The use of nasal CPAP (NCPAP) maintaining FRC and timely surfactant replacement has made a significant difference in Hyaline Membrane Disease management, dramatically reducing mechanical ventilation especially in the greater than 1200 g infants. We describe an innovation to better maintain oxygenation and FRC during surfactant replacement. Once the decision to infuse surfactant is made, the appropriate equipment is prepared and the surfactant is warmed. Ideally the resuscitation bag (RB) has PEEP-maintaining capabilities. In our case we use the Ambu Spur II with an Airlife PEEP valve set at 5 cm water. Alternatively the Neopuff infant resuscitator (Fisher & Paykel) set at a PEEP of 5 cm water and a PIP of 16–20 cm water may be a better option. Once ready, the child is removed from the NCPAP and placed on Nasal Cannula at 2 Liters per minute flow at 100% to provide ancillary oxygen in the oropharynx for the intubation process. The infant is then intubated. The tube placement is confirmed and the RB is removed and the surfactant is instilled. Better, if using the Neopuff, one does not have to detach; the surfactant can be instilled through the T-piece portal, maintaining PEEP throughout the procedure. Recruitment breaths are given. The resuscitator repositions the RB towards the chest to allow for free access of the head for re-attachment of the NCPAP set-up. Once ready, the child can then be extubated with the mouth closed, maintaining PEEP with minimal loss of FRC.
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