Surfactant treatment during continuous positive airway pressure

In premature infants, surfactant is administered by tracheal instillation, which requires the placement of an endotracheal tube. Therefore, surfactant is usually administered at initiation of or during mechanical ventilation (MV). However, MV itself may induce lung injury, associated to epithelial disruption, fluid leakage and inflammatory response that can inactivate surfactant. Moreover, MV has been implicated as the single most important risk factor for the later development of bronchopulmonary dysplasia (BPD). Results of some trials have suggested that surfactant instillation during nasal continuous positive airway pressure (nCPAP) in infants with moderate-to-severe respiratory distress syndrome (RDS) may reduce the need for subsequent MV by half after a single dose of surfactant and the need of repeated surfactant doses. This effect was more pronounced if the surfactant treatment was given early in the course of the disease. On these bases, a Swedish group have studied the effects of a new method for surfactant administration by transient intubation during nCPAP, labelled INSURE (i.e. INtubation SURfactant Extubation) for moderately preterm infants with RDS. The study was designed as a retrospective follow-up of infants with gestational age 27 to 34 weeks and diagnosed with RDS born in one Swedish neonatal care center (Karolinska Huddinge) during a 10-year period, 1993 to 2002, comparing the 5-year period before and after the introduction of INSURE (in 1998). Results were compared with those obtained in another center (Karolinska Solna), in which conventional surfactant therapy in conjunction with MV was continued throughout the study. It is noteworthy that MV was not available in the first center and therefore infants requiring this treatment needed to be transferred to the second one. In total, 420 infants were evaluated. Results show that in the first center implementation of INSURE have reduced the number of infants requiring MV by 50% (P<0.01), resulted in earlier surfactant administration and increased overall surfactant use. Moreover, INSURE-treatment improved oxygenation and the treatment response was sustained over time with only 17% of the infants requiring > 1 dose of surfactant. In the second center, which did not adopt the INSURE method, the MV rates were unaltered between the first and second 5-year period. Results of this study may suggest that a treatment strategy involving surfactant administration by transient intubation during nCPAP, such as INSURE, could be a safe alternative to surfactant treatment followed by MV in moderately preterm infants with RDS. This strategy significantly reduces the need for MV with no adverse effects on the outcome. For smaller neonatal units, this approach is an option to administer surfactant earlier and effectively treat RDS, particularly in a care setting where transfer is needed for MV. This also holds the benefit of a possible reduction of costs and may facilitate a family-centered neonatal care.

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