Table 1 Surfactant indicator table. Considerations for Surfactant Administration for RDSa (Need to fulfill at least 3 of 4 criteria).

From: RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS

Gestational age

23 0/7–27 6/7

Weeks

28 0/7–36 6/7

Weeks

Clinical status

(Downes’ Scoreb)

4–7

4–7

Respiratory support status

Intubated at any timec

OR

NIPPV: MAP ≥ 6; CPAP ≥ 6

Intubated at any timec

OR

NIPPV: MAP ≥ 7; CPAP ≥ 7

FiO2 requirementd,e

≥0.3 if early (≤2 h of life)

OR

≥0.4 if late (>2 h of life)

≥0.3 if early (≤2 h of life) OR

≥0.4 if late (>2 h of life)

Blood gas statusf

pH <7.25, pCO2 > 60

pH <7.25, pCO2 > 60

  1. EARLY (≤2 h of life); LATE (>2 h of life).
  2. CPAP continuous positive airway pressure, ETT endotracheal tube, INSURE INtubation-SURfactant-Extubation, FiO2 fraction of inspired oxygen, LISA less-invasive surfactant administration, LMA laryngeal mask airway, MAP mean airway pressure, MIST minimally invasive surfactant administration, NIPPV nasal intermittent positive pressure ventilation, pCO2 partial pressure of carbon dioxide, RDS respiratory distress syndrome, SpO2 oxygen saturations (pulse oximetry).
  3. aHistory, signs, and symptoms consistent with surfactant deficiency.
  4. bDetails of the Downes’ scoring system is shown in Supplementary Table D. Briefly, includes 0-2 points each for Respiratory Rate (60, 60–80, 80), Retractions (0, mild, severe), Cyanosis (no in room air, relieved by O2, yes even with O2), Air Entry (good, mildly decreased, none), Grunting (non, w/stethoscope, audible).
  5. cIf infant is intubated for resuscitation or meets other clinical parameters for surfactant administration, consider giving surfactant before extubating.
  6. dTo maintain a preductal SpO2 of 90–95%. Infants transitioning to extrauterine life and stable on CPAP in the delivery room may require a higher FiO2 temporarily that may not necessarily warrant surfactant administration. Severe respiratory distress, even with a lower FiO2, may warrant earlier surfactant administration.
  7. eEvaluate the risk of the intervention for surfactant administration (via LISA-MIST/INSURE/LMA vs ETT), followed by the risk of exposure to invasive mechanical ventilation.
  8. fArterial or capillary blood gas, only if available.
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