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Key messages

  • Early administration of surfactant to intubated infants with respiratory distress syndrome (RDS) is desirable.
  • Discuss with the PIPER consultant (1300 137 650) when considering surfactant therapy prior to transfer to a Level 6 neonatal unit.
  • Access to x-ray and blood gas facilities is essential when considering the use of surfactant therapy.
  • Place the infant in the supine, sniffing position.
  • There is no evidence to support placing the infant in multiple positions during administration of surfactant.
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    In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines with a view to completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

    Surfactant replacement therapy should be considered when the diagnosis is respiratory distress syndrome (RDS) based on clinical grounds +/- chest x-ray. Also consider surfactant replacement therapy if:

    • the birth is at < 30 weeks in a special care nursery (SCN) setting
    • the infant is intubated, regardless of gestation and requiring FiO2 > 0.4
    • the baby is at risk of developing RDS.

    Treatment is not usually commenced if these criteria are only fulfilled after the infant is 48 hours old or has an oxygen requirement < 40%.


    Access to x-ray and blood gas facilities is essential when considering the use of surfactant therapy. Preparation includes:

    • correction of hypothermia, hypoglycaemia, acidosis and hypovolaemia are essential aspects of treatment and correction is recommended prior to administration of surfactant
    • antibiotics
    • placement of a saturation probe and monitoring of oxygen saturation
    • a chest x-ray should be performed to confirm diagnosis and check position of endotracheal (ET) tube prior to giving surfactant
    • blood gas assessment is required after commencing assisted ventilation; the placement of a peripheral arterial line or umbilical arterial line is desirable, but optional. Capillary blood gas is acceptable.

    Natural surfactants

    Natural surfactants are derived from animal lungs. Natural surfactant is associated with greater early improvement in the need for ventilator support, fewer air leaks and fewer deaths. Natural surfactants should be used and given early in the course of RDS. Repeat doses of surfactant may be required if there is ongoing evidence of RDS.

    Curosurf® is an exogenous pulmonary surfactant made by purification of the lipids and apoproteins extracted from minced porcine lungs. Curosurf® (poractant alfa) is supplied in 1.5 ml vials (120 mg).


    Initial recommended dose is 200 mg/kg/dose (2.5  mL/kg), up to 2 repeat doses of 100 mg/kg may be considered at 12 hourly intervals.

    Table 1: Surfactant dose guide

    Recommended doses to minimise waste and use of additional vials.

    Weight ⃰ Initial Curosurf® Volume Initial Surfactant dose
    < 600g 2.5 mL /kg 200mg / kg
    600g -> 1.2 kg 1.5 mL (1 vial) 200mg/ kg -> 100mg / kg
    1.2 kg -> 2.4 kg 3 mL (2 vials) 200mg / kg -> 100mg / kg
    2.4 kg -> 3.6 kg 4.5 mL (3 vials) 150mg / kg -> 100mg / kg
    > 3.6 kg Consider the indications for surfactant use in this population  

    ⃰  Individual discretion can be applied at the margins of these weight categories.

    For example a baby weighing 555g could be given 1 vial (2.7 mL /kg, 216mg /kg) and a baby weighing 1250g could receive 1 vial (1.2 mL /kg, 96mg /kg)


    Procedure for the administration of surfactant:

    Criteria for administration

    • ventilated infants <32 weeks gestation with clinical and radiological RDS, who have a significant oxygen requirement to maintain their oxygen saturation within target range
    • all other babies should be discussed with PIPER (1300 137 650) before administration of surfactant (e.g. infants >32 weeks gestation, Meconium Aspiration Syndrome)

    Prior to administration

    • ensure correct endotracheal tube placement is confirmed
    • all babies must have heart rate and/or oxygen saturation monitoring
    • suction ETT if necessary ( i.e. if there are secretions present on auscultation)
    • before use, slowly warm vial of Curosurf® to room temperature by removing from the fridge and any packaging, and placing on a bench. Artificial warming methods should not be used
    • visually inspect surfactant for discolouration - Curosurf® should be white / creamy white
    • Medical Officer to order surfactant dose on Medication Chart


