Optimal ventilatory strategies and surfactant to protect the preterm lungs

Invasive ventilation via the endotracheal tube is one of the most common therapeutic interventions performed in preterm infants with respiratory failure. Respiratory distress syndrome (RDS) occurs in about 50% of preterm infants born at less than 30 weeks of gestational age. Mechanical ventilation using conventional or high-frequency ventilation and surfactant therapy have become the standard of care in management of preterm infants with RDS. However, bronchopulmonary dysplasia (BPD) remains as a major morbidity with adverse pulmonary and nonpulmonary outcomes in preterm infants despite these interventions. Ventilator-associated lung injury appears to be related to the duration of invasive ventilation via the endotracheal tube rather than the mode of ventilation. Randomized controlled trials comparing conventional mechanical ventilation and high-frequency ventilation, using 'optimal ventilatory strategies', have shown no significant difference in rates of BPD. Use of noninvasive ventilation, such as nasal continuous positive airway pressure and nasal intermittent positive pressure ventilation has shown a significant decrease in postextubation failure as well as reduced incidence of BPD. Optimal ventilatory strategy in preterm infants with RDS may begin in the delivery room with application of sustained inflation to establish functional residual capacity, followed by surfactant therapy and rapid extubation to noninvasive ventilation to decrease the incidence of BPD and improve overall outcome.