Physiological Changes During Intubation-Surfactant-Extubation (InSurE) Procedure in Infants ≥30 Weeks' Gestation: A Retrospective Pilot Study.

Physiological Changes During Intubation-Surfactant-Extubation (InSurE) Procedure in Infants ≥30 Weeks' Gestation: A Retrospective Pilot Study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Physiological Changes During Intubation-Surfactant-Extubation (InSurE) Procedure in Infants ≥30 Weeks' Gestation: A Retrospective Pilot Study. Jorge Lopez Da Re, Julie Pepe, Sofia Lopez Villalba, Marina Kalson, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8960141/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : To describe peri‑procedural physiological changes during the non‑premedicated Intubation–Surfactant–Extubation (InSurE) procedure in infants ≥30 weeks’ gestation with respiratory distress. Study Design : This retrospective pilot study included infants who underwent the InSurE procedure without premedication in AdventHealth Central Florida NICUs. Heart rate, respiratory rate, mean arterial pressure, oxygen saturation, and FiO₂ were recorded 3 hours before intubation, during the procedure, and 3 hours after extubation. Results : Forty‑eight infants met inclusion criteria. Physiological parameters remained stable from baseline to the intra‑procedural period with no significant changes in heart rate, respiratory rate, blood pressure, oxygen saturation, or FiO₂. By 3 hours post‑procedure, oxygen saturation improved, FiO₂ requirements decreased, respiratory rate increased, and heart rate declined slightly. Desaturation events fell from 16.2% intra‑procedure to none post‑procedure. No severe desaturation or tracheal intubation–associated events occurred. Conclusion : The non‑premedicated InSurE procedure was well‑tolerated, with stable physiology and improved oxygenation after surfactant administration. Health sciences/Health care/Paediatrics Health sciences/Medical research Background and Rationale Respiratory distress with respiratory failure is the most common reason for intubation in both preterm and term newborns. In preterm infants, it is the primary cause of morbidity compared with term infants, 1-4 and its incidence increases as gestational age decreases. When non‑invasive respiratory support fails to achieve adequate oxygenation and ventilation in more mature infants (≥30 weeks’ gestation), selective intubation and surfactant therapy with subsequent extubation (InSurE) is often used. The InSurE procedure involves endotracheal intubation, surfactant administration, followed by rapid extubation to non-invasive respiratory support. In addition to the InSurE technique, other, less invasive approaches have been introduced to optimize surfactant delivery. These techniques include surfactant administration through a thin catheter less invasive surfactant administration (LISA), minimally invasive surfactant therapy (MIST), surfactant delivery via a supraglottic airway device (SALSA), and aerosolized or nebulized surfactant. LISA and MIST have been shown to decrease the incidence of bronchopulmonary dysplasia (BPD); however, recent randomized controlled trials indicate that LISA does not provide additional benefit compared with the InSurE procedure. 5-8 Early InSurE has been associated with significant reductions in the need for mechanical ventilation, bronchopulmonary dysplasia, and air‑leak syndromes. Rapid and sustained recovery of spontaneous respiratory drive represents a key clinical outcome of this procedure.¹³ For the purposes of this study, we defined three primary goals of the InSurE procedure: clinical, performance, and procedural. The clinical goal is to improve lung compliance and achieve timely extubation to non‑invasive ventilation following surfactant administration. The performance goal is to achieve successful endotracheal intubation on the first attempt—ideally within 30 seconds—without complications.¹⁴ The procedural goal is to complete the entire sequence of intubation, surfactant administration, and extubation efficiently and safely, while minimizing airway manipulation, limiting the duration of laryngoscopy, and ensuring rapid transition to non‑invasive respiratory support. Neonatal endotracheal intubation is high risk; the immediate aim is to limit physiological instability and prevent tracheal intubation–associated events (TIAEs). First‑attempt success within ~30 seconds is associated with fewer disturbances and lower rates of severe TIAEs compared with multiple or prolonged attempts.¹⁵ - ²¹ TIAEs are reported as non-severe (e.g., esophageal intubation with immediate recognition, transient bradycardia, main‑stem intubation, non‑aspirated emesis, epistaxis, lip trauma, medication error, hypertension) and severe (e.g., cardiac arrest requiring compressions, delayed‑recognition esophageal intubation, emesis with aspiration, hypotension requiring therapy, laryngospasm, pneumothorax/pneumomediastinum, direct airway injury).¹⁸ Intubation without premedication is generally reserved for resuscitation, acute deterioration, or upper‑airway anomalies when maintaining spontaneous respiratory drive is essential. When used, premedication can improve success and reduce airway injury; typical regimens include preoxygenation, analgesic/hypnotic agents, atropine (vagolytic), and a muscle relaxant to optimize conditions.²² – ³¹ Nonpharmacologic measures (e.g., swaddling, positioning) can further enhance comfort.³³ – ³⁵ Nonetheless, clinicians report concerns—airway loss in an apneic infant, hemodynamic instability, apnea, bradycardia, desaturation, hypotension, difficult or prolonged intubation, added preparation time, and chest rigidity—and uncertainties about optimal drug choices and long‑term effects. A recent Cochrane review of midazolam concluded that evidence is insufficient to support routine neonatal use; across six trials in extremely preterm, ventilated infants, effects on key outcomes remain uncertain and overall certainty is very low.³² Despite the increasing use of less invasive surfactant delivery techniques, including LISA and MIST, the InSurE procedure remains widely performed in many neonatal intensive care units. However, contemporary data describing documented physiological responses during the InSurE procedureare limited. Establishing baseline peri-procedural physiological patterns may help future comparisons with alternative surfactant delivery strategies and guide procedural monitoring in current clinical practice. To our knowledge, documentation of physiological events during InSurE has not been systematically reported; this gap forms the basis of our primary objective. Our secondary objective was to compare physiological responses between newborns who received premedication before intubation and those who did not. Materials and Methods Study design: This is a retrospective, observational study to evaluate peri‑procedural physiological changes in newborns with respiratory distress who required endotracheal intubation and surfactant administration using the Intubation–Surfactant–Extubation (InSurE) procedure. The study was reported following STROBE guidelines for cohort studies. Study Population Electronic medical records from AdventHealth Central Florida NICUs (level II–IV) were reviewed to identify infants ≥30 weeks’ gestation who were treated with surfactant via InSurE. Infants were categorized as: Premedicated: received sedative, analgesic, or vagolytic agents prior to intubation. Non‑premedicated: underwent InSurE without premedication. Exclusion criteria: major congenital heart disease, lung malformations, surfactant protein deficiency, air‑leak syndromes, brain malformations, genetic syndromes, multiorgan failure, seizures, neonatal death, or need for continued invasive ventilation or re‑intubation within 3 hours post‑procedure. Data Sources and Procedural Epochs Physiological data were abstracted from the electronic medical record (EMR) at three predefined retrospective epochs: Pre‑procedural (baseline) values were defined as the clinically documented average of physiological parameters recorded during the 3‑hour period preceding endotracheal intubation. Intra‑procedural values corresponded to the single physiological measurement documented contemporaneously with endotracheal intubation and surfactant administration, as recorded by respiratory therapy and nursing staff. Post‑procedural values were defined as the clinically documented average over the 3‑hour period following extubation, using the value closest to the 3‑hour target time point. Continuous waveform data were unavailable; therefore, true nadirs/peaks were not captured. Cohort‑level minimum/maximum values were tabulated for descriptive context. Validated neonatal pain/stress scores (e.g., NIPS, PIPP‑R, COMFORT‑Neo) were not obtained for this study. Variables and Operational Definitions Recorded variables included heart rate (HR, beats/min), respiratory rate (RR, breaths/min), mean arterial pressure (MAP, mmHg), oxygen saturation (SpO₂, %), and fraction of inspired oxygen (FiO₂, %). Adverse events were defined a priori: bradycardia HR 160 