The INSURE method in preterm infants of less than 30 weeks' gestation

The standard treatment of infant respiratory distress syndrome (RDS) includes artificial respiratory support and surfactant treatment. Among the respiratory supports, nasal continuous positive airway pressure (NCPAP) and mechanical ventilation (MV) are effective in reducing mortality and morbidity due to RDS. However, MV is invasive and may damage airways and lung parenchyma, potentially determining the onset of bronchopulmonary dysplasia (BPD). Thus, treatment with early NCPAP and surfactant, which are effective in decreasing the need for MV, may be a promising strategy to reduce the incidence of BPD in preterm infants with RDS. An Italian group has previously demonstrated that preterm infants with RDS who did not require MV and were treated with the INSURE method (NCPAP and surfactant administration followed by the immediate re-institution of NCPAP) had a better short-outcome than infants receiving MV after surfactant administration. In fact, the INSURE method reduced the need for MV, the duration of respiratory support, and the need for surfactant. However, INSURE cannot be given to all infants and is unsuccessful in others.
On this basis, the same group has conducted an observational prospective analysis aimed at identifying clinical characteristics which could differentiate infants who need initial treatment with MV from those who can be managed with INSURE and which could predict INSURE success or failure.
Overall, 125 infants (median gestational age: 27 weeks, range 23–29) were observed: 30 (24%) required MV, 75 (60%) received INSURE treatment, and 20 (16%) were treated with NCPAP. Sixty-eight (91%) infants were successfully treated with the INSURE method. Infants in the success group had less severe RDS and reduced occurrence of sepsis and pneumothorax, lower mortality, and shorter duration of stay in the NICU than infants in the failure group. A birth weight <750 g, pO2/FiO2 <218, and a/ApO2 <0.44 at the first blood gas analysis were independent risk factor for INSURE failure.
Taken together, these findings suggest that, despite the low gestational age of the analyzed population only 24% of studied infants needed MV in the delivery room, while the majority of them (76%) could be managed for their respiratory failure with INSURE (60%) or NCPAP alone (16%). Moreover, these data confirm that the need for MV is associated with lower gestational age, lower rate of antenatal steroid treatment, and more severe RDS, but mainly that it is associated with a higher risk of PDA, IVH, mortality, and mortality plus BPD.
In conclusion, short-term outcomes, i.e. reduced occurrence of complications and mortality, are better in preterm infants supported with a respiratory strategy aimed at minimizing the use of MV. The INSURE method, which combines NCPAP and surfactant administration, can be applied to the majority of extremely preterm infants with a high percentage of success.

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