Surfactant Administration in the NICU

  • Introduction

    Pulmonary surfactant is a complex mixture of phospholipids and proteins that creates a cohesive surface layer over the alveoli which reduces surface tension and maintains alveolar stability therefore preventing atelectasis. 

    Surfactant deficiency is a recognized cause of respiratory distress syndrome in the preterm neonate. Secondary surfactant deficiency also contributes to acute respiratory morbidity in late-preterm and term neonates with meconium aspiration syndrome, pulmonary haemorrhage, and pneumonia/sepsis. Many clinical trials have demonstrated that surfactant replacement therapy is a safe, effective and beneficial treatment as it significantly reduces respiratory morbidity (air leaks, pulmonary interstitial emphysema), ventilatory requirements and mortality in these neonates.


    The aim of this guideline is to outline the principles of surfactant replacement therapy and the safe administration of surfactant in neonates in the Butterfly ward - Newborn Intensive Care Unit (NICU)

    Definition of Terms 

    • Neonate – infant less than 28 days old
    • Surfactant - complex and highly surface active material composed of lipids and proteins which is found in the fluid lining the alveolar surface of the lungs, which serves to reduce alveolar surface tension
    • RDS – respiratory distress syndrome
    • FiO2 - fraction of inspired oxygen


    Clinical indications

    Surfactant replacement therapy should be considered in:

    • neonates with clinical and radiographic evidence of RDS
    • neonates at risk of developing RDS (e.g. <32 weeks or low birth weight <1300g)
    • neonates who are intubated, regardless of gestation, and requiring FiO2 >40%

    Surfactant replacement therapy may be considered in:

    • Severe meconium aspiration syndrome with severe respiratory failure – may improve oxygenation and reduce the need for extracorporeal membrane oxygenation (ECMO)
    • Pulmonary haemorrhage with clinical deterioration
    • Severe respiratory syncytial virus-induced respiratory failure - may improve gas exchange and respiratory mechanics and shorten the duration of invasive mechanical ventilation 




    Prepare equipment/supplies:

    • Continuous cardiovascular monitoring equipment 
    • Transcutaneous CO2 monitor (TCM) or end tidal CO2 monitor (etCO2) if appropriate 
    • Surfactant 
    • Surfactant kit (if available) containing 4Fr 20cm tube, 5mL syringe, needle free device or blunt needle OR 
    • Alternative to surfactant kit: Size 5Fr feeding tube, 3mL or 5mL compatible syringe (dose dependent), Large gauge needle (18g, 19g or 20g) 
    • Alcohol swab 70% 
    • Sterile towel or drape 
    • Tape measure 
    • Sterile scissors 
    • Emergency equipment: Neopuff and mask, suction


    • Surfactant administration is a two-person procedure. It should be performed by at least one medical practitioner or a neonatal nurse practitioner (NNP) who administers the surfactant and one registered nurse as the assistant
    • Record baseline observations: heart rate, respiration rate, oxygen saturation, TCO2/etCO2, plus a blood gas if required
    • Ensure and confirm correct position of the endotracheal tube (ETT) via chest x-ray prior to giving surfactant. Auscultation of the chest for equal bilateral air entry confirmed by a NICU fellow or consultant is an additional method of confirming ETT placement
    • If neonate is not intubated (e.g. a premature neonate on continuous positive airway pressure (CPAP)), an in-out intubation will need to be performed to administer the surfactant (INSURE technique – Intubation, Surfactant then Extubation). Refer to the guideline on elective intubation.
    • Check and prepare emergency equipment at bedside (e.g. Neopuff, suction). If performing intubation, also prepare intubation drugs, laryngoscope with appropriate blade size, appropriate size ETT, and Pedicap/CO2 detector.
    • Ensure patency of ETT. Suction ETT as necessary prior to administration.
    • Slowly warm the vial of surfactant to room temperature before administration, visually inspect suspension for discolouration, should be creamy to white. Gently turn vial upside-down to obtain a uniform suspension, DO NOT SHAKE. Remove plastic cap, clean the rubber vial top with an alcohol swab. Inform parent(s)


