APPROPRIATE SURFACTANT USAGE IN 1996

Surfactant therapy has been proven effective in the prevention and tre atment of respiratory distress syndrome. Over 6,000 infants have been studied in randomized controlled trials. These studies have demonstrat ed that both prophylactic administration of surfactant and administrat ion of surfactant to premature infants with established respiratory di stress syndrome will decrease the risk of pneumothorax and decrease th e risk of mortality. Currently, over 50% of very low birth weight infa nts in North America receive some sort of surfactant preparation. Howe ver, many questions remain regarding optimal usage of surfactant prepa rations. Recent randomized controlled trials have evaluated issues reg arding surfactant dosage, treatment strategy, method of administration , and surfactant preparation. Initial doses in the range of 100-200 mg /kg with repeat doses to selected infants who relapse appears to be th e best approach to therapy. Prophylactic surfactant therapy leads to a small but statistically significant reduction in the risk of pneumoth orax and mortality. The clinical relevance of these advantages and the cost effectiveness of this care remains under debate. A variety of me thods of administration have been used in randomized controlled trials . Trials which compare these methods of administration demonstrate the adequacy of currently tested bolus administration. However, other met hods of administration, such as slow infusion of surfactant leads to u neven distribution of surfactant and poor response. Both synthetic sur factants and natural surfactant extracts have been proven effective in the care of these infants. However, randomized controlled trials whic h directly compare these two preparations demonstrate a small advantag e to the use of natural surfactant extracts. Natural surfactant extrac ts improve initial ventilatory status and decrease the risk of pneumot horax. Surfactant replacement therapy has proven to be effective in th e treatment of very low birth weight premature infants. Current clinic al trials support the early institution of treatment either prophylact ically or as soon as possible in intubated babies with signs of respir atory distress syndrome. Repeat treatment may be important in optimizi ng outcome due to surfactant inactivation. Currently available natural surfactant extracts improve early clinical outcome and decrease pneum othorax compared to the available synthetic preparations.