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Introduction: Respiratory distress syndrome (RDS) is defined as acute respiratory distress caused by surfactant deficiency that disturbs gas exchange in preterm infants. It is one of the most common neonatal problems and has been considered to be the most common cause of mortality and morbidity in preterm babies., Aim: In this study, different variables were studied to predict factors for INSURE failure that might help in choosing infants for this procedure early., Methods: Sixty three (63) patients were enrolled in this study as they met the inclusion criteria. All neonates were intubated briefly less than 2 hours, given natural surfactant in the dose of 3 ml/kg. As soon as it was appropriate and the neonate was stable in the form of normal heart rate and oxygenation, extubation was done and the baby connected to NCPAP at a pressure of 6 cmH2O. INSURE failure was considered if the patient needed mechanical ventilation for more than 72 hours while INSURE success was considered if we were able to wean the patient from CPAP or if the patient didn't need mechanical ventilation in the first 72 hours after surfactant administration. The indications for mechanical ventilation after INSURE procedure were respiratory distress with desaturation (02 sat less than 90%), recurrent apnea, Pco2 more than 60 mmHg., Results: Since INSURE procedure is being largely applied in the neonatal intensive care units, it is important to determine the candidate neonate for this procedure with the minimum failure rate. Although the sample of our study is small, but we can suggest that neonate with gestational age less than 28, birth weight less than 1000 gm, umbilical PH of less than 7, low Apgar score and anemic patients are at high risk for INSURE failure., Conclusion: Early diagnosis of PDA and IVH is essential to avoid INSURE method in these patients., Competing Interests: There are no conflicts of interest., (© 2019 Faten Awaysheh, Nisreen Alhmaiedeen, Raeda Al-ghananim, Areej Bsharat, Mohammad AL-Hasan.)