INTRODUCTION

Pulmonary surfactant is a complex mixture of phospholipids and proteins that creates a

cohesive surface layer over the alveoli which reduces surface tension and maintains alveolar
stability therefore preventing atelectasis. Surfactant deficiency is a recognized cause of
respiratory distress syndrome in the preterm neonate. Secondary surfactant deficiency also
contributes to acute respiratory morbidity in late-preterm and term neonates with meconium
aspiration syndrome, pulmonary haemorrhage, and pneumonia/sepsis. Many clinical trials
have demonstrated that surfactant replacement therapy is a safe, effective and beneficial
treatment as it significantly reduces respiratory morbidity (air leaks, pulmonary interstitial
emphysema), ventilatory requirements and mortality in these neonates. 

Aim

 The aim of this guideline is to outline the principles of surfactant replacement therapy
and the safe administration of surfactant in neonates in the Butterfly ward - Newborn
Intensive Care Unit (NICU)

Definition of Terms 

 Neonate – infant less than 28 days old

 Surfactant - complex and highly surface active material composed of lipids and
proteins which is found in the fluid lining the alveolar surface of the lungs, which
serves to reduce alveolar surface tension
 RDS – respiratory distress syndrome
 FiO2 - fraction of inspired oxygen
 Multicomponent complex of several phospholipids, neutral lipids, and associated
proteins.
 Synthesized and secreted by Type II epithelial cells (pneumocytes) within the lung.
 Reduces collapsing force in the alveolus, conferring stability and maintaining alveolar
surface free of liquid.Production begins from 16 wks GA onwards and ends at 32-
35weeks GA
 FUNCTIONS
 Decrease the surface tension
 Promotes lung expansion during inspiration
  Prevents alveolar collapse and loss of lung volume at the end of expiration

Assessment

Clinical indications

Surfactant replacement therapy should be considered in:

 neonates with clinical and radiographic evidence of RDS

 neonates at risk of developing RDS (e.g. <32 weeks or low birth weight <1300g)
 neonates who are intubated, regardless of gestation, and requiring FiO2 >40%

 Treatment of intubated infants on 30% or more oxygen whose clinical presentation

and chest x-ray are consistent with RDS.
 Prophylactic administration may be considered in infants < 26 weeks EGA.
 Secondary surfactant dysfunction, inactivation or post surfactant slump.

Dosing Guidelines for Surfactant Replacement Therapy in the NICU

Surfactant replacement therapy may be considered in:

 Severe meconium aspiration syndrome with severe respiratory failure – may improve
oxygenation and reduce the need for extracorporeal membrane oxygenation (ECMO)
 Pulmonary haemorrhage with clinical deterioration
 Severe respiratory syncytial virus-induced respiratory failure - may improve gas
exchange and respiratory mechanics and shorten the duration of invasive mechanical
ventilation 

Dosing
 Description Surfactant

Premature infants with RDS  < 700 g Survanta

Premature infants with RDS > 700 g Curosurf

Premature infants unresponsive to 2 doses of Survanta Infasurf

Premature infants unresponsive to 2 doses of Curosurf  Infasurf

Premature infants with inactivation, dysfunction or post surfactant slump Infasurf

Term infants with surfactant inactivation or dysfunction Infasurf

Etiology of surfactant inactivation or dysfunction:

 pulmonary hemorrhage, sepsis, pneumonia, meconium aspiration, and post surfactant slump.

Surfactant replacement therapy for RDS - Early rescue therapy should be practiced: 

First dose needs to be given as soon as diagnosis of RDS is made. RDS in a premature infant
is defined as respiratory distress requiring more than 30% oxygen delivered by positive
pressure using either Nasal CPAP or an ET Tube with a chest radiograph that has diffuse
infiltrates with a ground glass granular appearance with air bronchograms.  Ideally the dose
should be given within 1 hr of birth but definitely before 2 hours of age.  A repeat dose
should be given within 4 - 12 hours if the patient is still intubated and requiring more than 30
to 40% oxygen.

