First, out of 296 infants of respiratory distress syndrome (RDS) requiring continuous positive airway pressure (CPAP), a total of 150 infants required intubation for invasive ventilation and another 53 infants requiring intubation couldn’t be randomized due to non-availability of designated ventilator. This means that there was a CPAP failure in 69% of the cases. Studies from India itself had shown a much lower CPAP failure rate of around 25 to 40% despite the use of surfactant in selected cases [2, 3]. This high failure rate of CPAP raises its own set of issues: how accurately was the definition of respiratory distress syndrome (RDS) being applied? What is the policy for surfactant administration in the unit? Are these findings generalizable to settings where the rate of CPAP failure is almost half?

Second, the authors have excluded the infants which were off ventilation within 24 hours after randomization. This is despite of the fact that oxygenation index at 1 and 6 hours of ventilation was also the part of primary outcome. These infants constituted more than one fourth of the total participants in the trial and their exclusion could have resulted in biased results. What is the reason of their exclusion and how were they adjusted in the final analysis needs clarification?

1. Singh SN, Malik GK, Prashanth GP, Singh A, Kumar M. High frequency oscillatory ventilation versus synchronized intermittent mandatory ventilation in preterm neonates with hyaline membrane disease: A randomized controlled trial. Indian Pediatr. 2012;49:405-8.

2. Koti J, Murki S, Gaddam P, Reddy A, Reddy MD. Bubble CPAP for respiratory distress syndrome in preterm infants. Indian Pediatr. 2010;47:139-43.

3. Saxena A, Thapar RK, Sondhi V, Chandra P. Continuous positive airway pressure for spontaneously breathing premature infants with respiratory distress syndrome. Indian J Pediatr. 2012 Mar 7. [Epub ahead of print]

4. Speer CP, Gefeller O, Groneck P, Laufkötter E, Roll C, Hanssler L, et al. Randomised clinical trial of two treatment regimens of natural surfactant preparations in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed. 1995;72:F8-13.