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Surfactant administration in NICU

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The administration of exogenous surfactant to newborn infants with or at risk of Respiratory Distress Syndrome (RDS) is established practice. Infants with RDS who are treated with early surfactant and CPAP are less likely to need mechanical ventilation, suffer from an air leak and develop BPD than are infants treated with CPAP and later surfactant therapy (rescue surfactant).1,2 In early trials the delivery of surfactant was by endotracheal intubation. There are several non-invasive methods for surfactant delivery being explored; nebulised, laryngeal mask airway and thin-catheter.3,4 Recent systematic reviews and meta-analysis have found that surfactant delivery techniques which minimise mechanical ventilation (thin-catheter surfactant and INSURE - intubation, surfactant, extubation technique) are associated with better outcomes.5,6 The optimal strategy is currently unclear, particularly in infants managed on CPAP with adequate antenatal steroid cover but there is growing evidence to support the use of thin catheter delivered surfactant to infants maintained on CPAP support.7 Early use of thin catheter surfactant administration appears to be safe and reduces the need for mechanical ventilation in many preterm infants whilst it does not increase the risk of IVH, pneumothorax or BPD.3,8

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 the treatment of RDS in premature infants.
  • Surfactant (Beractant used in trials) administration in ventilated infants with Meconium Aspiration Syndrome (MAS) has been found to improve oxygenation in most studies but there are many non-responders and the effect may be transient. Pooled data also suggest a potential reduction in the requirement for Extracorporeal Membrane Oxygenation (ECMO) (2 Trials, 208 infants; RR0.64, 95% CI 0.46, 0.91; NNT 6, 95% CI 3 to 25) but does not affect mortality, air leak or ventilator days.9
  • There are no studies to support the use of surfactant in infants with bacterial pneumonia.
  • There is insuffcient evidence to support use of surfactant as treatment for pulmonary haemorrhage.

When to give surfactant

Babies at risk of RDS should be started on CPAP from birth.

In babies <32 weeks, CPAP failure is predicted by FiO2 requirements over 0.30 in the first hours of life, with those failing having worse outcomes.10 If RDS develops and surfactant is needed, the earlier surfactant is given the better the outcome (reduced air leaks and avoidance of mechanical ventilation).2,6 There is no advantage in prophylactic surfactant over initiation of CPAP alone; however, surfactant should be strongly considered in delivery suite for extremely preterm babies of whom the mother did not receive antenatal steroids or for preterm infants who need intubation for stabalisation.11,12

The European Consensus Group recommends infants <=26 weeks with an FiO2 > 0.30 and infants > 26 weeks with FiO2 > 0.40 should be given surfactant. In preterm babies receiving oxygen, the saturation target should be between 90-94% (alarm limits 89-95%).12

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. With increasing respiratory support requirements e.g. FiO2 >40%, pH<7.25, PaO2 <7.0 kPa, PaCO2 > 7.0 kPa, (or A/a < 0.22) or need for mechanical ventilation.

A second (at least 6 hours after the first dose) and sometimes third dose of surfactant should be given if there is evidence of ongoing RDS and need for mechanical ventilation (discuss with consultant).

Methods to deliver surfactant

Less Invasive Surfactant Administration - LISA3,4 whereby the surfactant is administered via a thin catheter into the trachea in small aliquots while the baby remains on CPAP support throughout, may be used as an alternative to INSURE.

In infants 29-32 weeks gestation, LISA may reduce the occurrence of pneumothorax and need for mechanical ventilation.13 Safety and efficacy of minimally invasive techniques of surfactant delivery in infants <28 weeks is still being assessed.

Endotracheal intubation, brief ventilation and extubation - INSURE strategy should be considered for infants who are failing on CPAP and LISA technique was unsuccessful or sedation medication is required to facilitate the procedure.


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 stabilised, resume the dosing procedure.

If the infant is intubated, ensure tube position is not too deep prior to the surfactant dose; either by auscultation, rechecking endotracheal tube (ETT) distance at nose/mouth or chest radiograph, as a deep position of the ETT places the baby at risk of selective surfactant administration into the right main bronchus.

