Preterm babies are born with immature lungs and usually are deficient in surfactant. Fujiwra first administered surfactant in 1980 in preterm as therapy for hyaline membrane disease [1]. This is first therapy which was intended to be used only for the neonates. Over years we have tried different modes of administering the surfactant. As we are advancing, we understood that less invasive we are, better is the outcome as far as morbidity and mortality is concerned. We started our journey with intratracheal administration of surfactant followed by ventilation. Soon the side effects of prolonged ventilation on preterm lungs were recognized. Intubation surfactant extubation (INSURE) was a technique started to reduce the ventilatory associated lung injury [2]. Even brief period of ventilation was damaging to the fragile preterm lungs and hence other Less Invasive Surfactant Administration (LISA) and Minimal Incase Surfactant (MIST) were tried and found to be successful [3]. Sometimes we have babies who have difficult airway like Pierre Robin syndrome, Cornelia de Lange, cleft palate, and Beckwith–Wiedemann syndrome where it becomes difficult to intubate. In such cases airway is secured with laryngeal mask airway (LMA) [4],[5],[6],[7]. Laryngeal mask airway is recommended to be used for neonatal resuscitation [8]. Schmölzer et al. in a systematic review on supraglottic airway devices in neonatal resuscitation established that resuscitation with an LMA was viable and harmless in infants of >34 weeks’ gestational age (GA) and a birth weight WO 6 (BW) >2,000 g [4].

Laryngeal mask airway is less invasive to the lungs and the neonate is exposed to a lower hemodynamic strain reaction throughout LMA positioning and removal. Laryngoscopy and tracheal intubation are often associated with complications like local trauma, the stress-response reflex, and malpositioning of the endotracheal tube in the esophagus or deep in right bronchial tree. It may also generate hypertension and cyanosis in infants.

Its practice may be lifesaving in neonates with malformations of the upper airway when tracheal intubation and mask ventilation fail.

Complications of LMA are soft tissue trauma, vomiting, regurgitation, stridor, and if not placed properly may lead to partial airway obstruction and apnea [9],[10].

When these babies require surfactant, we cannot use the same methods to administer it. Surfactant administration through laryngeal supraglottic airway (SALSA) is one such new method. Its new and very few units are practicing it. One single small trial showed LMA surfactant administration in preterm infants ≥ 1200 g with RDS may have a short-term favorable effect on reduced oxygen requirements [11] to have better outcome, correct technique to insert LMA, and administer surfactant is important.

We had one preterm 31-week baby born with macroglossia, micrognathia fitting in criteria of Beckwith–Wiedemann syndrome who required resuscitation at birth but failed intubation due to macroglossia. Laryngeal mask airway was inserted in the baby and ventilation was provided by LMA. In neonatal intensive care unit (NICU) found to have RDS requiring surfactant administration. We administered surfactant through LMA and it was effective. The oxygen requirement and the ventilatory requirement decreased. The baby required a second dose of surfactant which was also given through LMA. The baby tolerated the procedure well and could be brought down on FiO₂ requirements.

This instructional video 1 was made to educate the step wise to administer surfactant using new method SALSA technique. As far as we know there is no video on live baby demonstrating the LMA insertion and surfactant administration.

• Prepare equipment/supplies: o Continuous cardiovascular monitoring equipment
  • CO₂ detector (Pedicap)
  • Surfactant
  • LISA catheter
  • 3 mL or 5 mL syringe (dose dependent)
  • Large gauge needle (18 g)
  • Alcohol swab 70%
  • Sterile towel or drape
  • Tape measure o Sterile scissors
  • Emergency equipment: Neopuff and mask, suction, laryngoscope
  • LMA (size according to the gestation and weight). Use the correct size of LMA for the patient. Size 1 is suitable for neonates weighing 2.5–5 kg. It has been postulated that a smaller size (0.5) could be useful in preterm newborns.
• Surfactant administration is a two-person procedure. It should be performed by at least one medical practitioner who administers the surfactant and one registered nurse as the assistant
• Record baseline observations: heart rate, respiration rate, oxygen saturation, plus a blood gas if required
• Insert the LMA
  • Fully deflate the cuff, and lubricate the back of the mask tip.
  • Press the tip of the LMA against the hard palate. During this procedure, the practitioner should grasp the LMA like a pen with the index finger at the junction between the mask and the distal end of the airway tube.
  • Gently advance the LMA with one single movement, applying continuous pressure against the palatopharyngeal curvature with the index finger. The path of the force applied must be cranially and not caudally.
  • Continue pushing LMA against soft palate it cannot be pushed further inwards.
  • Inflate the mask to the minimum air volume necessary to ascertain sufficient seal. Do not hold the tube of the LMA during cuff inflation, as the tube may be seen to move out during cuff inflation permitting correct positioning.
  • Connect the proximal end of the airway tube to a CO₂ detector (Pedicap) and then to device T piece resuscitator or self-inflating bag. Look for change in color of the CO₂ detector which should turn yellow.
• Slowly warm the vial of surfactant to room temperature before administration.
• Administering doctor and nurse performs hand hygiene and put on sterile gloves.
• Using surgical aseptic technique, cut a sterile LISA catheter to the length so that the tip lies 1 cm above the end of the endotracheal tube (usually we take weight plus 6). This safeguards that the surfactant is directed intratracheal. Curosurf/Survanta should not be instilled into a main stem bronchus.
• Slowly withdraw a little more than required dose into a 3- or 5-mL plastic syringe using a large-gauge needle. Attach the pre-cut LISA catheter to the syringe, prime, or fill the catheter with surfactant to the end.
• Ensure bed is flat. Place the neonate in supine position. There is no evidence to support the practice of changing positions of neonate during administration.
• Assistant disconnects the LMA from T piece resuscitator (Neopuff).
• Doctor administers the surfactant via the pre-cut LISA catheter in a single or two doses as quickly as the neonate tolerates. The total dose is usually given in less than a minute.
• Surfactant can occlude the LMA and it may have to cease instilling till the tube is cleared and chest wall movement restarts.
• Reconnect LMA to T piece resuscitator (Neopuff) as soon as possible.
• Ventilator support or inspired oxygen may need to be temporarily increased.
• Medical practitioner to remain at bedside until the neonate is stable.

We conclude that LMA is alternative, unique, and effective method of surfactant administration in difficult airway even in preterm babies 31 weeks of gestation.