Article Text

Download PDFPDF
Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature
  1. Kirsten Glaser1,
  2. Nicolas A Bamat2,
  3. Clyde J Wright3
  1. 1 Division of Neonatology, Department of Women’s and Children’s Health, University of Leipzig Medical Center, Leipzig, Germany
  2. 2 Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3 Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
  1. Correspondence to Dr Clyde J Wright, University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045, USA; Clyde.wright{at}


Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today’s neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.

  • Neonatology
  • Physiology
  • Intensive Care Units, Neonatal

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

View Full Text


  • Twitter @nbamat

  • Contributors KG, NB and CJW drafted and edited the manuscript and approved the final version.

  • Funding This work was supported by NIH Grant R01HL132941 to CJW.

  • Competing interests CJW reports to have worked as a consultant to Chiesi Farmaceutici, Parma, Italy.

  • Provenance and peer review Commissioned; externally peer reviewed.

Linked Articles

  • Highlights from this issue
    Ben J Stenson