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.