How to Administer Surfactant to an Infant with RDS?

Surfactant is the deficient factor in preterm infants which has a major responsibility for respiratory distress syndrome. Exogenous surfactant replacement therapy is the treatment of choice in this setting. There is no clear evidence about the best way to administer surfactant in these patients. I witnessed a successful way to administer it last night when we had a late preterm baby admitted to NICU for suspected respiratory distress syndrome.


General Considerations

A policy statement revised in February 2008 by American Academy of Pediatrics mentioned recommendations should be incorporated when and wherever we need to treat patient with exogenous surfactant:

1. Surfactant replacement therapy should be directed by physicians qualified and trained in its use and administration. Qualifications should include experience in management of the respiratory care of low birth weight infants, particularly those on mechanical ventilation.
2. Nursing and respiratory therapy personnel experienced in the management of low birth weight infants, including mechanical ventilation, should be available within the unit at the bedside when surfactant therapy is administered.  
3. Equipment necessary for managing and monitoring the condition of low birth weight infants, including that needed for mechanical ventilation, should be available on-site when surfactant therapy is administered. Radiology and laboratory support to manage a broad range of needs of these infants should be available.
4. More important, surfactant therapy should be used only in institutions in which facilities and personnel are available for the management of multisystem disorders and low birth weight infants. 
5. An institutionally approved surfactant therapy protocol, which is a mandatory component of the quality assurance program for neonates, should exist.
6. In the institutions not satisfying recommendations 2 through 5, and when timely transfer to an appropriate institution cannot be achieved, surfactant therapy may be given, but only by a physician skilled in endotracheal intubation. Under these circumstances, consultation with a subspecialty center should be obtained. Infants should be transferred from such institutions if appropriate and when feasible to a center with appropriate facilities and staff trained to care for multisystem morbidity in low birth weight infants. 

In Practice

• The surfactant ampule is kept in refrigerator at temperature of 4 degree degree celsius. It should be out enough time before being used to have room temperature.
• The dose of surfactant could be divided in 2 to 4 doses depending on the strategy will be used. We use the method of 4 divided doses (4 different positions of the baby during administration)
• All processes used in surfactant administration should be under sterile condition.
• Intubate with the proper size endotracheal tube.
• You can attach baby to respirator or use the method of in/out intubation just for surfactant administration. 
• New methods of using inhaled surfactant without intubation is under investigations
• Put patient in 4 different positions:
• 45 degrees up and to right
• 45 degrees up and to left
• 45 degrees down and to right
• 45 degrees down and to left
• Administer surfactant slowly in each position
• If patient attached to respirator, adjust the inspiratory pressure to be minimal during surfactant adminstration. If you ventilate manually, be aware about the pressure you apply to be less than 15
• Monitor vital signs and tidal volume of lungs during and after administration as patient is at high risk to develop pulmonary hemorrhage or pneumothorax. Tidal volume should be around 6 ml per kg per breath. Reaching 10 is a high risk to have these complications.
• Monitor patient very closely for adequate time post administration (up to one hour)

Video

Doctor in this video is administering surfactant using the two position method (2 different doses). He also ventilate the patient manually.