INTRODUCTION
Respiratory distress syndrome (RDS), one of the most common respiratory illness in preterm infants, is mainly due to the lack of pulmonary surfactant, leading to atelectasis, ventilation-perfusion (V/Q) mismatch, and often resulting in neonatal morbidity and mortality (1,2). Since the early 1990s, Surfactant replacement therapy (SRT) for RDS has been a standard of care across neonatal intensive care units (NICU) (3). Along with invasive ventilation, it plays a vital role in the pathophysiology of bronchopulmonary dysplasia (BPD), which remains common morbidity in preterm neonates (4,5). Nasal continuous positive airway pressure (nCPAP) is frequently used for RDS to decrease the incidence of acute lung injury. The combination of Surfactant therapy with nCPAP for alveolar recruitment has transformed the management of RDS(6). The classical InSurE technique introduced by Verder et al. (1990) involving Intubation, Surfactant administration with brief positive pressure ventilation, and Extubation, along with nCPAP has been the standard of care for RDS(7). To avoid intubation for delivering surfactant in preterm infants with RDS, less invasive surfactant administration (LISA) ,also known as minimally invasive surfactant therapy (MIST) techniques have been described (8–10). LISA came into focus by attaining surfactant delivery while maintaining spontaneous breathing and avoiding the need for endotracheal tube intubation even for a split second(11). LISA technique has been suggested as the preferred way of surfactant administration to preterm infants with RDS as an alternative to InSurE(12–14).
nCPAP has been a part of the standard of care in managing preterms with RDS. Although it reduces the need for invasive mechanical ventilation(IMV), there is substantial evidence of nCPAP failure as high as 35-50%(6,15,16). Hence, nasal intermittent positive pressure ventilation (NIPPV) can be a better option as it delivers time cycled peak inspiratory pressure (PIP) above Positive End Expiratory Pressure (PEEP), thereby delivering higher mean airway pressure at nasal interface compared to nCPAP(17). Evidence from the literature suggests that NIPPV as primary mode of respiratory support has lower rates of failure and need for IMV(18–21).
There is limited data about the feasibility and efficacy of LISA from developing countries. Moreover, hardly very few RCTs have been published comparing LISA vs InSurE using NIPPV as a primary mode of respiratory support. This prospective open-label RCT was planned to study the comparative efficacy of LISA with InSurE in preterm (28-36 weeks of gestation) with RDS using NIPPV as a primary mode of respiratory support.
The primary objective was to find need of intubation and mechanical ventilation within 72 hrs of birth. Neonates were followed until discharge/death for adverse events and complications.