Surfactant and Modern Respiratory Management: Understanding Traditional and Emerging Delivery Methods

Surfactant is one of the most important therapies in neonatal care. Before surfactant became widely available, respiratory distress syndrome (RDS) was a major cause of illness and death in premature infants. Today, surfactant remains a cornerstone of neonatal respiratory management, but the way it is administered continues to evolve.

As neonatal teams have learned more about lung injury, mechanical ventilation, and lung-protective strategies, newer methods of surfactant administration have emerged. The goal is no longer simply to deliver surfactant. The goal is to provide surfactant while minimizing lung injury and supporting spontaneous breathing whenever possible.

What is surfactant?

Surfactant is a substance produced by type II pneumocytes within the lungs. Its primary role is to reduce surface tension inside the alveoli.

Think of surfactant as a lubricant for the lungs. It helps the alveoli open and close smoothly with each breath. Without adequate surfactant, the alveoli become stiff, sticky, and prone to collapse. As a result, babies must work harder to breathe and often require additional respiratory support.

Why do premature infants develop surfactant deficiency?

Surfactant production begins before birth but increases significantly during the third trimester.

Although some surfactant is produced earlier, the greatest increase typically occurs between 28 and 32 weeks gestation. Because of this, infants born prematurely may not have enough surfactant to keep their alveoli open effectively after birth.

The earlier a baby is born, the greater the risk of surfactant deficiency and respiratory distress syndrome. However, gestational age is only part of the story. Maternal diabetes, antenatal steroid exposure, placental function, and overall fetal health can all influence lung maturity.

The impact of surfactant on neonatal care

The introduction of surfactant dramatically improved outcomes for premature infants.

Clinical trials demonstrated significant reductions in mortality and respiratory complications. The results were so dramatic that surfactant quickly became one of the most important therapies used in neonatal intensive care.

For many years, surfactant administration followed a relatively simple approach: intubate the infant, administer surfactant through the endotracheal tube, and continue mechanical ventilation.

While effective, clinicians eventually recognized that mechanical ventilation itself could contribute to lung injury.

This realization led to the development of newer, less invasive approaches.

Traditional endotracheal tube administration

Traditional surfactant administration involves placing an endotracheal tube and delivering surfactant directly into the lungs.

Advantages

• Direct delivery into the lungs

• Reliable medication administration

• Complete airway control

• Useful for critically ill infants

Limitations

• Requires intubation

• Increased risk of airway trauma

• Exposure to mechanical ventilation

• Increased risk of ventilator-associated lung injury

• Longer time on respiratory support for some infants

Although traditional administration remains an important option, it also created interest in developing less invasive methods.

INSURE: Intubate, Surfactant, Extubate

INSURE stands for Intubate, Surfactant, Extubate.

With this approach, the infant is briefly intubated, receives surfactant, and is then extubated to noninvasive respiratory support such as CPAP or NIPPV.

The goal is to obtain the benefits of direct surfactant administration while minimizing time on mechanical ventilation.

Potential benefits

• Reduced exposure to mechanical ventilation

• Lower risk of ventilator-associated lung injury

• Direct surfactant delivery

Challenges

• Still requires intubation

• Extubation may not always be successful

• Some infants ultimately require ongoing ventilation

LISA and MIST

LISA (Less Invasive Surfactant Administration) and MIST (Minimally Invasive Surfactant Therapy) represent a major shift in surfactant delivery.

Rather than intubating the infant and placing them on a ventilator, surfactant is delivered through a thin catheter while the infant remains on CPAP and continues spontaneous breathing.

The goal is to provide surfactant without exposing the infant to mechanical ventilation.

Potential benefits

• Preserves spontaneous breathing

• Avoids mechanical ventilation

• Reduces exposure to positive pressure ventilation

• May reduce bronchopulmonary dysplasia (BPD) in some populations

Challenges

• Requires specialized training

• Technical skill is essential

• Not appropriate for every infant

• Availability varies between institutions

As neonatal respiratory care continues to evolve, LISA has become increasingly common in many NICUs around the world.

SALSA

SALSA stands for Surfactant Administration through Laryngeal or Supraglottic Airways.

Instead of an endotracheal tube, a laryngeal mask airway is used to deliver surfactant.

This approach may provide another option for surfactant delivery while avoiding tracheal intubation.

Potential benefits

• Less invasive than traditional administration

• Avoids endotracheal intubation

• May be easier to perform than LISA in some settings

Challenges

• Not appropriate for all infants

• Limited experience in some NICUs

• Long-term data remain more limited than traditional approaches

Emerging therapies and future directions

Researchers continue to explore additional methods of surfactant administration.

Current areas of investigation include:

• Aerosolized surfactant

• Nebulized surfactant

• Pharyngeal surfactant administration

• Other noninvasive delivery systems

One of the major goals of future research is improving access to surfactant worldwide. Many premature infants globally still lack access to advanced respiratory support and surfactant therapy.

Future innovations may help expand treatment options in resource-limited settings while further reducing the need for invasive procedures.

What NICU nurses should know

Understanding surfactant involves much more than knowing how it is administered.

NICU nurses play a critical role in:

• Recognizing worsening respiratory distress

• Monitoring oxygen and ventilation requirements

• Preparing for surfactant administration

• Supporting families before and after treatment

• Assessing the infant's response

• Recognizing complications or unexpected deterioration

• Anticipating changes in respiratory support following treatment

As newer delivery methods emerge, nursing assessment and clinical judgment remain essential components of safe respiratory care.

Key takeaways

Surfactant transformed neonatal care and remains one of the most important therapies used in premature infants with respiratory distress syndrome. While traditional administration relied on intubation and mechanical ventilation, newer approaches such as INSURE, LISA, MIST, and SALSA aim to provide surfactant while minimizing lung injury and supporting spontaneous breathing.

The future of surfactant administration will likely focus on making treatment safer, less invasive, and more accessible worldwide. Regardless of the method used, NICU nurses remain central to recognizing respiratory distress, supporting treatment, monitoring response, and educating families throughout the infant's NICU journey.