Surfactant in Neonates - Administration of

Publication: 20/03/2013  --
Last review: 23/02/2017  
Next review: 01/02/2020  
Clinical Guideline
ID: 3273 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Administration of Surfactant in Neonates

Summary of Guideline

Newborn infants, especially if born prematurely may have surfactant deficiency that causes respiratory distress. Surfactant replacement therapy may be given to alleviate the severity the condition. Correct dosing and post-administration management is essential.

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Pulmonary surfactant is a surface-active lipoprotein complex formed by type II alveolar cells. Its main function is to reduce surface tension throughout the lung and stabilise alveoli.

Exogenous Surfactant is administered when pulmonary surfactant is thought to be deficient. Curosurf®, a natural surfactant from porcine origin is used in Leeds Teaching Hospital NHS Trust. Respiratory distress syndrome (RDS) is due, at least in part, to surfactant deficiency. Early and enough replacement of surfactant reduces mortality and morbidity including oxygenation deficit, pulmonary air leaks and reduces duration of ventilatory support. (1, 2)

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Prophylaxis in RDS-

1. All Preterm infants born ≤26+6 weeks Gestational Age- surfactant to be administered in Delivery suite as soon as neonate stabilised and position of ET tube checked clinically.

2. Preterm infants ≥27+0 weeks Gestational Age

  1. If they require intubation in delivery suite for stabilisation.
  2. For babies 27-30 weeks gestation prophylactic surfactant should be considered if the infant consistently requires >30% oxygen.
  3. For babies >30weeks gestation prophylactic surfactant should be considered if the infant consistently requires >40% oxygen.

Neonates delivered at  ≤26+6 weeks have very little surfactant production and prophylaxis with surfactant before developing RDS is the best approach. The earlier the surfactant is given, better the outcome. It is now a routine practice to take surfactant to delivery suite and administer it as soon as neonate is stabilised and position of ET tube checked.(2)

All babies receiving surfactant in delivery suite should be transported to the Neonatal unit intubated. (3)

For the later preterm, ≥27+0 GA (usually between 27-32 weeks GA) who require intubation or have worsening respiratory distress,  surfactant administration as prophylaxis is shown to have better outcome than when it is given as a rescue therapy for RDS.(1, 2)

Rescue therapy for RDS-
When surfactant is administered to neonates where the diagnosis of RDS is established, it is considered as ‘rescue’ treatment. Discuss with consultant if neonate is >48hrs old.

Clinical presentation of neonatal RDS
Cyanosis/low saturations, tachypnoea, grunting and recession

Other conditions that may benefit from surfactant therapy

  1. Meconium aspiration syndrome (only if on HFOV or in 100% oxygen)
  2. Pulmonary Haemorrhage (discuss with the consultant first)
  3. Pneumonia (consultant decision only)

These conditions, in newborn period, are shown to alter surfactant morphology and function. Administration of surfactant in such situations has shown benefits and clinical improvement (4, 7).

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Diagnosis is usually a clinical one although the following may be helpful

  1. Blood gas analysis- showing respiratory failure
  2. Chest X Ray- showing ground glass appearance and air bronchograms (these features are not pathognomonic of RDS).(1)

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Treatment / Management

Dose of Surfactant-
Leeds Teaching Hospital NHS Trust currently uses Curosurf® which is available in:

Curosurf® 120mg/vial
Curosurf® 240mg/vial

Evidence now suggests that a dose of 200mg/kg is better as it results in a longer half-life, fewer retreatments and better oxygenation index values. (2, 6)

The dose should be rounded up so as to give the whole of the opened vial unless using the whole vial will result in a dose greater than 200mg/kg, when the volume should be adjusted accordingly. (See Table 1)

Repeat dosing
After the first dose, there may be need for further dose of surfactant and evidence suggests better outcome with multiple doses. Repeat dose is always given at 100mg/kg.

The main indicator for further dosing is clinical condition of neonate. There is no need to wait 12 hours before the next dose. If after a few hours there is still a significant oxygen requirement and on-going evidence of RDS, then a second dose should be given.

