Ancillary therapies to enhance success of non-invasive modes of respiratory support - Approaches to delivery room use of surfactant and caffeine?

During recent decades, non-invasive respiratory support has become popular for treating neonates with respiratory failure. Several prospective randomized controlled trials have been performed to compare use of continuous positive airway pressure (CPAP) as primary respiratory support in preterm infants with respiratory distress syndrome (RDS) to endotracheal intubation, mechanical ventilation and surfactant therapy. Systematic reviews of these studies suggest that routine CPAP at delivery is efficacious in decreasing bronchopulmonary dysplasia (BPD), death, or both. This led to the recommendation to consider CPAP to avoid endotracheal intubation. As surfactant therapy is known to reduce BPD and death, several ways to combine CPAP with surfactant have been described. With the increasing use of CPAP immediately after birth, the early use of caffeine to stimulate respiration has become a point of discussion. This review focuses on different modes of surfactant application during CPAP and on the early use of caffeine as ancillary therapies to enhance CPAP success.