LAUSR

Dear Sir, We read with great interest the article “High-Flow Nasal Cannula versus Nasal Continuous Positive Airway Pressure for Primary Respiratory Support in Preterm Infants with Respiratory Distress: A Randomized Controlled Trial” by Murki et al. [1] published in this journal. The study concluded that when comparing high-flow nasal cannula (HFNC) to nasal continuous positive airway pressure (nCPAP) as a primary noninvasive respiratory support in preterm neonates with respiratory distress, HFNC was inferior to nCPAP in preventing the failure of the respiratory support mode within the first 72 h of birth. Having gone through the article, we would like to add the following. Though the proportion of respiratory distress syndrome (RDS) was 45.8 and 56.1% in the HFNC group and nCPAP group, respectively, the rate of intubation was actually higher in the HFNC group. This may be due to causes other than RDS, which needs to be elucidated by the authors. There was also increased surfactant usage in the nCPAP group (though not statistically significant), which might have helped in preventing the failure of the intervention in the nCPAP group. In the study, infants were extubated to the randomized mode as per the study protocol, though InSurE classically means intubation, surfactant administration, and then extubation to nCPAP, and not HFNC. Besides, there have not been many studies on the actual continuous distending pressure produced by HFNC. There is not enough data yet on post-InSurE HFNC and, hence, a subgroup analysis between postsurfactant nCPAP and HFNC (in the neonates assigned to the HFNC group) would be very informative. A Cochrane meta-analysis [2] as well as a recent Korean study [3] found similar rates of efficacy in initial respiratory support for preterm infants with respiratory distress, although they included infants over 30 weeks of gestation or 1,250 g. There is definitely a need for generating more evidence from further studies to define the role of HFNC, particularly in lower gestation infants. Disclosure Statement