highlighting the need for standardization and optimization.
- Challenges in Adoption: LISA requires highly skilled practitioners and specific clinical conditions, which may limit its broader implementation.
- Research Gaps: High-risk and low-quality studies influenced outcomes for SN, calling for more robust trials.
- Future Directions: Optimizing non-invasive methods like SN and LMA for broader neonatal populations and studying their long-term outcomes is essential.
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