Surfactant replacement therapy

DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment

Early administration of natural surfactant decreases the risk of acute pulmonary injury and neonatal mortality
Early CPAP and selective administration of surfactant is preferable to routine intubation and prophylactic surfactant
Natural surfactant preparations are superior to protein-free synthetic preparations containing only phospholipids for reducing mortality and air leaks
Poractant alfa (Curosurf^®) at 200 mg/kg shows survival advantage compared to beractant or poractant alfa in a dose of 100 mg/kg
Multiple rescue doses result in greater improvements in oxygenation and ventilatory requirements, a decreased risk of pneumothorax and a trend toward improved survival
Use of LISA (less invasive surfactant administration) technique for early surfactant administration reduces the need for ventilation and improves survival
- see LISA section below

INDICATIONS

Babies born <28 weeks' gestation

Routine intubation of these babies solely for the purpose of administration of surfactant is not necessary, and a policy of early CPAP with selective surfactant administration is preferred
If requiring intubation for respiratory support during resuscitation or if mother has not had antenatal steroids, give surfactant as prophylaxis in delivery room once ETT position confirmed through chest movement, auscultation and CO₂ detector
Otherwise, institute early CPAP and administer surfactant selectively as per Early rescue treatment

Preterm babies who require invasive ventilation for stabilisation should be given surfactant

Babies born ≤33 weeks’ gestation who are not ventilated

Use LISA technique to give surfactant if FiO₂ >0.30 on CPAP pressure ≥6 cm of H₂O and increased work of breathing
- if LISA cannot be undertaken, endotracheal surfactant administration followed by early extubation should be used

Ventilated babies with meconium aspiration syndrome (may need repeat dose after 6–8 hr)
Term babies with pneumonia and less compliant lungs

Natural surfactant, poractant alfa (Curosurf^®) 200 mg/kg (2.5 mL/kg) round to the nearest whole vial (prophylaxis and rescue doses can differ)
Sterile gloves
TrachCare Mac™ catheter (do not cut NGT) or specific surfactant administration set

Calculate dose of surfactant required and warm to room temperature
Ensure correct endotracheal tube (ETT) position
- check ETT length at lips
- listen for bilateral air entry and look for chest movement
- if in doubt, ensure ETT in trachea using laryngoscope and adjust to ensure bilateral equal air entry
- chest X-ray not essential before first dose
Refer to manufacturer’s guidelines and Neonatal Formulary
Invert surfactant vial gently several times, without shaking, to resuspend the material
Draw up required dose
Administer via TrachCare Mac™ device or specific surfactant administration pack

Do not suction ETT for 8 hr following instillation of surfactant
Be ready to adjust ventilator/oxygen settings in response to changes in chest movement, tidal volume and oxygen saturation. Use of volume-targeted ventilation can facilitate responsiveness to rapid changes in lung compliance following surfactant instillation. Be ready to reduce FiO₂ soon after administration of surfactant to avoid hyperoxia
Arterial/capillary blood gas within 30 min

If baby remains ventilated at FiO₂ >0.3 with mean airway pressure >7 cm H₂O, give further dose of surfactant 6–12 hr after first dose
Third dose should be given only at request of attending consultant

Method using a thin catheter to deliver surfactant in spontaneously breathing preterm baby with respiratory distress syndrome receiving non-invasive ventilator support
- continue non-invasive ventilator support during procedure

Persistant/worsening respiratory acidosis despite optimal non-invasive ventilation

Determine and document indication for LISA
Ensure baby is loaded with caffeine or is already on maintenance caffeine (spontaneous breathing extremely important for LISA)
Inform parents (if present)
Ensure venous access (peripheral cannula)
Ensure team of 3 for procedure (including at least 1 nurse and 1 doctor)
Draw up surfactant 200 mg/kg
Attach T-piece to end of syringe with Luer-lock system
Wash hands
Use sterile gloves
Place baby supine, ensuring incubator doors do not limit movement of laryngoscope
Minimise heat loss
- if necessary increase incubator temperature, use blankets, swaddling and transwarmer
Baby will remain on non-invasive ventilation support (CPAP/HFNC) during procedure – have naso-/orogastric tube (N/OGT) in situ to help identify oesophagus
Administer sedation: atropine and fentanyl IV
Visualise vocal cords using laryngoscope/video laryngoscope (some gentle cricoid pressure may be necessary)
Insert LISAcath^® until required markings (see Table)
- tip should be 1.5 cm below vocal cords
Other guidance according to gestational age and weight

Close mouth around LISAcath^® with your fingers, ensuring not to apply any pressure on soft tissue
Maintain LISAcath^® in midline position to avoid traumatising mucosal lining of trachea

This is not an emergency procedure.
Stop if you are having difficulty and consider alternatives

Ask helper to administer surfactant in 4 aliquots very slowly (with gaps of 30 sec over 3–5 min), to avoid surfactant coming back up
Aspirate the N/OGT after each aliquot of surfactant to confirm that surfactant has not been instilled into the stomach. If this occurs, stop administering surfactant and reassess position of LISAcath^®
Remove LISAcath^® and ensure baby clinically stable with normal cardiorespiratory parameters before repositioning baby and closing incubator
Following procedure, document:
- procedure
- how well tolerated
- FiO₂

See Guideline Supporting Information