Article | Published:

Continuous positive airway pressure delivery during less invasive surfactant administration: a physiologic study



We sought to investigate the pressure delivery during less invasive surfactant administration, as we hypothesize that it might be reduced.

Study design

Physiologic in vitro study in a ventilation lab, using different pressure generators, levels, and leaks in a model of neonatal airways/lung mimicking mechanical characteristics of respiratory distress syndrome. Pressure was measured at the lung and verified in vivo measuring pharyngeal pressure in 19 neonates under same conditions. Data were analyzed using repeated measures-analysis of variance.


Pressure delivery in vitro is significantly and variably reduced during minimally invasive surfactant administration: pressure loss is ≈99% and ≈10–97%, during mouth opening and closure, respectively. Pressure loss seems independent from the type of CPAP and interface. In vivo measurements showed similar pressure drops.


Pressure transmission during minimally invasive surfactant administration is significantly reduced or totally absent. Pressure drop occurs despite the increased airway resistances and the airflow limitation due to the tracheal catheterization, but is independent from the type of pressure generator and interface.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    Committee on Fetus and Newborn; American Academy of Pediatrics. Respiratory support in preterm infants at birth. Pediatrics. 2014;133:171–4.

  2. 2.

    Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome—2016 Update. Neonatology. 2017;111:107–125.

  3. 3.

    Schmölzer GM, Kumar M, Pichler G, Aziz K, O’Reilly M, Cheung PY. Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis. BMJ. 2013;347:f5980.

  4. 4.

    Fischer HS, Buhrer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis. Pediatrics. 2013;132:e1351–60.

  5. 5.

    De Paoli AG, Morley CJ, Davis PG, Lau R, Hingeley E. In vitro comparison of nasal continuous positive airway pressure devices for neonates. Arch Dis Child Fetal Neonatal Ed. 2002;87:F42–5.

  6. 6.

    Kieran EA, Twomey AR, Molloy EJ, Murphy JF, O’Donnell CP. Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics. 2012;130:e1170–6.

  7. 7.

    Courtney SE, Pyon KH, Saslow JG, Arnold GK, Pandit PB, Habib RH. Lung recruitment and breathing pattern during variable versus continuous flow nasal continuous positive airway pressure in premature infants: An evaluation of three devices. Pediatrics. 2001;107:304–8.

  8. 8.

    Dargaville PA. Innovation in surfactant therapy I: Surfactant lavage and surfactant administration by fluid bolus using minimally invasive techniques. Neonatology. 2012;101:326–36.

  9. 9.

    Dargaville PA, Aiyappan A, Cornelius A, Williams C, De Paoli AG. Preliminary evaluation of a new technique of minimally invasive surfactant therapy. Arch Dis Child Fetal Neonatal Ed. 2011;96:F243–8.

  10. 10.

    Kribs A, Roll C, Göpel W, Wieg C, Groneck P, Laux R, et al. NINSAPP trial investigators: Nonintubated surfactant application vs conventional therapy in extremely preterm infants: A randomized clinical trial. JAMA Pediatr. 2015;169:723–30.

  11. 11.

    Pandit PB, Courtney SE, Pyon KH, Saslow JG, Habib RH. Work of breathing during constant- and variable-flow nasal continuous positive airway pressure in preterm neonates. Pediatrics. 2001;108:682–5.

  12. 12.

    De Luca D, Costa R, Visconti F, Piastra M, Conti G. Oscillation transmission and volume delivery during face mask-delivered HFOV in infants: Bench and in vivo study. Pediatr Pulmonol. 2016;51:705–12.

  13. 13.

    De Luca D, Carnielli VP, Conti G, Piastra M. Noninvasive high frequency oscillatory ventilation through nasal prongs: bench evaluation of efficacy and mechanics. Intensive Care Med. 2010;36:2094–100.

  14. 14.

    Harjeet M, Sahni D, Batra YK, Rajeev S. Anatomical dimensions of trachea, main bronchi, subcarinal and bronchial angles in fetuses measured ex vivo. Paediatr Anaesth. 2008;18:1029–34.