beats/min or ≥20% above baseline. When multiple intra‑procedural events occurred, the earliest onset time was used as the primary event; hypotension was defined as MAP < gestational age (weeks) or <30 mmHg for infants ≥30 weeks; desaturation SpO₂ <90%; severe desaturation SpO₂ ≤80%; apnea was defined cessation of breathing ≥20 seconds requiring intervention. Clinically significant hypotension was defined as MAP < gestational age requiring intervention (e.g., fluid bolus or vasopressor). The absence of documented treatment in the EMR was considered a proxy for no clinically significant hypotension. Data Processing and Quality Control All physiological values were reviewed for internal consistency. FiO₂ values recorded as fractions (≤1.0) were multiplied by 100 and reported as percentages for consistency across epochs. No outlier removal was applied; cohort‑level minima and maxima reflect the EMR values as recorded. Missing Data Handling Analyses used available‑case (pairwise) methods at each epoch. If an infant did not have a documented value for a given variable and epoch, the infant was excluded from that specific comparison; Sample size therefore varied accordingly and were reported in tables/footnotes. No imputation was performed. Statistical Analysis Continuous variables were summarized as mean ± SD (95% CI) and compared across epochs using paired t‑tests or Wilcoxon signed‑rank tests as appropriate. Categorical paired outcomes were assessed using McNemar’s or exact McNemar tests when cell counts were small. Exploratory comparisons between premedicated and non‑premedicated cohorts used Welch’s t‑test and Fisher’s exact test. Statistical significance was defined as α=0.05. All analyses were performed using IBM SPSS Statistics, version 29 (IBM Corp., Armonk, NY) and Microsoft Excel for Microsoft 365 (Microsoft Corp., Redmond, WA). Results A total of 58,311 newborns at ≥30 weeks’ gestation were delivered at AdventHealth Central Florida Neonatology Group between January 1, 2022, and October 31, 2025; 260 presented with respiratory distress. For the primary objective, 48 infants met the inclusion criteria. Of 24 infants who received premedication during the study period, 12 underwent InSurE and formed the exploratory premedicated subgroup. However, because of the small sample size, there was a very high probability of alpha and beta errors, therefore, we decided to abandon our attempt to address the secondary objective. The readers are welcome to seek the data from our lead corresponding author. Table 1 summarizes the physiological parameters during the pre‑procedure, intra‑procedure, and post‑procedure epochs for infants included in the primary analysis (n = 48). No significant changes in cardiovascular and respiratory parameters, as well as adverse events were observed during the intra-procedural period as compared to the pre-procedure. However, several statistically significant differences were identified during the post procedure epoch . Heart rate decreased significantly from the intra‑procedural to the post‑procedural period (mean ± SD 145.7 ± 14.3 bpm vs 141.7 ± 11.8 bpm; p = 0.031). Respiratory rate increased significantly from pre‑ to post‑procedure (55.45 ± 14.26 vs 63.46 ± 17.25 breaths/min; p = 0.011). Oxygen saturation improved significantly from baseline to 3 h post‑extubation (93.72 ± 3.47% to 95.74 ± 2.76%; p = 0.001). FiO₂ requirements decreased significantly from pre‑ to post‑procedure (37.98 ± 16.74% to 30.20 ± 15.54%; p = 0.003) and also decreased significantly from intra‑ to post‑procedure (p < 0.001). In addition, the proportion of infants with any desaturation (SpO₂ < 90%) decreased significantly from intra‑procedure to post‑procedure (7/43 [16.2%] vs 0/48 [0%]; p = 0.016). Table 2 provides maternal and newborn demographic and clinical characteristics for the study. Maternal age was 30.8 (5.9) years; 25/46 (54.3%) mothers with race recorded were White. Hypertensive disorders and diabetes occurred in 15/48 (31.2%) and 7/48 (14.6%) pregnancies, respectively, with 3/48 (6.2%) having both. Infants had a gestational age of 35.5 (2.9) weeks and a birth weight of 2,797 (853) g. Cesarean delivery occurred in 38/48 (79.2%) births. Infants required 6.2 (5.9) days of respiratory support and had a hospital stay of 13.7 (8.9) days. Table 3 presents procedural performance, physiological responses, and adverse events during endotracheal intubation in the InSurE procedure among non‑premedicated infants ≥30 weeks’ gestation with reference to the number of attempts to intubate. First‑attempt intubation was successful in 33/48 (68.8%) infants, and 46/48 (95.8%) were successfully intubated within ≤2 attempts among those with documented attempt counts. During the intra‑procedural epoch, tachycardia (>160 bpm) occurred in 4/25 (16.0%) first‑attempt intubations and in 0/10 (0.0%) infants requiring multiple attempts (p=0.303). Any desaturation (SpO₂ <90%) occurred in 5/30 (16.7%) first‑attempt intubations versus 1/17 (5.9%) among infants with ≥2 attempts (p=0.650). No severe desaturation events (SpO₂ ≤80%) or severe TIAEs were recorded. Discussion This study demonstrates that the non‑premedicated InSurE procedure was associated with no documented severe physiological instability in infants ≥30 weeks’ gestation with respiratory distress, with preserved cardiovascular parameters across predefined peri‑procedural epochs and short‑term respiratory improvement with higher SpO₂ and lower FiO₂ within 3 hours after the procedure, while respiratory rate increased modestly. To our knowledge, this study provides the first systematic description of peri‑procedural physiological patterns during InSurE using EMR‑based data, supporting the feasibility and short‑term safety of performing InSurE without routine premedication in appropriately selected late‑preterm and term infants. 36–39 During intubation (intra‑procedural), none of the prespecified physiological variables differed significantly from baseline. The proportion of infants with any desaturation was higher intra‑procedurally than at baseline, but this increase was not statistically significant; severe desaturation (≤80%) and apnea were not observed. These findings indicate that intra‑procedural physiology was not significantly perturbed relative to baseline in this cohort. During the post‑procedure, oxygenation improved with lower FiO₂ requirements and a modest increase in RR, while cardiovascular parameters remained overall stable compared with baseline; HR also showed a small but statistically significant decrease from the intra‑procedural to the post‑procedural epoch (p = 0.031), a difference of uncertain clinical importance. These findings are consistent with previous reports demonstrating the efficacy of InSurE in reducing the need for mechanical ventilation and minimizing lung injury. All infants undergoing InSurE were extubated to non-invasive ventilation (e.g., NIPPV or nCPAP), in accordance with the procedure’s goal of minimizing alveolar damage. 40-48 The cohort reflects a population at moderate to high risk for neonatal respiratory distress, based on maternal and newborn characteristics, including a high prevalence of cesarean delivery (~80%), male sex, late‑preterm birth (with an incidence two to three times higher than in term infants), and maternal complications such as hypertensive disorders (31%) and diabetes (15%). 1–3 Adverse physiological events during endotracheal intubation were uncommon. Mild tachycardia and desaturation occurred in a minority of infants, and no severe tracheal intubation–associated events were identified. In our cohort, the first‑attempt intubation success rate was 68.8%, compared with 49% reported in multicenter registries such as the NEAR4NEOS network, recognizing that NEAR4NEOS includes a broader, higher‑acuity neonatal population. Notably, the number of intubation attempts, including first versus multiple attempts, did not significantly influence the frequency of physiological instability. This finding supports the procedural safety of InSurE when performed by trained providers and aligns with national NEAR4NEOS definitions of tracheal intubation–associated events. 18 Because the premedicated subgroup was too small to support meaningful comparison, no inferences regarding physiological differences were drawn; however, prior studies provide relevant context on physiological responses and adverse events during neonatal intubation. 