Background: Respiratory distress syndrome (RDS) is a leading cause of premature infant death. One of the most successful therapies for Bronchopulmonary dysplasia (BPD) is anti-inflammatory medication using corticosteroids. However, systemic corticosteroid administration is not suggested due to long-term side effects. We aim to study the effect of early intratracheal instillation of surfactant/budesonide with surfactant in preterm infants with severe Respiratory distress syndrome (RDS). Patients and methods: This cross sectional study was carried out in the Pediatric Department, on 60 preterm infants weighing less than 1,500g who were admitted to the neonatal intensive care unit (NICU) of Zagazig University Hospital, during the period from November 2021 to November 2022. The treatment group (surfactant and budesonide) was given a mixture of 0.25 mg/kg (1 mL/kg) of budesonide and 100 mg/kg (4 mL/kg) of surfactant, and the control group (surfactant only) was given 100 mg/kg (4 mL/kg) of surfactant only. Results: There was no statistical significant difference between studied groups as regard Surfactant redoes, BPD, BPD moderate to severe, duration of non invasive ventilation, duration of invasive ventilation, death, intraventricular hemorrhage (IVH), ROP and NEC. Among Surfactant- budesonide group; 16.7% Surfactant redoes, 26.7% BPD, 16.7% death, 6.7% IVH, 16.7% ROP, 0 % NEC and median duration of non invasive ventilation is 3 days for surfactant- budesonide and control groups. Conclusion: Early intratracheal administration of budesonide and surfactant in preterm infants with sever RDS might decrease BPD and mortality without disturbing surfactant functionز