Benefits of Surfactant Therapy in Respiratory Distress Syndrome
Surfactant replacement therapy substantially reduces mortality and respiratory morbidity in preterm infants with RDS, decreasing death rates, pneumothoraces, pulmonary interstitial emphysema, and the combined outcome of chronic lung disease or death. 1
Mortality and Survival Benefits
- Surfactant therapy reduces overall mortality with a relative risk of 0.63 (95% CI: 0.47-0.84), meaning approximately 1 in 3 deaths are prevented in treated infants. 2
- Early rescue surfactant administered within 1-2 hours of birth significantly decreases mortality compared to delayed treatment (RR 0.84; 95% CI 0.74-0.95). 3
- The number needed to treat to prevent one death varies by timing and preparation, but the mortality benefit is consistent across multiple high-quality trials. 1
Reduction in Air Leak Syndromes
- Surfactant therapy dramatically reduces pneumothorax risk (RR 0.62; 95% CI 0.42-0.89), preventing approximately 1 pneumothorax for every 22 infants treated. 2
- Pulmonary interstitial emphysema is reduced with a relative risk of 0.54 (95% CI: 0.36-0.82). 2
- Early administration results in fewer air leaks (RR 0.61; 95% CI 0.48-0.78) compared to delayed treatment. 3
Chronic Lung Disease and Bronchopulmonary Dysplasia
- The combined outcome of bronchopulmonary dysplasia (BPD) or death at 28 days is significantly reduced (RR 0.85; 95% CI: 0.76-0.95). 2
- Early rescue surfactant decreases chronic lung disease risk (RR 0.69; 95% CI 0.55-0.86) compared to delayed administration. 3
- When combined with early CPAP strategies, surfactant therapy further reduces BPD rates compared to routine intubation approaches. 3, 2
Improved Respiratory Function
- Surfactant restores surface activity to the lungs, lowering surface tension and stabilizing alveoli against collapse. 4
- Treatment results in faster weaning from supplemental oxygen and mechanical ventilation. 5
- The INSURE strategy (Intubation, Surfactant administration, Extubation to CPAP) significantly reduces the need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79). 3
FDA-Approved Indications
- Poractant alfa (CUROSURF) is FDA-approved for rescue treatment of RDS in premature infants, specifically for reduction of mortality and pneumothoraces. 6
- Beractant (SURVANTA) replenishes surfactant and restores surface activity to the lungs of premature infants with RDS. 4
Synergistic Effects with Antenatal Steroids
- Antenatal steroids and postnatal surfactant work independently and additively, reducing mortality, RDS severity, and air leaks more effectively than either intervention alone. 3, 2
- This synergistic effect is particularly important for extremely preterm infants at highest risk. 2
Optimal Timing Considerations
- Early rescue surfactant (within 1-2 hours) is superior to delayed treatment (≥2 hours after birth) across all major outcomes including mortality, air leak, and chronic lung disease. 3
- The current recommended approach is early CPAP with selective surfactant administration for infants showing worsening respiratory distress, rather than routine prophylactic surfactant. 3, 7
- For infants <30 weeks gestation requiring mechanical ventilation due to severe RDS, surfactant should be administered after initial stabilization. 3, 7
Important Clinical Caveats
- Animal-derived surfactants are more effective than first-generation synthetic surfactants, showing lower mortality rates (RR 0.86; 95% CI 0.76-0.98) and fewer pneumothoraces (RR 0.63; 95% CI 0.53-0.75). 3
- Transient adverse effects during administration include bradycardia, hypotension, endotracheal tube blockage, and oxygen desaturation, requiring temporary cessation and appropriate intervention. 6
- Surfactant administration requires specialized expertise and should only be performed by clinicians experienced in intubation and ventilator management of premature infants. 3