Practical considerations in the selection and use of pulmonary surfactant therapy for neonatal respiratory distress syndrome in the intensive care setting.

Pulmonary surfactant is the treatment of choice for neonatal respiratory distress syndrome, as it significantly reduces infant morbidity and mortality. Extensive clinical trials compare the surfactant products and their optimal usage, but often the practical administration issues are less frequently discussed. Herein, a panel of respiratory therapists and neonatal nurse practitioners share their experience regarding surfactant usage. According to the panelists, the primary criteria for surfactant selection are the ability to rapidly decrease ventilatory requirements toward extubation, a low incidence of adverse effects, cost-effectiveness, and ease of use. In most cases, surfactant is most efficacious when given as early as possible where indicated. The surfactant products differ in their storage, handling, preparation, and administration traits, and this may affect rapid dosing of the surfactant during acute treatment. During and after administration, optimal response to therapy depends on efficient management of ventilator settings, which requires vigilant monitoring of the infant. Common adverse effects include endotracheal tube reflux, bradycardia, and desaturation. Using a surfactant which requires a small dosing volume may decrease the incidence of these adverse effects. An emerging trend in clinical practice is the quick extubation of the infant to nasal continuous positive airway pressure after surfactant administration. This practice can reduce the need for ventilation and reduce the risk of ventilator-related lung damage. Nebulization of surfactant may be a future avenue of delivery, but further research is required to determine its precise role. The practical considerations summarized in this discussion may be useful for other clinicians in their own practice.