Surfactant therapy: the current practice and the future trends

The efficacy of surfactant preparations used in the prevention and treatment of respiratory distress syndrome (RDS) is a well known fact; however, many controversies remain. The debate over which surfactant to be used, when and what is the best mode of delivery is still raging. Currently, animal-derived surfactants are preferred and clearly recommended by various practice guidelines, but new synthetic surfactants containing peptides that mimic the action of surfactant proteins are emerging and they seem to have a comparable efficacy profile to the natural surfactants. It is hoped that with further improvements, they will outperform their natural counterparts in terms of reliability and cost-effectiveness. Early surfactant administration was shown to further reduce the risk of RDS and its complications. However, as nasal continuous positive airway pressure (nCPAP) is becoming increasingly the preferred first-line therapy for RDS, the less invasive approaches of respiratory support along with early selective surfactant administration (e.g. INSURE) appears to provide a better option. Although neonatal RDS is still the main indication of surfactant therapy, other pathological processes received considerable attention and major research has been dedicated to explore the role of surfactant in their management, Meconium aspiration syndrome (MAS) and congenital pneumonia are two worthy examples. The most updated practice guidelines do recommend the use of endotracheal instillation as the preferred mode of surfactant delivery. However, aerosolization and other non-invasive methods are being investigated with some success; nonetheless, further improvements are very much in need.