• Users Online: 123
  • Print this page
  • Email this page

 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 6  |  Page : 280-282

Surfactant administration via laryngeal mask or supraglottic airway

Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission02-Oct-2022
Date of Decision02-Nov-2022
Date of Acceptance14-Nov-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Satish Saluja
Department of Neonatology, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi - 110 060
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmrp.cmrp_109_22

Rights and Permissions

Surfactant therapy has been the mainstay of treatment in preterm neonates with respiratory distress syndrome. Delivery of surfactant through endotracheal intubation has been the commonly used technique. Intubation requires expertise and is associated with complications. In addition, there is also an increased future risk of chronic lung disease. Newer techniques of surfactant delivery abating the need of intubation have been reported. One such minimally invasive technique is surfactant administration through a supraglottic airway device. In this report, we describe the delivery of surfactants using this technique.

Keywords: Integrated neonatal care unit, intubation–surfactant–extubation, respiratory distress syndrome, supraglottic airway device, surfactant administration through laryngeal mask or supraglottic airway

How to cite this article:
Kansakar P, Saluja S, Modi M, Thakur A, Soni A. Surfactant administration via laryngeal mask or supraglottic airway. Curr Med Res Pract 2022;12:280-2

How to cite this URL:
Kansakar P, Saluja S, Modi M, Thakur A, Soni A. Surfactant administration via laryngeal mask or supraglottic airway. Curr Med Res Pract [serial online] 2022 [cited 2023 Apr 1];12:280-2. Available from: http://www.cmrpjournal.org/text.asp?2022/12/6/280/366167

  Introduction Top

Surfactant therapy in preterm neonates with respiratory distress syndrome (RDS) has decreased morbidity and mortality.[1] Delivery of surfactant through endotracheal intubation is commonly practiced. However, endotracheal intubation itself has been found to be associated with respiratory morbidity and bronchopulmonary dysplasia (BPD).[2],[3] With the introduction of delivery room nasal continuous positive airway pressure (nCPAP), fewer preterm babies are electively intubated in early life. However, many preterm neonates still require surfactant administration later as rescue therapy for RDS. In these babies, intubation is followed by surfactant delivery, and extubation (InSurE) is the commonly used technique, but it still needs intubation skills.[2] This necessitated the need of an alternative conduit to deliver surfactant.[4],[5] We report a case of administration of surfactant through the laryngeal mask or supraglottic airway (SALSA) which is a minimally invasive method of delivering surfactant.

  Case Report Top

A female baby was delivered at 36 weeks through lower segment caesarean section to a primigravida mother and cried immediately after birth. She weighed 2220 g and developed respiratory distress soon after birth. She required respiratory support through nCPAP at 6.5 cm of water with a fraction of inspired oxygen (FiO2) of 40%. A clinical decision was made to deliver SALSA.

This was the first case in our institute to receive SALSA. A 1-day training on SALSA was given to the residents by experts. All the residents were trained for the insertion of a supraglottic airway device (SAD) on a mannequin. After obtaining informed consent from parents, all the equipment required for the procedure was assembled which included an iGel SAD [Figure 1], an 8Fr nasogastric tube (NG), a colorimetric end-tidal CO2 (ETCO2) detector, a self-inflating bag and a suction apparatus. Equipment for intubation was kept ready in case of a failed attempt. An orogastric (OG) tube and intravenous cannula were placed in situ. Gastric contents were aspirated before the procedure. The NG tube which was to be inserted inside the SAD device to deliver surfactant was precut to a length where the distal end was in the lower half of the body of the laryngeal mask airway. The integrated neonatal intensive care unit platform was used to record continuous vital parameters, such as heart rate and oxygen saturation.[6] The procedure was recorded on video, and the neonatal infant pain score (NIPS) was calculated to assess pain.[7]
Figure 1: IGeL supraglottic airway device used during surfactant through a laryngeal mask or supraglottic airway

