title: Exogenous surfactant: intubated present, nebulized future?
abstract: BACKGROUND
  exogenous surfactant is currently administered via intra-tracheal instillation, a method which can increase the possibility of clinical instability in the peri-surfactant administration period. Since its introduction, there has been an increase in understanding of the pathology of respiratory distress syndrome and surfactant biology. This includes development of a potential nebulized surfactant which has the potential to increase the number, safety and timely administration of the medication in preterm infants.
  
  
  METHODS
  based on recent original publications in the field of surfactant biology, we reviewed our experience with surfactant administration and discussed the available evidence on nebulized surfactant and outlined potential barriers toward widespread introduction of this therapy.
  
  
  RESULTS
  surfactant has revolutionized modern neonatal management and nebulized surfactant is attractive and a vector for administration. However, issues regarding costeffectiveness, development of nebulizer devices capable of administration, deposition of medication in the airway and dosing strategies remain unresolved.
  
  
  CONCLUSIONS
  nebulized surfactant has the potential to be a therapeutic breakthrough by eliminating the potent volu-and-baro-traumatic effects of mechanical ventilation in the peri-surfactant period. Nebulization would likely lead to increased administration immediately after birth and more emphasis on noninvasive ventilator strategies. These features will aid clinical implementation of nebulized surfactant as a standard of treatment after introduction.
authors.affiliation: Department of Pediatrics, State University of New York at Stony Brook, Stony Brook, New York 11791, USA. shetal.shah@stonybrook.edu
authors.forename: Shetal
authors.initials: S
authors.lastname: Shah
mesh_terms: D000328:Adult; D006548:Hernia, Diaphragmatic / Q000188:drug therapy*; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000639:trends*; D008471:Meconium Aspiration Syndrome / Q000188:drug therapy* / Q000628:therapy; D009330:Nebulizers and Vaporizers / Q000639:trends*; D037701:Pulmonary Surfactant-Associated Protein B / Q000172:deficiency / Q000187:drug effects; D011663:Pulmonary Surfactants / Q000008:administration & dosage*; D012128:Respiratory Distress Syndrome / Q000188:drug therapy* / Q000628:therapy; D012127:Respiratory Distress Syndrome, Newborn / Q000188:drug therapy* / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D037701:Pulmonary Surfactant-Associated Protein B; D011663:Pulmonary Surfactants