Prophylaxis versus rescue treatment

There does not appear to be additional benefit from prophylactic surfactant compared to nasal CPAP and early rescue surfactant ^{4, 6} (LOE I, GOR B).

Post-ventilatory surfactant (after resuscitation) reduces mortality and chronic lung disease 36-40 weeks ⁷ (LOE II, GOR B).

Nasal continuous positive airway pressure (nCPAP) with rescue thin catheter surfactant versus nCPAP with rescue intubation and surfactant reduces the risk of intubation and pneumothorax and reduces the incidence of chronic lung disease ^8-12 (LOE I, GOR B).

Nasal CPAP with rescue thin catheter surfactant is better tolerated than nCPAP with rescue intubation and surfactant and immediate extubation (InSurE) with no difference in other clinical outcomes ^10-12 (LOE I, GOR B).

Higher first dose poractant (200 mg/kg compared to 100 mg/kg) reduces need for re-dosing without proven clinical benefit ^13,14 (LOE 1, GOR B). Higher dose poractant 200 mg/kg compared to lower dose beractant 100 mg/kg reduces mortality and need for re-dosing ^15-17 (LOE 1, GOR B).

Multiple doses of surfactant (up to 4) given to infants with ongoing respiratory insufficiency leads to improved clinical outcomes ¹⁸ (LOE 1, GOR A).

Meconium aspiration syndrome: Surfactant replacement therapy for meconium aspiration syndrome reduces the incidence of respiratory failure ¹⁹ (LOE 1, GOR B). Trials used surfactant 100−200 mg/kg every 6 hours up to a maximum 4 doses. Trials reported response from earlier (before 6 hours) and frequent surfactant replacement (every 6 hours for 3−4 doses) ^{20, 21}.