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Changes in practice of less-invasive surfactant administration (LISA) in United Kingdom neonatal Units1

 

Shetty S, Tolentino D, Lau C, Duffy D, Greenough A. Changes in practice of less-invasive surfactant administration (LISA) in United Kingdom neonatal units. Acta Paediatr. 2024; 00: 1–5.

 

Introduction

 
 

Less-invasive surfactant administration (LISA) delivers surfactant into the lungs of preterm infants with respiratory distress syndrome (RDS) through a fine catheter, avoiding intubation and mechanical ventilation (MV).2

European guidelines favour LISA for preterm infants with RDS on continuous positive airway pressure (CPAP).2 The adoption of LISA in Europe has been extensive and linked to improved outcomes.3,4 In the UK, however, uptake had been slower, with only 18% of neonatal units using LISA in 2018, despite favourable evidence from multiple studies.5,6

 

Rationale:

 

Shetty et al aimed to determine if LISA adoption had increased in the UK since the 2018 survey, as LISA’s effectiveness and safety profile have been supported by larger cohort studies and improved training and equipment, such as video laryngoscopy.1–4 Increasing LISA use could enhance care for preterm infants with RDS and reduce MV use.1,2 

Study design:1

 

This was a cross-sectional survey of all 191 neonatal units in the United Kingdom conducted between June 2023 and May 2024. One consultant from each unit was randomly selected to complete the study, and the results were compared with data from a 2018 survey to assess changes in LISA use, focusing on LISA adoption, techniques, location of procedures, staffing practices and FiO2 criteria (Figure 1).1 

 

Including sub-questions, the survey consisted of 16 multiple-choice and open-ended questions. The questions were designed to be reflective of unit policy and not personal preference. Caution was also advised during the telephone survey that the answers should be reflective of the unit practice. 

 

Results:1

 
 

Uptake of LISA in neonatal units 

 

There was a 100% response rate from the 191 neonatal units. Fifty-three responders were neonatal intensive care units (NICU=level 3), 86 local neonatal units (LNU=level 2) and 52 special care baby units (SCBU=level 1).

 
 

The use of LISA increased significantly, with 70% (134/191) of units implementing LISA in 2024, compared with 19% (35/187) in 2018. Among units that did not adopt LISA, the main barriers were lack of training (51%; 22/43) and the absence of standardised guidelines (49%; 21/43) (Figure 2). 

 

The practice of performing LISA in the delivery suite (DS) was evaluated, showing a notable increase in usage. The percentage of units performing LISA in the DS rose from 2% (4/35) in 2018 to 16% (31/134) in 2024, indicating a growing willingness to provide LISA immediately after birth in this setting.   

 

Among units not performing LISA in the DS, the primary reasons cited were logistical and practical challenges (98%; 101/103), lack of experience or training (27%; 28/103), a perceived need for more evidence of efficacy (9.7%; 10/103), concerns about conducting the procedure while the infant is awake (2%; 2/103), and insufficient time for post-procedure observation (2%; 2/103). 

 
 

Operator roles and technology: 

 

A notable shift occurred in who performs LISA procedures. In 2018, consultants most commonly performed LISA (91.7%), but by 2024, the procedure was increasingly performed by more junior staff, including registrars and Advanced Neonatal Nurse Practitioners (ANNPs) in 94% of total cases (Figure 3). 

The use of video laryngoscopy, which enhances visualisation and accuracy during LISA was also collected. In 2024, 60% (93/134) of units routinely used video laryngoscopy, 4% (5/134) used both direct and video laryngoscopy and 27% (36/134) did not use video laryngoscopy routinely (Figure 3). 

 
 

Criteria for the use of LISA: 

 

Oxygen requirements for initiating LISA were reduced. Whereas FiO2 criteria of 0.4 or 0.5 were previously common, 77.6% (104/134) of units in 2024 adopted an FiO2 threshold of ≥0.3, consistent with European Consensus Guideline
(Figure 4).1,2

 

For infants born <28 weeks GA, 45% (60/134) of units considered LISA for an FiO2 ≥0.3, 12% (16/134) for an FiO2 ≥0.4, and 5% (7/134) if FiO2 ≥0.5. For infants born ≥28 weeks GA, 43% (57/134) of units used an FiO2 ≥0.3, 20%
(27/134) ≥0.4, and 7% (10/134) ≥0.5. (Figure 4).

 

For full-term infants (>37 weeks GA), only 3% (4/134) of units considered using LISA when FiO2 was ≥0.4. Additionally, 39% (52/134) of units did not have specific criteria based on GA, and in 3% (4/134), the decision to use LISA was left to consultant judgment.

 
 

Sedation and side effects: 

 

There was a decrease in the use of pharmacological premedication, with only 33.6% of units routinely using sedation compared to 51% in 2018. Instead, 66.4% of units used non-pharmacological methods, such as swaddling and sucrose, and administered sedation only if necessary. The most commonly administered agents were atropine (24%; 32/134), fentanyl (42%; 56/134), morphine (5.2%; 7/134) and propofol (6%; 8/134). 
 
The study also reported a higher incidence of side effects in 2024 compared with 2018, with an incidence of desaturation/hypoxia in 61.3% of units, bradycardia in 59.6% and surfactant reflux in 27.4% (Figure 5).

 

Conclusion:1

 

The use of LISA in the UK has significantly increased since 2018, with more neonatal units adopting it and expanding its use in the delivery suite. However, challenges persist, particularly logistical barriers and a need for more training, which remains the primary reason for non-adoption in some units. Additionally, FiO2 thresholds for administering LISA have aligned with European guidelines, with a shift toward non-pharmacological analgesia options. While reports of side effects have risen, possibly due to increased reporting by junior staff, the survey underscores the critical need for comprehensive training programs to support safe and consistent LISA implementation across units.

 
 
 

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Abbreviations

 

ANNP, advanced neonatal nurse practitioner; CPAP, continuous positive airway pressure; DS, delivery suite; FiO2, fraction of inspired oxygen; GA, gestational age; LISA, less-invasive surfactant administration; LNU, local neonatal unit; MV, mechanical ventilation; NNU, neonatal unit; NICU, neonatal intensive care unit; RDS, respiratory distress syndrome; SCBU, special care baby unit. 

 
 

References

  1. Shetty S, et al. Changes in practice of less-invasive surfactant administration (LISA) in United Kingdom neonatal units. Acta Paediatr. 2024:doi: 10.1111/apa.17446. 
  2. Sweet DG, Carnielli VP, Greisen G, et al. European consensus guidelines on the Management of Respiratory Distress Syndrome: 2022 update. Neonatology. 2023;120(1):3-23. 
  3. Hartel C, Herting E, Humberg A, et al. Association of Administration of surfactant using less invasive methods with outcomes in extremely preterm infants less than 27 weeks of gestation. JAMA Netw Open. 2022;5(8):e2225810. 
  4. Reynolds P, Bustani P, Darby C, et al. Less-invasive surfactant Administration for Neonatal Respiratory Distress Syndrome: a consensus guideline. Neonatology. 2021;118(5):586-92. 
  5. Jeffreys E, Hunt K, Dassios T, Greenough A. UK survey of less invasive surfactant administration. Arch Dis Child Fetal Neonatal Ed. 2019;104(5):F567. 
  6. Abdel-Latif ME, et al. Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database of Systematic Reviews 2021;5:DOI: 10.1002/14651858.CD011672.pub2. 
 
 

IE-CUR-2400063 | January 2025

 

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