# Minimally invasive surfactant administration in extremely preterm infants <28 weeks gestation with spontaneous breathing: a retrospective quality improvement study on reducing invasive ventilation burden

## TL;DR

Using a less invasive method to give surfactant to extremely preterm infants reduced their need for mechanical ventilation and lowered complications like heart issues and infections.

## Contribution

This study shows that minimally invasive surfactant administration reduces invasive ventilation and complications in extremely preterm infants.

## Key findings

- MISA reduced median IMV duration in the first 72 hours from 71 hours to 0 hours.
- MISA was linked to lower rates of patent ductus arteriosus and nosocomial pneumonia.
- Non-invasive ventilation duration increased with MISA use.

## Abstract

Invasive surfactant delivery via endotracheal intubation increases exposure to invasive mechanical ventilation (IMV) in extremely preterm infants (EPIs, <28 weeks). This quality improvement (QI) initiative aimed to evaluate whether minimally invasive surfactant administration (MISA) was associated with a reduced IMV burden in EPIs.

A single-center retrospective QI study (2013–2024) included 115 infants (24–27⁺⁶ weeks) with spontaneous breathing diagnosed with respiratory distress syndrome (RDS). Controls (2013–2019, n = 55) received surfactant via intubation; the MISA group (2020–2024, n = 60) received surfactant via thin catheter during nasal continuous positive airway pressure/nasal intermittent positive pressure ventilation (NCPAP/NIPPV). Apart from the structured implementation of MISA, background respiratory and supportive care practices evolved gradually over time without other major structural changes. Multivariable regression and interrupted time-series analyses were performed to account for potential confounding and secular trends.

Baseline infant characteristics were comparable. The median duration of IMV within the first 72 h after birth was 0 h (IQR: 0–0) in the MISA group compared to 71.0 h (IQR: 19.0–72.0) in the control group (P < 0.001), and the difference remained significant after adjustment. Additionally, total IMV duration was reduced [0 h (IQR: 0–14) vs. 111 h (IQR: 39–264); P < 0.001], while non-invasive ventilation (NIV) duration was longer [51.5d (IQR: 41–57) vs. 37d (IQR 30–50); P < 0.001]. Lower incidences of hemodynamically significant patent ductus arteriosus (hsPDA) (35.0% vs. 69.1%; P < 0.001) and nosocomial pneumonia (18.9% vs. 67.9%; P < 0.001) were observed during the MISA implementation period, with consistent findings after multivariable adjustment. No significant differences were observed in severe intraventricular hemorrhage (IVH grade 3–4) (8.33% vs. 20.4%; P = 0.123), mortality (6.7% vs. 16.4%; P = 0.101), or other secondary outcomes (all P > 0.05). Interrupted time-series analysis demonstrated an immediate reduction in early IMV duration following MISA implementation, whereas changes in secondary outcomes did not reach statistical significance.

MISA was associated with reduced early and overall IMV exposure in EPIs <28 weeks, and with lower observed incidences of hsPDA and nosocomial pneumonia. These associations warrant confirmation in prospective multicenter studies.