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

EBNEO commentaries on manuscripts relevant to evidence-based neonatal practice are welcomed and published after a formal peer-review process. To learn more visit contact Dr. Amy Keir < [email protected] > or Clyde J. Wright with questions. Surfactant deficiency is major cause of CPAP failure in extremely preterm infants. avoid harmful effects associated invasive mechanical ventilation, alternative techniques surfactant administration have evolved, combining the positive early CPAP. The INtubation-SURfactant-Extubation (IN-SUR-E) procedure comprises intubation, intra-tracheal immediate extubation CPAP.1, 2 It widely used, although not always successful.3 In animal models respiratory distress, lung recruitment prior was shown improve homogenous distribution efficacy.4 This prospective unblinded RCT sought evaluate efficacy safety modified IN-SUR-E approach applying high-frequency oscillatory ventilation (HFOV) (IN-REC-SUR-E) compared standard IN-SUR-E. an important study—since being first large trial addressing this question very immature authors present intention-to-treat analysis as gold address missing data well per-protocol analysis. study showed reduced need for 72 h life intervention group—with number needed treat 7.2, without adversely affecting in-hospital mortality other secondary outcomes. current findings suggest that IN-REC-SUR-E safe effective infants managed failing However, it acknowledge some limitations. As far primary outcome concerned, seems critical protocol lacked precise criteria re-intubation. Given blinding, design potentially introduced significant bias among group. Differences time intervals between sedation display further weaknesses. While directly followed intubation randomised IN-SUR-E, took 30 min median establish successful patients allocated IN-REC-SUR-E, subsequently passing metabolism sedative drugs. fact may had impact likelihood success post-surfactant non-invasive ventilatory support. Heterogeneity strategies limitation. received during manual administered babies while continuing HFOV. According given parameters, been maximally protective control group—potentially reflected by higher numbers death including six cases fatal pulmonary haemorrhage. Of note, both groups, included 1–2 manoeuvres sustained inflation (SLI) management delivery room, SLI no longer recommended premature infants.5-7 Despite limitations, indicates application manoeuvre. Further RCTs method regard short-term long-term Moreover, comparison less (LISA) procedures applied spontaneously breathing completely avoiding desirable.8, 9 https://ebneo.org/ung-recruitment-in-sur-e. None.