49–53 Strengths of the study include prespecified peri‑procedural epochs, structured extraction of hemodynamic and respiratory variables, and detailed reporting of intubation procedure. . imitations include the retrospective single‑ center design, modest sample size, incomplete intra‑procedural documentation, center‑specific practices, and the absence of validated neonatal pain or distress scales. In this study, all three predefined goals of the InSurE procedure—clinical, performance, and procedural—were achieved, with preserved hemodynamic stability, improved respiratory parameters, high intubation success rates, and no documented severe tracheal intubation–associated events. Overall, these findings support the feasibility of performing the InSurE procedure without routine premedication in this population of infants, in settings with experienced airway providers and continuous monitoring. Prospective comparative studies are needed to evaluate non‑premedicated versus premedicated InSurE or LISA/MIST, using clinically meaningful outcomes and standardized procedural monitoring. Conclusion No physiological instability or tracheal intubation–associated adverse events were documented, during intubation, and beneficial effects of surfactant were observed following the InSurE procedure in infants ≥ 30 weeks’ gestation without premeditation. Abbreviations AH: AdventHealth BPD: Bronchopulmonary dysplasia BPM: beats per minute. CI: Confidence interval EMR: Electronic medical record FiO2: Fraction of inspired oxygen GA: Gestational age HR: Heart rate INSURE: Intubation, surfactant administration, and extubation LISA: Less invasive surfactant administration MAP: Mean arterial pressure MIST: Minimally invasive surfactant therapy RR: Respiratory rate SD: Standard deviation STROBE: Strengthening the Reporting of Observational Studies in Epidemiology. SpO2: Oxygen saturation by pulse oximetry TIAE: Tracheal intubation-associated event Declarations Conflict of Interest Disclosures: The authors have no conflicts of interest. Funding/Support: No external funding was received. Ethics Approval and Consent to Participate: The AdventHealth Institutional Review Board approved this study. A waiver of parental consent was granted due to the retrospective nature of the research and the absence of direct interventions. The study was conducted in accordance with the Declaration of Helsinki. Consent for Publication: Not applicable. Availability of Data and Materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Author Contributions: JMLDR conceptualized the study, collected data, and drafted the initial manuscript; SL and MK collected the data, and JP assisted in statistical analysis; WO supervised the study, interpreted the data, and critically revised the manuscript. All authors approved the final manuscript as submitted. References Anadkat JS, Kuzniewicz MW, Chaudhari BP, Cole FS, Hamvas A. Increased risk for respiratory distress among white, male, late preterm and term infants. J Perinatol. 2012 Oct;32(10):780-5. doi: 10.1038/jp.2011.191. Epub 2012 Jan 5. PMID: 22222548; PMCID: PMC3461404. Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et . 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BMC Pulm Med 22, 421 (2022). https://doi.org/10.1186/s12890-022-02223-4 (This 2022 review highlights the importance of early extubation to NIV (e.g., CPAP or NIPPV) to reduce lung injury in preterm infant Chen IL, Chen HL. New developments in neonatal respiratory management. Pediatr Neonatol. 2022 Jul;63(4):341-347. doi: 10.1016/j.pedneo.2022.02.002. Epub 2022 Mar 16. PMID: 35382987. Vento G, et al. Efficacy of a new technique - INtubate-RECruit-SURfactant-Extubate - "IN-REC-SUR-E" - in preterm neonates with respiratory distress syndrome: study protocol for a randomized controlled trial. Trials. 2016 Aug 18;17:414. doi: 10.1186/s13063-016-1498-7. PMID: 27538798; PMCID: PMC4991115. Mazmanyan P, Mellor K, Doré CJ, Modi N. A randomized controlled trial of flow driver and bubble continuous positive airway pressure in preterm infants in a resource-limited setting. Arch Dis Child Fetal Neonatal Ed. 2016 Jan;101(1):F16-20. doi: 10.1136/archdischild-2015-308464. Epub 2015 Aug 13. PMID: 26271753. Dargaville PA, Aiyappan A, De Paoli AG, Dalton RG, Kuschel CA, Kamlin CO, et al. Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences. Neonatology. 2013;104(1):8-14. doi: 10.1159/000346460. Epub 2013 Apr 4. PMID: 23595061. Reiterer F, Schwaberger B, Freidl T, Schmölzer G, Pichler G, et al; Lung-protective ventilatory strategies in intubated preterm neonates with RDS. Paediatr Respir Rev. 2017 Jun;23:89-96. doi: 10.1016/j.prrv.2016.10.007. Epub 2016 Oct 26. PMID: 27876355. Ajanwaenyi J, Bamidele O, Osim C, Salami O, Umukoro C, et al ; The minimal invasive surfactant therapy: experience from a low resource setting. J Matern Fetal Neonatal Med. 2022 Dec;35(25):5177-5183. doi: 10.1080/14767058.2021.1875438. Epub 2021 Jan 24. PMID: 33491516. Stevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev. 2007 Oct 17;2007(4):CD003063. doi: 10.1002/14651858.CD003063.pub3. PMID: 17943779; PMCID: PMC8554819. Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2012 Mar 14;2012(3):CD000510. doi: 10.1002/14651858.CD000510.pub2. PMID: 22419276; PMCID: PMC12034442. Kribs A, Roll C, Göpel W, et al. Nonintubated surfactant application vs conventional therapy in extremely preterm infants: a randomized clinical trial. JAMA Pediatr. 2015;169(8):731–739. doi:10.1001/jamapediatrics.2015.1082 Göpel W, Kribs A, Ziegler A, et al. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomized, controlled trial. Lancet. 2011;378(9803):1627–1634. doi:10.1016/S0140-6736(11)60986-0 Roberts KD, Leone TA, Edwards WH, Rich WD, Finer NN. Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. Pediatrics. 2006 Oct;118(4):1583-91. doi: 10.1542/peds.2006-0590. PMID: 17015550. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317(21):1321-9. doi: 10.1056/NEJM198711193172105. Quinn MW, et al. Randomised double-blind controlled trial of effect of morphine on catecholamine concentrations in ventilated pre-term babies. Lancet. 1993;342(8867):324-7. doi: 10.1016/0140-6736(93)91472-x. Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr. 2005;146(5):638–641. Tarawneh A, Kaczmarek J, Bottino MN, Sant'anna GM. Severe airway obstruction during surfactant administration using a standardized protocol: a prospective, observational study. J Perinatol. 2012 Apr;32(4):270-5. doi: 10.1038/jp.2011.89. Epub 2011 Jul 7. PMID: 21738121. Katheria AC, Leone TA. Changes in hemodynamics after rescue surfactant administration. J Perinatol. 2013 Jul;33(7):525-8. doi: 10.1038/jp.. 2012.166. Epub 2013 Jan 17. PMID: 23328925. Tables Table 1. Physiological Variables Pre-procedure, During, and Post-procedure in Infants ≥30 Weeks’ Gestation with Respiratory Distress undergoing InSurE procedure (N=48) Variable Pre-procedure (3 h before) Intra-procedure (During intubation) Post-procedure (3 h after) P (Pre vs Intra) P (Pre vs Post) P (Intra vs Post) Cardiovascular Heart rate, mean ± SD [95% CI], bpm 144.36 ± 14.7 [140.09–148.63] 145.71 ± 14.3 [140.80–150.63] 141.71 ± 11.78 [138.28–145.13] 0.378 0.170 *0.031 Bradycardia (160 bpm), n/N (%) 7/48 (14.6%) 6/35 (17.1%) 4/48 (8.3%) 0.630 0.125 0.125 Mean arterial pressure (MAP), mean ± SD [95% CI], mmHg 41.9 ± 6.67 [39.64–44.16] 42.67 ± 11.31 [35.48–49.85] 42.74 ± 6.52 [40.39–45.09] 0.374 0.494 0.259 Hypotension (MAP < GA), n/N (%) 4/36 (11.1%) 0/11 (0%) 4/32 (12.5%) 0.250 0.690 0.250 Respiratory Respiratory rate, mean ± SD [95% CI], breaths/min 55.45 ± 14.26 [51.31–59.60] 57.65 ± 17.02 [51.71–63.59] 63.46 ± 17.25 [58.45–68.46] 0.213 *0.011 0.088 SpO₂, mean ± SD [95% CI], % 93.72 ± 3.47 [92.71–94.73] 94.48 ± 4.18 [93.21–95.75] 95.74 ± 2.76 [94.94–96.54] 0.210 **0.001 0.113 Any desaturation (SpO₂ <90%), n/N (%) 4/48 (8.3%) 7/43 (16.2%) 0/48 (0%) 0.688 0.125 * 0.016 Severe desaturation (SpO₂ ≤80%), n/N (%) 0/48 (0%) 0/43 (0%) 0/48 (0%) — — — FiO₂, mean ± SD [95% CI], % 37.98 ± 16.74 [33.12–42.84] 40.42 ± 19.36 [34.46–46.38] 30.20 ± 15.54 [25.53–34.87] 0.487 **0.003 **<0.001 Apnea recorded, n/N (%) 0/48 (0%) 0/48 (0%) 0/48 (0%) — — — Footnote: Values are Mean ± SD [95% CI] or n/N (%). P-values from paired t tests (HR, RR, SpO₂, FiO₂), Wilcoxon signed-rank test (MAP), or McNemar’s test (dichotomous). *p < 0.05, **p < 0.01. Hypotension is defined as MAP (mmHg) < gestational age in completed weeks. Ns vary due to missing intra-procedure recordings. Table 2. Maternal and Newborn Demographic and Clinical Characteristics of Infants ≥30 Weeks’ Gestation Treated With InSurE in the Non-premedicated cohort (N = 48). Variable Value Maternal Demographics Maternal age, mean ± SD (years) 30.83 ± 5.9 Race, n (%) White 25/46 (54.3%); Non-White 21/46 (45.7%) Pregnancy Data Maternal hypertension, n (%) 15/48 (31.2%) Maternal diabetes mellitus, n (%) 7/48 (14.6%) Both hypertension and diabetes, n (%) 3/48 (6.2%) Maternal steroids (<35 weeks GA), n (%) 16/20 (80%) Newborn Characteristics Sex, n (%) – Female / Male 13/48 (27.1%) / 35/48 (72.9%) Gestational age, mean ± SD (weeks) 35.5 ± 2.94 Birth weight, mean ± SD (g) 2797 ± 853 Delivery mode, n (%) – NSVD / C-section 10/48 (20.8%) / 38/48 (79.2%) Days on respiratory support, mean ± SD 6.21 ± 5.94 Length of stay, mean ± SD (days) 13.69 ± 8.9 Footnote: Values are mean ± standard deviation (SD) for continuous variables and n (%) for categorical variables. Maternal steroid exposure was calculated only for infants born at <35 weeks’ gestation. Race category “Unknown” was included in descriptive counts but excluded from statistical testing (n=2). Table 3. Procedural Performance, Physiological Responses, and Adverse Events During Endotracheal Intubation in the InSurE Procedure in Non‑Premedicated Infants ≥30 Weeks’ Gestation (N = 48) with reference to number of attempts to intubate. Procedural Performance Outcome n/N (%) Successful intubation on first attempt 33/48 (68.8%) Successful intubation within ≤2 attempts 46/48 (95.8%) Overall intubation success 48/48 (100%) Physiological Responses intra-procedure, Stratified by Number of Attempts. Outcome First Attempt (n/N, %) Multiple Attempts (≥2 or NA) (n/N, %) Total (n/N, %) Fisher’s exact p (two-sided) Odds Ratio (95% CI) Non-severe tracheal intubation-associated event — — — — — Tachycardia (>160 bpm) 4/25 (16.0%) 0/10 (0.0%) 4/35 (11.4%) 0.303 4.40 (0.22, 89.49) Any desaturation (SpO₂ <90%) 5/30 (16.7%) 2/13 (15.4%) 7/43 (16.3%) 1.000 1.10 (0.18, 6.57) Severe desaturation (SpO₂ ≤80%) 0/30 (0.0%) 0/13 (0.0%) 0/43 (0.0%) 1.000 — Footnote: Values are n/N (%). First attempt = one documented intubation attempt; multiple attempts = ≥2 attempts. Records with undocumented attempt number were excluded from attempt‑stratified analyses. Success rates are descriptive and were not subjected to inferential testing. Odds ratios and 95% confidence intervals were calculated using exact methods; when zero cells occurred, odds ratios were not estimable and exact p‑values are reported. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8960141","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":600906420,"identity":"d7a3e0d5-2380-4cdb-ae63-2c6eadc332cb","order_by":0,"name":"Jorge Lopez Da Re","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYLCCBAYLIJl8gIGxgTgNjA0JDBJAOi2BBC0MYC05BsRp0W0/+/zBwx0ScubsOd8kfu6wkWNgP3x0Az4tZmfSDRsSz0gYW/a83SbZeybNmIEnLe0GXi0H0hgbEtskEjfcyN0mwdt2OLFBgscMv5bzz2Bacp5J/iVKyw24LTls0sTZcuMZ4wygFqBfnhlby7alGbMR9Mv5NIaPP9tsgCGW/PDmWyCDn/3wMbxa4MCAgYEFFDsMbEQph2ph/kC06lEwCkbBKBhRAADYnU1oppIRsgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-9196-7318","institution":"AdventHealth","correspondingAuthor":true,"prefix":"","firstName":"Jorge","middleName":"Lopez Da","lastName":"Re","suffix":""},{"id":600906421,"identity":"a3072c9a-a5fd-4e52-96ee-ddd084083504","order_by":1,"name":"Julie Pepe","email":"","orcid":"","institution":"Advent Health","correspondingAuthor":false,"prefix":"","firstName":"Julie","middleName":"","lastName":"Pepe","suffix":""},{"id":600906422,"identity":"d4ccdcf7-02ba-4963-ac35-2de743e77c9e","order_by":2,"name":"Sofia Lopez Villalba","email":"","orcid":"","institution":"AdventHealth Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Sofia","middleName":"Lopez","lastName":"Villalba","suffix":""},{"id":600906423,"identity":"dc851a07-55ae-4a8a-ad39-dc824e9691c3","order_by":3,"name":"Marina Kalson","email":"","orcid":"","institution":"AdventHealth Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Marina","middleName":"","lastName":"Kalson","suffix":""},{"id":600906424,"identity":"b5960d72-a937-4b97-a495-73e92a69c966","order_by":4,"name":"William Oh","email":"","orcid":"","institution":"Advent Health","correspondingAuthor":false,"prefix":"","firstName":"William","middleName":"","lastName":"Oh","suffix":""}],"badges":[],"createdAt":"2026-02-24 18:00:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8960141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8960141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106725923,"identity":"63ad8ddf-598c-4992-9d81-f662f74fdeee","added_by":"auto","created_at":"2026-04-12 18:34:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1037630,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8960141/v1/c4d2cfd3-8c3f-4557-b875-bcd87e079ad3.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Physiological Changes During Intubation-Surfactant-Extubation (InSurE) Procedure in Infants ≥30 Weeks' Gestation: A Retrospective Pilot Study.","fulltext":[{"header":"Background and Rationale","content":"\u003cp\u003eRespiratory distress with respiratory failure is the most common reason for intubation in both preterm and term newborns. In preterm infants, it is the primary cause of morbidity compared with term infants,\u003csup\u003e1-4\u003c/sup\u003e and its incidence increases as gestational age decreases. When non‑invasive respiratory support fails to achieve adequate oxygenation and ventilation in more mature infants (\u0026ge;30 weeks\u0026rsquo; gestation), selective intubation and surfactant therapy with subsequent extubation (InSurE) is often used.\u003c/p\u003e\n\u003cp\u003eThe InSurE procedure involves endotracheal intubation, surfactant administration, followed by rapid extubation to non-invasive respiratory support. In addition to the InSurE technique, other, less invasive approaches have been introduced to optimize surfactant delivery. These techniques include surfactant administration through a thin catheter less invasive surfactant administration (LISA), minimally invasive surfactant therapy (MIST), surfactant delivery via a supraglottic airway device (SALSA), and aerosolized or nebulized surfactant. LISA and MIST have been shown to decrease the incidence of bronchopulmonary dysplasia (BPD); however, recent randomized controlled trials indicate that LISA does not provide additional benefit compared with the InSurE procedure. \u003csup\u003e5-8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eEarly InSurE has been associated with significant reductions in the need for mechanical ventilation, bronchopulmonary dysplasia, and air‑leak syndromes. Rapid and sustained recovery of spontaneous respiratory drive represents a key clinical outcome of this procedure.\u0026sup1;\u0026sup3;\u003c/p\u003e\n\u003cp\u003eFor the purposes of this study, we defined three primary goals of the InSurE procedure: clinical, performance, and procedural. The clinical goal is to improve lung compliance and achieve timely extubation to non‑invasive ventilation following surfactant administration. The performance goal is to achieve successful endotracheal intubation on the first attempt\u0026mdash;ideally within 30 seconds\u0026mdash;without complications.\u0026sup1;⁴ The procedural goal is to complete the entire sequence of intubation, surfactant administration, and extubation efficiently and safely, while minimizing airway manipulation, limiting the duration of laryngoscopy, and ensuring rapid transition to non‑invasive respiratory support.\u003c/p\u003e\n\u003cp\u003eNeonatal endotracheal intubation is high risk; the immediate aim is to limit physiological instability and prevent tracheal intubation\u0026ndash;associated events (TIAEs). First‑attempt success within ~30 seconds is associated with fewer disturbances and lower rates of severe TIAEs compared with multiple or prolonged attempts.\u0026sup1;⁵\u003csup\u003e-\u003c/sup\u003e\u0026sup2;\u0026sup1;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTIAEs are reported as non-severe (e.g., esophageal intubation with immediate recognition, transient bradycardia, main‑stem intubation, non‑aspirated emesis, epistaxis, lip trauma, medication error, hypertension) and severe (e.g., cardiac arrest requiring compressions, delayed‑recognition esophageal intubation, emesis with aspiration, hypotension requiring therapy, laryngospasm, pneumothorax/pneumomediastinum, direct airway injury).\u0026sup1;⁸\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntubation without premedication is generally reserved for resuscitation, acute deterioration, or upper‑airway anomalies when maintaining spontaneous respiratory drive is essential.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen used, premedication can improve success and reduce airway injury; typical regimens include preoxygenation, analgesic/hypnotic agents, atropine (vagolytic), and a muscle relaxant to optimize conditions.\u0026sup2;\u0026sup2;\u003csup\u003e\u0026ndash;\u003c/sup\u003e\u0026sup3;\u0026sup1; Nonpharmacologic measures (e.g., swaddling, positioning) can further enhance comfort.\u0026sup3;\u0026sup3;\u003csup\u003e\u0026ndash;\u003c/sup\u003e\u0026sup3;⁵ Nonetheless, clinicians report concerns\u0026mdash;airway loss in an apneic infant, hemodynamic instability, apnea, bradycardia, desaturation, hypotension, difficult or prolonged intubation, added preparation time, and chest rigidity\u0026mdash;and uncertainties about optimal drug choices and long‑term effects. \u0026nbsp;A recent Cochrane review of midazolam concluded that evidence is insufficient to support routine neonatal use; across six trials in extremely preterm, ventilated infants, effects on key outcomes remain uncertain and overall certainty is very low.\u0026sup3;\u0026sup2;\u003c/p\u003e\n\u003cp\u003eDespite the increasing use of less invasive surfactant delivery techniques, including LISA and MIST, the InSurE procedure remains widely performed in many neonatal intensive care units. However, contemporary data describing documented physiological \u0026nbsp;responses during the InSurE procedureare limited. Establishing baseline peri-procedural physiological patterns may help future comparisons with alternative surfactant delivery strategies and guide procedural monitoring in current clinical practice. To our knowledge, documentation of physiological events during InSurE has not been systematically reported; this gap forms the basis of our primary objective. \u0026nbsp;Our secondary objective was \u0026nbsp;to compare physiological responses between newborns who received premedication before intubation and those who did not.