Prophylactic therapy

 (before chest radiograph) can be considered in patients with respiratory distress who are
intubated and are < 26 weeks gestation.
 Dosing Guidelines in the NICU

Dosing Description

Survant 4 ml/kg in 4 aliquots, repeat dose as needed if responsive

a

Infasurf 3 ml/kg in 2 aliquots, repeat dose as needed, (use of "drip dosing on HFOV" discuss with
staff/fellow)

Curosur 2.5 ml/kg in 2 aliquots, repeat dose (1.25 ml/kg) as needed, (use of "in and out therapy" -
f rapid extubation after one dose, discuss with staff/fellow)

Subsequent doses are generally withheld if the infant requires less than 30% oxygen. The
technical details of administration are discussed in the package insert and in the NICU
Nursing Protocols on administration.

PROCEDURE
 OTHER MODES

 Pharyngeal instillation before first breath

 Laryngeal mask airway (LMA) administration

 Bronchoalveolar lavage

 Aerosolized surfactant
Ventilator Management:  A blood gas should be checked within 15 - 20 minutes of the dose
and the ventilator settings should be weaned appropriately to minimize the risk of a
pneumothorax. A chest radiograph should be checked both 1 hour and 4 - 6 hours after the
initial dose to avoid hyperinflation.

 The RCH NICU (Butterfly ward) uses poractant alfa (Curosurf) which is a natural
porcine surfactant. 
 Management

Administration

 Prepare equipment/supplies:

o Continuous cardiovascular monitoring equipment 

o Transcutaneous CO2 monitor (TCM) or end tidal CO2 monitor (etCO2) if
appropriate 
 o Surfactant 
o Size 5 Fr feeding tube 
o 3ml or 5ml syringe (dose dependent) 
o Large gauge needle (18g, 19g or 20g)
o Alcohol swab 70% 
o Sterile towel or drape 
o Tape measure 
o Sterile scissors 
o Emergency equipment: Neopuff and mask, suction

 Surfactant administration is a two-person procedure. It should be performed by at

least one medical practitioner or a neonatal nurse practitioner (NNP) who administers
the surfactant and one registered nurse as the assistant
 Record baseline observations: heart rate, respiration rate, oxygen saturation,
TCO2/etCO2, plus a blood gas if required
 Ensure and confirm correct position of the endotracheal tube (ETT) via chest x-ray
prior to giving surfactant. Auscultation of the chest for equal bilateral air entry
confirmed by a NICU fellow or consultant is an additional method of confirming ETT
placement.
 If neonate is not intubated (eg. a premature neonate on continuous positive airway
pressure (CPAP)), an in-out intubation will be performed to administer the surfactant
(INSURE technique – Intubation, Surfactant then Extubation). Refer to the guideline
on elective intubation. . 
 Check and prepare emergency equipment at bedside (e.g. Neopuff, suction). If
performing intubation, also prepare intubation drugs, laryngoscope with appropriate
blade size, appropriate size ETT, and Pedicap/CO2 detector.
 Ensure patency of ETT. Suction ETT as necessary prior to administration.
 Slowly warm the vial of surfactant to room temperature before administration
 Administering medical practitioner performs hand hygiene and dons sterile gloves.
 Using surgical aseptic technique, cut a sterile 5 fg feeding tube to the length so that
the tip lies 1 cm above the end of the endotracheal tube. This ensures that the
surfactant is administered intra-tracheal. Curosurf should not be instilled into a main
stem bronchus.
  Slowly withdraw a little over the required dose into a 3 or 5 mL plastic syringe using
a large-gauge needle. Attach the pre-cut 5 Fr catheter to the syringe, prime or fill the
catheter with surfactant to the end. Discard excess surfactant through the catheter so
that only the dose to be given remains in the syringe.
 Ensure bed is flat. Place the neonate in supine position. There is no evidence to
support the practice of placing the neonate in multiple positions during administration.
 Assistant disconnects the ETT from the ventilator.
 Medical practitioner or NNP to administer the surfactant via the pre-cut 5 Fr catheter
in a single bolus dose as quickly as the neonate tolerates. The total dose is usually
given less than a minute.
 Surfactant can occlude the ETT and it may be necessary to cease administration until
the tube is cleared and chest wall movement resumes
 Reconnect ETT to ventilator as soon as possible. If neonate was on CPAP, positive
pressure ventilation is given via the Neopuff. Holding the ETT upright may facilitate
surfactant drainage and minimize reflux up the ventilator circuit 
 Ventilator support or inspired oxygen may need to be temporarily increased.
 Medical practitioner/NNP to remain at bedside until the neonate is stable.

