Early Versus Delayed Selective Surfactant Treatment of RDS
Although there are no statistically significant benefits to prophylactic use of surfactant when compared with prophylactic CPAP, several studies have investigated whether administration of surfactant early in the course of respiratory insufficiency improves clinical outcomes. Early rescue is defined as surfactant treatment within 1 to 2 hours of birth, and late rescue is defined as surfactant treatment 2 or more hours after birth. A recent meta-analysis of early (within 2 hours) versus delayed surfactant treatment concluded that the risks of mortality (RR 0.84; 95% CI 0.74–0.95), air leak (RR 0.61; 95% CI 0.48–0.78), chronic lung disease (RR 0.69; 95% CI 0.55–0.86), and chronic lung disease or death (RR 0.83; 95% CI 0.75–0.91) were significantly decreased. There were no differences in other complications of prematurity.7
Early Administration of Surfactant Followed by Brief Ventilation and Extubation to CPAP (INSURE Strategy)
The INSURE strategy is widely used throughout the world. In randomized clinical trials performed before 2008, the INSURE approach, compared with rescue surfactant administration in infants with RDS, was associated with a significantly reduced need for mechanical ventilation (RR 0.67; 95% CI 0.57–0.79) and a reduced need for oxygen at 28 days.6 In an analysis stratified by fraction of inspired oxygen requirement at study entry, a significantly higher frequency of patent ductus arteriosus was observed among infants in the rescue surfactant group, who required a fraction of inspired oxygen greater than 0.45 (RR 2.15; 95% CI 1.09–4.23). The Vermont Oxford Network Delivery Room Management Trial (n = 648) randomly assigned infants born at 26 to 29 weeks’ gestation to 1 of 3 treatment groups: prophylactic surfactant and continued ventilation, prophylactic surfactant and rapid extubation to CPAP (INSURE), or nasal CPAP without surfactant.15 When compared with the group of infants receiving prophylactic surfactant and continued ventilation, the RR of death or BPD was 0.78 (95% CI 0.59–1.03) for the INSURE group and 0.83 (95% CI 0.64–1.09) for the CPAP group. However, in the nasal CPAP group, 48% were managed without intubation and 54% without surfactant treatment. A recent meta-analysis demonstrated that prophylactic surfactant (with rapid extubation to CPAP) was associated with a higher risk of death or BPD (RR 1.12; 95% CI 1.02–1.24; number needed to harm of 17) when compared with early stabilization with CPAP and selective surfactant administration.5 In infants with birth weight ≥1250 g and mild to moderate RDS, elective intubation and administration of surfactant decreased the need for mechanical ventilation but had no effect on the duration of oxygen therapy, ventilator therapy, or hospital stay.16