Early administration of surfactant in spontaneous breathing with nCPAP:: feasibility and outcome in extremely premature infants (postmenstrual age ≤27 weeks)

Background: Spontaneous breathing supported by nasal continuous positive airway pressure (nCPAP) is thought to have some advantages compared with mechanical ventilation in extremely premature infants. In addition, early or prophylactic surfactant administration has been shown to be superior to delayed use. A strategy to combine these two principles was tested in our neonatal intensive care unit (NICU). The aim of this feasibility study was to describe the procedure and compare short-term results with a historical control. Methods: The study took place in a level III NICU. In the observational period all extremely premature infants with clinical signs of moderate to severe respiratory distress syndrome despite nCPAP received 100 mg.kg(-1) of a natural surfactant preparation via an intratracheal catheter during spontaneous breathing. In the historical control period those infants were intubated and ventilated to receive surfactant. Results: Twenty-nine of 42 infants fulfilled the criteria and were treated with the new approach. In five cases ventilation with manual bag was necessary after administration of surfactant but all infants could be retransferred to nCPAP within a few minutes. Ten infants were intubated later during the first 3 days. Mortality was 7% in the group of infants treated in this way and 12% in all infants treated during the observational period. Mortality was 35% in the historical control period. Morbidity was within ranges reported by other authors. Conclusions: Surfactant administration during nCPAP is feasible. First results indicate that early complications are rare. This warrants a prospective randomized trial.