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Reprinted from the August 1994 issue of RESPIRATORY CARE [Respir Care 1994:39(8):824–829]

AARC Clinical Practice Guideline

Surfactant Replacement Therapy


Surfactant replacement therapy in the neonate


Natural, endogenous surfactant is a compound composed of phospholipids, neutral lipids, and proteins(1-5) that forms a layer between the alveolar surface and the alveolar gas and reduces alveolar collapse by decreasing surface tension within the alveoli.(3-5) Surfactant deficiency is almost always associated with the formation of hyaline membranes in the immature lung and the onset of respiratory distress syndrome (RDS)-a major cause of morbidity and mortality in premature infants.(3) Without surfactant, alveoli may never inflate or may collapse on expiration and require inordinate force to re-expand on inspiration, leading to the development of RDS.(3,5) The incidence of RDS is related more to lung immaturity than to gestational age.(6) However, in general, the more premature the infant, the less the surfactant production and the higher the probability for RDS.(4,6) Direct tracheal instillation of surfactant has been shown to reduce mortality and morbidity in infants with RDS.(7-25)

Surfactant can be extracted from animal lung lavage and from human amniotic fluid or produced from synthetic materials.

Two basic strategies for surfactant replacement have emerged: (1) prophylactic or preventive treatment in which surfactant is administered at the time of birth or shortly thereafter to infants who are at high risk for developing RDS and (2) rescue or therapeutic treatment in which surfactant is administered after the initiation of mechanical ventilation in infants with clinically confirmed RDS.(2,10-12,26,27)


Administered by trained personnel in
3.1 Delivery room
3.2 Neonatal intensive care unit


4.1 Prophylactic administration may be indicated in
4.1.1 infants at high risk of developing RDS because of short gestation (< 32 weeks)(8,10-12,21,25-29) or low birthweight (< 1,300 g),(21-25,28) which strongly suggest lung immaturity.
4.1.2 infants in whom there is laboratory evidence of surfactant deficiency such as lecithin/sphingomyelin ratio less than 2:1,11,14,28,30,31 bubble stability test indicating lung immaturity,(15,32) or the absence of phosphatidylglycerol.(11,14,22-24,28,30)
4.2 Rescue or therapeutic administration is indicated in preterm or full-term infants
4.2.1 who require endotracheal intubation and mechanical ventilation because of increased work of breathing as indicated by an increase in respiratory rate, substernal and suprasternal retractions, grunting, and nasal flaring.(8,11,14-16,29,33-35) increasing oxygen requirements as indicated by pale or cyanotic skin color, agitation, and decreases in PaO2, SaO2, or SpO2 mandating an increase in FIO2 above 0.(4011,12,15,26,33,36-38)
4.2.2 have clinical evidence of RDS,(13,39) including chest radiograph characteristic of RDS,(8,11-16,33,34,36,37,40-42) mean airway pressure greater than 7 cm H2O to maintain an adequate PaO2, SaO2, or SpO2.(11,14,15,26,43)


Relative contraindications to surfactant administration are
5.1 the presence of congenital anomalies incompatible with life beyond the neonatal period,(8,14,15,26,28,29,31,33,36,41,44)
5.2 respiratory distress in infants with laboratory evidence of lung maturity.(9,14,27-29,33,36,41)


6.1 Procedural complications resulting from the administration of surfactant include
6.1.1 plugging of endotracheal tube (ETT) by surfactant;(2)
6.1.2 hemoglobin desaturation and increased need for supplemental O2;(11,33,41)
6.1.3 bradycardia due to hypoxia;(9,33,41,45)
6.1.4 tachycardia due to agitation, with reflux of surfactant into the ETT;(34,41)
6.1.5 pharyngeal deposition of surfactant;
6.1.6 administration of surfactant to only one lung;
6.1.7 administration of suboptimal dose secondary to miscalculation or error in reconstitution.
6.2 Physiologic complications of surfactant replacement therapy include
6.2.1 apnea,(7,13,15)
6.2.2 pulmonary hemorrhage,(12,15,18,32,34,38,46,47)
6.2.3 mucus plugs,(48)
6.2.4 increased necessity for treatment for PDA,(18,29,30)
6.2.5 marginal increase in retinopathy of prematurity,(11)
6.2.6 barotrauma resulting from increase in lung compliance following surfactant replacement and failure to change ventilator settings accordingly.(30,49)


7.1 Surfactant administered prophylactically may be given to some infants in whom RDS would not have developed.(10,12,26,33)
7.2 When surfactant is administered prophylactically in the delivery room, ETT placement may not have been verified by chest radiograph resulting in the inadvertent administration to only one lung or to the stomach.(26)
7.3 Prophylactic surfactant administration may delay patient stabilization.(26)
7.4 Atelectasis and lung injury may occur prior to therapeutic administration.(26,33)
7.5 Tracheal suctioning should be avoided following surfactant administration.(9,11,13,14,27,33,38,44,50)
7.6 Not all infants who are treated with a single dose of surfactant experience a positive response39 or the response may be transient.
7.7 Positioning recommended for surfactant administration may further compromise the unstable infant.(9,11,12,14,16,28,33,38-40)


Determine that valid indications are present.
8.1 Assess lung immaturity prior to prophylactic administration of surfactant by gestational age and birthweight and/or by laboratory evaluation of tracheal or gastric aspirate.
8.2 Establish the diagnosis of RDS by chest radiographic criteria and the requirement for mechanical ventilation in the presence of short gestation and/or low birthweight.