Consider second dose if

  • Needing mechanical ventilation and is requiring >30% O2 or PIP >22cms H2O. (On volume guarantee mode, if the baby appears to be consistently needing pressures of 22 to deliver the set tidal volume)
  • On CPAP or BiPAP > 50% oxygen, respiratory failure/apnoea. (5)


Table 1- Surfactant Use Summary 


Gestational age

Vial to use

Give as soon as stabilised in Delivery Suite.

≤25 weeks- all neonates

One whole vial of 120mg*

26-28 weeks- all neonates

One whole vial of 240mg*

*if a dose of a whole vial results in > 200mg/kg DO NOT administer the whole amount


Rescue for RDS

Gestational age


Give as early as possible once RDS suspected.

Any gestation

200mg/kg- round up to use the whole opened vial.

Discuss with consultant if neonate is >48hrs old 


Repeat Dosing

Gestational age


 For all repeat doses.

Any gestation


Decisions for 3rd dose should be taken by the consultant. 


Administration of Surfactant:  Endotracheal instillation

Step 1- Select the correct vial according to dose calculated; warm the vial by holding in hands for few minutes.
Step 2- Open the designated Vygon surfactant administration set. Measure the catheter first so that the feeding tube catheter tip ends up just to the tip of ETT. Withdraw the required amount of surfactant and a small volume of air (this air acts as a chaser)
Step 3- Check the position of Endotracheal Tube (ETT) by auscultation and capnography.
Step 4- Disconnect the Neonate from T-Piece/ or ventilator
Step 5- With head in midline; introduce the catheter which is pre-measured. Administer the Surfactant and the air (acts as a chaser) as a single bolus.
Step 6- Commence T-Piece/Neopuff for at least one minute before reconnecting to ventilator.
Step 7- Lung compliance changes dramatically after surfactant administration. Monitor oxygen saturations and tidal volumes and act promptly to reduce hyperoxia.

Adverse effects

  • Bradycardia,
  • Hypotension,
  • Endotracheal tube blockage, and
  • Oxygen desaturation.

These events are transient but require stopping CUROSURF administration and taking appropriate measures to alleviate the condition. After the patient is stable, dosing may proceed with appropriate monitoring.


  • All babies receiving surfactant in delivery suite should be transported to the Neonatal unit intubated. (3)
  • Respiratory compliance can change rapidly after surfactant administration. Review the neonate and ventilation parameters closely.
  • Ventilate as per ventilation guideline
  • Avoid ETT suction for a minimum of 1 hour post surfactant administration.
  • Document the dose, timing and reason for surfactant use both on drug chart and case notes.
  • Make a clear plan for further ventilation strategies and the need for further dose.

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Record: 3273

To improve the diagnosis and management of surfactant deficient lung disease (respiratory distress syndrome, RDS) in the newborn baby.

To provide evidence-based recommendations for appropriate diagnosis, investigation and management of RDS requiring surfactant treatment.

Clinical condition:

Surfactant deficiency

Target patient group: Newborn infants
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. Guidelines for good practice in the management of neonatal respiratory distress syndrome. Report of the second working group of the British Association of Perinatal Medicine.
  2. European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants – 2016 Update Neonatology 2017;111:107-125 DOI: 10.1159/000448985
  3. RCPCH Guidelines for good practice. Management of neonatal Respiratory distress syndrome. Dec 2000.Paediatric Respiratory Reviews Volume 5, Supplement 1, Pages S289-S297, January 2004.
  4. Surfactant use for neonatal lung injury: beyond respiratory distress syndrome, Neil N. Finer. University of California, San Diego, USA.
  5. European consensus guidelines on the management of neonatal respiratory distress syndrome. International Guidelines. Sweet D et al. J Perinat Med. 2007;35(3):175-86.
  6. Dosing of Porcine Surfactant: Effect on Kinetics and Gas Exchange in Respiratory Distress Syndrome. Paola Elisa Cogo et al. Pediatrics 2009; 124; e950.
  7. Surfactant for meconium aspiration syndrome in full term/near term infants. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD002054.

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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