Instilled bolus surfactant is the only approved surfactant treatment for neonatal respiratory distress syndrome. However, recent trends towards increased utilization of noninvasive respiratory support for preterm infants with surfactant deficiency have created a demand for a similarly noninvasive means of administering exogenous surfactant. Past approaches to surfactant nebulization met with varying success due to inefficient aerosol devices resulting in low intrapulmonary delivery doses of surfactant with variable clinical effectiveness. The recent development of vibrating membrane nebulizers, coupled with appropriate positioning of the interface device, indicates that efficient delivery of aerosolized surfactant is now a realistic goal in infants. Evidence of clinical effect despite low total administered dose in pilot studies, together with suggestions of enhanced homogeneity of pulmonary distribution indicate that this therapy may be applied in a cost-effective manner, with minimal patient handling and disruption. These studies need to be subjected to appropriately designed randomized controlled trials. Further work is also required to determine the optimum delivery route (mask, intranasal prong, nasopharyngeal or laryngeal), dosing amount and redosing interval.

Stevens TP, Harrington EW, Blennow M, Soll RF: 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 Syst Rev 2007;4:CD003063.
Dijk PH, Heikamp A, Oetomo SB: Surfactant nebulization versus instillation during high frequency ventilation in surfactant-deficient rabbits. Pediatr Res 1998;44:699–704.
Bhandari A, Bhandari V: Pitfalls, problems, and progress in bronchopulmonary dysplasia. Pediatrics 2009;123:1562–1573.
Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB: Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008;358:700–708.
Sandri F, Plavka R, Ancora G, Simeoni U, Stranak Z, Martinelli S, Mosca F, Nona J, Thomson M, Verder H, Fabbri L, Halliday H: Prophylactic or early selective surfactant combined with nCPAP in very preterm infants. Pediatrics 2010;125:e1402–e1409.
Gopel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C, Siegel J, Avenarius S, von der Wense A, Vochem M, Groneck P, Weller U, Moller J, Hartel C, Haller S, Roth B, Herting E: Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011;378:1627–1634.
Dargaville PA, Aiyappan A, Cornelius A, Williams C, De Paoli AG: Preliminary evaluation of a new technique of minimally invasive surfactant therapy. Arch Dis Child Fetal Neonatal Ed 2011;96:F243–F248.
Trevisanuto D, Grazzina N, Ferrarese P, Micaglio M, Verghese C, Zanardo V: Laryngeal mask airway used as a delivery conduit for the administration of surfactant to preterm infants with respiratory distress syndrome. Biol Neonate 2005;87:217–220.
Alarie Y, Robillard E, Paganuzzi P, Garand A: Modifications of pressure-volume curves obtained in rat lungs after inhalation of surface-active substances and agents. Rev Can Biol 1964;23:141–149.
Robillard E, Alarie Y, Dagenais-Perusse P, Baril E, Guilbeault A: Microaerosol administration of synthetic beta-gamma-dipalmitoyl-L-alpha-lecithin in the respiratory distress syndome: a preliminary report. Can Med Assoc J 1964;90:55–57.
Lewis JF, Ikegami M, Jobe AH, Tabor B: Aerosolized surfactant treatment of preterm lambs. J Appl Physiol 1991;70:869–876.
Dijk PH, Heikamp A, Bambang Oetomo S: Surfactant nebulisation: lung function, surfactant distribution and pulmonary blood flow distribution in lung lavaged rabbits. Intensive Care Med 1997;23:1070–1076.
Schermuly RT, Gunther A, Weissmann N, Ghofrani HA, Seeger W, Grimminger F, Walmrath D: Differential impact of ultrasonically nebulized versus tracheal-instilled surfactant on ventilation-perfusion (VA/Q) mismatch in a model of acute lung injury. Am J Respir Crit Care Med 2000;161:152–159.
Wagner MH, Amthauer H, Sonntag J, Drenk F, Eichstadt HW, Obladen M: Endotracheal surfactant atomization: an alternative to bolus instillation? Crit Care Med 2000;28:2540–2544.
Dijk PH, Heikamp A, Bambang Oetomo S: Surfactant nebulisation prevents the adverse effects of surfactant therapy on blood pressure and cerebral blood flow in rabbits with severe respiratory failure. Intensive Care Med 1997;23:1077–1081.
