PT - JOURNAL ARTICLE AU - Glaser, Kirsten AU - Bamat, Nicolas A AU - Wright, Clyde J TI - 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 AID - 10.1136/archdischild-2022-324530 DP - 2023 Nov 01 TA - Archives of Disease in Childhood - Fetal and Neonatal Edition PG - 554--560 VI - 108 IP - 6 4099 - http://fn.bmj.com/content/108/6/554.short 4100 - http://fn.bmj.com/content/108/6/554.full SO - Arch Dis Child Fetal Neonatal Ed2023 Nov 01; 108 AB - 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.Data sharing not applicable as no datasets generated and/or analysed for this study.