What are the guidelines for surfactant administration in neonates with respiratory distress syndrome?

Guidelines for Surfactant Administration in Neonates with Respiratory Distress Syndrome

Preterm infants born at <30 weeks' gestation who need mechanical ventilation because of severe RDS should be given surfactant after initial stabilization, while using CPAP immediately after birth with subsequent selective surfactant administration is recommended as an alternative to routine intubation with prophylactic surfactant. 1

Primary Recommendations for Surfactant Administration

For Preterm Infants with RDS:

1. Initial Respiratory Support Strategy:

   • Start with CPAP immediately after birth rather than routine intubation with prophylactic surfactant 1
   • Use selective surfactant administration only when needed 1

2. Indications for Surfactant Administration:

   • Preterm infants <30 weeks with severe RDS requiring mechanical ventilation 1
   • Early rescue surfactant (<2 hours of age) for infants with evolving RDS decreases mortality, air leak, and chronic lung disease 1
   • Surfactant should be given as soon as possible after intubation irrespective of exposure to antenatal steroids or gestational age 1

3. Dosing Protocol (based on FDA-approved poractant alfa): 2

   • Initial dose: 2.5 mL/kg birth weight (200 mg/kg)
   • Up to two repeat doses of 1.25 mL/kg birth weight may be administered at approximately 12-hour intervals
   • Maximum total dose: 5 mL/kg

INSURE Technique (Intubation, Surfactant, Extubation)

The INSURE approach is strongly supported by evidence:

• Intubate briefly
• Administer surfactant
• Extubate to nasal CPAP 3, 4

This technique is associated with:

• 43% decreased need for mechanical ventilation by day 5 4
• Lower incidence of air leak syndromes 3
• Reduced bronchopulmonary dysplasia 3

Secondary Indications for Surfactant

Rescue surfactant may be considered for infants with hypoxic respiratory failure attributable to secondary surfactant deficiency, including: 1

• Meconium aspiration syndrome
• Sepsis/pneumonia
• Pulmonary hemorrhage

Implementation Considerations

1. Personnel Requirements:

   • Preterm and term neonates receiving surfactant should be managed by nursery and transport personnel with technical and clinical expertise 1
   • Providers without expertise should wait for transport team arrival 1

2. Administration Methods:

   • Administer intratracheally either in two divided aliquots through a 5 French end-hole catheter, or
   • As a single bolus through secondary lumen of a dual lumen endotracheal tube without interrupting mechanical ventilation 2

3. Monitoring During Administration:

   • Watch for transient adverse effects including bradycardia, hypotension, endotracheal tube blockage, and oxygen desaturation 2
   • If these occur, stop administration and take appropriate measures to alleviate the condition 2

Special Considerations

1. Antenatal Steroids:

   • Antenatal steroids and postnatal surfactant replacement independently and additively reduce mortality, severity of RDS, and air leaks in preterm infants 1
   • May reduce the need for prophylactic surfactant in infants born after 27-28 weeks gestation 1

2. High-Frequency Oscillatory Ventilation (HFOV):

   • Early surfactant administration followed by HFOV facilitates respiratory stabilization during acute phase of severe RDS 5
   • May reduce incidence of chronic lung disease or death compared to delayed dosing 5

3. Treatment Threshold:

   • Lower treatment threshold (FiO2 <0.45) confers greater advantage in reducing air leak syndromes and BPD 3
   • Higher treatment threshold (FiO2 >0.45) is associated with increased risk of PDA 3

Outcomes and Benefits

Surfactant replacement therapy has been shown to:

• Reduce mortality in preterm infants with RDS 1
• Decrease incidence of pneumothorax and air leaks 1
• Reduce need for ECMO in meconium aspiration syndrome 1
• Early administration (<2 hours) decreases risk of mortality, air leak, and chronic lung disease 1

However, surfactant replacement has not been shown to affect neurologic, developmental, behavioral, medical, or educational outcomes in preterm infants 1.

Common Pitfalls to Avoid

1. Delaying surfactant administration in infants who clearly need it
2. Routine intubation for prophylactic surfactant when CPAP with selective surfactant may be more beneficial
3. Administering surfactant without proper expertise and monitoring
4. Not considering surfactant for secondary causes of respiratory failure
5. Using surfactant in infants with congenital diaphragmatic hernia (does not improve outcomes) 1

Following these guidelines will optimize outcomes for neonates with respiratory distress syndrome while minimizing complications associated with mechanical ventilation.