BackgroundClinical trials have shown that surfactant replacement therapy in RDS decreases mortality and improves clinical outcomes of ventilated premature newborns (Jobe, 1993). For infants at high risk for RDS, prophylactic (pre- or post-ventilation) or early (<2 h of age) surfactant replacement therapy compared to later selective surfactant administration of established RDS significantly improves survival and reduces the incidence of bronchopulmonary dysplasia (BPD) or death, and incidence of air leak (Soll and Morley, 2002).
 Early implementation of continuous distending pressure (CDP) can avoid mechanical ventilation and prolonged intubation and is an effective treatment for RDS. It has been speculated that greater use of CPAP may be associated with a lesser risk of BPD. Combination therapy with CPAP and surfactant replacement therapy offers potential synergy to treat RDS, avoid mechanical ventilation, and prevent lung injury that may lead to development of BPD.
ParticipantsInfants < 37 weeks' gestation with signs of RDS (oxygen requirement, respiratory distress and consistent chest radiograph).
InterventionEarly surfactant administration with planned brief mechanical ventilation (less than 1h) followed by extubation.
ComparisonSelective surfactant administration continued mechanical ventilation, and extubation from low respiratory support.
Outcome(s)• Need for mechanical ventilation (incidence of ventilation continuing for 1h or more after surfactant administration in the early treatment group or initiated for respiratory insufficiency or apnea in either group)
 • Incidence of bronchopulmonary dysplasia (BPD, need for oxygen at 28 days of age)
 • Incidence of chronic lung disease (CLD, need for oxygen at 36 weeks postmenstrual age)
 • Incidence of neonatal mortality (mortality < 28 days of age)
 • Incidence of mortality prior to hospital discharge
StudiesRandomized or quasi-randomized controlled trials.
Study description and settingSix randomized controlled clinical trials met selection criteria and were included in this review.
ResultsIn infants with signs and symptoms of RDS, intubation and early surfactant therapy followed by extubation to nasal CPAP (NCPAP) compared with later selective surfactant administration was associated with a lower incidence of mechanical ventilation (typical RR 0.67, 95% CI 0.57, 0.79, NNT 5(4–9)), air leak syndromes (typical RR 0.52, 95% CI 0.28, 0.96, NNT 24(12–100)) and BPD (typical RR 0.51, 95% CI 0.26, 0.99, NNT 12(7–100)). A larger proportion of infants in the early surfactant group received surfactant than in the selective surfactant group (typical RR 1.62, 95% CI 1.41, 1.86, NNH 3(2–4)). The number of surfactant doses per patient was significantly greater among patients randomized to the early surfactant group (WMD 0.57 doses per patient, 95% CI 0.44, 0.69).
Confidence in resultsHigh quality evidence for all primary outcomes reported.
Key figure(s)
thumbnail image
Figure captionNeed for mechanical ventilation
Search for eligible studiesCENTRAL, MEDLINE, EMBASE, CINAHL, abstracts from scientific meetings published in Pediatric Research and reference lists of identified trials and reviews were searched through June 2007.
ConclusionIn infants with signs and symptoms of RDS, intubation and early surfactant therapy followed by extubation to nasal CPAP (NCPAP) compared with later selective surfactant administration leads to a lower incidence of mechanical ventilation, air leak syndromes and BPD. However, this approach leads to increased surfactant utilization.
CitationStevens TP, Blennow M, Myers EH, Soll R. 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 2007, Issue 4. Art. No.: CD003063. DOI: 10.1002/14651858.CD003063.pub3.
Date completed22 February 2010
People who helped prepare this Cochrane PICO:Roger Soll and Martin Offringa, editors


  1. Top of page
  2. References
  • Jobe AH. Pulmonary surfactant therapy. New Eng J Med 1993; 328: 861868.
  • Soll RF, Morley CJ. Prophylactic versus selective use of surfactant for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2002; Issue (1).