In an observational study LISA technique was associated with increased risk of spontaneous intestinal perforation (SIP) in extremely preterm infants.14

Adverse reactions

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


See Poractant alpha protocol. We use both LISA and INSURE techniques. Infants should be less than 48 hours old.


Selected infants may be considered for thin catheter administration of surfactant.

Infants should have good respiratory effort.

One-to-one nursing is recommended for the duration of the administration and observations.

CPAP continues during LISA procedure but be prepared to support infant on Neopuff temporarily.

Inform the level 3 specialist and staff in case the infant requires intubation.


In general infants requiring intubation will be moved to Level 3 as intubation drugs may be required when performing INSURE technique, acknowledging that this may prolong recovery time and some infants will therefore require ongoing ventilation.

Ensure endotracheal tube position prior to surfactant dose by reviewing the insertion distance and ascultating the chest.

Position the baby supine with head in a neutral position.

Extubate to CPAP as soon as clinically able.

Ideally a registrar/NS-ANP should remain on NICU for 30 minutes following extubation.

If mechanically ventilated, either briefly connect to Neopuff or reconnect to the ventilator circuit straight after surfactant administration. Note that infants may briefly require ventilation at higher pressures and with longer inspiratory times until stable. Preferably use volume guarantee mode as ventilator requirements should rapidly improve following surfactant administration. If no improvement post-surfactant, discuss with SMO. Options may include a repeat chest radiograph or ongoing positive pressure ventilation.

Infants on high frequency ventilation mode (HFOV) should receive manual ventilation using the Neopuff until the surfactant is adequately dispersed.

Suctioning should be avoided for 4 hours (unless absolutely indicated for a blocked ETT).


  1. Stevens TP, Blennow M, Myers EH, Soll R. Early surfactant administration with brief ventilation versus selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane database of systematic reviews 2007. CD003063. 
  2. Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database of Systematic Reviews 2012. Issue 11. CD001456 
  3. Göpel W, Kribs A, Ziegler A, Laux R, et al. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): An open-label, randomised controlled trial. Lancet 2011;378:1627-33. 
  4. Dargaville PA, Aiyappan A, De Paoli AG, Kuschel CA, Kamlin CO et al. Minimally invasive surfactant therapy in preterm infants on continuous positive airway pressure. Arch Dis Child Fetal Ed 2013;98:F122-126.
  5. Isayama T, Iwami H, McDonald S, Beyene J. Association of Noninvasive Ventilation Strategies with Mortality and BPD among preterm infants. A systematic review and Meta-analysis. JAMA 2016;316(6):611-24.
  6. Aldana-Aguirre JC et al. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: Systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2017;102:F17-23.
  7. Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane database of systematic reviews. 2012 CD000510.
  8. Kribs A, Roll C, Gopel W et al. Nonintubated surfactant application vs conventional therapy in extremely preterm infants. A randomized clinical trial. JAMA Pediat 2015;169(8):723-730.
  9. Shahed AIE, Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration syndrome in term and late preterm infants. The Cochrane database of systematic reviews 2014. CD002054.
  10. Dargaville PA, Aiyappan A, De Paoli AG et al. Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences. Neonatology 2013;104:8-14.
  11. Isayama T, Chai-Adjsaksopha C, McDonald SD. Noninvasive ventilation with vs without early surfactant to prevent chronic lung disease in preterm infants. A systematic review and meta-analysis. JAMA Pediatrics. 2015;169(8):731-39.
  12. European Consensus Guidelines on the management of Respiratory Distress Syndrome 2016 Update. Sweet DG, Carielle V, Greisen G et al. Neonatology 2017;111(2):107-125.
  13. Dargaville PA, Ali SKM, Jackson HD, Williams C and De Paoli AG. Impact of minimally invasive surfactant therapy in preterm infants at 29-32 weeks gestation. Neonatology 2018;113:7-14.
  14. Hartel C, Paul P, Hanke K et al. Less invasive surfactant administration and complications of preterm birth. Nature Scientific reports (2018) 8:8333DOI:10.1038/s41598-018-26437-x

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Document Control

  • Date last published: 19 December 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years