Experimental: IN-REC-SUR-E

INRECSURE infants will receive preintubation medications and HFOV starting at MAP 8 cmH2O; frequency 15 Hz, with volume-guarantee (1.5-1.7 mL/kg). The I:E will be 1:1. An oxygenation guid-ed lung recruitment procedure will be performed using stepwise increments then decrements in MAP. The starting MAP will be increased stepwise as long as SpO2 improves reducing the FiO2 keeping SpO2 within the target range (90-94 %) until the oxygenation no longer improves or the FiO2 is equal to or less than 0.25 (opening MAP). Next, the MAP will be reduced stepwise until the SpO2 deterio-rates (closing MAP). After a second recruitment maneuver at the opening pressure, the optimal MAP will be set 2 cmH2O above the closing MAP. Then 200 mg/kg of poractant alfa (Chiesi Farmaceutici S.p.A., Parma, Italy) via a closed administration system will administrate. Infants with sufficient res-piratory drive will be extubated within 30 minutes after surfactant administration starting nCPAP (7-9 cm H2O) or NIPPV.

Active_comparator: Less Invasive Surfactant Administration

By contrast, infants allocated to the LISA group will receive 200 mg/kg of poractant alfa (Chiesi Farmaceutici S.p.A., Parma, Italy) according to the following protocol: during nasal CPAP with a pressure of 7-8 cm H2O, surfactant will be administered over 0.5-3 min using the SurfCath™ tracheal instillation catheter (VYGON S.A. - Ecouen, France), or a 4- 6 F end-hole catheter, according to local protocols. After the same pre-procedural medications, the catheters will be positioned during laryngoscopy with or without Magill forceps. The catheter will be connected to a syringe pre-filled with the surfactant, and the surfactant is instilled slowly. The infant's mouth will be closed. In cases of apnoea or bradycardia, positive pressure ventilation will be performed until recovery. After surfactant administration, CPAP (7-9 cm H2O) therapy (16) or NIPPV will be continued.