9.1 Reduction in FIO2 requirement(12,33,34,36-39,41,44)
9.2 Reduction in work of breathing(51)
9.3 Improvement in lung volumes and lung fields as indicated by chest radiograph(13,16,33,40)
9.4 Improvement in pulmonary mechanics (eg, compliance, airways resistance, VT, VE, transpulmonary pressure) and lung volume (ie, FRC)(42,43,50,52-59)
9.5 Reduction in ventilator requirements (PIP, PEEP, Paw)(2,8,9,12,13,27,30,33,36-39,41,44,50,52)
9.6 Improvement in ratio of arterial to alveolar PO2 (a/A PO2), oxygen index(13,16,28,30,33,34,37-41,44)


Administration procedures recommended for specific preparations of surfactant should be adhered to.
10.1 Equipment(10-14,16,26-28,33,34,39,40,50,60)
10.1.1 Administration equipment Syringe containing the ordered dose of surfactant, warmed to room temperature(11,12,16,38,40) 5-Fr feeding tube or catheter, or endotracheal tube connector with delivery port Mechanical ventilator or manual ventilator (resuscitation bag)(8,16,33,36,38-40,44,50,52)
10.1.2 Resuscitation equipment Laryngoscope and endotracheal tube(10-12,14,16,26,38) Manual resuscitation bag(9-12,16,26-28,36,39,40,50) and airway manometer Blended oxygen source(9,16,28,44) Suction equipment (ie, catheters, sterile gloves, collecting bottle and tubing, and vacuum generator)(9,33,50,60) Radiant warmer ready for use
10.1.3 Monitoring equipment Neonatal tidal volume monitor if available(50) Airway pressure monitor Pulse oximeter or transcutaneous PCO2 monitor(11,26,34,39-41,52) Cardiorespiratory monitor
10.2 Personnel-- Surfactant replacement therapy should be performed under the direction of a physician by credentialed personnel (eg, CRTT, RRT, RN) who competently demonstrate
10.2.1 proper use, understanding, and mastery of the equipment and technical aspects of surfactant replacement therapy;
10.2.2 comprehensive knowledge and understanding of neonatal ventilator management and pulmonary anatomy and pathophysiology;
10.2.3 neonatal patient assessment skills, including the ability to recognize and respond to adverse reactions and/or complications of the procedure;
10.2.4 knowledge and understanding of the patient's history and clinical condition;
10.2.5 knowledge and understanding of airway management;
10.2.6 ability to interpret monitored and measured blood gas variables and vital signs;
10.2.7 proper use, understanding, and mastery of emergency resuscitation equipment and procedures;
10.2.8 ability to evaluate and document outcome (Section 9.0);
10.2.9 understanding and proper application of Universal Precautions.


The following should be monitored as part of surfactant replacement therapy.
11.1 Variables to be monitored during surfactant administration
11.1.1 Proper placement and position of delivery device
11.1.2 FIO2 and ventilator settings(8,9,11,13-15,27-29,33,36,38,44)
11.1.3 Reflux of surfactant into ETT(34,41)
11.1.4 position of patient (ie, head direction)(9,11,33)
11.1.5 Chest-wall movement(61)
11.1.6 Oxygen saturation by pulse oximetry(11,26,34,39-41,52)
11.1.7 Heart rate, respirations, chest expansion, skin color, and vigor(16,26,27,34,41,45,52)
11.2 Variables to be monitored after surfactant administration
11.2.1 Invasive and noninvasive measurements of arterial blood gases(8,9,11,12-16,26-29,33,36,38,39,41,44)
11.2.2 Chest radiograph(11-16,28,36,38-40,44)
11.2.3 Ventilator settings (PIP, PEEP, Paw) and FIO2(8,9,11,13-16,28,29,33,36,38)
11.2.4 Pulmonary mechanics and volumes
11.2.5 Heart rate, respirations, chest expansion, skin color, and vigor(16,26,27,34,41,45,52)
11.2.6 Breath sounds(11,38)
11.2.7 Blood pressure1(3,16,33,40,44,45)


Repeat doses of surfactant are contingent upon the continued diagnosis of RDS. The frequency with which surfactant replacement is performed should depend upon the clinical status of the patient and the indication for performing the procedure. Additional doses of surfactant, given at 6- to 24-hour intervals, may be indicated in infants who experience increasing ventilator requirements or whose conditions fail to improve after the initial dose.(7,9,11,12,14,15,26,30,34,37,39,52)


13.1 Universal Precautions(62) should be implemented.
13.2 Aseptic technique should be practiced.
13.3 Appropriate infection control guidelines for the patient should be posted and followed.
Perinatal-Pediatrics Guidelines Committee:

Lynne K Bower RRT, Chairman, Boston MA
Sherry L Barnhart RRT, Mattoon IL
Peter Betiti BS RRT, Boston MA
Barbara Hendon BA RRT RCP, Wylie TX
Joanne Masi-Lynch BS RRT, Salt Lake City UT
Barbara G Wilson MEd RRT, Durham NC

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Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

Reprinted from the August 1994 issue of RESPIRATORY CARE [Respir Care 1994:39(8):824–829]

You are here: » Clinical Practice Guidelines