TOP 22 - Utilizing Video Conferencing to implement SALSA (Surfactant Administration through Laryngeal or Supraglottic Airways) to improve outcomes in African NICUs

Publication Number: 1782.TOP 22

Manjari Pophale, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Michelle D.. Yates, Soddo Christian Hospital, Oakhurst, CA, United States; Saron Estifanos Yohannes, Soddo Christian Hospital, Addis Ababa, YeDebub Biheroch Bihereseboch na Hizboch, Ethiopia; Habeneyom Tebeje Kibret, Soddo Christian hospital, Wolayita soddo, YeDebub Biheroch Bihereseboch na Hizboch, Ethiopia; PauL M. Opare-Addo, Michigan State University College of Human Medicine, VALENCIA, CA, United States; Anne Mburu, PCEA Chogoria Hospital, Chogoria, Eastern, Kenya; Catherine Hodge, In His Image International, Merritt Island, FL, United States; Ian Matandika, Kamuzu University of Health Sciences, Blantyre, Balaka, Malawi; Paa Kwesi Essandoh-Yeddu, Hope Christian Hospital, Tema, Greater Accra, Ghana; Scott Guthrie, Children's Hospital at Erlanger, Chattanooga, TN, United States

Background: Respiratory distress syndrome is a leading cause of neonatal mortality in low- and middle-income countries, with rates of 28-41/1,000 live births compared to 3/1,000 in high-income settings. Surfactant replacement therapy (SRT) improves survival by 33% when combined with CPAP. SALSA offers a minimally invasive, easy-to-learn method for surfactant delivery that eliminates laryngoscopy and enables SRT in settings previously limited by expertise promoting equitable global neonatal survival

Objective: To implement SALSA training virtually in African neonatal units and evaluate its impact on survival, length of stay, and respiratory outcomes

Design/Methods: This multicenter quality improvement project focuses on implementation of SALSA via virtual training in four African neonatal units: Soddo Christian Hospital (Ethiopia, pilot site), Chogoria Hospital (Kenya), Nkhoma Mission Hospital (Malawi), and Hope Christian Hospital (Ghana). Units are staffed by family physicians, pediatricians, or general practitioners. Baseline data (Aug 2023-Jul 2024) include neonates requiring respiratory support, FiO₂ ≥ 21%, or clinical surfactant deficiency. At Soddo (n = 112), 14% received surfactant (69% via SALSA) with overall survival 84.5%; post-surfactant deaths primarily due to sepsis. At Chogoria (n = 122), survival 87% and Nkhoma (n = 71), survival 60%, both with limited CPAP and no surfactant. Hope data will be included in the final analysis. All baseline outcome data are presented in Table 1.
A standardized CPAP protocol was developed to ensure consistent management across sites. Virtual training has been completed and incorporates simulation videos, real-time feedback, and e-learning modules. Eligibility criteria for SALSA are outlined in Figure 1 and Key Driver Diagram in Figure 2. Data are prospectively collected in REDCap, including demographics, surfactant use (timing, method, complications), respiratory support duration, length of stay, and survival. Provider training completion and protocol display are tracked as process measures. The primary aim is for >50% of eligible infants to receive SALSA within one year. Secondary aims include a 25% mortality reduction, improved noninvasive ventilation, and reduced hospital stay.
The project launched in October, and early post-implementation data (n=10) demonstrate successful SALSA use in infants as small as 625 g (others 1.1-1.5 kg) showing rapid improvement in oxygen needs and procedural competence. At project completion, we aim to share training resources and advocate for sustainable surfactant access to enable replication of success across units.

Table 1: Baseline Neonatal Outcomes Across Participating SALSA Implementation Sites
Soddo served as the pilot site with established surfactant use (SALSA and InSurE), demonstrating high survival (84.5%). Chogoria and Nkhoma achieved good survival with CPAP alone but lack surfactant access. These baseline findings underscore the potential impact of expanding SALSA implementation particularly in lower-resource units

Figure 1: Eligibility and Exclusion Criteria for SALSA
Infants must meet clinical and respiratory criteria after optimized CPAP management

Figure 2: Key Driver Diagram: Virtual Implementation of SALSA