Wolfson MR, Wu J, Hubert TL, Mazela J, Gregory TJ, Clayton RG, Shaffer TH: Dose-response to aerosolized KL4 surfactant in the spontaneously breathing CPAP-supported preterm lamb: Pediatric Academic Societies. Denver. Pediatr Res 2011;70:751.
Arroe M, Pedersen-Bjergaard L, Albertsen P, Bode S, Greisen G, Jonsbo F, et al: Inhalation of aerosolized surfactant (exosurf) to neonates treated with nasal continuous positive ariway pressure. Prenat Neonat Med 1998;1998:346–352.
Berggren E, Liljedahl M, Winbladh B, Andreasson B, Curstedt T, Robertson B, Schollin J: Pilot study of nebulized surfactant therapy for neonatal respiratory distress syndrome. Acta Paediatr 2000;89:460–464.
Finer NN, Merritt TA, Bernstein G, Job L, Mazela J, Segal R: An open label, pilot study of Aerosurf® combined with nCPAP to prevent RDS in preterm neonates. J Aerosol Med Pulm Drug Deliv 2010;23:303–309.
Jorch G, Hartl H, Roth B, Kribs A, Gortner L, Schaible T, Hennecke KH, Poets C: Surfactant aerosol treatment of respiratory distress syndrome in spontaneously breathing premature infants. Pediatr Pulmonol 1997;24:222–224.
Minocchieri S, Burren JM, Bachmann MA, Stern G, Wildhaber J, Buob S, Schindel R, Kraemer R, Frey UP, Nelle M: Development of the premature infant nose throat-model (print-model): an upper airway replica of a premature neonate for the study of aerosol delivery. Pediatr Res 2008;64:141–146.
O’Doherty MJ, Thomas SH, Page CJ, Treacher DF, Nunan TO: Delivery of a nebulized aerosol to a lung model during mechanical ventilation. Effect of ventilator settings and nebulizer type, position, and volume of fill. Am Rev Respir Dis 1992;146:383–388.
Harvey CJ, O’Doherty MJ, Page CJ, Thomas SH, Nunan TO, Treacher DF: Comparison of jet and ultrasonic nebulizer pulmonary aerosol deposition during mechanical ventilation. Eur Respir J 1997;10:905–909.
Wagner MH, Wiethoff S, Friedrich W, Mollenhauer I, Obladen M, Boenick U: Ultrasonic surfactant nebulization with different exciting frequencies. Biophys Chem 2000;84:35–43.
Dolovich MA: Influence of inspiratory flow rate, particle size, and airway caliber on aerosolized drug delivery to the lung. Respir Care 2000;45:597–608.
Yeo LY, Friend JR, McIntosh MP, Meeusen EN, Morton DA: Ultrasonic nebulization platforms for pulmonary drug delivery. Expert Opin Drug Deliv 2010;7:663–679.
Fok TF, Monkman S, Dolovich M, Gray S, Coates G, Paes B, Rashid F, Newhouse M, Kirpalani H: Efficiency of aerosol medication delivery from a metered dose inhaler versus jet nebulizer in infants with bronchopulmonary dysplasia. Pediatr Pulmonol 1996;21:301–309.
Geller DE: The science of aerosol delivery in cystic fibrosis. Pediatr Pulmonol 2008;43:S5–S17.
Dubus JC, Vecellio L, De Monte M, Fink JB, Grimbert D, Montharu J, Valat C, Behan N, Diot P: Aerosol deposition in neonatal ventilation. Pediatr Res 2005;58:10–14.
Kesser KC, Geller DE: New aerosol delivery devices for cystic fibrosis. Respir Care 2009;54:754–767.
Mallol J, Rattray S, Walker G, Cook D, Robertson CF: Aerosol deposition in infants with cystic fibrosis. Pediatr Pulmonol 1996;21:276–281.
Marcinkowski AL, Garoff S, Tilton RD, Pilewski JM, Corcoran TE: Postdeposition dispersion of aerosol medications using surfactant carriers. J Aerosol Med Pulm Drug Deliv 2008;21:361–370.
Mazela J, Merritt TA, Finer NN: Aerosolized surfactants. Curr Opin Pediatr 2007;19:155–162.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.