  15. 15.

    De Paoli AG, Lau R, Davis PG, Morley CJ. Pharyngeal pressure in preterm infants receiving nasal continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed. 2005;90:F79–81.

  16. 16.

    Colnaghi M, Matassa PG, Fumagalli M, Messina D, Mosca F. Pharyngeal pressure value using two continuous positive airway pressure devices. Arch Dis Child Fetal Neonatal Ed. 2008;93:F302–4.

  17. 17.

    Gizzi C, Klifa R, Pattumelli MG, Massenzi L, Taveira M, Shankar-Aguilera S, et al. Continuous positive airway pressure and the burden of care for transient tachypnea of the neonate: Retrospective cohort study. Am J Perinatol. 2015;32:939–43.

  18. 18.

    Isayama T, Iwami H, McDonald S, Bejene J. Association of noninvasive ventilation strategies with mortality and bronchopulmonary dysplasia among preterm infants: A systematic review and meta-analysis. JAMA. 2016;316:611–24.

  19. 19.

    Aldana-Aguirre JC, Pinto M, Featherstone RM, Kumar M. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2017;102:F17–23.

  20. 20.

    Mukerji A, Belik J. Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission. J Perinatol. 2015;35:716–19.

  21. 21.

    Gerdes JS, Sivieri EM, Abbasi S. Factors influencing delivered mean airway pressure during nasal CPAP with the RAM cannula. Pediatr Pulmonol. 2016;51:60–9.

  22. 22.

    Chilton HW, Brooks JG. Pharyngeal pressures in nasal CPAP. J Pediatr. 1979;94:808–10.

  23. 23.

    Antonelli M, Conti G, Rocco M, Arcangeli A, Cavaliere F, Proietti R, et al. Noninvasive positive-pressure ventilation vs conventional oxygen supplementation in hypoxemic patients undergoing diagnostic bronchoscopy. Chest. 2002;121:1149–54.

  24. 24.

    Antonelli M, Conti G, Riccioni L, Meduri GU. Noninvasive positive pressure ventilation via face mask during bronchoscopy with BAL in high-risk hypoxemic patients. Chest. 1996;110:724–28.

  25. 25.

    Matsushima Y, Jones RL, King EG, Moysa G, Alton JD. Alterations in pulmonary mechanics and gas exchange during routine fiberoptic bronchoscopy. Chest. 1984;86:184–88.

  26. 26.

    More K, Sakhuja P, Shah PS. Minimally invasive surfactant administration in preterm infants: a meta-narrative review. JAMA Pediatr. 2014;168:901–8.

  27. 27.

    Goldstein RA, Rohatgi PK, Bergofsky EH, Block ER, Daniele RP, Dantzker DR, et al. ATS Board of Directors. Clinical role of bronchoalveolar lavage in adults with pulmonary disease. Am Rev Respir Dis. 1990;142:481–86.

  28. 28.

    McNiece WL, Dierdorf SF. The pediatric airway. Semin Pediatr Surg. 2004;13:152–65.

  29. 29.

    Mehler K, Oberthuer A, Haertel C, Herting E, Roth B, Goepel W. German Neonatal Network (GNN). Use of analgesic and sedative drugs in VLBW infants in German NICUs from 2003–2010. Eur J Pediatr. 2013;172:1633–9.

  30. 30.

    Oncel MY, Arayici S, Uras N, Alyamac-Dizdar E, Sari FN, Karahan S, et al. Nasal continuous positive airway pressure versus nasal intermittent positive-pressure ventilation within the minimally invasive surfactant therapy approach in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2016;101:F323–8.

Download references

Author information

Conflict of interest

The authors declare that they have no conflict of interest.

Correspondence to Daniele De Luca.

Electronic supplementary material

  1. Supplementary video-1

  2. Supplementary video-2

Rights and permissions

To obtain permission to re-use content from this article visit RightsLink.

About this article

Fig. 1
Fig. 2