Procedural Outcomes of Minimally Invasive Surfactant Therapy: An International Matched Cohort Study

Objectives To compare procedural safety and success outcomes between catheter placement for minimally invasive surfactant therapy (MIST) and tracheal intubation (TI) for surfactant, and to identify characteristics associated with improved procedural outcomes among patients treated with MIST. Study design We conducted a retrospective, multicenter, observational, matched cohort study from an international airway registry from 2016 to 2024. Patients treated with MIST and patients who received TI for surfactant without paralytic premedication, were matched 1:1 on gestational age, procedure location, and laryngoscope type. The primary outcome was severe oxygen desaturation (≥20% SpO2 decrease). Secondary outcomes included SpO2 <80%, any adverse event, and first attempt success. Using conditional logistic regression, the association between procedure type and outcomes was assessed. Among patients who received MIST, a multiple logistic regression model assessed the association between procedural characteristics and outcomes. Results There were 383 patients treated with MIST matched to 383 patients who underwent TI for surfactant. Compared with TI, MIST procedures were associated with lower adjusted odds of severe oxygen desaturation (aOR 0.66, 95% CI 0.45-0.97) and SpO2 <80% (aOR 0.59 95% CI: 0.40-0.85) and higher odds of first attempt success (aOR 2.93 95% CI 1.94-4.43). Odds of adverse events did not differ (aOR 0.88 95% CI 0.50-1.56). Factors associated with improved MIST outcomes included video laryngoscopy, first airway provider, commercial catheter type, and patient weight. Conclusions MIST is associated with improved procedural safety and success compared with TI for surfactant. Several factors are associated with improved MIST procedural outcomes.