369 - Impact of implementing less invasive surfactant therapy on short-term outcomes in preterm infants over time: a trend-analysis

Publication Number: 369.5321

Rosemarie de Ridder, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Noord-Holland, Netherlands; Anton van Kaam, Emma Children's Hospital Amsterdam UMC, Amsterdam, Noord-Holland, Netherlands; Wes Onland, Emma Children's Hospital Amsterdam UMC, Amsterdam, Noord-Holland, Netherlands

Background: Randomized controlled trials have shown that compared with administration via an endotracheal tube (ETT) combined with mechanical ventilation, surfactant administration via the ‘less invasive surfactant therapy‘ (LISA) procedure is effective in reducing intubation rates, invasive mechanical ventilation (IMV) duration, mortality, and bronchopulmonary dysplasia (BPD) in preterm infants. How these trial results translate to real life clinical care is unknown.

Objective: To evaluate the impact of LISA implementation on short-term clinical outcomes in our neonatal intensive care unit (NICU).

Design/Methods: This retrospective cohort study included preterm infants born before 30 weeks gestational age (GA) between 2009-2023, admitted to the NICU of the Amsterdam UMC within 24 hours of birth and receiving surfactant therapy. Infants with severe congenital abnormalities or deemed non-viable after birth were excluded. The study period included a pre-LISA epoch (2009-2012), an epoch in which LISA was stepwise introduced (2013-2017), and an epoch in which LISA was fully implemented (2018-2023). Primary outcomes were the need of IMV within 72 hours after birth, and death or moderate/severe BPD at 36 weeks postmenstrual age (PMA). Statistical analyses focused on the pre-LISA and the LISA epoch and involved trend tests and regression analyses adjusted for the confounders GA, small for GA, gender, and any antenatal corticosteroids.

Results: Of the 807 eligible infants, 189 (23.4%) infants were treated in the pre-LISA epoch, and 277 (34.3%) infants in the LISA epoch. Over time, LISA use increased from 0% to 83.0%, while surfactant administration via an ETT decreased from 100% to 60.0% (Figure 1). The need for IMV within 72 hours decreased from 100% in the pre-LISA epoch to 45.3% in the LISA epoch (p < 0.01) (Table 1). The analysis showed no difference in the composite outcome death or BPD at 36 weeks PMA (aOR 0.84, 95%CI 0.67-1.06, p=0.15), or the component BPD over time. However, the risk of death decreased in the LISA epoch compared with the pre-LISA epoch (aOR 0.62, 95%CI 0.48-0.79, p< 0.001). Infants in the LISA epoch had a lower risk of (multiple) intubation rates and intraventricular hemorrhage (IVH), a decreased IMV duration, but needed more often multiple surfactant doses and more days on supplemental oxygen (Table 1).

Conclusion(s): The implementation of LISA in preterm infants resulted in significant reductions in intubation rate within 72 hours after birth, but no difference in combined outcome death or BPD. Further research is needed to evaluate long-term outcomes.

Table 1: Primary and secondary outcomes.
a Defined as death before 36 weeks PMA or moderate or severe BPD at 36 weeks PMA. b Reported as median (interquartile range).
* Adjusted for gestational age, gender, small for gestational age (defined as birthweight <10th percentile of Dutch reference curve) and antenatal corticosteroid therapy (defined as >1 dose) as confounders and interaction terms.

LISA: less invasive surfactant therapy. BPD: bronchopulmonary dysplasia. IMV: invasive mechanical ventilation. NICU: neonatal intensive care unit. PMA: post menstrual age. SF: surfactant. NEC: necrotizing enterocolitis. IVH: intraventricular hemorrhage. OR: odds ratio. aOR: adjusted odds ratio.


Figure 1: Use of surfactant via an ETT and LISA therapy: A 15-Year Trend Analysis
Surfactant_via_LISA: Use of LISA surfactant technique in all infants born below 30 weeks GA who received surfactant therapy.
Surfactant_via_ETT: Use of ETT surfactant technique in all infants born below 30 weeks GA who received surfactant therapy.
Each dots represents the absolute incidence for that year.

LISA: less invasive surfactant therapy. ETT: endotracheal tube. GA: gestational age.