Surfactant replacement therapy in preterm infants: UK national consensus

Key recommendations

Consensus recommendations for the management of RDS in preterm infants are as follows:

1. All neonatal units should have an agreed policy for the management of early RDS.

2. Early rescue surfactant rather than prophylaxis is recommended. In some situations, this may include surfactant administration in the delivery suite.

3. In babies with evolving RDS, rescue surfactant should be administered early in the course of the disease. Inspired oxygen concentration above 30% in the first hours of life is a reasonable predictor of CPAP failure.

4. (a) For rescue therapy using natural surfactants, poractant alfa at an initial dose of 200 mg/kg reduces mortality and the need for redosing compared to 100 mg/kg of surfactant.4 There is an absence of data on other natural surfactants at doses >100 mg/kg.

4. (b) The surfactant dose should be calculated and administered based on the baby’s weight. If the surfactant is required before the baby’s birth weight is known, it is reasonable to use whole vial dosing based on an estimated weight.

This recommendation supports the accurate dosing of surfactant, which should be calculated based on the infant's weight. Weight-based dosing applies to both early rescue administration and treatment of established RDS. For some surfactant preparations of lesser volume (e.g. poractant alfa), whole-vial dosing, based on estimated weight, is reasonable, for example when administered for early rescue in the delivery suite.

4. (c) A second and sometimes a third dose of surfactant can be considered in ongoing RDS.

On occasions, it may be necessary to administer a second, and sometimes a third dose of surfactant in ongoing RDS (lack of improvement, persistent high oxygen requirement, increased work of breathing on noninvasive support, or continuing need for MV).

5. There is emerging evidence that the LISA technique may be the preferred method for spontaneously breathing preterm infants kept on NIV, as an alternative to the intubation-surfactant-extubation (INSURE) technique.

INSURE describes surfactant administration after endotracheal intubation, followed by brief ventilation, timely extubation (within 60 min) and reinstitution of NIV. However, the implementation of INSURE is variable, particularly with regard to the length of MV following surfactant administration; in some instances, MV may be prolonged for different reasons, including the physician’s preference. The LISA technique, also referred to as minimally invasive surfactant therapy (MIST), is a method for administering surfactant via an endotracheally placed catheter to infants spontaneously breathing on NIV. Up-to-date education on theory, mannequin simulations, and the use of video laryngoscopy are advisable. Clear guidelines and local audits should be in place to identify local strengths and challenges for LISA implementation.