Early INSURE Therapy Reduces CPAP Failure in Late Preterm Newborns with Respiratory Distress Syndrome

Background: INSURE (Intubation, Surfactant administration, and Extubation) therapy is controversial in managing respiratory distress syndrome (RDS) in late preterm newborns. This study aims to determine whether the use of the INSURE in late preterm infants with RDS is associated with improved outcomes compared to similar infants managed with CPAP alone. Methods: A retrospective cohort study compared two different neonatal care units with two different treatments of RDS in late preterm infants in Bucaramanga, Colombia. One cohort used selective bubble CPAP and rescue surfactant, the second cohort used selective bubble CPAP and INSURE within the first hour of life. We included all the newborns with gestational age between 33 - 366/7 weeks, born between 2012 to 2017, that developed early RDS and were treated with CPAP.  Results: We recruited 208 patients   (57 CPAP and rescue surfactant and 151 CPAP + INSURE).  Early INSURE was reported in 117 patients (56.3 %). INSURE therapy was associated with a reduced risk of CPAP failure (RR = 0.50; 95 % CI 0.26 - 0.98); this effect was evident only when surfactant was administered within the first two hours of life (RR = 0.29; 95 % CI 0.12 - 0.69). Early INSURE was associated with a decreased risk of pneumothorax (RR = 0.07; 95 % CI 0.01 - 0.77) and pulmonary hypertension (RR = 0.34; 95 % CI 0.14 - 0.78). Conclusions: Early INSURE therapy was associated with a reduced incidence of CPAP failure, pneumothorax, and pulmonary hypertension in late preterm infants with moderate to severe RDS. Large, well-powered randomized controlled trials are needed to confirm these observations, but its use is supported by studies with similar results in more premature infants.