Infants born preterm (before 36 weeks' gestation age) have immature lungs and struggle to breathe on their own. They are supported via respiratory machines like ventilators, as well as pharmaceutical aids like surfactant replacement therapy. Surfactant replacement therapy is an established therapy for the treatment of respiratory distress syndrome, which is a common illness in infants born preterm.
Surfactant replacement therapy can be delivered to an infant's lungs a few ways, including via a small tube that is briefly placed down an infant's throat. This is considered the least invasive method currently available, and is becoming more popular. It is referred to as minimally invasive surfactant therapy (MIST). A baby can receive surfactant via MIST if they are receiving non-invasive respiratory support, like from a continuous positive airway pressure (CPAP) machine.
Doctors and researchers are looking for simple ways to make MIST more effective. This clinical trial will investigate if briefly increasing the air pressure delivered by a CPAP machine before giving MIST therapy will make MIST more effective. This strategy is called a lung recruitment manoeuvre (LRM), because it opens up more of the lungs - 'recruits' them - to help with oxygenation. The CPAP setting that is briefly changed is called positive end expiratory pressure (PEEP) - it increases the amount of air left in the lungs at the end of a breath. This stops parts of the lung collapsing when exhaling, which commonly occurs in the lungs of infants born preterm as they are immature.
The goal of this clinical trial is to investigate if a LRM prior to MIST improves ventilation and lung aeration in preterm infants born 24-32 weeks' gestation. The main question it aims to answer is: How a LRM prior to MIST might impact patterns of ventilation and lung aeration in preterm infants, compared to no LRM prior to MIST.
The current standard of care is no LRM before MIST. Researchers will compare this current standard against a LRM before MIST to see if it potentially improves patterns of ventilation.
Participants will be randomly placed (by chance) to receive either no LRM before MIST (control) or a LRM before MIST (intervention). Participants will be randomised once their treating clinical team have decided to give MIST.
Born between 24 to 31+6 weeks' gestation, by best obstetric estimate
Admitted to a participating NICU
A parent/guardian who can provide informed consent
Receiving CPAP respiratory support
Receiving any form of respiratory support other than CPAP
Receiving more than 8 cmH2O PEEP via CPAP in the 4 hours prior to surfactant administration (except in the Delivery Room as part of resuscitation at birth)
The infant's clinical team has concern regarding clinical stability and tolerability of EIT
The infant's skin integrity will not tolerate the EIT belt and gel
Parallel
Lung Recruitment Manoeuvre prior to Minimally Invasive Surfactant Therapy
DeviceLung recruitment manoeuvre prior to minimally invasive surfactant therapy. CPAP PEEP is increased from 7-8 cmH2O to 10 cmH2O in one step for 20 mins prior to MIST. PEEP will be decreased to 7-8 cmH2O after surfactant administration.
Control (Minimally Invasive Surfactant Therapy)
DeviceMinimally Invasive Surfactant Therapy (MIST) as per unit protocol
Mean Change in the Centre of Ventilation (ventro-dorsal)
An electrical impedance tomography-based measure, this is a measure of the homogeneity of air distribution in the lungs along the ventral to dorsal axis. A baseline measurement will be taken pre-MIST occurring. A final measurement will be taken 60 minutes after MIST has occurred. The difference between these values will be compared as the primary outcome measure.
Number of total surfactant doses
Need for intubation within 72 hours of MIST
Yes / No response
FiO2 % 24 hours after MIST
FiO2 %
Number of days on respiratory support
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