Intubation-Surfactant: Extubation on Continuous Positive Pressure Ventilation. Who Are the Best Candidates?

Introduction: Respiratory distress syndrome (RDS) continues to be the leading cause of illness and death in preterm infants. Studies indicate that INSURE strategy (INtubate-SURfactant administration and Extubate to nasal continuous positive airway pressure [nCPAP]) is better than mechanical ventilation (MV) with rescue surfactant, for the management of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates, as it has a synergistic effect on alveolar stability.
Aim of the study: To identify the factors associated with INSURE strategy failure in preterm infants with gestational age (GA) ≤ 32 weeks.
Materials and Methods: This was a retrospective cohort study, based on data collected in the Romanian National Registry for RDS patients by three regional (level III) centers between 01.01.2010 and 31.12.2011. All preterm infants of ≤ 32 weeks GA were included. Prenatal and neonatal information were compared between (Group 1), the preterm infants successfully treated using INtubation-SURfactant-Extubation on nasal CPAP (INSURE) strategy and (Group 2 ), those who needed mechanical ventilation within seventy-two hours after INSURE.
Results: A total of 637 preterm infants with GA ≤ 32 weeks were included in the study. INSURE strategy was performed in fifty-seven cases (8.9%) [ Group 1] and was successful in thirty-one patients (54.4%). No differences were found as regards the studied prenatal and intranatal characteristics between (Group 1) and Group 2 who needed mechanical ventilation. Group 2 preterm infants who needed mechanical ventilation within 72 hours after INSURE had significantly lower mean Apgar scores at 1 and 5 minutes and lower peripheral oxygen saturation (SpO2) during resuscitation at birth (p<0.05). Successful INSURE strategy was associated with greater GA, birth weight (BW), fraction of inspired oxygen (FiO2) during resuscitation, and an increased mean dose of surfactant but these associations were not statistically significant (p>0.5).
Conclusion: In preterm infants ≤ 32 weeks gestation, increased INSURE failure rates are associated with complicated pregnancies, significantly lower Apgar scores at 1 and 5 minutes, and lower peripheral oxygen saturation during resuscitation.