surfactant has become standard therapy in preterm infants with respiratory distress syndrome ( rds ) 
 1 
 .
surfactant lowers the alveolar surface tension and prevents expiratory alveolar collapse increasing compliance , reducing pulmonary vascular resistance and improving ventilation - perfusion mismatching .
surfactant can be inactivated in term infants with pneumonia , meconium aspiration syndrome , lung hypoplasia and pulmonary hemorrhage .
this inactivation may be caused by various plasma proteins and local inflammatory cytokines that pass into the airways , damage type ii pneumocytes and alveolar cells rendered vulnerable by mechanical ventilation .
case reports and studies from literature suggest that surfactant might be beneficial to infants with sepsis and pneumonia 
 2 
 .
this study aimed to evaluate the effects of exogenous surfactant on ventilation parameters and oxygenation of term infants with respiratory failure .
this is a case series study in which mechanically ventilated infants diagnosed with early neonatal sepsis and respiratory failure that had received a single dose of exogenous bovine surfactant ( survanta ) between january 2008 and december 2010 , with a gestational age above 37 weeks were retrospectively studied .
diagnoses like meconium aspiration syndrome , persistent pulmonary hypertension of the newborn , asphyxia , and pulmonary hemorrhage were excluded .
all infants suffered from severe respiratory failure according to definition of the european - american consensus conference with arterial oxygen partial pressure ( mmhg ) ( pao2)/ fraction of inspired oxygen ( fio2 ) below 200 mmhg 
 3 
 .
diagnosis was confirmed with antenatal history , clinical , radiological and laboratory findings . because signs of sepsis are nonspecific , any term newborn infant with sudden onset of respiratory distress or other signs of illness
was evaluated for sepsis including complete blood count , blood smear , c - reactive protein , blood cultures and tracheal aspirates .
all infants were followed with synchronized intermittent mandatory ventilation ( simv ) mode of ventilator ( sle 2000 ) .
early outcomes of surfactant treatment were evaluated via respiratory indices including oxygenation index ( oi ) , mean alveolar pressure ( map ) , fio2 , pao2 , arterial oxygen saturation ( sao2 ) and pao2/fio2 values .
these values were carried out using arterial blood gas values and ventilator parameters of the infants before and six hours after surfactant administration .
oi and map were calculated using the following equation : oi=(map  fio2  100)/ pao2 
  map=[(pipxti)+(peepxte)]/ti + te pip : peak inspiratory pressure ( cmh20 ) ti : time of inspiration ( sec ) peep : positive end expiratory pressure ( cmh2o ) te : time of expiration ( sec ) comparisons between groups were done with wilcoxon signed ranks test and mann - whitney u test .
mean gestational age of the infants was 38.31 weeks , mean birth weight was 3088 grams and median hospitalization day was 1 day ( table 1 ) .
although gbs screening was negative in all mothers , eight mothers had clinical or histological chorioamnionitis , seven had prolonged ruptured membranes ( > 24 hours ) and three had fever ( > 38.3c ) before labor .
all infants had leucocytosis ( 165026704/mm ) , elevated crp ( 33.03.4 mg / l ) , and bilateral alveolar densities with air bronchograms on chest x - rays ; however , tracheal and blood cultures were negative in all patients so that patients were diagnosed as suspected sepsis . 
  demographic characteristics of infants meanstandard deviation ; median ( minimum , maximum ) in all of the 18 infants pulmonary gas exchange was critically impaired with median pao2/fio2 below 100 mmhg prior to surfactant administration .
all patients received a single dose ( total phospholipid dose 100mg / kg ) surfactant when mechanical ventilation failed to improve oxygenation .
of these infants , one suffered from pneumothorax within 24 hours after surfactant administration and two infants died due to multiorgan failure within the first week postpartum . before the surfactant treatment ,
median ( minimum and maximum ) oi , map , fio2 , pao2 , sao2 and pao2/fio2 values were as follows ; 15.3 ( 10.0 - 52.8 ) ; 8.5 ( 7.0 - 15.0 ) ; 80.0 ( 50.0 - 100.0 ) ; 45.4 ( 21.5 - 56.9 ) ; 83.5 ( 42.0 - 97.0 ) ; 60.3 ( 21.5 - 99.2 ) .
following surfactant treatment these values were ; 3.4 ( 1.5 - 35.0 ) ; 8.0 ( 6.0 - 14.0 ) ; 40.0 ( 21.0 - 100.0 ) ; 83.5 ( 39.0 - 118.0 ) ; 97.0 ( 50.0 - 99.5 ) ; 234.0 ( 39.0 - 422.0 ) respectively .
