The BeginningDr. Von Neergaard first detected the surface tension in the gasliquid interphase and its role in the lung compliance in 1929, showing that more pressure was required to inflate lungs with air than with aqueous solution like water and concluding that retractile force of the lung was dependent on the surface tension in the alveoli [1]. To date, great advances in this field have been done. In 1959, Dr. Avery stablished the causal relationship between the hyaline membrane diseases in the premature infant with the absence of a substance that decreased the surface tension and so, increased the lung volume [2].After these discoveries, research study was headed for finding a way to create that foamy mix of proteins and fats called surfactant, but it was not until twenty years later, in 1980, when Dr. Fujiwara published the first clinical experience with exogenous surfactant, showing an improvement in oxygenation [3]. Ten years later the FDA approved the clinical use of this substance and contributed to the stunning advances in the prognosis of the premature infants with RDS, reducing air leak, oxygenation and neonatal death [4]. Nowadays trend about the management of neonatal RDS in the premature infant can be summarized in one main idea: the softer the management is, the better. With this concept in mind a new goal comes into view: avoiding intubation. This is the reason why the non-invasive respiratory support tries to become a substitute to intubation and mechanical ventilation when it is possible. This modality has shown a reduction in intubation, surfactant administration and non-significant reduction of death or bronchopulmonary dysplasia [RR 0.80 (CI 95% 0.58-1.12)] [8]. When comparing intubation and surfactant administration to non-invasive respiratory support, the latest is a valid alternative [9].
Type and DoseOn the other hand, newborns managed with non-invasive respiratory support, may need intubation and surfactant administration in a later phase of their evolution, and consequently, they cannot take advantage from the early surfactant therapy. This failure has been studied and estimated in 22% in the premature infants managed initially with this non-invasive support [10].
Early Surfactant and Early Non-Invasive Respiratory SupportBoth early surfactant and non-invasive respiratory support have shown benefits, so the next question should be which one is the best option. In this new age of softer management of preterm infants the question should turned into: why not using both?The option of giving surfactant reducing mechanical ventilation as much as possible is the INSURE technique (INtubate-SURfactantExtubate). This method consists in intubation to instill exogenous surfactant and after that, extubation and connecting the patient to a non-invasive respiratory support. A reduction in mechanical ventilation needs has been shown in previous studies [11,12]. Some disadvantages about the INSURE method can be stated as follows: we are not completely avoiding intubation or mechanical ventilation, alth...
