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Before we changed our approach in 2001, we performed noninvasive surfactant application in individual cases of very immature children the parents of whom did not consent to intubation and mechanical ventilation. These infants presented good spontaneous breathing but clearly needed surfactant. After explaining to the parents that surfactant application might be possible following an experimental not evidence-based approach without intubation and mechanical ventilation http://www.selleckchem.com/products/ly2157299.html to apply surfactant, they consented. After we observed how well the infants did following this approach and considering the growing evidence of the negative effects of PPV to very immature preterm lungs, we decided to change our protocol and defined the here presented approach as our new centre-specific standard management for very immature babies. As the changes were not performed within a clinical study, the ethics committee was not informed in 2001, a time where ethical regulations in Germany were less strict. Furthermore, two multi-centred, randomized controlled trials for surfactant application without intubation had been initiated in 2007 and 2008, for which the ethical boards of all participating institutions had confirmed that this approach was ethical. Therefore, retrospectively, our protocol was approved by our ethics committee. In total, clinical data of 208 infants were compared. One hundred sixty-four infants were treated following our revised delivery room management policy (study group). Data of these children were compared with 44 ELGAN infants defined as a historical control group. As highlighted in Table?S1, demographic data and perinatal risks http://www.selleck.cn/products/XL184.html were similar in both groups. Significant differences between the two groups were observed for the following criteria: 5-min Apgar http://www.selleckchem.com/products/z-vad-fmk.html scores were higher in the control subgroup of infants born after 22-week GA, clinically suspected chorioamnionitis was present significantly more often in study patients born after 25?weeks of gestation and the control subcohort of children born after 25?weeks of gestation comprised significantly more boys (Table?S1). In both cohorts, infants with a GA of 22?weeks were less frequently born by Caesarean section (23% vs. 86% study group, p?