Practical considerations in the pulmonary surfactant therapy

Although a number of clinical trials have been conducted to compare different surfactant agents, the practical issues relevant to neonatologists are sometimes not properly assessed in these studies. Herein, in a recent paper, a panel of respiratory therapists and neonatal nurse practitioners share their experience regarding surfactant usage.

• The ideal surfactant has a low rate of adverse effects, is well ansorbed, allows for an early extubation, and demonstrates improvement in chest x-ray findings. It is also very important to consider that a surfactant able to produce the same effects with a small infusion volume, such as poractant alfa, can increase tolerance by reducing obstruction and reflux. A smaller volume is also associated with less product wastage.
• Early surfactant administration demonstrated superior outcomes compared to delayed one. Ideally, surfactant should be administered within 15-30 minutes. An early rescue approach could also decrease the number of subsequent surfactant doses needed, the time to reach extubation, and the overall cost.
• All available surfactants require gentle turning of the vial for complete mixing. Gentle turning also avoids denaturation of the proteins.
• All surfactant products require storage in a refrigerator: unused vials at room temperature may be returned to refrigerated storage for future use, no more than once.
• Surfactants should be warmed prior to administration. However, warming too quickly may cause denaturation of surfactant-associated proteins, and products that require a longer warming, such as vials that contain large volumes of surfactant, may be less advantageous, since they determine a delay in the administration.
• Because the ideal surfactant should have a rapid response, it is advisable not to disconnect the infant from the ventilator during administration, so that transient settings can be adjusted appropriately.
• Monitoring protocols after surfactant administration may vary, although the common goal is to quickly and safely wean then extubate. During surfactant administration, infants must be observed and, if an adverse response occurs, immediate steps should be taken. After the immediate dosing time period, further monitoring is required; moreover, a follow-up chest x-ray 30 minutes after administration of surfactant can be compared to the pre-dose one to monitor distribution and response.
• Research has shown that fewer infants require more than one dose of surfactant when poractant alfa is used. This variable also influence the time requirements for administration and monitoring, as well as stress to the infant and cost-effectiveness.
• Usually, infants will tolerate the initial dose well; however, the clinician should be vigilant for reflux and desaturation with subsequent doses. Conversely, if the infant has trouble tolerating the first dose or two, a greater monitoring is to be planned.
• It is important to monitor the ventilator settings during and after surfactant administration. After surfactant administration, agressive weaning of ventilator pressures within the first hour is suggested. A surfactant with a rapid onset and earlier efficacy may increase the rate at which supplemental oxygen can be weaned.
• Recent research indicates that extubation to nasal continuous positive air pressure (CPAP) is associated with several advantages. Therefore, a more aggressive in attempting to extubate qualified infants to CPAP after surfactant administration, within 30 minutes or less whenever possible, is suggested. A rapid-acting surfactant can reduce the time to extubation to CPAP.
• Nebulization provides can reduce intubation and its complications. However, studies presently indicate that aerosolized surfactant tends to be deposited in less-injured areas of the lung, and that loss of product may occur, thus impeding proper dosing. Administration via nebulization would also be more time consuming: therefore, it is possible that nebulization may increase the exposure to high concentrations of oxygen.

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