\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy design:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis is a retrospective, \u0026nbsp;observational \u0026nbsp; study to evaluate peri‑procedural physiological changes in newborns with respiratory distress who required endotracheal intubation and surfactant administration using the Intubation–Surfactant–Extubation (InSurE) procedure. \u0026nbsp;The study was reported following STROBE guidelines for cohort studies.\u003c/p\u003e\n\u003cp\u003eStudy Population\u003c/p\u003e\n\u003cp\u003eElectronic medical records from AdventHealth Central Florida NICUs (level II–IV) were reviewed to identify infants ≥30 weeks’ gestation who were treated with surfactant via InSurE. Infants were categorized as:\u003c/p\u003e\n\u003cp\u003ePremedicated: received sedative, analgesic, or vagolytic agents prior to intubation.\u003c/p\u003e\n\u003cp\u003eNon‑premedicated: underwent InSurE without premedication.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: major congenital heart disease, lung malformations, surfactant protein deficiency, air‑leak syndromes, brain malformations, genetic syndromes, multiorgan failure, seizures, neonatal death, or need for continued invasive ventilation or re‑intubation within 3 hours post‑procedure.\u003c/p\u003e\n\u003cp\u003eData Sources and Procedural Epochs\u003c/p\u003e\n\u003cp\u003ePhysiological data were abstracted from the electronic medical record (EMR) at three predefined retrospective epochs:\u003c/p\u003e\n\u003cp\u003ePre‑procedural (baseline) values were defined as the clinically documented average of physiological parameters recorded during the 3‑hour period preceding endotracheal intubation.\u003c/p\u003e\n\u003cp\u003eIntra‑procedural values corresponded to the single physiological \u0026nbsp;measurement documented contemporaneously with endotracheal intubation and surfactant administration, as recorded by respiratory therapy and nursing staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePost‑procedural values were defined as the clinically documented average over the 3‑hour period following extubation, using the value closest to the 3‑hour target time point.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eContinuous waveform data were unavailable; therefore, true nadirs/peaks were not captured. Cohort‑level minimum/maximum values were tabulated for descriptive context. Validated neonatal pain/stress scores (e.g., NIPS, PIPP‑R, COMFORT‑Neo) were not obtained for this study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVariables and Operational Definitions\u003c/p\u003e\n\u003cp\u003eRecorded variables included heart rate (HR, beats/min), respiratory rate (RR, breaths/min), mean arterial pressure (MAP, mmHg), oxygen saturation (SpO₂, %), and fraction of inspired oxygen (FiO₂, %). Adverse events were defined a priori: bradycardia HR \u0026lt;100 beats/min; tachycardia HR \u0026gt;160 beats/min or ≥20% above baseline. When multiple intra‑procedural events occurred, the earliest onset time was used as the primary event; hypotension was defined as MAP \u0026lt; gestational age (weeks) or \u0026lt;30 mmHg for infants ≥30 weeks; desaturation SpO₂ \u0026lt;90%; severe desaturation SpO₂ ≤80%; apnea was defined \u0026nbsp;cessation of breathing ≥20 seconds requiring intervention. Clinically significant hypotension was defined as MAP \u0026lt; gestational age requiring intervention (e.g., fluid bolus or vasopressor). The absence of documented treatment in the EMR was considered a proxy for no clinically significant hypotension.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Processing and Quality Control\u003c/p\u003e\n\u003cp\u003eAll physiological values were reviewed for internal consistency. FiO₂ values recorded as fractions (≤1.0) were multiplied by 100 and reported as percentages for consistency across epochs. No outlier removal was applied; cohort‑level minima and maxima reflect the EMR values as recorded.\u003c/p\u003e\n\u003cp\u003eMissing Data Handling\u003c/p\u003e\n\u003cp\u003eAnalyses used available‑case (pairwise) methods at each epoch. If an infant did not have a documented value for a given variable and epoch, the infant was excluded from that specific comparison; Sample size therefore varied accordingly and were reported in tables/footnotes. No imputation was performed.\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eContinuous variables were summarized as mean ± SD (95% CI) and compared across epochs using paired t‑tests or Wilcoxon signed‑rank tests as appropriate. Categorical paired outcomes were assessed using McNemar’s or exact McNemar tests when cell counts were small. Exploratory comparisons between premedicated and non‑premedicated cohorts used Welch’s t‑test and Fisher’s exact test. Statistical significance was defined as α=0.05. All analyses were performed using IBM SPSS Statistics, version 29 (IBM Corp., Armonk, NY) and Microsoft Excel for Microsoft 365 (Microsoft Corp., Redmond, WA). \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 58,311 newborns at \u0026ge;30 weeks\u0026rsquo; gestation were delivered at AdventHealth Central Florida Neonatology Group between January 1, 2022, and October 31, 2025; 260 presented with respiratory distress. For the primary objective, 48 infants met the inclusion criteria. Of 24 infants who received premedication during the study period, 12 underwent InSurE and formed the exploratory premedicated subgroup. However, because of the small sample size, there was a very high probability of \u0026nbsp; \u0026nbsp;alpha \u0026nbsp;and beta errors, therefore, we decided to abandon our attempt to address the secondary objective. The readers are welcome to seek the data from our lead corresponding \u0026nbsp;author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;1\u003c/strong\u003e\u0026nbsp; summarizes \u0026nbsp;the physiological parameters \u0026nbsp;during the pre‑procedure, intra‑procedure, and post‑procedure epochs for infants included in the primary analysis (n = 48). No significant changes in cardiovascular and respiratory parameters, as well as adverse events \u0026nbsp;were observed during the intra-procedural period as compared to the pre-procedure. However, several statistically significant differences were identified during the post procedure epoch . Heart rate decreased significantly from the intra‑procedural to the post‑procedural period (mean \u0026plusmn; SD 145.7 \u0026plusmn; 14.3 bpm vs 141.7 \u0026plusmn; 11.8 bpm; p = 0.031). Respiratory rate increased significantly from pre‑ to post‑procedure (55.45 \u0026plusmn; 14.26 vs 63.46 \u0026plusmn; 17.25 breaths/min; p = 0.011). Oxygen saturation improved significantly from baseline to 3 h post‑extubation (93.72 \u0026plusmn; 3.47% to 95.74 \u0026plusmn; 2.76%; p = 0.001). FiO₂ requirements decreased significantly from pre‑ to post‑procedure (37.98 \u0026plusmn; 16.74% to 30.20 \u0026plusmn; 15.54%; p = 0.003) and also decreased significantly from intra‑ to post‑procedure (p \u0026lt; 0.001). In addition, the proportion of infants with any desaturation (SpO₂ \u0026lt; 90%) decreased significantly from intra‑procedure to post‑procedure (7/43 [16.2%] vs 0/48 [0%]; p = 0.016).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2\u003c/strong\u003e provides maternal and newborn demographic and clinical characteristics for the study. Maternal age was 30.8 (5.9) years; 25/46 (54.3%) mothers with race recorded were White. Hypertensive disorders and diabetes occurred in 15/48 (31.2%) and 7/48 (14.6%) pregnancies, respectively, with 3/48 (6.2%) having both. Infants had a gestational age of 35.5 (2.9) weeks and a birth weight of 2,797 (853) g. Cesarean delivery occurred in 38/48 (79.2%) births. Infants required 6.2 (5.9) days of respiratory support and had a hospital stay of 13.7 (8.9) days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;3\u003c/strong\u003e presents procedural performance, physiological \u0026nbsp;responses, and adverse events during endotracheal intubation in the InSurE procedure among non‑premedicated infants \u0026ge;30 weeks\u0026rsquo; gestation \u0026nbsp;with reference to the number of attempts to intubate. First‑attempt intubation was successful in 33/48 (68.8%) infants, and 46/48 (95.8%) were successfully intubated within \u0026le;2 attempts among those with documented attempt counts. During the intra‑procedural epoch, tachycardia (\u0026gt;160 bpm) occurred in 4/25 (16.0%) first‑attempt intubations and in 0/10 (0.0%) infants requiring multiple attempts (p=0.303). Any desaturation (SpO₂ \u0026lt;90%) occurred in 5/30 (16.7%) first‑attempt intubations versus 1/17 (5.9%) among infants with \u0026ge;2 attempts (p=0.650). No severe desaturation events (SpO₂ \u0026le;80%) or severe TIAEs were recorded.