Recommendations for neonatal surfactant therapy

Question 1

What are the benefits of surfactant therapy?

Answer 1

1. Reduced mortality
2. Reduced deficits in oxygenation
3. Reduced pneumothorax and pulmonary interstitial emphysema
4. Reduced duration of ventilatory support
5. Increases likelihood of survival without BPD by improving survival not reducing incidence of BPD
6. Reduced LOS hospital
7. Reduced costs of NICU treatment

Question 2

What are the indications for surfactant therapy?

Answer 2

1. Intubated infants with RDS
2. Intubated infants with meconium aspiration syndrome requiring >50% oxygen
3. Sick newborn infants with pneumonia and an OI > 15
4. Inntubated newborn infants with pulmonary hemorrhage leading to clinical deterioration

No recommendations for lung hypoplasia or congenital diaphragmatic hernia

Question 3

What are the risks of exogenous surfactant therapy?

Answer 3

1. Bradycardia during instillation
2. Hypoxemia during instillation
3. Blockage of the ETT
4. Increased pulmonary hemorrhage but not death related to pulmonary hemorrhage
5. Hyperventilation with low PCO2 and lung distension can occur if pressures are no reduced
6. Potential transfer of prions

Question 4

Which is better natural or synthetic surfactants?

Answer 4

Natural surfactants

Question 5

Which is better surfactant prophylaxis or rescue therapy for preterm infants with RDS?

Answer 5

Infants who are at significant risk of RDS should receive prophylactic natural surfactant therapy as soon as they are stable within a few minutes after intubation

Question 6

How should surfactant replacement therapy be given?

Answer 6

Instill liquid form via ETT

Either in one bolus or over aliquots

Question 7

What dosage should be used?

Answer 7

Up to 120mg/kg for first dose

Question 8

Should multiple or single doses of surfactant be used?

Answer 8

Infants with RDS who have persistent or recurrent oxygen and ventilatory requirements within the first 72 h of life should have repeated doses of surfactant. Administering more than three doses has not been shown to have a benefit

Question 9

What are the criteria for, and timing of, retreatment?

Answer 9

Retreatment should be considered when there is a persistent or recurrent oxygen requirement of 30% or more and it may be given as early as 2 h after the initial dose or, more commonly, 4 h to 6 h after the initial dose

Question 10

How should ventilatory management after surfactant therapy be approached?

Answer 10

Options for ventilatory management that can be considered after prophylactic surfactant therapy include very rapid weaning and extubation to CPAP within 1h

Question 11

If postnatal surfactant therapy is available does the infant still need to use antenatal steroids?

Answer 11

According to established guidelines, mothers at risk of delivering babies with less than 34 weeks gestation should be given antenatal steroids regardless of the availability of postnatal surfactant therapy

Question 12

Should surfactant therapy be given before the transport of a baby with RDS?

Answer 12

1. Intubated infants with RDS should receive exogenous surfactant therapy before transport
2. Centres administering surfactant therapy to newborn infants must ensure the continuous on-site availability of personnel that are competent and licensed to deal with the acute complications of assisted ventilation and surfactant therapy

Question 13

How should surfactant replacement therapy be used outside a tertiary centre?

Answer 13

1. Mothers with threatened delivery before 32 weeks gestation should be transferred to a tertiary centre if at all possible.
2. Infants who deliver at less than 29 weeks gestation outside of a tertiary centre should be considered for immediate intubation followed by surfactant administration after stabilization, if competent personnel are available