Background INtubate-SURfactant-Extubate (INSURE) method is one of the effective methods in treatment of infants with respiratory distress syndrome (RDS). This study was performed to predict risk factors for the failure of INSURE method in treatment of RDS in preterm infants. Materials and Methods: In this cross-sectional study, 192 infants who born between July 2011 and April 2016 at women and children's hospital of Amiralmoemenin in Semnan, Iran, were included to the study. Inclusion criteria were infants with moderate to severe RDS, 26 to 38 gestational weeks and weighted 500 to 3, 500 grams. All patients were treated with INSURE method, then were divided to success and failure INSURE. Severity of RDS was determined by RDS scoring system. The collected data including gender status, gestational age (GA), birth weight (BW), maternal diabetes mellitus, delivery type and neonatal morbidity (including intraventricular haemorrhage (IVH), Necrotizing enterocolitis (NEC) stage 1, sepsis, chronic lung disease (CLD), pneumothorax, and pulmonary bleeding. Statistical analysis was done using SPSS software, version 22. 0. Results: Of the 192 patients, 82 (42. 7%) infants were females. The mean GA and BW were 30. 25 ± 1. 85 weeks and 1950 ± 270 grams, respectively. Of all the patients, 156 infants (81. 25%) were born via cesarean section. INSURE failure was observed in 79 infants (41. 1 %) and INSURE success was observed in 113 (58. 9%). Among the factors, INSURE method failure had a significant relationship with GA, BW, RDS severity and increased probability of IVH, CLD, pneumothorax and pulmonary bleeding (p<0. 05). Based on logistic regression analysis, there was a significant relationship between the failure of INSURE method and RDS severity (odds ratio [OR]= 6. 31, 95% 95%CI [CI]= 2. 07-19. 19, P=0. 001), and GA OR=0. 78, 95% CI= 0. 67-0. 91, P=0. 001). Conclusion: According to the finding, among the risk factors, only higher severity of RDS and GA were able to predict INSURE method failure in treatment of RDS in preterm infants. Additional studies are recommended in this regard.

Administration of endotracheal surfactant is potentially the main treatment for neonates suffering from RDS (Respiratory Distress Syndrome), which is followed by mechanical ventilation. Late and severe complications may develop as a consequence of using mechanical ventilation. In this study, conventional methods for treatment of RDS are compared with surfactant administration, use of mechanical ventilation for a brief period and NCPAP (Nasal Continuous Positive Airway Pressure), (INSURE method ((Intubation, Surfactant administration and extubation)). A randomized clinical trial study was performed, including all newborn infants with diagnosed RDS and a gestational age of 35 weeks or less, who were admitted in NICU of Valiasr hospital. The patients were then divided randomly into two CMV (Conventional Mechanical Ventilation) and INSURE groups. Surfactant administration and consequent long-term mechanical ventilation were done in the first group (CMV group). In the second group (INSURE group), surfactant was administered followed by a short-term period of mechanical ventilation. The infants were then extubated, and NCPAP was embedded. The comparison included crucial duration of mechanical ventilation and oxygen therapy, IVH (Intraventricular Hemorrhage), PDA (Patent Ductus Arteriosus), air-leak syndromes, BPD (Broncho-Pulmonary Dysplasia) and mortality rate. The need for mechanical ventilation in 5th day of admission was 43% decreased (P=0.005) in INSURE group in comparison to CMV group. A decline (P=0.01) in the incidence of IVH and PDA was also achieved. Pneumothorax, chronic pulmonary disease and mortality rates, were not significantly different among two groups. (P=0.25, P=0.14, P=0.25, respectively). This study indicated that INSURE method in the treatment of RDS decreases the need for mechanical ventilation and oxygen-therapy in preterm neonates. Moreover, relevant complications as IVH and PDA were observed to be reduced. Thus, it seems rationale to perform this method as the initial treatment for neonates with mild to moderate RDS.

Background: Respiratory distress syndrome (RDS) is considered one of the most common causes of morbidity in neonates. None of the interventions made in the last three decades to manage this disease has been able to affect the development of RDS as much as surfactant replacement. Objectives: Although the standard approach is intubation during surfactant administration, the development of alternative methods in surfactant administration, such as surfactant administration using nebulizers, has been considered that is the aim of the current study. Methods: This randomized controlled trial was conducted on neonates with a gestational age of 28 - 32 weeks with RDS under nasal continuous positive airway pressure (nCPAP) in Beheshti Medical Center in Isfahan, Iran, within March 2018 to August 2020. The neonates requiring the fraction of inspired oxygen 0.4 for periods longer than 30 minutes to maintain oxygen saturation in the right hand within the range of 89 - 95% while being supported under continuous distending pressure 5 cm H2O were randomly divided into a control group and an intervention group. Survanta was administered in the control group through INSURE method and aerosolization using mesh nebulizers in the intervention group. Results: This study showed no significant difference in the arterial/alveolar oxygen ratio gradient after Survanta administration (P-value: 0.10), need for subsequent doses of surfactant (P-value: 0.771) and mechanical ventilation (P-value: 0.145), prevalence of pneumothorax (P-value: 0.50), chronic lung disease (P-value: 0.269), and high-grade intraventricular hemorrhage (P-value: 0.221), duration of nCPAP support (P-value: 0.089), or prevalence of death between the two groups (P-value: 1.00). Conclusions: Since aerosolization is considered to be a noninvasive method, it is required to perform further studies to improve this approach.