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Objectives: Our aim was to evaluate whether single and multiple intubation-surfactant-extubation (INSURE) procedures have similar effects on the need of mechanical ventilation (MV) and occurrence of bronchopulmonary dysplasia (BPD) in extremely preterm infants., Methods: We studied infants of <30 weeks of gestation with respiratory distress syndrome (RDS) who were treated with single (FiO(2)>0.30 without need of MV) or multiple (FiO(2)>0.40 without need of MV) INSURE procedures., Results: Seventy-five infants were studied: 53 (71%) received single INSURE and 22 (29%) received multiple INSURE procedures. Infants in the single and multiple groups had similar rates of need of MV (15 vs. 23%) and occurrence of BPD (9 vs. 9%), although the latter were more immature and affected by more severe RDS (higher FiO(2), lower a/ApO(2), and pO(2)/FiO(2)) than the former., Conclusions: Single and multiple INSURE procedures were followed by similar respiratory outcome in a cohort of extremely preterm infants. Further studies are warranted to evaluate whether the multiple INSURE strategy enhances the success rate of INSURE in preventing the need of MV and the occurrence of BPD.

Surfactant treatment has been demonstrated to decrease pneumothorax and mortality in preterm infants. Natural surfactants are better than synthetic surfactants. Early rescue treatment with surfactant is better than late treatment, whereas the role of surfactant prophylaxis is under re-evaluation due to the actual large diffusion of antenatal steroid and nasal continuous positive airway pressure treatment which have changed the clinical characteristics of preterm infants with respiratory distress syndrome. It is possible that in the next future anti-inflammatory and anti-oxidant properties of exogenous natural surfactants may be improved through their combination with adequate agents with the aim of counteracting the pathogenetic role of inflammatory and oxidative lung injury injuries in the development of brochopulmonary dysplasia.