Randomised trials have shown exogenous surfactant therapy to reduce mortality and morbidity among very low birthweight (VLBW) infants with respiratory distress syndrome (RDS). Surfactant therapy is normally given to infants on mechanical ventilation. In the Stockholm area, 12 VLBW infants born after 27-30 gestational weeks and suffering from RDS were recently treated using the INSURE (Intubation-SURfactant-Extubation) approach--i.e., surfactant therapy during brief intubation, immediately followed by extubation and continuous positive airway pressure (CPAP) treatment. The treatment was successful in all 12 cases, the mean (+/- SD) a/A ratio increasing significantly from 0.17 +/- 0.04 before the INSURE procedure to 0.46 (0.12 after (P < 0.001). Only one infant later needed mechanical ventilation for RDS.