Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil’s safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks’ gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.

Pediatric inpatient admissions for viral respiratory infections decreased worldwide during the early part of the coronavirus disease 2019 (COVID-19) pandemic. This was likely due to social distancing measures and mask mandates leading to a decreased spread of viruses. We question if there was an increase in respiratory admissions during the winter of 2020-2021 due to the overlap of seasonal respiratory viruses and COVID-19 and the severity of those admissions. We performed a single-center retrospective chart review of all respiratory admissions to our pediatric intensive care unit (PICU) from October to April during the years 2018-2019, 2019-2020, and 2020-2021. We compared the total number of respiratory admissions from different viruses and respiratory admissions by diagnoses among those time periods. Second, we compared the PICU length of stay and duration of mechanical ventilation (both invasive and non-invasive) for these respiratory admissions during those years. We saw a drastic decrease in the total respiratory admissions to the PICU in 2020-2021 compared to the same period of time in the last two years. The greatest contributor to this decrease was admissions secondary to bronchiolitis. We noticed a statistically significant decrease in both asthma (p<0.001) and chronic respiratory failure admissions (p=0.0029) during the pandemic winter compared to previous winters. Although, the total number of all respiratory viral admissions is not significant, admissions specific to the respiratory syncytial virus (RSV) (p<0.0001), rhino-enterovirus (p<0.0001), and multi-virus (p=0.0016), achieved statistical significance. There was no statistical difference between the PICU length of stay and duration of mechanical ventilation during the three years. Despite a decrease in pediatric respiratory admissions during the COVID-19 pandemic, the severity of illness based on length of stay in the PICU and length of time on respiratory support remains unchanged compared to the previous two years.

Background/Objectives: Pneumothorax is a common complication of neonatal respiratory distress syndrome, which is decreased by surfactant therapy. Rescue administration of surfactant in neonates with severe RDS complicated by pneumothorax requires management of the pneumothorax to optimize surfactant distribution while avoiding positive pressure ventilation to minimize iatrogenic exacerbation of the air leak. Methods: We retrospectively reviewed our center’s experience with neonates who had clinically significant pneumothorax complicating RDS, in whom we used a novel technique to administer surfactant through a laryngeal mask/supraglottic airway device without applying positive pressure ventilation. Results: In 13 of the 20 neonates in our cohort, subsequent invasive ventilation and chest tube insertion were avoided. There were no major complications or unfavorable outcomes. We describe our experience with this method and suggest an approach to individualize the management of neonates with pneumothorax preceding surfactant therapy. Conclusions: In our setting, laryngeal mask airway devices are now the preferred method to deliver surfactant in neonates with RDS and pre-existing pneumothorax. We believe this approach is readily applicable in most neonatal care settings.