Less invasive surfactant administration (LISA) use in preterm infants has been linked to the lowest likelihood of the composite outcome of either death or bronchopulmonary dysplasia (BPD), according to research published in JAMA.

Tetsuya Isayama, MD, MSc, Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Center, Toronto, and colleagues, conducted a randomized clinical trial to compare the efficacy of 7 ventilation strategies among infants younger than 33 weeks gestational age, implemented within 24 hours of birth who had not been intubated.

The researchers compared the outcomes of nasal continuous positive airway pressure (CPAP), intubation and surfactant administration followed by immediate extubation (INSURE), less invasive surfactant administration (LISA), noninvasive intermittent positive pressure ventilation, nebulized surfactant administration, surfactant administration via laryngeal mask airway, and mechanical ventilation.

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Nearly 5600 infants participated across 30 trials. The primary outcome – a composite of death or BPD at 36 weeks postmenstrual age – occurred in 33% of cases (1665 of 4987, including 505 deaths and 1160 cases of BPD). Secondary outcomes – including death, severe intraventricular hemorrhage, and air leak by discharge – occurred in 6% of air leak cases and 26% of BPD cases. LISA had lower odds of the primary outcome, compared to mechanical ventilation.

“Ranking probabilities indicated that LISA was the best strategy with a surface under the cumulative ranking curve of 0.85 to 0.94, but this finding was not robust for death when limited to higher-quality evidence,” concluded Dr Isayama. “These findings were limited by the overall low quality of evidence and lack of robustness in higher-quality trials.”


  1. Isayama T, Iwami H, McDonald S, Beyene J. Association of noninvasive ventilation strategies with mortality and bronchopulmonary dysplasia among preterm infants. A systematic review and meta-analysis. JAMA. 2016;316(6):611-624; doi: 10.1001/jama.2016.10708