Administration of liquid surfactant through an endotracheal tube for the treatment of respiratory distress syndrome has been the standard of care for decades. A skilled health care provider is needed to perform this procedure. In lower-income and middle-income countries (LMICs), healthcare resources are often limited, leading to increased mortality of premature infants, many of whom would benefit from surfactant administration. Therefore, having a simplified procedure for delivery of surfactant without the need for advanced skills could be life-saving, potentially diminish gaps in care, and help ensure more equitable global neonatal survival rates. Modifications to the standard approach of surfactant administration have been put into practice and these include: INtubation-SURfactant-Extubation (INSURE), thin catheter surfactant administration (TCA), aerosolized surfactant, and surfactant administration through laryngeal or supraglottic airways (SALSA). Although there is a need for larger studies to evaluate the comparative effectiveness of these newer methods, these methods are being embraced by the global community and being implemented in various settings throughout the world. Because the SALSA technique does not require laryngoscopy, a provider skilled in laryngoscopy is not required for the procedure. Therefore, because of the ease of use and safety profile, the SALSA technique should be strongly considered as a viable method of delivering surfactant in LMICs.

An anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac condition that typically presents with poor feeding and failure to thrive from progressive myocardial ischaemia. Previous reports of ALCAPA presenting with ventricular fibrillation (VF) have suggested a causative relationship. In this case, we present a neonate with VF without apparent cause after an extensive evaluation. Following implantable cardioverter-defibrillator placement for presumed idiopathic VF, at which time she also underwent surgical ligation of a patent ductus arteriosus (PDA), the neonate developed haemodynamic instability that ultimately was found to be due to ALCAPA. Numerous echocardiograms had missed the ALCAPA in the setting of mildly elevated pulmonary artery pressure. We discuss the limitations of current ultrasound technology in diagnosing ALCAPA in the setting of pulmonary hypertension and explain why the relationship between this patient's diagnosis of ALCAPA and her episode of VF is not clearly causative.

Pulmonary surfactant is a lifesaving treatment for preterm infants with respiratory distress syndrome (RDS). With the advent of less-invasive surfactant delivery techniques that minimize or eliminate exposure to invasive mechanical ventilation, the question of prophylactic surfactant administration has reemerged. This review discusses the evidence for less-invasive surfactant therapy applied prophylactically. In summary, prophylactic surfactant administration by pharyngeal deposition or brief intubation are not recommended. Surfactant delivery via supraglottic airway or by aerosolization have not been investigated as prophylaxis for RDS. Recent evidence suggests that prophylactic surfactant administration via thin catheter is safe and effective. Several ongoing randomized clinical trials are further evaluating the efficacy of prophylactic surfactant administration via thin catheter. Prophylactic surfactant administration via supraglottic airway devices and aerosolization should be evaluated in future studies.

For preterm infants with respiratory distress syndrome, delivery of surfactant via brief intubation (INtubate, SURfactant, Extubate; InSurE) has been the standard technique of surfactant administration. However, this method requires intubation and positive pressure ventilation. It is thought that even the short exposure to positive pressure inflations may be enough to initiate the cascade of events that lead to lung injury in the smallest neonates. In an effort to avoid tracheal intubation and positive pressure ventilation, several alternative and less invasive techniques of exogenous surfactant administration have been developed over the years. These have been investigated in clinical studies, including randomized clinical trials, and have demonstrated advantages such as a decrease in the need for mechanical ventilation and incidence of bronchopulmonary dysplasia. These newer techniques of surfactant delivery also have the benefit of being easier to perform. Surfactant delivery via pharyngeal instillation, laryngeal mask, aerosolization, and placement of a thin catheter are being actively pursued in research. We present a contemporary review of surfactant administration for respiratory distress syndrome via these alternative methods in the hope of guiding physicians in their choices for surfactant application in the neonatal intensive care unit. Cite this article as: Erdeve Ö, Okulu E, Roberts KD, et al. Alternative methods of surfactant administration in preterm infants with respiratory distress syndrome: State of the art. Turk Arch Pediatr. 2021; 56(6): 553-562.