    • open sterile plastic drape onto clean working surface
    • open top of Curosurf® and swab with alcohol wipe. Allow to dry
    • open syringe and needles onto aseptic field
    • perform hand hygiene and use sterile gloves
    • using sharp 19G needle, pierce vial of Curosurf® and draw up ordered dose into syringe with assistance from second staff member
    • remove sharp 19G needle and discard in sharps container
    • replace with blunt needle onto syringe for administration. Leave 0.5mL of air behind the surfactant to ensure entire dose is given
    • assistant ensures infant is in supine position, with his/her head in the midline. During administration, ensure infant's neck is not flexed and the ETT remains upright with the ventilation circuit / tubing supported
    • assistant to disconnect ventilator circuit from ETT
    • using a non-touch technique, administer entire dose of Curosurf® as one "push" including the 0.5 ml of air directly into the lumen of the ETT
    • if Curosurf is visible in the ETT, deliver a manual breath via the ventilator to assist with dispersion of the surfactant dose throughout the infant's lungs
    • ensure surfactant dose is correctly charted and signed on Medication Chart
    • document date, time and response to administration in patient progress notes

    After administration

    • medical / nursing staff to remain with the baby for at least 30 minutes after administration
    • observe and document baby's chest movement, oxygen saturation, heart rate and any other events every 10 minutes for 30 minutes
    • observe ventilation flow pattern, measured tidal volumes, and transcutaneous pO2 and pCO2 readings when available
    • nursing and medical staff must be aware that there may be a need to decrease the PIP on the Neopuff within a few minutes of administration
    • increase or decrease inspired oxygen concentration to achieve target saturations
    • consider performing a blood gas 30 minutes after administration, or as requested by the medical staff
    • do not suction airway for at least 1 hour after surfactant administration unless signs of significant airway obstruction occur.

    Adverse effects

    • Bradycardia
    • Hypotension
    • Endotracheal tube blockage
    • Oxygen desaturation
    • Potential for pneumothorax due to sudden changes in pulmonary compliance
    • Pulmonary haemorrhage (low incidence, but reported).

    Safety and precautions

    • whenever possible the baby should be put on a ventilator after surfactant administration, rather than using the Neopuff to 'bag' any surfactant that may remain in the ETT to ensure that the Curosurf® is dispersed into the lungs
    • Curosurf® is stored in the refrigerator (at 2 - 8 degrees C). Unused vials of Curosurf® that have been warmed to room temperature, but not opened or punctured, should be given to PIPER at the time of transport to the Level 6 neonatal unit
    • protect from light
    • do not shake - vials are for single use only
    • after opening the vial discard any unused portion.

    Religious considerations

    • Surfactant use is clearly permitted according to the strict Jewish Halachah.
    • Muslims are allowed to consume medications which contain pig by-products (e.g. insulin) if it is a lifesaving necessity.
    • Pork derivatives are prohibited when taken by mouth or in diet but not if they are used for indications other than food or diet (e.g. intratracheal instillation).

    Other methods of administration in clinical practice

    INSURE Strategy

    Studies indicate the INSURE strategy [Intubate-SURfactant-Extubate to nasal continuous positive airway pressure (NCPAP)] is better than mechanical ventilation and surfactant administration for the management of RDS.


    Minimally invasive surfactant therapy (MIST) does not require sedation, minimises airway injury and avoids placing positive pressure ventilation on an immature lung. Spontaneously breathing preterm infants with RDS receive surfactant via a gastric tube placed in the trachea by direct laryngoscopy with no sedation.

    More information

    Further reading

    Get in touch

    Clinical Guidance Team
    Safer Care Victoria

    Version history

    First published: August 2013
    Review by: August 2016

    Uncontrolled when downloaded
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