What is the recommended treatment for a premature newborn with respiratory distress syndrome (RDS), specifically regarding surfactant therapy, such as beractant (recombinant human surfactant) or poractant alfa (porcine-derived surfactant)?

Surfactant Therapy for Premature Infants with Respiratory Distress Syndrome

Administer animal-derived surfactant (poractant alfa or beractant) as soon as possible after intubation for premature infants with RDS, with poractant alfa showing advantages in reducing mortality, need for repeat dosing, and faster extubation compared to beractant. 1, 2

Choice of Surfactant Preparation

Animal-derived surfactants (poractant alfa, beractant, calfactant) are superior to first-generation synthetic surfactants, demonstrating lower mortality rates (RR: 0.86; 95% CI: 0.76–0.98; NNT: 40) and fewer pneumothoraxes (RR: 0.63; 95% CI: 0.53–0.75; NNT: 22). 1

Poractant Alfa vs Beractant

While both are effective, poractant alfa demonstrates clinically meaningful advantages:

• Reduced need for repeat dosing: Only 12% of infants required ≥2 doses with poractant alfa versus 31% with beractant (p=0.023) 2
• Faster extubation: 81% extubated within 3 days with poractant alfa versus 55.9% with beractant (p=0.004) 2
• Lower oxygen requirements: Significantly reduced FiO₂ on days 1,3, and 5 post-treatment 2
• Better survival free of bronchopulmonary dysplasia: 78.7% with poractant alfa versus 58.5% with beractant (p=0.015) 2
• Fewer clinically significant PDAs: 32% with poractant alfa versus 76% with beractant (p=0.002) 3

However, beractant is significantly more economical with similar efficacy when using the LISA technique, making it a reasonable choice in resource-limited settings. 4

Timing and Administration Strategy

Initiate CPAP (5-6 cm H₂O) immediately after birth as first-line treatment for spontaneously breathing preterm infants with respiratory distress. 5 This CPAP-first approach with selective surfactant administration reduces bronchopulmonary dysplasia and death compared to prophylactic surfactant (RR 0.53,95% CI 0.34-0.83). 5

When to Administer Surfactant

Give surfactant as soon as possible after intubation when:

• Infant shows worsening respiratory distress despite CPAP support 5
• Preterm infants <30 weeks' gestation require mechanical ventilation for severe RDS 5
• Early rescue surfactant (<2 hours of age) significantly decreases mortality (RR 0.84; 95% CI 0.74-0.95), air leak (RR 0.61; 95% CI 0.48-0.78), and chronic lung disease (RR 0.69; 95% CI 0.55-0.86) 5

Prophylactic surfactant should be considered only for extremely preterm infants at high risk of RDS, especially those not exposed to antenatal steroids. 1

Dosing Regimen

Poractant Alfa (Curosurf)

• Initial dose: 2.5 mL/kg (200 mg/kg) birth weight 6
• Repeat doses: Up to two doses of 1.25 mL/kg (100 mg/kg) at approximately 12-hour intervals 6
• Maximum total dose: 5 mL/kg (400 mg/kg) 6

Beractant

• Initial dose: 100 mg/kg 4
• Administer repeat doses as needed for persistent respiratory distress 1

Critical Timing Considerations

Do not redose more frequently than every 12 hours unless surfactant is being inactivated by infection, meconium, or blood. 5 Plan for up to 3 additional doses in the first 48 hours if the infant continues to require mechanical ventilation with FiO₂ ≥0.30. 5

Administration Technique

Use the INSURE strategy (Intubation, Surfactant administration, Extubation to CPAP) when possible, as it significantly reduces the need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79) and oxygen requirement at 28 days. 5

Poractant Alfa Administration

• Administer intratracheally either as two divided aliquots through a 5 French end-hole catheter OR as a single bolus through the secondary lumen of a dual lumen endotracheal tube 6
• Warm vial slowly to room temperature before use 6
• Gently turn vial upside-down to obtain uniform suspension—DO NOT SHAKE 6
• Discard if suspension is discolored (should be white to creamy white) 6

Monitoring and Complications

Expect transient airway obstruction, oxygen desaturation, bradycardia, and alterations in cerebral blood flow during administration. 5

Essential Monitoring Parameters

• Continuous oxygen saturation and heart rate monitoring 5
• Make expeditious ventilator setting changes after surfactant administration to minimize lung injury and air leak 5
• Monitor for signs requiring repeat dosing: persistent FiO₂ ≥0.30 on mechanical ventilation 5

Special Populations and Considerations

Antenatal Steroids

Antenatal steroids and postnatal surfactant work independently and additively, reducing mortality, RDS severity, and air leaks more than either alone. 1, 5 However, the optimal surfactant dosing strategy for infants exposed to antenatal steroids remains undetermined. 1

Secondary Surfactant Deficiency

Consider rescue surfactant for late-preterm and term neonates with secondary surfactant deficiency from meconium aspiration syndrome, pneumonia/sepsis, or pulmonary hemorrhage, as it improves oxygenation and reduces ECMO requirements. 1, 5 These conditions may require more frequent redosing due to surfactant inactivation. 5

Contraindications

Do not use surfactant for congenital diaphragmatic hernia, as it has not shown improved outcomes. 5

Personnel Requirements

Surfactant must be administered by or under supervision of clinicians experienced in intubation, ventilator management, and general care of premature infants. 1, 5, 6 Ensure proper endotracheal tube placement and patency before administration. 6

Common Pitfalls to Avoid

• Avoid routine intubation with prophylactic surfactant as first-line approach—start with CPAP instead 5
• Do not delay surfactant administration once intubation is required—early rescue is superior to delayed treatment 5
• Do not redose more frequently than every 12 hours unless infection, meconium, or blood is present 5
• Do not shake the surfactant vial—gently invert to mix 6
• Avoid excessive fluid administration (>160 mL/kg/day), which increases risk of PDA, NEC, and BPD 7