P1.176: Comparing Outcomes of Minimally Invasive Surfactant Therapy vs. Intubation-Surfactant-Extubation in Preterm Neonates with Neonatal Respiratory Distress Syndrome: A Meta-Analysis

Background: Neonatal respiratory distress syndrome (NRDS) remains a major cause of morbidity and mortality among preterm infants. Minimally invasive surfactant therapy (MIST) has emerged as a promising alternative, aiming to reduce mechanical ventilation while preserving spontaneous breathing. Studies suggest that MIST may lower the incidence of death or BPD and decrease oxygen and ventilation requirements compared to the intubation-surfactant-extubation (INSURE) method. This study aims to systematically compare the efficacy and safety of MIST versus INSURE in preterm neonates with NRDS.

Methods: A literature search was conducted in PubMed, Scopus, and Embase. Eligible studies were screened via the Rayyan platform by two independent reviewers. Inclusion criteria encompassed preterm neonates ( < 37 weeks) with NRDS requiring surfactant therapy, focusing on observational cohort studies and randomized controlled trials comparing MIST and INSURE. Data extraction was systematically performed, capturing study characteristics, patient demographics, and key clinical outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for randomized controlled trials. For statistical analysis, risk ratios (RR) were calculated for dichotomous variables and mean differences for continuous variables, both with 95% confidence intervals. A random-effects model was applied to all outcomes, and heterogeneity was assessed using I² statistics.

Results: Seventeen studies met the inclusion criteria, with a total of 1,931 neonates (MIST: 913, INSURE: 932). The groups had comparable baseline characteristics, including gestational age and sex distribution. No significant difference in mortality was observed between MIST and INSURE (RR 0.62; 95% CI 0.38–1.01; p=0.05). However, the INSURE group had a higher risk of bronchopulmonary dysplasia (RR 0.59; 95% CI 0.45–0.76; p< 0.001), intraventricular hemorrhage (RR 0.66; 95% CI 0.48–0.92; p=0.02), patent ductus arteriosus (RR 0.75; 95% CI 0.61–0.93; p=0.01), and pneumothorax (RR 0.54; 95% CI 0.34–0.87; p=0.02), while pulmonary hemorrhage (RR 0.69; 95% CI 0.38–1.25; p=0.18) and surfactant reflux (RR 1.47; 95% CI 0.71–3.03; p=0.22) were similar between groups. MIST was associated with fewer days requiring oxygen (MD -2.45; 95% CI -4.78 to -0.12; p=0.04) and a reduced need for mechanical ventilation (RR 0.54; 95% CI 0.39–0.75; p=0.002), though no significant differences were found in the duration of ventilation or NICU stay.

Conclusion: Our findings support MIST as a safer and more effective alternative to INSURE for preterm infants with NRDS, demonstrating reduced complications and a lower need for mechanical ventilation. Notably, MIST was associated with an overall decrease in complications, reinforcing its potential as an emerging treatment option. Further research is needed to overcome implementation challenges and optimize its application across diverse clinical settings.