Click here to view

Throughout the procedure, the baby was placed supine on a flat surface with a slight extension of the neck and was supported on nCPAP of 6.5 cm of water. No premedication or sedation was used. The SAD device was attached to an ETCO2 detector. The resident performing the SALSA stood behind the infant's head and opened the mouth and grasped the tongue with the left thumb. The SAD was inserted with the right hand using the index finger and was guided along the curvature of the hard palate. Gentle pressure was applied to overcome the resistance due to the baby's tongue. The device was advanced further till resistance was felt. The placement was confirmed by the change in colour of the ETCO2 detector. Positive pressure ventilation (PPV) device was attached to the CO2 detector, a few breaths were provided, and the SAD device was adjusted to optimise CO2 detection, bilateral air entry was confirmed, and the baby stabilised. The CO2 detector along with the PPV device was detached from the SAD device and precut NG tube was inserted into the SAD device. Surfactant was delivered through this NG tube at the dose of 100 mg of phospholipids/kg in four separate aliquots. It was followed by PPV each time until there was no surfactant left in the SAD and the baby stabilised. After the last aliquot, SAD was removed and nCPAP continued at 6.5 cm of water and FiO2 was adjusted to maintain the baby's saturation at 90%–95% which was 40% in our case. The aspirated gastric content was about 1 ml in our case. During the procedure, the baby maintained her heart rate and saturation. The maximum NIPS during the procedure was 3 which suggested moderate discomfort. The FiO2 requirement decreased to 21% after 4 h. The baby was removed from nCPAP support after 17 h. The baby remained well and was discharged at 5 days of life

  Discussion Top

In our case report, we report delivery of surfactant in preterm neonates through a minimally invasive SAD. Before its use as a conduit to deliver surfactant, SAD was used in neonates to provide PPV for short procedures by anaesthesiologists. It had also been used in neonatal resuscitation.[8] In a Cochrane review, the use of SAD during neonatal resuscitation was associated with fewer endotracheal intubations, shorter ventilation times and reduced need for NICU admission. There was no difference in mortality or hypoxic ischaemic encephalopathy. There were also no clinically significant differences in insertion time or failure to insert the device correctly.[8]

When SAD is used to deliver surfactant, it has certain benefits. As the device does not require visualisation of the vocal cords, it is relatively fast and easy. The skills required for SALSA are meagre compared to the expertise needed for intubation.[9] In our case, the procedure was performed by a resident following a short training by experts.

In addition, there is less chance of physiological instability during placement, as well as the need for premedication. While the device is being placed, PEEP can be delivered throughout the procedure to maintain lung function. Furthermore, PPV breaths may be administered to the baby in case of hypoxaemia or bradycardia induced by surfactant administration.[9],[10] Several case reports and randomised control trials (RCT) on the use of SALSA in neonates focussing on short-term outcomes have been published. A systematic review and meta-analysis including five RCTs enrolling 307 neonates, compared surfactant administration through SAD versus nCPAP alone or InSurE. Surfactant administration through SAD reduced the need for intubation/mechanical and short-term oxygen requirements compared to nCPAP alone. Surfactant administration through SAD reduced the need for intubation/mechanical ventilation, but increased short-term oxygen requirements compared to InSurE approach. In addition, an increased number of surfactant doses was needed when compared with either nCPAP alone or surfactant administration through InSurE.[11] Another recent systematic review and meta-analysis including 6 RCTs with 357 newborns were published comparing SAD to CPAP alone or the InSurE procedure. The analysis showed decreased FiO2 requirement, decreased intubation and decreased MV. There were no significant differences between groups for death, BPD or pneumothorax. The amount of post-procedural gastric aspirate volumes varied in different studies even more than 50%. The meta-analysis also stated that a single dose of SALSA was sufficient in 75% of the neonates for successful surfactant delivery.[12] Our baby received CPAP throughout the procedure and could be immediately placed on CPAP post-procedure. The FiO2 requirement decreased to 21% in 4 h and the post-gastric aspirate was 1 ml. There were no complications post-procedure and no repeat dose of surfactant was required.

