Surfactant Administration Practice Guidelines for Late Pre-Term and Greater Gestation Neonates

The purpose of this project was to develop a surfactant administration guideline to decrease the rate of pneumothoraces in moderate-late preterm and term neonates. Currently there are no clear guidelines for surfactant administration in this population yet research has pointed to significant benefits in reducing pneumothoraces when surfactant is given. A pneumothorax prevents lung expansion due to air between the visceral pleura of the lungs and the parietal pleura of the thoracic cavity. Many conditions can cause a pneumothorax in preterm or term newborns. Surfactant can be administered to neonates to prevent a pneumothorax by facilitating lung expansion. The need for a guideline was evident after collection of baseline data from 41 neonatal medical records from 2015 at a Utah tertiary care NICU. The number of pneumothoraces in this population was higher than any other facility in the state and included 32 infants out of 41 that were > 32 weeks gestation. Although all had conditions treatable with surfactant administration, only 2 received the treatment while 30 other infants could have potentially avoided a pneumothorax if a guideline for surfactant was in place. The project objectives included, 1) develop a clinical practice guideline for surfactant administration in neonates > 32 weeks gestation, 2) present a proposed guideline at the facility where the above data was collected and seek approval and intention to implement it in the future, 3) disseminate the guideline to a broader group of neonatal medical providers for proposed implementation within the hospital network statewide. To explain the gap in care, collected neonatal data and current research on surfactant use was developed into a presentation and a guideline with content expert input. This information was presented to the quality improvement team (n=14) at the project facility (neonatologists, NICU medical director, neonatal nurse practitioners, nurses and the head respiratory therapist). Participant feedback informed revisions and a second presentation is planned for the NICU Developmental Team (neonatologists, nurse practitioners and nurse managers) who implement protocols for the hospital system throughout the state of Utah. American Academy of Pediatrics (AAP) recommends that neonates >30 weeks gestation should receive surfactant when in hypoxic respiratory failure. Additionally, AAP states that surfactant administration "should be considered" in neonates with underlying treatable respiratory disease processes like respiratory distress syndrome or secondary surfactant deficiency due to inactivation of surfactant from meconium aspiration, pneumonia or sepsis. Current research supports early surfactant replacement with extubation to nasal continuous positive airway pressure (CPAP) and indicates that this is effective at decreasing the occurrence of pneumothorax and bronchopulmonary dysplasia (BPD) regardless of gestation or birth weight. Results showed that neonates >32 weeks gestation developed pneumothoraces before reaching hypoxic respiratory failure and all suffered from underlying respiratory conditions treatable with surfactant. Surfactant should be administered to improve outcomes in this patient population. Use of a guideline will increase appropriate surfactant administration in the moderate-late preterm and term neonatal population. The guideline is likely to reduce the incidence of pneumothoraces, improve patient outcomes and be cost effective.