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Standardizing a Less Invasive Surfactant Administration Method

Jocelyn Blount, MSN RNC-NIC NEA-BC
Cari Brown, BSN RNC-NIC

Mechanical ventilation and endotracheal intubation pose significant patient risks including barotrauma, volutrauma, pneumothorax, intraventricular hemorrhage, increased necessity for patent ductus arteriosus (PDA) treatment, vocal cord or tracheal trauma, and increased bronchopulmonary dysplasia (BPD) rates (Kakkilaya et al., in press).

To reduce the risk of these adverse events, methods of surfactant administration have evolved from utilizing the endotracheal tube to other less invasive methods (Flanagan, 2016; Aguar et al., 2014). The less invasive surfactant administration (LISA) method is an approach to administering surfactant without the need for endotracheal intubation (Aguar et al., 2014). For the LISA method, a thin catheter is passed through the visualized vocal cords and removed after the instillation of surfactant. The following is a description of one unit’s experience developing a standard guideline for care of the infant while receiving surfactant via the LISA method.

Parkland Health and Hospital System is an 882-bed tertiary hospital in Dallas, TX (Parkland Health & Hospital System, 2019). The Neonatal Intensive Care Unit (NICU) is a 96-bed unit that provides care for 1400 neonatal admissions annually with an average daily census of 71 (Parkland Health & Hospital System, 2019). Parkland is one of the busiest delivery hospitals in the country with over 12,000 deliveries annually (Parkland Health & Hospital System, 2019). An interprofessional team was formed to develop a standardized process for LISA in the NICU. This group consisted of physicians, advanced practice nurses, respiratory therapists, neonatal educators, and direct care nurses.

After performing an extensive literature review, the team met regularly to create a standardized procedure. To ensure its success, each team worked to provide in-depth education to ensure patient safety and procedural consistency. Initial education was developed in collaboration with clinical educators by creating an informative video demonstration of the procedure. The video was deployed to all staff utilizing the organization’s learning management system. The group developed an algorithm (FIGURE 1) that provided guidance for the escalation of airway pressures and when to administer surfactant via LISA. The algorithm was laminated and used as a bedside visual aid when infants were admitted to the NICU on continuous positive airway pressure (CPAP). Having the algorithm readily available at the bedside decreased variability in treatment and prevented delays in surfactant therapy (Kakkilaya et al., in press).

When the procedure was standardized, LISA supplies were prepackaged and placed in a designated area in the unit. These LISA Kits (FIGURE 2) include a 5-mL syringe; 18-gauge needle; 16-gauge, 5.5-in. angiocath; a sterile marker; a sterile tape measure; and a sterile towel. Supplies not included in the kit include CUROSURF® (poractant alpha) 2.5 ml/kg, appropriate size sterile gloves, and emergency intubation equipment.

Infants admitted to the NICU on CPAP requiring both an increase in CPAP pressures and an oxygen requirement of greater than 30% at 1 hour of life are identified as candidates for the LISA procedure (Kakkilaya et al., in press). Once the provider establishes the need for LISA, the nurse verifies the order for CUROSURF in the electronic medical record. The nurse positions the infant’s head at the foot of the bed, gathers the necessary supplies, and prepares the CUROSURF 2.5ml/kg as ordered. Per the manufacturer’s recommendations, the CUROSURF is warmed and drawn from the vial with an 18-gauge needle after the metal casing and rubber seal is removed from the vial to prevent any fragments from being aspirated and instilled into the trachea and lungs during administration (Chiesi Farmaceutici, 2019).

Prior to the procedure, a time-out is performed using two patient identifiers. The nurse also ensures emergency equipment, such as a bag and mask, are readily available. Throughout the procedure, the cardiorespiratory monitor is utilized for audible beat-to-beat ECG monitoring. The patient’s head is kept in midline position. The nurse monitors for complications including desaturation, bradycardia, or apnea. The infant remains on nasal prong CPAP throughout the procedure to retain functional residual capacity (FRC).

After the procedure is complete, the nurse gently aspirates stomach contents from the orogastric tube to assess for any surfactant presence in the stomach which could indicate reflux of surfactant and an unsuccessful procedure. The patient is observed for a minimum of 10 minutes post procedure for any complications or need for escalation in care. It is recommended to wait to suction until 1-2 hours after administration.

Postprocedural complications may include desaturations, increased need for supplemental oxygen, bradycardia, pneumothorax, and pulmonary hemorrhage. Reduction in oxygen requirements may be seen within minutes of successful administration, and oxygen should be weaned to maintain saturations within the unit’s specific target range. With successful weaning of supplemental oxygen and maintenance of FiO2 less than 0.25, the nurse should anticipate an order to decrease CPAP pressures. Documentation includes vital signs, duration of the procedure, any complications, and patient tolerance.

Since implementing LISA in the NICU, Parkland has seen a decrease in CPAP failure rates, need for mechanical intubation, pneumothorax, and PDA treatment in preterm infants born less than or equal to 29 weeks gestation (Kakkilaya et al., in press). The success of this new procedure was due to the efforts of the interprofessional committee and educators who provided valuable training and simulation sessions to NICU nurses and providers. The LISA procedure is provided to infants after admission to the NICU, and a process for implementation in the delivery room is being developed.


Aguar, M., Vento, M., & Dargaville, P. (2014). Minimally invasive surfactant therapy: An update. NeoReviews, 15(7), e275-e285. https://10.1542/neo.15-7-e275

Chiesi Farmaceutici. (2019). Curosurf (poractant alfa) user’s guide.

Flanagan, K. A. (2016). Noninvasive ventilation in premature neonates. Advances in Neonatal Care, 16(2), 91-98.

Kakkilaya, V., Weydig, H., Wagner, S., Garcia, K., He, H., Smithhart, W., Renfro, S., Metoyer, G., Brown, C., Brown, S., Kapadia, V., Savani, R., Jaleel, M. (in press). Decreasing nasal continuous positive airway pressure failure in preterm infants by optimizing CPAP and less invasive surfactant administration. Pediatrics.

Parkland Health & Hospital System. (2019). Parkland annual report 2019.

Disclaimer: The information presented and opinions expressed herein are those of the authors and do not necessarily represent the views of the National Association of Neonatal Nurses.

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