Surfactant Use for Respiratory Distress Syndrome (RDS) in Preterm Infants - First Dose

1. Prophylactic treatment for preventing or ameliorating the severity of RDS is recommended for all inborn infants with a gestational age of < 27 weeks. Treatment should be accomplished as soon after delivery as possible, following intubation and clinical ascertainment of proper endotracheal tube placement.
2. Inborn infants > 27 weeks and < 30 weeks gestation should receive surfactant without delay if they require intubation and supplemental oxygen for respiratory failure.
3. Infants > 30 weeks gestation should receive surfactant therapy if they require mechanical ventilation and have a diagnosis of RDS.

Surfactant Use for RDS in Preterm Infants - Additional Doses

1. Infants < 30 weeks gestation with the diagnosis of RDS should receive a second dose of surfactant as a bolus 6-12 hours after the first dose if they continue intubated on mechanical ventilation, regardless of the inspired oxygen concentration.
2. Infants > 30 weeks gestation with the diagnosis of RDS should receive a second dose of surfactant as a bolus 6-12 hours after the first dose if they continue intubated on mechanical ventilation and require > 30% inspired oxygen. If the infant remains intubated with an inspired oxygen concentration between 21-29%, one should consider a second dose of surfactant.
3. One may consider continued treatment with additional doses of surfactant (total of 4 doses maximum) for preterm infants with RDS and worsening oxygenation 6-12 hours after the second dose.
4. The Survanta dose is 4 mL/kg/dose.
5. There is no contraindication to following another type of exogenous surfactant given at an outside institution (e.g., Exosurf) with the NICU standard dose of Survanta.
6. Generally speaking, initial treatment should not be initiated if the infant is greater than 48 hours of postnatal age.
7. Treatment is not contraindicated by endotracheal tube suction material that is blood streaked.

SELECTED REFERENCES

1. Schwartz,RM,Luby, AM, Scanlon, JW, Kellogg, RJ: Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g. N. Engl. J. Med. 1994;330:1476-1480.
2. Horbar, JD, Wright, EC, Onstad, L, and the Members of the National Institute of Child Health and Human Developement Neonatal Research Network: Decreasing mortality associated with the introduction of surfactant therapy: an observational study of neonates weighing 601 to 1300 grams at birth. Pediatrics 1993;1992:191-196.
3. Egberts, J, deWinter, JP, Sedin, G, deKleine, JK, Broberger, U, van Bel, F, Curstedt, T, Robertson, B: Comparison of prophylaxis and rescue treatment with Cursourf in neonates less than 30 weeks' gestation: a randomized trial. Pediatrics 1993;92:768-774.
4. Kattwinkel, J, Bloom, BT, Delmore, P, Davis, CL, Farrell, E, Friss, H, Jung, Al, King, K, Mueller, D: Prophylactic administration of calf lung surfactant extract is more effective than early treatment of respiratory distress syndrome in neonates of 29 through 32 weeks' gestation. Pediatrics 1993;92:90-98.
5. Dunn, MS: Surfactant replacement therapy: prophylaxis or treatment? Pediatrics 1993;148-149.
6. Long, W, Corbet, A, Cotton, R, Courtney, S, McGuiness, G, Walter, D, Watts, J, Smyth, J, Bard, H, Chernick, V: A controlled trial of synthetic surfactant in infants weighing 1250 g or more with respiratory distress syndrome. N. Engl. J. Med. 1991;325:1696-1703.
7. Dunn, MS, Shennan, AT, Zayack, D, Possmayer, F: Bovine surfactant replacement therapy in neonates of less than 30 weeks' gestation: a randomized controlled trial of prophylaxis versus treatment. Pediatrics1991;87:377-386.
8. Long, W, Thompson, T, Sundell, H, Schumacher, R, Volberg, F, Guthrie, R, and the American Exosurf Neonatal Study Group: Effects of two rescue doses of a synthetic surfactant on mortality rate and survival without bronchopulmonary dysplasia in 700 to 1350 gram infants with respiratory distress syndrome. J. Pediatr. 1991;118:595-605.
9. Merritt, TA, Hallman, M, Berry, C, Pohjavuori, M, Edwards, DK, Jaaskelainen, J, Grafe, MR, Vaucher, Y, Wozniak, P, Heldt, G, Rapola, J: Randomized, placebo-controlled trial of human surfactant given at birth versus rescue administration in very low birth weight infants with lung immaturity. J. Pediatr. 1991;118(4):581-594.
10. Couser, RJ, Ferrara, TB, Ebert, J, Hoekstra, RE, Fangman, JJ: Effects of exogenous surfactant therapy on dynamic compliance during mechanical breathing in preterm infants with hyaline membrane disease. J.Pediatr. 1990;116:119-124

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