Several trials of delivery room management have investigated the relative benefits of intubating all the babies (and usually giving them all or most of them surfactant) or trying to maintain them on CPAP.
This table gives an outline of the methods (INSURE is INtubation SURfactant and immediate Extubation):
Trial ID |
n |
GA of subjects |
Age of intubation, control group. |
Initial Pressure of CPAP (CPAP group) |
Indications for failure, CPAP group |
Primary outcome |
SUPPORT |
1316 |
24-27 wk |
In DR, surfactant within 1 hr |
5 cmH2O |
FiO2>0.5, CO2>65, hemodynamic instability |
Death or BPD |
COIN |
610 |
25-28 wk |
5 min, surfactant optional, according to local protocol |
8 cmH2O |
FiO2 >0.6, pH <7.25 with PCO2>60, multiple apneas |
Death or BPD |
VON-DRM |
640 (3 groups) |
26-29 wk |
5 to 15 min, immediate surfactant, with either INSURE (group2) or progressive wean (group1) |
5 cmH2O (max 7) |
FiO2 >0.4 option to intubate>0.6 mandatory (or CO2 >65 or multiple apneas) |
Death or BPD |
CURPAP |
208 |
25-28 wk |
<30 min, INSURE |
6 to 7 cmH2O |
FiO2 >0.4, CO2>65 with pH<7.2 (multiple apneas) |
Need for ventilation within the 1st 5 days of life |
As for the results:
Support Study Group. Early CPAP versus surfactant in extremely preterm infants. The New England journal of medicine. 2010;362(21):1970-9. The SUPPORT trial http://www.nejm.org/doi/full/10.1056/NEJMoa0911783 . There was no difference in the primary outcome, survival without BPD, but some indication of less severe lung injury in the CPAP group
Morley CJ, et al. Nasal CPAP or intubation at birth for very preterm infants. The New England journal of medicine. 2008;358(7):700-8. The COIN trial. http://www.nejm.org/doi/full/10.1056/NEJMoa072788 There was no difference in survival without BPD, but there was somewhat less severe BPD in the CPAP group, and more pneumothoraces in the CPAP group.
Dunn MS, et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics. 2011;128(5):e1069-76. The VON DR management trial. http://pediatrics.aappublications.org/content/128/5/e1069.long Study was stopped early for declining enrollment. The CPAP group, and the INSURE group had better outcomes (death or BPD) than the intubation and ongoing ventilation group, but no significant differences.
Sandri F, et al. Prophylactic or Early Selective Surfactant Combined With nCPAP in Very Preterm Infants. Pediatrics. 2010;125(6):e1402-9. http://pediatrics.aappublications.org/content/125/6/e1402.abstract The CURPAP trial. No differences were found in important outcomes, including the primary, survival without BPD.
I performed a meta-analysis of these trials, dividing them according to whether the comparison was with INSURE or with surfactant and traditional weaning.
Which means that if you think you need to intubate a baby for surfactant, try to get them extubated again really fast.
Neonatal Research 