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• Dose to use

• Repeated doses (when, how, etc.)

• Administration (time, bolus, etc.)

• Immediate and late immunological implication

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Several points remain to be defined. Empirical supplementation must be followed by recognition of effective surfactant deficiency in order to ensure supplementation of correct dose when necessary. BAL before treatment can help in the evaluation of possible surfactant deficiency.

Use of repeated doses has to be investigated in order to define whether it is better to supplement surfactant when gas exchange deterioration is first noted or to wait until deterioration is fully evident. Precocious treatment may lead to treating patients who may have recovered in any case without surfactant therapy (ethical problem and higher costs). On the other hand, it appears evident that early treatment, and probable re-treatment, lead to better results.

Delivery techniques must adapted to the specific lung pathology. Bolus administration is easier to perform and therefore more used. The other two methods described need further study, and the difficulty of administration requires wide experience.

Even though no immunological effects have been described to date after single or repeated administration, the possibility of hypersensibilisation must always be considered.

Strayer DS, Merritt TA, Hallman M. Eur Respir J 1989

Marraro G, Foresti B, Casiraghi G, Monici-Preti P. Drugs Explt Clin Res 1991