A multicenter randomized controlled trial from Germany in infants 23 – 26 weeks with respiratory distress syndrome compared traditional surfactant administration following endotracheal intubation and positive pressure ventilation, versus less invasive surfactant administration (LISA) where surfactant was administered through a thin catheter passed into the trachea while the infant was on CPAP and spontaneously breathing (with no positive pressure used at all). Infants managed with LISA had a lower incidence of pneumothorax (5 vs 13%), a lower incidence of severe intraventricular hemorrhage (10 vs 22%), and a higher incidence of survival without severe adverse events (50 vs 36%).

Non-intubated surfactant administration in extremely preterm infants. Kribs et al, 2015.