***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND There are limited data to inform the choice between early treatment with continuous positive airway pressure ( CPAP ) and early surfactant treatment as the initial support for extremely-low-birth-weight infants . METHODS We performed a r and omized , multicenter trial , with a 2-by-2 factorial design , involving infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation . Infants were r and omly assigned to intubation and surfactant treatment ( within 1 hour after birth ) or to CPAP treatment initiated in the delivery room , with subsequent use of a protocol -driven limited ventilation strategy . Infants were also r and omly assigned to one of two target ranges of oxygen saturation . The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks ( with an attempt at withdrawal of supplemental oxygen in neonates who were receiving less than 30 % oxygen ) . RESULTS A total of 1316 infants were enrolled in the study . The rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group ( 47.8 % and 51.0 % , respectively ; relative risk with CPAP , 0.95 ; 95 % confidence interval [ CI ] , 0.85 to 1.05 ) after adjustment for gestational age , center , and familial clustering . The results were similar when bronchopulmonary dysplasia was defined according to the need for any supplemental oxygen at 36 weeks ( rates of primary outcome , 48.7 % and 54.1 % , respectively ; relative risk with CPAP , 0.91 ; 95 % CI , 0.83 to 1.01 ) . Infants who received CPAP treatment , as compared with infants who received surfactant treatment , less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia ( P<0.001 ) , required fewer days of mechanical ventilation ( P=0.03 ) , and were more likely to be alive and free from the need for mechanical ventilation by day 7 ( P=0.01 ) . The rates of other adverse neonatal outcomes did not differ significantly between the two groups . CONCLUSIONS The results of this study support consideration of CPAP as an alternative to intubation and surfactant in preterm infants . ( Clinical Trials.gov number , NCT00233324 . OBJECTIVE . Our objective was to determine whether continuous positive airway pressure therapy would safely reduce the need for up-transfer of infants with respiratory distress from nontertiary centers . METHODS . We r and omly assigned 300 infants at > 30 weeks of gestation with respiratory distress to receive either Hudson prong bubble continuous positive airway pressure therapy or headbox oxygen treatment ( st and ard care ) . The primary end point was “ up-transfer or treatment failure . ” Secondary end points included death , length of nursery stay , time receiving oxygen therapy , cost of care , and other measures of morbidity . RESULTS . Of 151 infants who received continuous positive airway pressure therapy , 35 either were up-transferred or experienced treatment failure , as did 60 of the 149 infants given headbox oxygen treatment . There was no difference in the length of stay or the duration of oxygen treatment . For every 6 infants treated with continuous positive airway pressure therapy , there was an estimated cost saving of $ 10000 . Pneumothorax was identified for 14 infants in the continuous positive airway pressure group and 5 in the headbox group . There was no difference in any other measure of morbidity or death . CONCLUSIONS . Hudson prong bubble continuous positive airway pressure therapy reduces the need for up-transfer of infants with respiratory distress in nontertiary centers . There is a clinical ly relevant but not statistically significant increase in the risk of pneumothorax . There are significant benefits associated with continuous positive airway pressure use in larger nontertiary centers A sequential controlled trial of continuous negative pressure versus oxygen in treatment of severe respiratory distress syndrome ( Pa O 2 O 2 70 per cent or greater ) was performed . CNP was applied by means of a newly design ed , inexpensive plastic chamber . Twenty-nine infants with RDS who weighed > 1,000 Gm . and who had no congenital malformations were studied ; there were 14 in the oxygen-treated control group and 15 in the CNP-treated group . Following the study , seven additional infants were treated with CNP .  Birth weights , sex , gestational ages , ages , and blood gases at the time of admission to the study were similar . Study failure was defined as a Pa O A controlled trial of elective intervention with continuous inflating pressure ( CIP ) was performed in infants with severe hyaline membrane disease who weighed more than 1000 g at birth . Infants entered the trial if their arterial oxygen tension ( PaO2 ) fell below 60 mmHg while breathing a fractional inspired oxygen concentration ( F1O2 ) greater than 0 - 95 . 11 out of 12 infants in the CIP-treated group and 10 out of 12 in the control group survived . 7 treated and 6 control infants required  mechanical ventilation .  When CIP was started the Pao2 of the treated infants increased , and they breathed high concentrations of oxygen for a significantly shorter period than the control infants . During the 31-month duration of the trial 107 other infants with severe hyaline membrane disease were admitted who did not meet the criteria for entry to the trial . 37 survived after breathing high concentrations of oxygen ( F1O2 greater than 0 - 60 ) spontaneously without any ventilatory assistance , and the remaining 70 infants were already being ventilated on their arrival in the unit , usually because they had required mechanical ventilation during transfer from other hospitals . The neonatal survival rate for those infants born in this hospital during the study period was 88 % ( 50 out of 57 infants ) and for those referred from other hospitals it was 69 % ( 51 out of 74 infants ) . The maximum further increase in overall survival rate that might have been achieved in our population of infants if CIP had been initiated very early in the course of the illness was 5%--i.e . from 77 % ( 101/131 ) to 82 % ( 107/131 ) OBJECTIVE To determine whether very low birth weight infants ( VLBWIs ) , initially supported with continuous positive airway pressure ( CPAP ) and then selectively treated with the INSURE ( intubation , surfactant , and extubation to CPAP ; CPAP/INSURE ) protocol , need less mechanical ventilation than those supported with