Surfactant

In ARDS there is decreased surfactant production, biochemical abnormality of the surfactant produced and inhibition of surfactant function. The net result is alveolar and small airway collapse. Surfactant also contributes to host defence against micro-organisms. Surfactant replacement would be expected to exert therapeutic effects on lung mechanics, gas exchange and host defence.

Instillation of surfactant (either as a liquid or nebulised) via the endotracheal tube into the lungs is associated with improved outcome in neonatal respiratory distress syndrome. Potential indications in adults include ARDS, pneumonia, chronic airflow limitation and asthma. Multiple studies in ARDS have yet to demonstrate mortality benefit, though this may be related to the type of surfactant, the volume used, or the delivery system.

Studies have demonstrated improved oxygenation with recombinant surfactant protein C and a trend to improved survival in patients with direct lung injury. Further studies are underway using recombinant surfactant protein C with phospholipids, and with surfactant proteins B and C. The surfactant is instilled into the lungs via an endotracheal catheter.

Complications of surfactant treatment have included increased cough, sputum production, bronchospasm, increasd peak airway pressure and adverse effects on pulmonary function. These can be minimised by adequate sedation and neuromuscular blockade before instilling surfactant.

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