Post-administration 

 Marked improvements may occur within minutes of administration. Ventilation

settings will need to be continually assessed and adjusted post administration to avoid
hyperoxygenation or exposure to excessive peak inspiratory pressures. 
 Extubation may be considered for some neonates (INSURE technique – Intubation,
Surfactant then Extubation) particularly the premature neonates who were on CPAP
prior to administration, and responded well to the surfactant administration. 
 At high ventilator rates (> 40) regurgitation of surfactant may occur in the expiratory
circuit, this can be remedied by holding the ETT upright for a few minutes post
administration and/or by reducing the ventilator rate.
 Monitor neonate’s vital signs closely every 10 minutes for 30 minutes then resume
normal frequency of monitoring. A repeat blood gas may be necessary 30-60 minutes
post administration.
 Do not suction airways for 1 hour after surfactant instillation unless signs of
significant airway obstruction occur
  Note and report changes in non-pulmonary haemodynamics that may indicate
significant changes - particularly in the very premature and/or unwell patient 

Potential complications and management 

 During administration, transient bradycardia, oxygen desaturation and ETT blockage

can occur – temporarily stop surfactant administration, provide ventilation or oxygen
as necessary, and resume administration after patient is stable
 ETT obstruction – if suspected, observe saturations and chest wall movement. Call for
medical assistance if obstruction is not alleviated and ventilation is impaired
 Pneumothorax – can occur due to sudden changes in pulmonary compliance if
ventilation settings are not appropriately changed
 Pulmonary haemorrhage – notify medical officer immediately. Ensure the PEEP
remains above 5cm H2O

Special considerations

 Storage and handling: Surfactant is stored in a refrigerator at +2 to +8oC. Surfactant

vial should be slowly warmed to room temperature and gently turned upside down in
order to obtain a uniform suspension. Do not shake the vial. Use the appropriate sized
vial for the prescribed volume and discard unused portion immediately after use. 
Unopened, unused vials of surfactant suspension that have warmed to room
temperature can be returned to refrigerated storage within 24 hours for future use. Do
not warm to room temperature and return to refrigerated storage more than once.
Protect from light.
 Infection control: Ensure hand hygiene is performed, surgical aseptic technique is
used and equipment is kept sterile/clean to minimize risk of infection 

COMPLICATIONS

 Plugging of ETT by surfactant

 Hemoglobin desaturation and increased need for supplemental O2
 Bradycardia
 Tachycardia
 Pharyngeal deposition of surfactant
  Administration of surfactant to only one lung
 Administration of suboptimal dose
 Increase in pulmonary hemorrhage following surfactant treatment
 barotrauma

References

1. Polin, R. A., & Carlo, W. A. (2014). Surfactant replacement therapy for preterm and
term neonates with respiratory distress. Pediatrics, (1), 156.
2. Chiesi Farmaceutici, S.p.A.. (2014). Curosurf (poractant alfa) intratracheal
suspension, Prescribing Information.
3. Stevens, T.P., Blennow, M., Myers, E.H., Soll, R. (2007). Early surfactant
administration with brief ventilation vs. selective surfactant and continued mechanical
ventilation for preterm infants with or at risk for respiratory distress syndrome.
Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003063. DOI:
10.1002/14651858.CD003063.pub3.
4. El Shahed AI, Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration
syndrome in term and late preterm infants. Cochrane Database of Systematic Reviews
2014, Issue 12. Art. No.: CD002054. DOI: 10.1002/14651858.CD002054.pub3
5. Ardell S, Pfister RH, Soll R. Animal derived surfactant extract versus protein free
synthetic surfactant for the prevention and treatment of respiratory distress syndrome.
Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD000144. DOI:
10.1002/14651858.CD000144.pub3
6. Soll R, Özek E. Multiple versus single doses of exogenous surfactant for the
prevention or treatment of neonatal respiratory distress syndrome. Cochrane Database
of Systematic Reviews 2009, Issue 1. Art. No.: CD000141. DOI:
10.1002/14651858.CD000141.pub2
7. Finer, N. N. (2004). Surfactant use for neonatal lung injury: beyond respiratory
distress syndrome. Paediatric Respiratory Reviews, 5 Suppl AS289-S297.