    • On clean surface gather and prepare equipment for procedure
    • Perform hand hygiene
    • Open aseptic field and peel open sterile equipment and drop onto aseptic field 
    • Perform hand hygiene and administering medical practitioner or NNP dons sterile gloves.
    • Using surgical aseptic technique, cut the 4Fr tube from the surfactant kit or a 5Fr feeding tube to length using the tape measure so that the tip lies 1 cm above the end of the endotracheal tube. This ensures that the surfactant is administered intra-tracheal. Curosurf should not be instilled into a main stem bronchus.
    • With vial held by assistant operator slowly draw up a little over the required dose of surfactant into the 3mL or 5mL syringe using the needle free device or a large-gauge needle. Attach the pre-cut tube to this syringe, prime or fill the tube with surfactant to the end. Discard excess surfactant through the attached tube so that only the dose to be given remains in the syringe.
    • Ensure bed is flat. Place the neonate in supine position. There is no evidence to support the practice of placing the neonate in multiple positions during administration.
    • Assistant disconnects the ETT from the ventilator.
    • Medical practitioner or NNP to administer the surfactant via the pre-cut tube to the distal end of the endotracheal tube in a single bolus dose or in two aliquots as quickly as the neonate tolerates. The total dose is usually given less than a minute.
    • Once the surfactant is administered, assistant delivers positive pressure ventilation via Neopuff or reconnects ETT to ventilator right after surfactant administration. If neonate was on CPAP, positive pressure ventilation is given via the Neopuff. Holding the ETT upright may facilitate surfactant drainage and minimize reflux up the ventilator circuit 
    • Surfactant can occlude the ETT and it may be necessary to cease administration until the tube is cleared and chest wall movement resumes
    • Ventilator support or inspired oxygen may need to be temporarily increased.
    • Medical practitioner/NNP to remain at bedside until the neonate is stable.
    • Clean surfaces, dispose of waste and perform hand hygiene
    • Document administration in EMR


    • Marked improvements may occur within minutes of administration. Ventilation settings will need to be continually assessed and adjusted post administration to avoid hyperoxygenation or exposure to excessive peak inspiratory pressures.
    • Extubation may be considered for some neonates (INSURE technique – Intubation, Surfactant then Extubation) particularly the premature neonates who were on CPAP prior to administration, and responded well to the surfactant administration.
    • At high ventilator rates (> 40) regurgitation of surfactant may occur in the expiratory circuit, this can be remedied by holding the ETT upright for a few minutes post administration and/or by reducing the ventilator rate.
    • Monitor neonate’s vital signs closely every 10 minutes for 30 minutes then resume normal frequency of monitoring. A repeat blood gas may be necessary 30-60 minutes post administration.
    • Do not suction airways for 1 hour after surfactant instillation unless signs of significant airway obstruction occur
    • Note and report changes in non-pulmonary haemodynamics that may indicate significant changes - particularly in the very premature and/or unwell patient 

    Potential complications and management

    • During administration, transient bradycardia, oxygen desaturation and ETT blockage can occur – temporarily stop surfactant administration, provide ventilation or oxygen as necessary, and resume administration after patient is stable
    • ETT obstruction – if suspected, observe saturations and chest wall movement. Call for medical assistance if obstruction is not alleviated and ventilation is impaired
    • Pneumothorax – can occur due to sudden changes in pulmonary compliance if ventilation settings are not appropriately changed
    • Pulmonary haemorrhage – notify medical officer immediately. Ensure the PEEP remains above 5cm H2O

    Special considerations

    • Storage and handling: Surfactant is stored in a refrigerator at +2 to +8oC. Surfactant vial should be slowly warmed to room temperature and gently turned upside down in order to obtain a uniform suspension. Do not shake the vial. Use the appropriate sized vial for the prescribed volume and discard unused portion immediately after use.  Unopened, unused vials of surfactant suspension that have warmed to room temperature can be returned to refrigerated storage within 24 hours for future use. Do not warm to room temperature and return to refrigerated storage more than once. Protect from light.

    Companion documents


    Evidence table

    The evidence table for this guideline can be viewed here.


    1. Polin, R. A., & Carlo, W. A. (2014). Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics, (1), 156.
    2. Chiesi Farmaceutici, S.p.A.. (2014). Curosurf (poractant alfa) intratracheal suspension, Prescribing Information.
    3. Stevens, T.P., Blennow, M., Myers, E.H., Soll, R. (2007). Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003063. DOI: 10.1002/14651858.CD003063.pub3.
    4. El Shahed AI, Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration syndrome in term and late preterm infants. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD002054. DOI: 10.1002/14651858.CD002054.pub3
    5. Ardell S, Pfister RH, Soll R. Animal derived surfactant extract versus protein free synthetic surfactant for the prevention and treatment of respiratory distress syndrome. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD000144. DOI: 10.1002/14651858.CD000144.pub3
    6. Soll R, Özek E. Multiple versus single doses of exogenous surfactant for the prevention or treatment of neonatal respiratory distress syndrome. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000141. DOI: 10.1002/14651858.CD000141.pub2
    7. Finer, N. N. (2004). Surfactant use for neonatal lung injury: beyond respiratory distress syndrome. Paediatric Respiratory Reviews, 5 Suppl AS289-S297.

    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Ella Eda, ANUM, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2021.