oi , map and fio2 values significantly decreased . whereas pao2 , sao2 and pao2/fio2 values significantly increased ( p<0,001 ) .
respiratory indices of patients before and after surfactant treatment1 
  median ( minimum - maximum )
preterm and late preterm infants have increased risk of rds so that surfactant treatment guidelines mostly focuses on these group of patients 
 4 
 .
term infants are also at risk of rds and any lung disease affecting these infants that involves surfactant dysfuncion or deficiency constitutes a potential target for replacement therapy .
anadkat et al , have demonstrated that male sex and white race ethnicity increase the risk of rds in late preterm and term infants 
 5 
 .
surfactant treatment response starts with improvement in po2 as also shown in our study , followed by improvement in compliance and oxygenation a more prolonged effect over hours that we evaluated by oi , then finally prolonged effect of the surfactant as substrate for surfactant metabolism persisting for weeks 
 6 
 .
preterm infants diagnosed with rds that have not responded to surfactant treatment as expected have been found to suffer from a significantly higher rate of infection and birth asphyxia 
 7 
 .
pneumonia in term infants might result in secondary surfactant deficiency or dysfunction as surfactant can be inactivated .
secondary surfactant deficiency can result in respiratory deterioration and this may potentially affect the severity of illness in infants with pneumonia .
these infants might also need ventilatory support or extracorporeal membrane oxygenation ( ecmo ) during their hospitalization .
if an infant is intubated and exhibits a deteriorating condition during this ventilatory support , exogenous surfactant may improve infant 's respiratory status because surfactant can be easily inactivated by the inflammatory products of lung injury caused by mechanical ventilation , supplemental oxygen or infection 
 8 
 . in a multicenter trial
it was shown that surfactant treatment of term infants with severe respiratory failure also can decrease the need for ecmo 
 9 
 . in this study infants were randomized to receive exogenous surfactant or placebo .
the infants responded to surfactant better if the surfactant had been given at the early stages of respiratory failure evaluated by oi . in our study
it is also shown that surfactant treatment rapidly improved gas exchange and oxygenation in infants with respiratory failure .
surfactant has important antimicrobial properties and since endogenous surfactant can potentially be inactivated by inflammation and edema in pneumonia patients , exogenous surfactant may be useful in the treatment . herting et al , studied the effects of surfactant on 8 children diagnosed with acute respiratory distress triggered with pneumonia and found that pao2/fio2 was immediately increased after surfactant instillation 
 10 
 .
it is also shown that surfactant therapy improves gas exchange in the majority of infants with streptococcal pneumonia but response was found to be slower compared with infants with rds 
 11 
 . referring to this study jobe concluded that there should be no concerns about treating infants with sepsis / pneumonia syndromes and respiratory failure with surfactant 
 12 
 . in our study
we also demonstrated that infants presenting with respiratory failure and early neonatal sepsis benefit from surfactant administration in the early hours of treatment .
first this was a retrospective study ; second , there was no control group ; thus there may have been confounding factors which contributed to the outcome .
although , there is still no consensus on the efficacy of surfactant in infants with suspected or proven pneumonia 
 13 
 , this study shows that surfactant treatment can improve respiratory indices in infants diagnosed with early neonatal sepsis and respiratory failure .
however larger randomized controlled trials are necessary to determine and conclude whether improved oxygenation is due to surfactant .
 objectivethe objective of the study was to evaluate the effects of exogenous surfactant on respiratory indices in term infants with respiratory failure.methodsconsecutive 18 mechanically ventilated term infants , who received a single dose of exogenous surfactant were retrospectively included into the study . 
 the respiratory outcome of surfactant rescue therapy was evaluated by comparing respiratory indices before and six hours after surfactant administration.findingsmedian oxygenation index ( oi ) , mean alveolar pressure ( map ) and fraction of inspired oxygen ( fio2 ) values were significantly decreased ( p<0.001 ) ; median arterial oxygen partial pressure ( pao2 ) , arterial oxygen saturation ( sao2 ) and pao2/fio2 values were significantly increased six hours after surfactant treatment ( p<0.001).conclusionrescue therapy with surfactant was found to be effective in the improvement of early respiratory indices in term infants with respiratory failure . 
Introduction
Subjects and Methods
Findings
Discussion
Conclusion
Conflict of Interest