Surfactant Toolkit Preamble:
Surfactant administration has dramatically impacted the care of premature newborns, saving thousands of lives. However, increased experience with other modalities of respiratory care and resuscitation have led CPQCC to revise its previous recommendations regarding prophylactic surfactant use.
Recent large multicenter trials show that the strategy of intubation, early surfactant administration and subsequent weaning to extubation does not improve major outcomes (death, BPD) compared to initial stabilization with nasal CPAP (NCPAP). Clearly, there are many infants whose RDS is mild enough that the beneficial effects of lung volume stabilization by NCPAP on endogenous surfactant metabolism and physiology is enough to support them without the use of exogenous surfactant. The act of intubation itself carries significant risks, such as trauma and misplacement. The ongoing presence of an endotracheal tube reduces airway resistance and impedes secretion clearance, and imposes risks of ventilator-associated pneumonia.
While we recognize that we don't always have to give surfactant, there are still many babies with severe enough RDS that they would benefit from its use. The strategy of briefly intubating for surfactant administration, then promptly extubating back to NCPAP has been shown to be an effective strategy for many infants with moderate RDS. Infants with RDS may require intubation for inadequate respiratory drive, which thereby reduces the risks of surfactant that would otherwise be linked to the act of intubation. There could still be populations at risk for such severe RDS (e.g. premature infants born to mothers who did not receive antenatal steroid) that could justify more immediate intubation and surfactant use.
While we no longer advocate across-the-board prophylactic surfactant administration as part of delivery room management and initial stabilization, we still promote the timely and judicious use of exogenous surfactant, when indicated. The sooner surfactant is administered, the sooner it will have its physiological benefits. Once a baby receives surfactant, we need to use our technologies and monitoring to maximize its benefits and minimize its risks. Supplemental oxygen concentration must be weaned to reduce oxidative injury to the lungs and other organs. Monitoring tidal volumes should reduce overinflation and measurement of carbon dioxide levels (by ABG, end-tidal or transcutaneously) is important to avoid reductions in cerebral perfusion that can arise from hyperventilation and hypocarbia.
Premature infants with RDS need stabilization of their lung volume, starting with resuscitation, yet they may or may not require the additional beneficial effects of exogenous surfactant. Surfactant need not be given prophylactically, but it remains an important part of our armamentarium for the treatment for RDS.