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis \u0026nbsp;study demonstrates that the non‑premedicated InSurE procedure was associated with no documented severe physiological \u0026nbsp;instability in \u0026nbsp; infants \u0026ge;30 weeks\u0026rsquo; gestation with respiratory distress, with preserved cardiovascular parameters across predefined peri‑procedural epochs and short‑term respiratory improvement with higher SpO₂ and lower FiO₂ within 3 hours after the procedure, while respiratory rate increased modestly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this study provides the first systematic description of \u0026nbsp;peri‑procedural physiological patterns during InSurE using EMR‑based data, supporting the feasibility and short‑term safety of performing InSurE without routine premedication in appropriately selected late‑preterm and term infants.\u003csup\u003e36\u0026ndash;39\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eDuring intubation (intra‑procedural), none of the prespecified physiological variables differed significantly from baseline. The proportion of infants with any desaturation \u0026nbsp; was higher intra‑procedurally than at baseline, but this increase was not statistically significant; severe desaturation (\u0026le;80%) and apnea were not observed. These findings indicate that intra‑procedural physiology was not significantly perturbed relative to baseline in this cohort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the post‑procedure, oxygenation improved \u0026nbsp; with lower FiO₂ requirements and a modest increase in RR, while cardiovascular parameters remained overall stable compared with baseline; HR also showed a small but statistically significant decrease from the intra‑procedural to the post‑procedural epoch (p = 0.031), a difference of uncertain clinical importance. These findings are consistent with previous reports demonstrating the efficacy of InSurE in reducing the need for mechanical ventilation and minimizing lung injury. All infants undergoing InSurE were extubated to non-invasive ventilation (e.g., NIPPV or nCPAP), in accordance with the procedure\u0026rsquo;s goal of minimizing alveolar damage.\u003csup\u003e40-48\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe cohort reflects a population at moderate to high risk for neonatal respiratory distress, based on maternal and newborn characteristics, \u0026nbsp;including a high prevalence of cesarean delivery (~80%), male sex, late‑preterm birth (with an incidence two to three times higher than in term infants), and maternal complications such as hypertensive disorders (31%) and diabetes (15%).\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAdverse physiological events during endotracheal intubation were uncommon. Mild tachycardia and desaturation occurred in a minority of infants, and no severe tracheal intubation\u0026ndash;associated events were identified. In our cohort, the first‑attempt intubation success rate was 68.8%, compared with 49% reported in multicenter registries such as the NEAR4NEOS network, recognizing that NEAR4NEOS includes a broader, higher‑acuity neonatal population. Notably, the number of intubation attempts, including first versus multiple attempts, did not significantly influence the frequency of physiological instability. This finding supports the procedural safety of InSurE when performed by trained providers and aligns with national NEAR4NEOS definitions of tracheal intubation\u0026ndash;associated events.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eBecause the premedicated subgroup was too small to support meaningful comparison, no inferences regarding physiological \u0026nbsp;differences were drawn; however, prior studies provide relevant context on physiological responses and adverse events during neonatal intubation.\u003csup\u003e49\u0026ndash;53\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Strengths of the study include prespecified peri‑procedural epochs, structured extraction of hemodynamic and respiratory variables, and detailed reporting of intubation procedure. . imitations include the retrospective single‑ center design, modest sample size, incomplete intra‑procedural documentation, center‑specific practices, and the absence of validated neonatal pain or distress scales.\u003c/p\u003e\n\u003cp\u003eIn this study, all three predefined goals of the InSurE procedure\u0026mdash;clinical, performance, and procedural\u0026mdash;were achieved, with preserved hemodynamic stability, improved respiratory parameters, high intubation success rates, and no documented severe tracheal intubation\u0026ndash;associated events.\u003c/p\u003e\n\u003cp\u003eOverall, these findings support the feasibility of performing the InSurE procedure without routine premedication in this population of infants, in settings with experienced airway providers and continuous monitoring. Prospective comparative studies are needed to evaluate non‑premedicated versus premedicated InSurE or LISA/MIST, using clinically meaningful outcomes and standardized procedural monitoring.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNo physiological instability or tracheal intubation\u0026ndash;associated adverse events were documented, during intubation, and beneficial effects of surfactant were observed following the InSurE procedure in infants \u0026ge; 30 weeks\u0026rsquo; gestation without premeditation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAH:\u003c/strong\u003e AdventHealth\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBPD:\u003c/strong\u003e Bronchopulmonary dysplasia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBPM:\u003c/strong\u003e beats per minute.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI:\u003c/strong\u003e Confidence interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEMR:\u003c/strong\u003e Electronic medical record\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFiO2:\u003c/strong\u003e Fraction of inspired oxygen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGA:\u003c/strong\u003e Gestational age\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHR:\u003c/strong\u003e Heart rate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eINSURE:\u003c/strong\u003e Intubation, surfactant administration, and extubation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLISA:\u003c/strong\u003e Less invasive surfactant administration\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAP:\u003c/strong\u003e Mean arterial pressure\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMIST:\u003c/strong\u003e Minimally invasive surfactant therapy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRR:\u003c/strong\u003e Respiratory rate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD:\u003c/strong\u003e Standard deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTROBE:\u003c/strong\u003e Strengthening the Reporting of Observational Studies in Epidemiology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpO2:\u003c/strong\u003e Oxygen saturation by pulse oximetry\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTIAE:\u003c/strong\u003e Tracheal intubation-associated event\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Disclosures:\u003c/strong\u003e The authors have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support:\u003c/strong\u003e No external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e The AdventHealth Institutional Review Board approved this study. A waiver of parental consent was granted due to the retrospective nature of the research and the absence of direct interventions. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e JMLDR conceptualized the study, collected data, and drafted the initial manuscript; SL and MK collected the data, and JP assisted in statistical analysis; WO supervised the study, interpreted the data, and critically revised the manuscript. All authors approved the final manuscript as submitted.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnadkat JS, Kuzniewicz MW, Chaudhari BP, Cole FS, Hamvas A. Increased risk for respiratory distress among white, male, late preterm and term infants. J Perinatol. 2012 Oct;32(10):780-5. doi: 10.1038/jp.2011.191. Epub 2012 Jan 5. PMID: 22222548; PMCID: PMC3461404.\u003c/li\u003e\n\u003cli\u003eSweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et . European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3-23. doi: 10.1159/000528914. Epub 2023 Feb 15. PMID: 36863329; PMCID: PMC10064400.\u003c/li\u003e\n\u003cli\u003eManuck TA, Rice MM, Bailit JL, Grobman WA, Reddy UM, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. 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Adv Neonatal Care. 2024 Oct 1;24(5):466-474. doi: 10.1097/ANC.0000000000001190. Epub 2024 Aug 27. PMID: 39141691.\u003c/li\u003e\n\u003cli\u003eDarretain H, Laborne FX, Lagadec S, Garrigue B, Maillard F, Harbi F, Waszak P, Granier M, Galand N, Walter-Nicolet E, Razafimahefa H. An Analgesic Technique for Orogastric Tube Insertion in Newborns: DOLATSONG, a Randomized Multicentric Controlled Trial. J Perinat Neonatal Nurs. 2024 Oct-Dec 01;38(4):361-368. doi: 10.1097/JPN.0000000000000746. Epub 2024 Nov 7. PMID: 38833575. \u003c/li\u003e\n\u003cli\u003eVitali, F., Galletti, S., Aceti, A. et al. Pilot observational study on haemodynamic changes after surfactant administration in preterm newborns with respiratory distress syndrome. Ital J Pediatr 40, 26 (2014). https://doi.org/10.1186/1824-7288-40-26.