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Lung recruitment prior to IN‐SUR‐E procedure–Safe and effective?

Surfactant deficiency is a major cause of CPAP failure in extremely preterm infants. To avoid harmful effects associated with invasive mechanical ventilation, alternative techniques of surfactant administration have evolved, combining the positive effects of surfactant and early CPAP. The INtubation- SURfactant- Extubation (IN- SUR- E) procedure comprises intubation, intra- tracheal surfactant administration and immediate extubation to CPAP. 1,2 It is widely used, although not always successful. 3 In preterm animal models of respiratory distress, lung recruitment prior to surfactant was shown to improve homogenous distribution and efficacy. 4 This prospective unblinded RCT sought to evaluate efficacy and safety of a modified IN- SUR- E approach applying high- frequency oscillatory ventilation (HFOV) lung recruitment prior to surfactant (IN- REC- SUR- E) compared to standard IN- SUR- E. It is an important study— since being the first large trial addressing this question in very immature preterm infants. The authors present intention- to-treat analysis as gold standard to address missing data as well as per-protocol analysis. The study showed a reduced need for mechanical ventilation in the first 72 h of life in the intervention group— with a number needed to treat of