INSURE = CPAP + Surfactant

Bohlin K, Gudmundsdottir T, Katz-Salamon M, et al. Implementation of surfactant treatment during continuous positive airway pressure. J Perinatol (July 2007); 27:422-427. Full Text | PDF

Objective: To study the effects of implementing a method for surfactant administration by transient intubation, INSURE (i.e. INtubation SURfactant Extubation) during nasal continuous positive airway pressure (nCPAP) for moderately preterm infants with respiratory distress syndrome (RDS).

Study design: A descriptive, retrospective, bi-center study in Stockholm, Sweden, comparing mechanical ventilation (MV) rates, surfactant use, treatment response and outcome of all inborn infants with gestational age 27 to 34 weeks and RDS, (n=420), during the 5-year periods before and after the introduction of the INSURE-strategy at one of the centers (Karolinska Huddinge) in 1998. The other center (Karolinska Solna) continued conventional surfactant therapy in conjunction with MV throughout the study.

Results: Implementation of INSURE at Karolinska Huddinge reduced the number of infants requiring MV by 50% (P<0.01), resulted in earlier surfactant administration and increased overall surfactant use. INSURE-treatment improved oxygenation and the treatment response was sustained over time with only 17% of the infants requiring >1 dose of surfactant. At Karolinska Solna, the MV rates were unaltered between the first and second 5-year period.

Conclusion: Implementing a strategy of surfactant administration by transient intubation during nCPAP reduces the need for MV without adverse effects on outcome and may be an option to more effectively treat RDS, particularly in a care setting where transfer is necessary to provide MV.

Comments. The surfactant used in this study was Curosurf, and infants were given a full vial (100 – 200 mg/kg). Prior to intubation, babies were loaded with theophylline to prevent apnea, and pre-medicated with morphine and pentobarbital. After intubation and surfactant treatment, nalaxone was given to reverse the respiratory depression from the morphine prior to extubation back to CPAP. Despite the study’s limitations (no randomization, historical controls, etc), it seems clear that the INSURE strategy will reduce the need for mechanical ventilation in moderately preterm infants with RDS. I was disappointed to see that no beneficial effects could be shown using this strategy for chronic lung disease, IVH, ROP, or mortality. ABK

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