\u003c/li\u003e\n\u003cli\u003ePolin RA, Carlo WA; Committee on Fetus and Newborn; American Academy of Pediatrics. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics. 2014 Jan;133(1):156-63. doi: 10.1542/peds.2013-3443. Epub 2013 Dec 30. PMID: 24379227.\u003c/li\u003e\n\u003cli\u003eHentschel, R., Bohlin, K., van Kaam, A. et al. Surfactant replacement therapy: from biological basis to current clinical practice. Pediatr Res 88, 176–183 (2020). https://doi.org/10.1038/s41390-020-0750-8.\u003c/li\u003e\n\u003cli\u003eEugene H Ng, Vibhuti Shah, Guidelines for surfactant replacement therapy in neonates, Paediatrics \u0026amp; Child Health, Volume 26, Issue 1, February 2021, Pages 35–41, https://doi.org/10.1093/pch/pxaa116\u003c/li\u003e\n\u003cli\u003eSangsari, R., Saeedi, M., Maddah, M. et al. Weaning and extubation from neonatal mechanical ventilation: an evidenced-based review. BMC Pulm Med 22, 421 (2022). https://doi.org/10.1186/s12890-022-02223-4 (This 2022 review highlights the importance of early extubation to NIV (e.g., CPAP or NIPPV) to reduce lung injury in preterm infant\u003c/li\u003e\n\u003cli\u003eChen IL, Chen HL. New developments in neonatal respiratory management. Pediatr Neonatol. 2022 Jul;63(4):341-347. doi: 10.1016/j.pedneo.2022.02.002. Epub 2022 Mar 16. PMID: 35382987. \u003c/li\u003e\n\u003cli\u003eVento G, et al. Efficacy of a new technique - INtubate-RECruit-SURfactant-Extubate - \"IN-REC-SUR-E\" - in preterm neonates with respiratory distress syndrome: study protocol for a randomized controlled trial. Trials. 2016 Aug 18;17:414. doi: 10.1186/s13063-016-1498-7. PMID: 27538798; PMCID: PMC4991115.\u003c/li\u003e\n\u003cli\u003eMazmanyan P, Mellor K, Doré CJ, Modi N. A randomized controlled trial of flow driver and bubble continuous positive airway pressure in preterm infants in a resource-limited setting. Arch Dis Child Fetal Neonatal Ed. 2016 Jan;101(1):F16-20. doi: 10.1136/archdischild-2015-308464. Epub 2015 Aug 13. PMID: 26271753.\u003c/li\u003e\n\u003cli\u003eDargaville PA, Aiyappan A, De Paoli AG, Dalton RG, Kuschel CA, Kamlin CO, et al. Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences. Neonatology. 2013;104(1):8-14. doi: 10.1159/000346460. Epub 2013 Apr 4. PMID: 23595061.\u003c/li\u003e\n\u003cli\u003eReiterer F, Schwaberger B, Freidl T, Schmölzer G, Pichler G, et al; Lung-protective ventilatory strategies in intubated preterm neonates with RDS. Paediatr Respir Rev. 2017 Jun;23:89-96. doi: 10.1016/j.prrv.2016.10.007. Epub 2016 Oct 26. PMID: 27876355.\u003c/li\u003e\n\u003cli\u003eAjanwaenyi J, Bamidele O, Osim C, Salami O, Umukoro C, et al ; The minimal invasive surfactant therapy: experience from a low resource setting. J Matern Fetal Neonatal Med. 2022 Dec;35(25):5177-5183. doi: 10.1080/14767058.2021.1875438. Epub 2021 Jan 24. PMID: 33491516.\u003c/li\u003e\n\u003cli\u003eStevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev. 2007 Oct 17;2007(4):CD003063. doi: 10.1002/14651858.CD003063.pub3. PMID: 17943779; PMCID: PMC8554819.\u003c/li\u003e\n\u003cli\u003eRojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2012 Mar 14;2012(3):CD000510. doi: 10.1002/14651858.CD000510.pub2. PMID: 22419276; PMCID: PMC12034442.\u003c/li\u003e\n\u003cli\u003eKribs A, Roll C, Göpel W, et al. Nonintubated surfactant application vs conventional therapy in extremely preterm infants: a randomized clinical trial. JAMA Pediatr. 2015;169(8):731–739. doi:10.1001/jamapediatrics.2015.1082\u003c/li\u003e\n\u003cli\u003eGöpel W, Kribs A, Ziegler A, et al. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomized, controlled trial. Lancet. 2011;378(9803):1627–1634. doi:10.1016/S0140-6736(11)60986-0\u003c/li\u003e\n\u003cli\u003eRoberts KD, Leone TA, Edwards WH, Rich WD, Finer NN. Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. Pediatrics. 2006 Oct;118(4):1583-91. doi: 10.1542/peds.2006-0590. PMID: 17015550.\u003c/li\u003e\n\u003cli\u003eAnand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317(21):1321-9. doi: 10.1056/NEJM198711193172105.\u003c/li\u003e\n\u003cli\u003eQuinn MW, et al. Randomised double-blind controlled trial of effect of morphine on catecholamine concentrations in ventilated pre-term babies. Lancet. 1993;342(8867):324-7. doi: 10.1016/0140-6736(93)91472-x. \u003c/li\u003e\n\u003cli\u003eLeone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr. 2005;146(5):638–641.\u003c/li\u003e\n\u003cli\u003eTarawneh A, Kaczmarek J, Bottino MN, Sant'anna GM. Severe airway obstruction during surfactant administration using a standardized protocol: a prospective, observational study. J Perinatol. 2012 Apr;32(4):270-5. doi: 10.1038/jp.2011.89. Epub 2011 Jul 7. PMID: 21738121.\u003c/li\u003e\n\u003cli\u003eKatheria AC, Leone TA. Changes in hemodynamics after rescue surfactant administration. J Perinatol. 2013 Jul;33(7):525-8. doi: 10.1038/jp.. 2012.166. Epub 2013 Jan 17. PMID: 23328925.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Physiological Variables Pre-procedure, During, and Post-procedure in Infants \u0026ge;30 Weeks\u0026rsquo; Gestation with Respiratory Distress undergoing \u0026nbsp;InSurE procedure (N=48)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"637\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePre-procedure (3 h before)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIntra-procedure (During intubation)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePost-procedure (3 h after)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Pre vs Intra)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Pre vs Post)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Intra vs Post)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHeart rate, mean \u0026plusmn; SD [95% CI], bpm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e144.36 \u0026plusmn; 14.7 [140.09\u0026ndash;148.63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e145.71 \u0026plusmn; 14.3 [140.80\u0026ndash;150.63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e141.71 \u0026plusmn; 11.78 [138.28\u0026ndash;145.13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e*0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBradycardia (\u0026lt;100 bpm), n/N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/29 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTachycardia (\u0026gt;160 bpm), n/N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/48 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6/35 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4/48 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMean arterial pressure (MAP), mean \u0026plusmn; SD [95% CI], mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41.9 \u0026plusmn; 6.67 [39.64\u0026ndash;44.16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.67 \u0026plusmn; 11.31 [35.48\u0026ndash;49.85]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.74 \u0026plusmn; 6.52 [40.39\u0026ndash;45.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.494\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.259\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypotension (MAP \u0026lt; GA), n/N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4/36 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/11 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4/32 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRespiratory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRespiratory rate, mean \u0026plusmn; SD [95% CI], breaths/min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.45 \u0026plusmn; 14.26 [51.31\u0026ndash;59.60]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.65 \u0026plusmn; 17.02 [51.71\u0026ndash;63.59]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.46 \u0026plusmn; 17.25 [58.45\u0026ndash;68.46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e*0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSpO₂, mean \u0026plusmn; SD [95% CI], %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.72 \u0026plusmn; 3.47 [92.71\u0026ndash;94.73]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94.48 \u0026plusmn; 4.18 [93.21\u0026ndash;95.