- Introduction
- Aim
- Definition of Terms
- Assessment
- Dosing
- Management
- Special Considerations
- Companion Documents
- Links
- Evidence Table
- References
Introduction
Pulmonary surfactant is a complex mixture of phospholipids and proteins that creates a cohesive surface layer over the alveoli which reduces surface tension and maintains alveolar stability therefore preventing atelectasis.
Surfactant deficiency is a recognized cause of respiratory distress syndrome in the preterm neonate. Secondary surfactant deficiency also contributes to acute respiratory morbidity in late-preterm and term neonates with meconium aspiration syndrome, pulmonary haemorrhage, and pneumonia/sepsis. Many clinical trials have demonstrated that surfactant replacement therapy is a safe, effective and beneficial treatment as it significantly reduces respiratory morbidity [air leaks, pulmonary interstitial emphysema], ventilatory requirements and mortality in these neonates.
Aim
The aim of this guideline is to outline the principles of surfactant replacement therapy and the safe administration of surfactant in neonates in the Butterfly ward - Newborn Intensive Care Unit [NICU]
Definition of Terms
- Neonate – infant less than 28 days old
- Surfactant - complex and highly surface active material composed of lipids and proteins which is found in the fluid lining the alveolar surface of the lungs, which serves to reduce alveolar surface tension
- RDS – respiratory distress syndrome
- FiO2- fraction of inspired oxygen
Assessment
Clinical indications
Surfactant replacement therapy should be considered in:
- neonates with clinical and radiographic evidence of RDS
- neonates at risk of developing RDS [e.g. 40] regurgitation of surfactant may occur in the expiratory circuit, this can be remedied by holding the ETT upright for a few minutes post administration and/or by reducing the
ventilator rate.
- Monitor neonate’s vital signs closely every 10 minutes for 30 minutes then resume normal frequency of monitoring. A repeat blood gas may be necessary 30-60 minutes post administration.
- Do not suction airways for 1 hour after surfactant instillation unless signs of significant airway obstruction occur
- Note and report changes in non-pulmonary haemodynamics that may indicate significant changes - particularly in the very premature and/or unwell
patient
Potential complications and management
- During administration, transient bradycardia, oxygen desaturation and ETT blockage can occur – temporarily stop surfactant administration, provide ventilation or oxygen as necessary, and resume administration after patient is stable
- ETT obstruction – if suspected, observe saturations and chest wall movement. Call for medical assistance if obstruction is not alleviated and ventilation is impaired
- Pneumothorax – can occur due to sudden changes in pulmonary compliance if ventilation settings are not appropriately changed
- Pulmonary haemorrhage – notify medical officer immediately. Ensure the PEEP remains above 5cm H2O
Special considerations
- Storage and handling: Surfactant is stored in a refrigerator at +2 to +8oC. Surfactant vial should be
slowly warmed to room temperature and gently turned upside down in order to obtain a uniform suspension. Do not shake the vial. Use the appropriate sized vial for the prescribed volume and discard unused portion immediately after use. Unopened, unused vials of surfactant suspension that have warmed to room temperature can be returned to refrigerated storage within 24 hours for future use. Do not warm to room temperature and return to refrigerated storage more than once. Protect from light.
Companion documents
- Assisting with elective intubation of the neonate on the Butterfly Ward
- Emergency airway management clinical practice guideline
- Aseptic technique
Links
- Curosurf manufacturer’s information: //chiesiusa.com/wp-content/uploads/Curosurf_PI.pdf
- Physicians Labeling Rule: Physician's Labeling Rule_Content [chiesiusa.com]
- Neonatal ehandbook topic “Surfactant replacement therapy” : //www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/neonatal-ehandbook/procedures/surfactant-replacement-therapy
Evidence table
The evidence table for this guideline can be viewed here.
References
- Polin, R. A.,
& Carlo, W. A. [2014]. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics, [1], 156.
- Chiesi Farmaceutici, S.p.A.. [2014]. Curosurf [poractant alfa] intratracheal suspension, Prescribing Information.
- Stevens, T.P., Blennow, M., Myers, E.H., Soll, R. [2007]. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for
respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003063. DOI: 10.1002/14651858.CD003063.pub3.
- El Shahed AI, Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration syndrome in term and late preterm infants. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD002054. DOI: 10.1002/14651858.CD002054.pub3
- Ardell S, Pfister RH, Soll R. Animal derived surfactant extract versus protein free synthetic
surfactant for the prevention and treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD000144. DOI: 10.1002/14651858.CD000144.pub3
- Soll R, Özek E. Multiple versus single doses of exogenous surfactant for the prevention or treatment of neonatal respiratory distress syndrome. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000141. DOI: 10.1002/14651858.CD000141.pub2
- Finer, N. N. [2004].
Surfactant use for neonatal lung injury: beyond respiratory distress syndrome. Paediatric Respiratory Reviews, 5 Suppl AS289-S297.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Ella Eda, ANUM, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2021.
Which of the following newborns would the nurse recognize as being most at risk for developing RDS?
Most cases of RDS occur in babies born before 37 to 39 weeks. The more premature the baby is, the higher the chance of RDS after birth.
What is most common causes of respiratory distress syndrome in newborn?
The most common etiology of neonatal respiratory distress is transient tachypnea of the newborn; this is triggered by excessive lung fluid, and symptoms usually resolve spontaneously. Respiratory distress syndrome can occur in premature infants as a result of surfactant deficiency and underdeveloped lung anatomy.
Which babies are at risk of RDS?
RDS occurs most often in babies born before their due date, usually before 28 weeks of pregnancy. Less often, RDS can affect full-term newborns. Most newborns who have RDS survive. However, these babies may need extra medical care after going home.
Why premature babies have a higher risk of respiratory distress at birth?
Respiratory distress syndrome [RDS] occurs in babies born early [premature] whose lungs are not fully developed. The earlier the infant is born, the more likely it is for them to have RDS and need extra oxygen and help breathing. RDS is caused by the baby not having enough surfactant in the lungs.