Reviewed by Malcolm Battin and Simon Rowley

July
2006

Background	Indications and Usage	Infants 30 weeks and Under	Infants above 30 weeks	Administration
Precautions	Adverse Reactions	Surfactant administration in Level 2		References

Background

The administration of exogenous surfactant to newborn infants with or at risk of Respiratory Distress Syndrome (RDS) is established practice.
Although clinical trials have used different preparations and entry criteria, improvements in ventilatory requirements, survival rates and air leak are consistently reported with both prophylactic and rescue treatment.
A small additional benefit, however, is reported from early (prophylactic) administration when compared to rescue therapy .

Indications and Usage

The current preparation of surfactant in use at National Women's NICU is poractant alpha (curosurf), a natural porcine surfactant.
Surfactant is indicated for both prevention and treatment (‘rescue’) of RDS in premature infants.
- Surfactant significantly reduces the incidence of RDS, mortality due to RDS and air leak complications although use in infants less than 600g or greater than 1750 g birthweight has not been evaluated in controlled trials.
Bolus surfactant (beractant) in ventilated infants with meconium aspiration syndrome (MAS) has been found to improve oxygenation in most studies but there are many non-reponders and the effect may be transient. Pooled data also suggest a potential reduction in the requirement for extracorporeal membrane oxygenation (ECMO) but no diminution of air leak or ventilator days. However, lavage may be the preferred option (see LessMAS trial).

Transient bradycardia or oxygen desaturation may occur. If necessary, stop the dosing procedure and initiate hand bagging/Neopuff or increase the pressure from the ventilator. Once the infant has stabilized, resume the dosing procedure.

Endotracheal tube blockage and pulmonary haemorrhage are potential complications of surfactant administration.

Surfactant therapy should be used early (<2 hours if possible) in ventilator dependent babies.
- As soon as the baby is on NICU and the doctor/NS-ANP is confident of the ET tube position, administer the first dose.

Exogenous surfactant should be used when a diagnosis of moderate or severe respiratory distress syndrome is clearly established. This will generally be on the basis of a combination of clinical, radiological, or laboratory findings such as:
- Clinical evidence of respiratory distress.
- Current chest radiograph available, consistent with RDS.
- Increasing ventilatory support requirements
  - e.g. FiO₂>40%, pH <7.25, PaO₂ <7.0kPa, PaCO₂ >7.0kPa, (or A/a < 0.22).

See poractant alpha protocol.
Note that infants may require ventilation with the Neopuff or ventilator at higher pressures until stable.
- Infants on HFOV should receive manual ventilation using the Neopuff until the surfactant is adequately dispersed.
Suction should be avoided for 4 hours (unless absolutely indicated for a blocked ETT).
Following surfactant administration, ventilator requirements may rapidly improve and ventilation should be adjusted appropriately.
- Consider the use of a volume guarantee mode.

In general, infants requiring surfactant will be in Level 3.
Selected infants in Level 2 may be considered for a brief period of intubation for the administration of surfactant.
- Infants should have good respiratory effort.
- Infants preferably should be less than 48 hours old.
Babies with RDS who also have significant apnoea/desaturation should be considered for transfer to Level 3.

Discuss with Level 2 Specialist and Charge Nurse.
One-to-one nursing is recommended for the duration of the administration and observations.
Inform the Level 3 specialist and staff in case the infant requires ongoing ventilation.
Intubation drugs should preferentially be used, acknowledging that this may prolong recovery time and some infants will therefore require ongoing ventilation.
Registrar or NS-ANP intubates and administers appropriate dose, and ventilates using the Neopuff until stable or until the baby clearly needs transfer to Level 3 for ongoing ventilation.
Extubate to CPAP as soon as possible.
If possible registrar/NS-ANP to remain on NICU for 30 minutes following extubation.
Blood gas before and 30 minutes after.
If no improvement post-surfactant, discuss with specialist on duty. Options may include a repeat chest radiograph or ongoing positive pressure ventilation.

1	Corbet A, Bucciarelli R, Goldman S et al: Decreased mortality rate among small premature infants treated at birth with a single dose of synthetic surfactant: a multicenter controlled trial. J Pediatr 1991;118: 277-84
2	Bose C, Corbet A et al: Improved outcome at 28 days of age for very low birth weight infants treated with a single dose of synthetic surfactant. J Pediatr 1990;117:947-53.
3	Soll RF, Blanco F. Natural surfactant extract versus synthetic surfactant for neonatal respiratory distress sundrome. Cochrnae Database Syst Rev 2001;(2):CD000144.
4	Kendig JW, Notter RH, Cox C et al: A comparison of surfactant as immediate prophylaxis and as rescue therapy in newborns of less than 30 weeks' gestation. N Engl J Med 1991; 324: 865-871.
5	Horbar JD, Wright LL, Soll RF, et al. A multicenter randomized trial comparing two surfactants for the treatment of neonatal respiratory distress syndrome. J Pediatr. 1993; 123(5): 757-66.
6	Halliday HL. Recent clinical trials of surfactant treatment for neonates. Biol Neonate 2006;89(4):323-9.
7	Verder H et al. Surfactant therapy and nasal continuous positive airway pressure for newborns with respiratory distress syndrome. New Engl J Med Oct 20 1994; 331(16).