542 - Success and Failure of Surfactant Administration Through Laryngeal or Supraglottic Airways, a Retrospective Analysis

Publication Number: 3523.542

Allison Froman, Mass General Brigham for Children, Boston, MA, United States; Carolyn La Vita, MassGeneral Hospital for Children, Boston, MA, United States; Kathleen Figurido, Massachusetts General Hospital, Boston, MA, United States; Megan Aurora, MassGeneral Hospital for Children, Boston, MA, United States; Jessica E. Shui, MassGeneral Hospital for Children, Lynnfield, MA, United States

Background: Exogenous surfactant can reduce the need for supplementary oxygen and improve the work of breathing in neonates with respiratory distress syndrome. Surfactant Administration through Laryngeal or Supraglottic Airways (SALSA) is an emerging minimally invasive delivery route compared to endotracheal tube administration, which requires insertion of a laryngoscope blade, sedation and/or positive pressure mechanical ventilation.

Objective: Determine subject characteristics of successful and failed SALSA to reduce supplemental oxygen requirement, and associated complications, in a level IV neonatal intensive care unit.

Design/Methods: This is a single-center retrospective study of all subjects who underwent SALSA from 6/2022-10/2025. Overall success was defined as ≥0.05 decrease in inspired oxygen (FiO2) requirement two hours post SALSA and robust response was defined as a ≥0.1 decrease in FiO2 or a final FiO2 of 0.21 post SALSA. Failure was defined as requiring intubation within 24 hours of SALSA. Equivocal response was not meeting the success or failure criteria.

Results: There were 137 subjects, characterized in Table 1. SALSA was successful in 46% of neonates (median FiO2 0.23 2 hours post SALSA), equivocal response in 27%, failure in 23%, and supraglottic airway was placed unsuccessfully in 3.6%. A robust response to SALSA was seen in 36% of neonates. When stratified by gestational age at birth, overall success was reached by 29.4% < 32 weeks, 46.4% of those 32 weeks to 37w6d, and 75.0% of those ≥38 weeks (Table 2). Robust response was seen in 23.5%, 37.5%, and 50% respectively. When stratified by hour of life at time of SALSA, overall success was reached by 40.4% 0-3 hours, 57.6% 3.5-6 hours, 42.2% 7-24 hours, and 46.7% 25-48 hours. (Table 2) Robust response was seen in 30.8%, 48.5%, 35.1%, and 33.3% respectively. Complications of esophageal injury after supraglottic airway placement occurred in 3% and pneumothorax after SALSA occurred in 4.3% (Table 3).

Conclusion(s): SALSA was successful in improving oxygenation and avoiding intubation across gestational ages. SALSA failure and abortion rates were lowest between 3.5-24 hours of life. Complications were rare; lower gestational age or lower birth weight was not associated with increased risk. We report a novel complication of esophageal injury with supraglottic airway placement, emphasizing the importance of heightened suspicion if there is difficulty with enteral tube replacement or pneumomediastinum. This data will guide future quality improvement interventions to improve rates of SALSA success.

Table 1 Population characteristics
Population characteristics. FiO2: Fraction of inspired oxygen; SALSA; Surfactant Administration through Laryngeal or Supraglottic Airways.

Table 2 Distribution of Oxygenation Response after SALSA by gestational age and chronological age
Distribution of Oxygenation Response after SALSA by gestational age and by age of life (hours). Success ≥0.05 decrease in FiO2. FiO2 fraction of inspired oxygen; SALSA: Surfactant Administration through Laryngeal or Supraglottic Airways.

Incidence of SALSA Complications
Distribution of esophageal injury and pneumothorax after SALSA by gestational age and by age of life (hours). SALSA: Surfactant Administration through Laryngeal or Supraglottic Airways.