A controlled trial of synthetic surfactant in infants weighing 1250 g or more with respiratory distress syndrome. The American Exosurf Neonatal Study Group I, and the Canadian Exosurf Neonatal Study Group

N Engl J Med. 1991 Dec 12;325(24):1696-703. doi: 10.1056/NEJM199112123252404.


Background: Surfactant-replacement therapy is now recognized as a life-saving and safe intervention in small premature infants, but there is little evidence concerning its risks and benefits in larger premature infants.

Methods: We conducted a placebo-controlled, blinded trial in 1237 infants with respiratory distress who were enrolled at 23 hospitals in the United States and 13 hospitals in Canada. At entry all the infants weighed at least 1250 g, were receiving mechanical ventilation, and had a ratio of arterial to alveolar oxygen tension below 0.22. The initial dose of either the synthetic surfactant (Exosurf, 5 ml per kilogram of body weight) or air (the placebo) was administered less than 24 hours after birth, with a second dose given 12 hours later. A total of 614 infants were assigned to receive surfactant, and 623 to receive placebo.

Results: Fewer infants in the surfactant group than in the placebo group died before 28 days of age or survived at 28 days with bronchopulmonary dysplasia (7 percent vs. 12 percent, P = 0.002). In the first 28 days of life, there were fewer deaths due to respiratory distress syndrome in the surfactant group (1 percent vs. 3 percent, P = 0.043), lower overall neonatal mortality (4 percent vs. 7 percent, P = 0.04), and a lower incidence of bronchopulmonary dysplasia (3 percent vs. 6 percent, P = 0.008). There was also a significantly lower incidence of pulmonary air leaks, intraventricular hemorrhage, patent ductus arteriosus, seizures, hypotension, and pulmonary hypertension in the surfactant group. The infants treated with surfactant were weaned from oxygen and mechanical ventilation significantly sooner than those given placebo, and they less often required high-frequency ventilation or extracorporeal membrane oxygenation. The primary side effect observed more frequently among the infants who received surfactant treatment was pulmonary hemorrhage (six infants vs. one infant, P = 0.055).

Conclusions: In infants weighing at least 1250 g at birth who have respiratory distress syndrome, treatment with two doses of synthetic surfactant improves survival and reduces perinatal morbidity.

Publication types

  • Clinical Trial
  • Controlled Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Birth Weight
  • Bronchopulmonary Dysplasia / mortality
  • Child
  • Drug Combinations
  • Fatty Alcohols / therapeutic use*
  • Female
  • Follow-Up Studies
  • Humans
  • Infant, Newborn
  • Infant, Premature, Diseases / mortality
  • Male
  • Phosphorylcholine*
  • Polyethylene Glycols / therapeutic use*
  • Pulmonary Surfactants / therapeutic use*
  • Respiratory Distress Syndrome, Newborn / drug therapy*
  • Ventilator Weaning


  • Drug Combinations
  • Fatty Alcohols
  • Pulmonary Surfactants
  • Phosphorylcholine
  • Polyethylene Glycols
  • dipalmitoylphosphatidylcholine, hexadecanol, tyloxapol drug combination