There are other methods of surfactant delivery such as pharyngeal instillation of surfactant, minimally invasive surfactant treatment and less invasive surfactant administration and administering surfactant as nebulisation. They have their own benefits and drawbacks.[4],[5],[13],[14],[15]

The biggest drawback in the widespread use of SAD for surfactant delivery is the lack of appropriate size SAD for neonates of different body weights.[9],[11],[12] Further, there is a lack of sufficient long-term data including pulmonary outcomes such as BPD.

To the best of our knowledge, this is the first case report of the successful administration of surfactant through the SAD in India. Further studies are needed to evaluate the feasibility and efficacy of its use in our settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent from the parents of the patient who have given consent for use of images and other clinical information. The patient's parents understand that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Suresh GK, Soll RF. Overview of surfactant replacement trials. J Perinatol 2005;25 Suppl 2:S40-4.  Back to cited text no. 1
Dargaville PA. Newer strategies for surfactant delivery. In: The Newborn Lung. (Third Edition). Bancalari E.(ed): Elsevier; 2019. p. 221-38.  Back to cited text no. 2
Gupta S, Donn SM. Novel approaches to surfactant administration. Crit Care Res Pract 2012;2012:278483.  Back to cited text no. 3
Sawyer T, Foglia E, Hatch LD, Moussa A, Ades A, Johnston L, et al. Improving neonatal intubation safety: A journey of a thousand miles. J Neonatal Perinatal Med 2017;10:125-31.  Back to cited text no. 4
Fischer HS, Schmölzer GM, Cheung PY, Bührer C. Sustained inflations and avoiding mechanical ventilation to prevent death or bronchopulmonary dysplasia: A meta-analysis. Eur Respir Rev 2018;27:180083.  Back to cited text no. 5
Singh H, Yadav G, Mallaiah R, Joshi P, Joshi V, Kaur R, et al. iNICU – Integrated neonatal care unit: Capturing neonatal journey in an intelligent data way. J Med Syst 2017;41:132.  Back to cited text no. 6
Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw 1993;12:59-66.  Back to cited text no. 7
Qureshi MJ, Kumar M. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev 2018;3:CD003314.  Back to cited text no. 8
Abu Leyah NA, Hasan AA, Juneau JN, Al Jammal MA, Jaber GA, Wilding GE, et al. Implementation of Surfactant Administration through Laryngeal or Supraglottic Airways (SALSA): A Jordanian NICU's Journey to improve surfactant administration. Children (Basel) 2022;9:1147.  Back to cited text no. 9
Guthrie SO, Fort P, Roberts KD. Surfactant administration through laryngeal or supraglottic airways. Neoreviews 2021;22:e673-88.  Back to cited text no. 10
Calevo MG, Veronese N, Cavallin F, Paola C, Micaglio M, Trevisanuto D. Supraglottic airway devices for surfactant treatment: Systematic review and meta-analysis. J Perinatol 2019;39:173-83.  Back to cited text no. 11
Al Ali RA, Gautam B, Miller MR, Coulson S, Yuen D. Laryngeal mask airway for surfactant administration versus standard treatment methods in preterm neonates with respiratory distress syndrome: A systematic review and meta-analysis. Am J Perinatol 2022;39:1433-40.  Back to cited text no. 12
Kattwinkel J, Robinson M, Bloom BT, Delmore P, Ferguson JE. Technique for intrapartum administration of surfactant without requirement for an endotracheal tube. J Perinatol 2004;24:360-5.  Back to cited text no. 13
De Luca D, Shankar-Aguilera S, Centorrino R, Fortas F, Yousef N, Carnielli VP. Less invasive surfactant administration: A word of caution. Lancet Child Adolesc Health 2020;4:331-40.  Back to cited text no. 14
Gaertner VD, Thomann J, Bassler D, Rüegger CM. Surfactant nebulization to prevent intubation in preterm infants: A systematic review and meta-analysis. Pediatrics 2021;148:e2021052504.  Back to cited text no. 15


  [Figure 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded39    
    Comments [Add]    

Recommend this journal