title: The future of exogenous surfactant therapy.
abstract: Since the identification of surfactant deficiency as the putative cause of the infant respiratory distress syndrome (RDS) by Avery and Mead in 1959, our understanding of the role of pulmonary surfactant in respiratory physiology and the pathophysiology of acute lung injury (ALI) has  advanced substantially. Surfactant replacement has become routine for the prevention and treatment of infant RDS and other causes of neonatal lung injury. The role of surfactant in lung injury beyond the neonatal period, however, has proven more complex. Relative surfactant deficiency, dysfunction,  and inhibition all contribute to the disturbed physiology seen in ALI and acute respiratory distress syndrome (ARDS). Consequently, exogenous surfactant, while a plausible therapy, has proven to be less effective in ALI/ARDS than in RDS, where simple deficiency is causative. This failure may  relate to a number of factors, among them inadequacy of pharmaceutical surfactants, insufficient dosing or drug delivery, poor drug distribution, or simply an inability of the drug to substantially impact the underlying pathophysiology of ALI/ARDS. Both animal and human studies suggest that  direct types of ALI (eg, aspiration, pneumonia) may be more responsive to surfactant therapy than indirect lung injury (eg, sepsis, pancreatitis). Animal studies are needed, however, to further clarify aspects of drug composition, timing, delivery, and dosing before additional human trials  are pursued, as the results of human trials to date have been inconsistent and largely disappointing. Further study and perhaps the development of more robust pharmaceutical surfactants offer promise that exogenous surfactant will find a place in our armamentarium of treatment of ALI/ARDS  in the future.
authors.affiliation: Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia 22908-0386, USA. dfw4m@virginia.edu
authors.forename: Douglas F
authors.initials: DF
authors.lastname: Willson
authors.forename: Robert H
authors.initials: RH
authors.lastname: Notter
mesh_terms: D015060:1,2-Dipalmitoylphosphatidylcholine / Q000031:analogs & derivatives / Q000032:analysis; D055371:Acute Lung Injury / Q000628:therapy*; D000818:Animals; D015199:Extracorporeal Membrane Oxygenation; D006801:Humans; D007231:Infant, Newborn; D011663:Pulmonary Surfactants / Q000008:administration & dosage / Q000737:chemistry / Q000145:classification / Q000627:therapeutic use*; D012128:Respiratory Distress Syndrome / Q000628:therapy; D012127:Respiratory Distress Syndrome, Newborn / Q000628:therapy*
chemical_list: C095411:DEPN 8; D011663:Pulmonary Surfactants; D015060:1,2-Dipalmitoylphosphatidylcholine