Since the introduction of surfactant into the treatment of respiratory distress syndrome (RDS) in preterm infants, the immense importance of this substance has become clear. Nothing has led to a greater increase in survival and a greater decrease in long-term sequelae in preterm infants.1 Some reviews of the body of literature on this subject have demonstrated that early or prophylactic administration of surfactant is more beneficial than late (rescue) therapy.2 3 Therefore, a policy of intubation, mechanical ventilation and surfactant administration has become an accepted standard for the therapy of infants at high risk of RDS in large parts of the world.

In some regions, however, especially in Scandinavia, a strategy with stabilisation of preterm infants with continuous positive airway pressure (CPAP) and surfactant administration as a rescue therapy has remained the standard therapy for preterm infants.4 5 Surprisingly, comparisons of populations treated in this way with populations treated with intubation, mechanical ventilation and surfactant administration revealed similar results with regard to mortality and neonatal morbidity.6,–,8 This has led to an intense discussion in the literature about the best way to manage preterm infants with RDS: intubation with surfactant administration and a shorter or longer period of mechanical ventilation or stabilisation with CPAP and surfactant administration via an endotracheal tube as an early rescue therapy. For a long time, this discussion grounded on analyses of retrospective population-based studies and led to the demand for prospective randomised studies.9 Recently, a couple of those studies have been published. Six hundred and ten infants born with a gestational age between 25 and 28 completed weeks were included in the Continuous Positive Airway Pressure or Intubation at Birth (COIN) trial and randomly assigned to receive CPAP or intubation 5 min after birth.10 The outcome …