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Key Features

  • Most common cause of respiratory distress in the preterm infant

  • Caused by a deficiency of surfactant production as well as surfactant inactivation by protein leak into airspaces

  • Incidence increases from 5% of infants born at 35–36 weeks' gestation to more than 50% of infants born at 26–28 weeks' gestation

Clinical Findings

  • Infants show all the clinical signs of respiratory distress

  • On auscultation, air movement is diminished despite vigorous respiratory effort

  • Tachypnea, cyanosis, and expiratory grunting are seen


  • Chest radiograph demonstrates diffuse bilateral atelectasis, causing a ground-glass appearance

  • Major airways are highlighted by the atelectatic air sacs, creating air bronchograms

  • In the unintubated child, doming of the diaphragm and hypoinflation occur


  • Supplemental oxygen, nasal CPAP, early intubation for surfactant administration and ventilation, and placement of umbilical artery and vein lines are initial required interventions

  • In stable infants, a trial of nasal CPAP at 5–6 cm H2O pressure can be attempted prior to intubation and surfactant administration

  • Nasal intermittent positive-pressure ventilation (NIPPV) is another modality that may be attempted for ventilatory support

  • Ventilators

    • Can deliver breaths synchronized with the infant's respiratory efforts (synchronized intermittent mandatory ventilation) and accurately deliver a preset tidal volume (5–6 mL/kg) should be used

    • Alternatively, pressure limited ventilation with measurement of exhaled tidal volumes can be used

    • High-frequency ventilators are available for rescue of infants doing poorly on conventional ventilation

  • Surfactant replacement

    • Dosages

      • Bovine-derived beractant (Survanta) is 4 mL/kg

      • Calf lung surfactant extract (Infasurf) is 3 mL/kg

      • Porcine-derived poractant (Curosurf) is 1.25–2.5 mL/kg, given intratracheally

      • Repeat dosing is indicated in infants who remain on the ventilator receiving more than 30–40% oxygen

      • A total of two to three doses given 8–12 hours apart may be administered

    • As the disease evolves, proteins that inhibit surfactant function leak into the air spaces, making surfactant replacement less effective.

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