Surfactant replacement therapy has been available for about 25 years, revolutionising neonatal respiratory care after its introduction in the 1980s. Along with antenatal steroids, surfactants improve survival for preterm babies and they are now recommended routinely as early in the course of respiratory distress syndrome (RDS) as possible. Prophylactic treatment, although appearing ideal, exposes some babies who might manage perfectly well on continuous positive airway pressure (CPAP) to intubation and ventilation, which may increase the risk of bronchopulmonary dysplasia. Recent studies attempt to determine the optimal balance between avoiding ventilation by using CPAP and giving surfactant in a timely fashion to babies with RDS. Surfactants are also used for conditions other than RDS, such as meconium aspiration, pulmonary haemorrhage and pneumonia, although the evidence base for their use in these indications is much weaker. Recently, surfactants have been used to deliver steroids directly to the lungs and this seems to be a promising technique worthy of further study. Finally, the quest goes on to develop a synthetic product that can match the effects of animal derived natural surfactants and could be produced at lower cost.
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Competing interests: DGS has received funding from Chiesi Farmaceutici, a manufacturer of a surfactant preparation, to present the European Guidelines for Management of Respiratory Distress Syndrome at an international meeting. HLH has received funding to present papers at international meetings from Ross Laboratories, Burroughs-Wellcome, Dey Laboratories and Chiesi Farmaceutici, manufacturers of surfactant preparations. He has also acted as a paid advisor to Chiesi Farmaceutici in relation to a number of medicinal products including surfactants.