SURFSUP Trial Completed: Can We Make Surfactant Delivery Simpler?

We are excited to share that recruitment to the SURFSUP Trial (SURFactant Administration by SUPraglottic Airway)has now been completed.

Led by Calum Roberts from Monash University, Melbourne, Australia, and Joyce E. O’Shea from the University of Glasgow and NHS Greater Glasgow and Clyde, Scotland, SURFSUP brought together neonatal teams across several centres and countries to answer a very practical question: Can surfactant be administered through a laryngeal mask as effectively as through minimally invasive surfactant therapy (MIST)?

Why does this matter?

Respiratory distress syndrome (RDS) is common in babies born prematurely because their immature lungs do not produce enough surfactant. Surfactant treatment helps keep the small air spaces in the lungs open and is one of the most important therapies available for preterm infants with RDS.

Over recent decades, neonatal care has increasingly moved towards avoiding intubation and mechanical ventilation whenever possible. Instead, many preterm infants are initially supported using non-invasive respiratory support such as continuous positive airway pressure (CPAP). For infants who need surfactant, this has also led to the development of less invasive ways of administering it.

ne of the most widely used approaches is minimally invasive surfactant therapy (MIST). During MIST, a clinician uses a laryngoscope to place a thin catheter through the vocal cords and surfactant is administered while the baby continues to breathe spontaneously.

MIST can be very effective, but it still requires direct laryngoscopy and specific airway skills. Maintaining these skills can be particularly challenging in neonatal units where intubation and MIST are performed relatively infrequently.

Could a laryngeal mask provide another option?

A supraglottic airway, commonly called a laryngeal mask, provides a potentially simpler alternative.

Rather than passing through the vocal cords, the device sits above the airway opening and can be inserted without direct laryngoscopy. Surfactant can then be administered through the device while the infant continues to receive respiratory support.

Previous smaller studies suggested that administering surfactant through a laryngeal mask was feasible and potentially effective.

However, when SURFSUP was designed, there had been no randomized controlled trial directly comparing laryngeal-mask surfactant administration with MIST, which has become an important standard approach for spontaneously breathing preterm infants

The SURFSUP Trial

SURFSUP was designed as a large, multicentre randomized controlled non-inferiority trial comparing surfactant administration through a supraglottic airway with MIST.

The trial included preterm infants born at less than 37 weeks' gestation who weighed at least 1,250 g, were less than 48 hours old, had RDS and required an FiO₂ of at least 0.30 while receiving non-invasive respiratory support.

The planned sample size was an impressive 1,000 infants—500 in each treatment group—making SURFSUP substantially larger than the earlier trials evaluating surfactant administration through a laryngeal mask.

The primary question was straightforward and clinically important:

Is surfactant administered through a laryngeal mask non-inferior to MIST in preventing the need for mechanical ventilation or additional surfactant treatment within 72 hours?

The investigators also collected information about what happened during the procedure, including oxygen desaturation, bradycardia, number of attempts, procedure duration and clinician satisfaction, as well as important respiratory and other clinical outcomes.

CSAR and SURFSUP

We are particularly proud that the Centre for the Studies of Asphyxia and Resuscitation (CSAR) served as the coordinating centre for SURFSUP in Canada, while also being one of the participating recruitment sites.

Our team contributed to the Canadian participation in this international collaboration and helped support the successful conduct and completion of this large neonatal randomized trial.

SURFSUP is a great example of what can be achieved through international neonatal research collaboration—bringing together investigators, research teams and clinicians across countries to answer a practical question that has the potential to directly improve care at the bedside.

A major milestone

Completing recruitment to a 1,000-infant international neonatal randomized trial is a tremendous achievement.

The question addressed by SURFSUP is particularly important because it is not simply about whether surfactant works—we already know that it does. Instead, it asks how we can deliver an established and effective treatment in a way that is safe, effective, less invasive and potentially easier to perform.

We congratulate Calum Roberts, Joyce E. O’Shea, the entire SURFSUP investigator group, all participating neonatal units and research teams, and—most importantly—the infants and families who participated in the trial.

With recruitment now complete, we eagerly await the results.

If administering surfactant through a laryngeal mask proves to be as effective as MIST while being easier to perform, the findings from SURFSUP could have important implications for how surfactant is delivered—not only in tertiary neonatal intensive care units, but potentially across a much broader range of neonatal care settings around the world.