supplemental oxygen , surfactant , and mechanical ventilation if required ( Oxygen/mechanical ventilation [ MV ] ) . STUDY DESIGN In a multicenter r and omized controlled trial , spontaneously breathing VLBWIs weighing 800 - 1500 g were allocated to receive either therapy . In the CPAP/INSURE group , if respiratory distress syndrome ( RDS ) did not occur , CPAP was discontinued after 3 - 6 hours . If RDS developed and the fraction of inspired oxygen ( FiO(2 ) ) was > 0.35 , the INSURE protocol was indicated . Failure criteria included FiO(2 ) > 0.60 , severe apnea or respiratory acidosis , and receipt of more than 2 doses of surfactant . In the Oxygen/MV group , in the presence of RDS , supplemental oxygen without CPAP was given , and if FiO(2 ) was > 0.35 , surfactant and mechanical ventilation were provided . RESULTS A total of 256 patients were r and omized to either the CPAP/INSURE group ( n = 131 ) or the Oxygen/MV group ( n = 125 ) . The need for mechanical ventilation was lower in the CPAP/INSURE group ( 29.8 % vs 50.4 % ; P = .001 ) , as was the use of surfactant ( 27.5 % vs 46.4 % ; P = .002 ) . There were no differences in death , pneumothorax , bronchopulmonary dysplasia , and other complications of prematurity between the 2 groups . CONCLUSION CPAP and early selective INSURE reduced the need for mechanical ventilation and surfactant in VLBWIs without increasing morbidity and death . These results may be particularly relevant for re source -limited regions OBJECTIVE To determine whether early versus late treatment with porcine surfactant ( Curosurf ) reduces the requirement of mechanical ventilation in very preterm infants primarily supported by nasal continuous positive airway pressure ( nasal CPAP ) . DESIGN Multicenter r and omized , controlled trial . PATIENTS The study population comprised 60 infants < 30 weeks ' gestation with respiratory distress syndrome ( RDS ) who had an arterial to alveolar oxygen tension ratio ( a/APO2 ) of 0.35 to 0.22 . The cohort from which the study population was generated comprised 397 infants . RESULTS The need for mechanical ventilation or death within 7 days of age was reduced from 63 % in the late-treated infants to 21 % in early-treated infants . Increasing numbers of antenatal steroid doses also improved the outcome , especially in the early-treated infants . Six hours after r and omization mean a/APO2 rose to 0.48 in the early-treated infants compared with 0.36 in the late-treated . The need of mechanical ventilation before discharge was reduced from 68 % in the late-treated to 25 % in the early-treated infants . CONCLUSIONS Nasal CPAP in combination with early treatment with Curosurf significantly improves oxygenation and reduces the subsequent need for mechanical ventilation in infants < 30 weeks ' gestational age with RDS OBJECTIVE : Early surfactant followed by extubation to nasal continuous positive airway pressure ( nCPAP ) compared with later surfactant and mechanical ventilation ( MV ) reduce the need for MV , air leaks , and bronchopulmonary dysplasia . This r and omized , controlled trial investigated whether prophylactic surfactant followed by nCPAP compared with early nCPAP application with early selective surfactant would reduce the need for MV in the first 5 days of life . METHODS : A total of 208 inborn infants who were born at 25 to 28 weeks ' gestation and were not intubated at birth were r and omly assigned to prophylactic surfactant or nCPAP within 30 minutes of birth . Outcomes were assessed within the first 5 days of life and until death or discharge of the infants from hospital . RESULTS : Thirty-three ( 31.4 % ) infants in the prophylactic surfactant group needed MV in the first 5 days of life compared with 34 ( 33.0 % ) in the nCPAP group ( risk ratio : 0.95 [ 95 % confidence interval : 0.64–1.41 ] ; P = .80 ) . Death and type of survival at 28 days of life and 36 weeks ' postmenstrual age and incidence of main morbidities of prematurity ( secondary outcomes ) were similar in the 2 groups . A total of 78.1 % of infants in the prophylactic surfactant group and 78.6 % in the nCPAP group survived in room air at 36 weeks ' postmenstrual age . CONCLUSIONS : Prophylactic surfactant was not superior to nCPAP and early selective surfactant in decreasing the need for MV in the first 5 days of life and the incidence of main morbidities of prematurity in spontaneously breathing very preterm infants on nCPAP This prospect i ve study was undertaken to investigate the efficacy of nasal continuous positive airway pressure ( nCPAP ) in a group of extremely small infants denied access to a neonatal intensive care unit ( NICU ) in South Africa . Consecutive infants weighing less than 1200 g and /or of a gestational age below 28 weeks admitted to the neonatal ward with respiratory distress syndrome ( RDS ) , and who were refused admission to the NICU , received either  nCPAP  ( Infant Flow System E.M.E. , UK ) of headbox oxygen . Of 22 infants , 11 infants were included in the treatment group ( nCPAP ) and 10 in the control group . Within the first 24 h , two infants ( 18 per cent ) in the nCPAP group and eight infants ( 80 per cent ) in the control group died ( p = 0.007 ) ( survival OR = 18 ; RR = 4.09 ) . A statistically significant improvement in the arterial-alveolar ( a/A ) oxygen ratio occurred in the nCPAP group between postnatal day 1 and day 3 of life ( 0.17 vs. 0.36 ; p < 0.005 ) . Neonatal complications occurred in six ( 55 per cent ) infants who survived the first 24 h of life . Eighty per cent of the infants with intraventricular haemorrhage ( IVH ) died , as well as all the infants who were born before arrival at the hospital . At the time of discharge from hospital , 45 per cent ( five infants ) in the nCPAP group survived vs. 20 per cent ( two infants ) in the control group . The neurodevelopmental outcome of six of the surviving seven infants were evaluated at 1 year of corrected age . The neurodevelopmental outcome as assessed by the Griffith Score was within normal limits in all infants . One infant has sensorineural deafness and one is deaf and has a possible mild spastic diplegia ( both in the treatment group ) . We conclude that nCPAP significantly improves the short-term survival 
    Output:
    
In preterm infants with respiratory distress , the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax .