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Updated: Dec 12, 2025
Surfactant Depletion Combined with Injurious Ventilation Results in a Reproducible Model of the Acute Respiratory Distress Syndrome ARDS
Published on: April 7, 2021
A Quality Improvement Project to Standardize Surfactant Delivery in the Era of Noninvasive Ventilation
Jeong Eun Kim1,2,3, Mariana Brewer1,2,3, Regina Spinazzola1,2,3
1Cohen Children's Medical Center, New Hyde Park, N.Y.
Insights
Implementing educational interventions and process changes significantly reduced the time to intubation and surfactant administration in premature infants. This improvement in timely treatment may help decrease the incidence of bronchopulmonary dysplasia.
Area of Science:
- Neonatal Medicine
- Pediatric Respiratory Care
- Healthcare Process Improvement
Background:
- Continuous positive airway pressure (CPAP) and surfactant therapy are crucial for premature infants with respiratory distress syndrome.
- Delays in surfactant administration, often due to prolonged CPAP trials or post-intubation observation, are linked to increased bronchopulmonary dysplasia.
- Bronchopulmonary dysplasia (BPD) contributes to significant morbidity and healthcare utilization in premature infants.
Purpose of the Study:
- To reduce the time from meeting intubation criteria to intubation in premature infants (<1,500g or <32 weeks gestation).
- To decrease the time from intubation to surfactant administration in this vulnerable population.
- To evaluate the impact of process changes on intubation and surfactant delivery times.
Main Methods:
- Retrospective data analysis of electronic medical records for infants <1,500g or <32 weeks gestation.
- Primary endpoints focused on time to intubation and time from intubation to surfactant administration.
- Balancing measures included adverse outcomes such as asymmetric lung disease, incorrect endotracheal tube placement, and pneumothorax.
Main Results:
- Mean time to intubation decreased from 321 to 81 minutes for infants 28-32 weeks gestation following physician education and notification orders.
- Time to intubation did not change for infants younger than 28 weeks gestation.
- Surfactant administration within 1 hour of intubation improved from 78% to 100% after implementing a trainee program and coordinating with radiology, with no adverse events.
Conclusions:
- Educational interventions and targeted process changes effectively implemented standard criteria for intubation and surfactant administration in premature infants.
- Engaging medical staff requires establishing an acceptable range of evidence-based practice.
- Timely intubation and surfactant administration are associated with a potential decrease in bronchopulmonary dysplasia.
Introduction:
Continuous positive airway pressure (CPAP) and surfactant both improve outcomes for premature infants with respiratory distress syndrome. However, prolonged trials of CPAP, as well as observation periods after intubation, may delay the administration of surfactant. Late surfactant treatment likely increases the incidence of bronchopulmonary dysplasia, which leads to significant morbidity and healthcare utilization.
Methods:
We aimed to decrease time from meeting standard criteria (start of a continuous run of FiO2 > 40% or PaCO2 > 65 for >90 min) to intubation, and from intubation to surfactant administration, for infants <1,500 g or younger than 32 weeks gestation. Retrospective data collection from the electronic medical record assessed those process measures as the primary endpoints. Balancing measures were the adverse outcomes of asymmetric lung disease, the inappropriate position of the endotracheal tube, or pneumothorax on the first x-ray (within 24 h) after surfactant.
Results:
Mean time to intubation for infants 28-32 weeks gestation decreased from 321 to 81 minutes in response to a literature review for physicians and free-text orders for notification. Time to intubation for infants younger than 28 weeks gestation did not change. Administration of surfactant within 1 hour of intubation improved from 78% to 100% after a program for trainees and coordination with radiology. There were no adverse occurrences.
Conclusions:
Educational interventions and targeted process change can successfully implement standard criteria for intubation and surfactant administration for premature infants. Determination of an acceptable range of evidence-based practice is essential for the engagement of medical staff. Timely intubation and surfactant may decrease bronchopulmonary dysplasia.
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