548 - MIST-ifying a Level IV NICU: a single center experience of introducing minimally invasive surfactant therapy and finding equipoise in a unit with routine use of laryngeal mask airway surfactant

Publication Number: 3529.548

Riane Richard, Albany Medical College, SARATOGA, NY, United States; Lesa A. Ward, Bernard Millie Duker Childrens Hospital, Rotterdam, NY, United States; Joaquim Pinheiro, Albany Medical College, Albany, NY, United States; Chad J.. Pezzano, Albany Medical College, Albany, NY, United States; Upender Munshi, Albany Medical College, Albany, NY, United States; Anshu Paul, Albany Medical College, Albany, NY, United States

Background: Less invasive methods of surfactant delivery are becoming more routine as neonatologists recognize the lung injury caused by mechanical ventilation. Albany Medical Center has a level IV NICU that routinely uses laryngeal mask airway (LMA) surfactant as a less invasive approach. However, due to the size limitations of the currently available LMAs, prior to March 2024, smaller infants ( < 1000-1500g) received surfactant through an endotracheal tube after intubation. Here, we report our experience with introducing minimally invasive surfactant therapy (MIST) in this population.

Objective: 1. Describe the baseline characteristics of infants who received MIST. 2. Analyze the procedural aspects of MIST administration and variation in attempts required by infant birth weight. 3. Characterize frequency of mechanical ventilation after initial MIST procedure.

Design/Methods: This MIST QI project was launched in early 2024. A guideline was developed for the procedure, and it was introduced to the NICU team via a series of presentations. This was followed by formal web-based education of the procedure for all NICU staff as well as simulation exposure for proceduralists. A paper audit tool was developed and used for data collection regarding the procedure itself. Additional data, including demographic data, was collected via retrospective chart review.

Results: There were 53 infants who received a MIST attempt between March 2024 and September 2025. Of those, 48 (90.6%) were successful procedures. The median gestational age of infants who successfully received MIST was 27.6 weeks with a median birth weight of 1005g. Concurrently, 98 neonates in a larger subpopulation (median GA 34 weeks, median BW 2425g) received surfactant via LMA. For infants who received their first dose of surfactant via MIST, the median age of surfactant delivery was 3 hours. 60.4% of MIST procedures were successful at first attempt, 25% required two attempts, and 14.6% required more than two attempts. Figure 1 shows a non-significant trend towards increased success in one attempt for infants >1000g. 16 (33.33%) infants required intubation and mechanical ventilation within 7 days of MIST procedure, including 9 (18.75%) within 24 hours.

Conclusion(s): In our level IV NICU, introduction of MIST has been overall successful, despite the majority of infants receiving MIST being very low birth weight infants. We show success in avoiding mechanical ventilation for ~66.7% of infants who had successful MIST delivery. As our center gains more experience with MIST, we hope to decrease the number of attempts required, especially in the < 1000g birthweight cohort.

Number of MIST Attempts by Birthweight
67% of neonates >1000g had successful surfactant delivery via MIST on the first attempt. For neonates 751-1000g, there was a 53% success rate for surfactant delivery on the first attempt, and neonates <750g had a 57% success rate for MIST on the first attempt. This shows a non-significant trend towards increased success in one attempt for infants >1000g.