Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery

Objective:to compare the effectiveness of surfactant delivery via endotracheal tube (ett) using an intubation-surfactant-rapid extubation approach with premedication) vs laryngeal mask airway (lma) in preventing the need for mechanical ventilation in preterm neonates with moderate respiratory distress syndrome (rds).study design:moderately preterm infants diagnosed with rds, receiving nasal continuous positive airway pressure with fio2 0.30 to 0.60, were randomized to two groups at age 3 to 48 h. those in the ett group were intubated following premedication with atropine and morphine, whereas the lma group received only atropine. both groups received calfactant before a planned reinstitution of nasal continuous positive airway pressure, and had equivalent pre-specified criteria for subsequent mechanical ventilation and surfactant retreatment. the primary outcome was failure of surfactant treatment strategy to avoid mechanical ventilation; we differentiated early from late failures to assess the contribution of potential mechanisms such as respiratory depression versus less-effective surfactant delivery. secondary outcomes addressed efficacy and safety end points.result:sixty-one patients were randomized, one excluded and 30 analyzed in each group, with similar baseline characteristics. failure rate was 77% in the ett group and 30% in the lma group (p<0.001). the difference was related to early failure, as late failure rates did not differ between groups. fio2 decrease after surfactant and rates of adverse events were similar between groups.conclusion:surfactant therapy through an lma decreases the proportion of newborns with moderate rds who require mechanical ventilation, when compared with a standard endotracheal intubation procedure with sedation. the efficacy of surfactant in decreasing rds severity appears similar with both methods. morphine premedication likely contributed to early post-surfactant failures.