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95.74 \u0026plusmn; 2.76 [94.94\u0026ndash;96.54]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e**0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAny desaturation (SpO₂ \u0026lt;90%), n/N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4/48 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/43 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e*\u0026nbsp;0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSevere desaturation (SpO₂ \u0026le;80%), n/N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/43 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFiO₂, mean \u0026plusmn; SD [95% CI], %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.98 \u0026plusmn; 16.74 [33.12\u0026ndash;42.84]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.42 \u0026plusmn; 19.36 [34.46\u0026ndash;46.38]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.20 \u0026plusmn; 15.54 [25.53\u0026ndash;34.87]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e**0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e**\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eApnea recorded, n/N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/48 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFootnote:\u003c/strong\u003e Values are Mean \u0026plusmn; SD [95% CI] or n/N (%). P-values from paired t tests (HR, RR, SpO₂, FiO₂), Wilcoxon signed-rank test (MAP), or McNemar\u0026rsquo;s test (dichotomous). *p \u0026lt; 0.05, **p \u0026lt; 0.01. Hypotension is defined as MAP (mmHg) \u0026lt; gestational age in completed weeks. Ns vary due to missing intra-procedure recordings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Maternal and Newborn Demographic and Clinical Characteristics of Infants \u0026ge;30 Weeks\u0026rsquo; Gestation Treated With InSurE in the Non-premedicated cohort (N = 48).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Demographics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMaternal age, mean \u0026plusmn; SD (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.83 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRace, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eWhite 25/46 (54.3%); Non-White 21/46 (45.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePregnancy Data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMaternal hypertension, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15/48 (31.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMaternal diabetes mellitus, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/48 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBoth hypertension and diabetes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3/48 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMaternal steroids (\u0026lt;35 weeks GA), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16/20 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNewborn Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex, n (%) \u0026ndash; Female / Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13/48 (27.1%) / 35/48 (72.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGestational age, mean \u0026plusmn; SD (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.5 \u0026plusmn; 2.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBirth weight, mean \u0026plusmn; SD (g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2797 \u0026plusmn; 853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDelivery mode, n (%) \u0026ndash; NSVD / C-section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10/48 (20.8%) / 38/48 (79.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDays on respiratory support, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.21 \u0026plusmn; 5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLength of stay, mean \u0026plusmn; SD (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.69 \u0026plusmn; 8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFootnote:\u0026nbsp;\u003c/strong\u003eValues are mean \u0026plusmn; standard deviation (SD) for continuous variables and n (%) for categorical variables. Maternal steroid exposure was calculated only for infants born at \u0026lt;35 weeks\u0026rsquo; gestation. Race category \u0026ldquo;Unknown\u0026rdquo; was included in descriptive counts but excluded from statistical testing (n=2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Procedural Performance, Physiological Responses, and Adverse Events During Endotracheal Intubation in the InSurE Procedure in Non‑Premedicated Infants \u0026ge;30 Weeks\u0026rsquo; Gestation (N = 48) with reference to number of attempts to intubate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedural Performance\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"566\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 337px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en/N (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 337px;\"\u003e\n \u003cp\u003eSuccessful intubation on first attempt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003e33/48 (68.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 337px;\"\u003e\n \u003cp\u003eSuccessful intubation within \u0026le;2 attempts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003e46/48 (95.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 337px;\"\u003e\n \u003cp\u003eOverall intubation success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003e48/48 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysiological Responses intra-procedure, Stratified by Number of Attempts.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"654\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFirst Attempt (n/N, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple Attempts (\u0026ge;2 or NA) (n/N, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n/N, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFisher\u0026rsquo;s exact p (two-sided)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNon-severe tracheal intubation-associated event\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTachycardia (\u0026gt;160 bpm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4/25 (16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/10 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4/35 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.40 (0.22, 89.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAny desaturation (SpO₂ \u0026lt;90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5/30 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2/13 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7/43 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.10 (0.18, 6.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSevere desaturation (SpO₂ \u0026le;80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/30 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/13 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0/43 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFootnote:\u003c/strong\u003e Values are n/N (%). First attempt = one documented intubation attempt; multiple attempts = \u0026ge;2 attempts. Records with undocumented attempt number were excluded from attempt‑stratified analyses. Success rates are descriptive and were not subjected to inferential testing. Odds ratios and 95% confidence intervals were calculated using exact methods; when zero cells occurred, odds ratios were not estimable and exact p‑values are reported.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8960141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8960141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To describe peri‑procedural physiological changes during the non‑premedicated Intubation–Surfactant–Extubation (InSurE) procedure in infants ≥30 weeks’ gestation with respiratory distress.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e: This retrospective pilot study included infants who underwent the InSurE procedure without premedication in AdventHealth Central Florida NICUs. Heart rate, respiratory rate, mean arterial pressure, oxygen saturation, and FiO₂ were recorded 3 hours before intubation, during the procedure, and 3 hours after extubation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Forty‑eight infants met inclusion criteria. Physiological parameters remained stable from baseline to the intra‑procedural period with no significant changes in heart rate, respiratory rate, blood pressure, oxygen saturation, or FiO₂. By 3 hours post‑procedure, oxygen saturation improved, FiO₂ requirements decreased, respiratory rate increased, and heart rate declined slightly. Desaturation events fell from 16.2% intra‑procedure to none post‑procedure. No severe desaturation or tracheal intubation–associated events occurred.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The non‑premedicated InSurE procedure was well‑tolerated, with stable physiology and improved oxygenation after surfactant administration.\u003c/p\u003e","manuscriptTitle":"Physiological Changes During Intubation-Surfactant-Extubation (InSurE) Procedure in Infants ≥30 Weeks' Gestation: A Retrospective Pilot Study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 17:52:05","doi":"10.21203/rs.3.rs-8960141/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a62d804-c678-43a1-a4ea-97d525018b91","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":63948576,"name":"Health sciences/Health care/Paediatrics"},{"id":63948577,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-04-09T11:28:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 17:52:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8960141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8960141","identity":"rs-8960141","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}