Category: UWHC Clinical Policy
Effective Date: January 1, 2016
Section: Respiratory Care ‐ Special Procedures
Surfactant is secreted by type II pneumocytes and functions to reduce lung collapse during end
exhalation by decreasing surface tension within the terminal airways and alveoli. Infants born
prematurely are likely to have surfactant deficiency which is associated with onset of respiratory distress
syndrome (RDS), a major cause of morbidity and mortality in premature infants. Surfactant therapy
reduces mortality and pneumothoraces associated with RDS.
Surfactant also reduces surface tension, improves lung compliance and stabilizes lung volumes at a
lower transpulmonary pressure. Prophylactic surfactant is administered to infants at risk of developing
RDS. Therapeutic or rescue surfactant is administered after the initiation of mechanical ventilation in
infants with clinically confirmed RDS.
A. Active pulmonary hemorrhage.
B. Congenital anomalies incompatible with life.
A. All patients will be assessed by the Respiratory Care Practitioner (RCP) to determine if
the appropriate indications for the therapy are present.
B. Therapy will be provided in accordance with a provider's order.
C. There must be two care providers present during the instillation of Surfactant.
D. The initial dose will be 2.5mL/kg of birth weight (found on left side of header bar in
E. Up to two repeat doses of 1.25mL/kg of birth weight can be administered 12 hours
F. Poractant alfa Curosurf® maximum recommendation of total dosing is 5mL/kg of birth
G. Poractant alfa Curosurf® is available in 1.5 and 3mL vials and should be stored under
refrigeration and protected from light.
H. Poractant alfa Curosurf ® should be warmed before use up to 24 hours before use and
can be returned to refrigeration once if not used after one rewarming.
I. Do not shake the vial.
J. Unused portions should be discarded after use.
K. One RT will only take out the number of vials needed for accurate billing.
A. Ballard Trach Care MAC (multi‐access catheter).
B. Emergent Use: Surfactant, alcohol wipe, needle and syringe.
A. Review and acknowledge provider’s order.
B. Review patient's chart.
C. Obtain the appropriate equipment.
D. Introduce yourself to the patient and/or family. Explain the reason for the procedure.
E. Assess the patient throughout the procedure.
F. Obtain the surfactant from pharmacy and scan the medication.
I. Obtain surfactant from NICU AcuDose refrigerator. Once an order is written and
verified by the pharmacist, the surfactant order will appear on the patient’s
profile in the AcuDose.
2. Remove the colored plastic cap from the surfactant bottle.
3. Wipe off the surfactant bottle with an alcohol wipe.
4. With a needle and syringe, draw up with initial dose of 2.5mL/kg of birth weight.
5. Dispose the needle in the needle box and cap syringe.
6. Throw away vial containing excess surfactant into drug receptacle.
7. Withdraw 0.5mL of air into syringe to account for volume lost in the MAC.
8. Warm the surfactant to room temperature.
G. Suction the infant prior to instillation.
H. Keep the infant in neutral position
I. For emergent use: instill directly into the ETT.
J. For schedule use: Replace the inline suction catheter and attach the MAC (multi access
catheter) to the ETT hub.
1. Determine the proper depth of the MAC which should be the same length as the
inline suction catheter.
2. Determine length of tube: Find the measurement on the ETT where the tip of
the ETT adapter fits in the ETT. You may need to measure up to the tip from a
number that you can see on the ETT. Take the number determined in step #2
and add 5cm (length of Ballard adapter). This will put you exactly to the bottom
of the ETT.
K. Withdraw the MAC until the point of the catheter inserts into the adapter. This becomes
the “window” or “observation area”.
L. Before instilling the surfactant, change the ventilator settings to respiratory rate of 40‐
60 breaths/minute, inspiratory time 0.5 seconds, and supplemental oxygen sufficient to
maintain Sa02 > 92%.
M. Insert the MAC to the measured depth.
N. With the syringe vertical, instill entire dose of surfactant plus the 0.5mL of air in
coordination with inhalation of breath.
O. Monitor the following before, during, and after instillation of surfactant:
1. Possible reflux of surfactant into the endotracheal tube (ETT)
2. Ventilator settings: tidal volumes, fraction of inspired oxygen (FiO2)
3. Pulmonary mechanics
4. Vital signs: oxygen saturations, breath sounds
5. Blood gases
6. Chest Radiography
P. Make appropriate ventilator adjustments based on patients response to the therapy.
Q. If possible, avoid tracheal suction for the first 4 hours after instillation, but can suction
after one hour if necessary.
A. “AARC Clinical Practice Guideline; Surfactant Replacement Therapy: 2013” Respiratory Care,
Feb. 2013 vol. 58 no. 2, pgs. 367‐375.
B. UWHC Respiratory Care Policy 2.30 “Direct Instillation of Medication/Lubricating Agent via