Changes in Lung Volume and Ventilation during
Surfactant Treatment in Ventilated Preterm Infants
Martijn Miedema1, Frans H. de Jongh1, Inez Frerichs2, Mariëtte B. van Veenendaal1,
and Anton H. van Kaam1
1
Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands; and 2Department of
Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Germany
Rationale: The immediate and regional effects of exogenous surfac-
tant in open lung high-frequency oscillatory ventilated (HFOV) pre-
term infants are unknown.
Objectives: To assess regional changes in lung volume, mechanics,
and ventilation during and after surfactant administration in HFOV
preterm infants with respiratory distress syndrome (RDS).
Methods: Using electrical impedance tomography, changes in lung
volume were continuously recorded during a stepwise recruitment
procedure before, during, and after surfactant administration in 15
preterm infants (gestational age: 28.3 wk; birth weight: 1,000 g).
Deflation limbs of the pressure-impedance curve before and after
surfactant were mapped and the effect of surfactant on oscillation
volumes and ventilation was determined. Data were analyzed for
the whole cross-section and the left, right, ventral, and dorsal lung
regions.
Measurements and Main Results: Surfactant increased lung volume by
61 6 39% within a median time of 241 seconds. The ventral to dorsal
ratio in lung volume changed significantly from 1.16 before to 0.81
after surfactant administration. The upper inflection point of the
deflation limb after surfactant (10.4 6 2.4 cm H2O) was significantly
lower compared with before surfactant (16.4 6 3.1 cm H2O). Surfac-
tant increased maximal compliance of the respiratory system, and
this effect was reached at lower airway pressures. Surfactant caused
a transient decrease in oscillatory volume but did not alter its re-
gional distribution.
Conclusions: Surfactant treatment in HFOV preterm infants with RDS
causes a rapid increase and subsequent stabilization of lung volume,
which is most prominent in dependent lung regions. It increased
maximal compliance, but this effect is only reached at lower airway
pressures.
Keywords: premature infant; surfactant; high-frequency oscillatory
ventilation; electrical impedance tomography
Despite the increasing use of noninvasive respiratory support,
almost one-half of extremely preterm infants with respiratory
distress syndrome (RDS) need invasive mechanical ventilation
and are treated with exogenous surfactant (1).
The effect of exogenous surfactant on lung function was ini-
tially studied in animal models, which showed that surfactant
increases and stabilizes functional residual capacity (FRC),
(Received in original form March 2, 2011; accepted in final form April 13, 2011)
Supported by Chiesi Pharmaceutical. The EIT device was kindly provided
by Carefusion.
Conception and design: M.M., F.d.J., M.v.V., A.v.K. Analysis and interpretation:
M.M., F.d.J., I.F., A.v.K. Drafting the manuscript for important intellectual con-
tent: M.M., F.d.J., I.F., M.v.V., A.v.K.
Correspondence and requests for reprints should be addressed to Martijn
Miedema, M.D., Department of Neonatology (H3-214), Emma Children’s Hos-
pital AMC, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail:
m.miedema@amc.uva.nl
This article has an online supplement, which is accessible from this issue’s table of
contents at ww.atsjournals.org
Am J Respir Crit Care Med Vol 184. pp 100–105, 2011
Originally Published in Press as DOI: 10.1164/rccm.201103-0375OC on April 21, 2011
Internet address: www.atsjournals.org
AT A GLANCE COMMENTARY
Scientific Knowledge on the Subject
Exogenous surfactant increases lung volume in preterm
infants with respiratory distress syndrome, but the reported
effect on compliance is conflicting.
What This Study Adds to the Field
Rescue surfactant treatment in high-frequency ventilated
preterm infants with respiratory distress syndrome causes
a rapid increase (minutes) and subsequent stabilization of lung
volume, which is most prominent in the dependent lung
regions. Maximal lung compliance increases but at lower airway
pressures. Ventilation distribution is not affected by surfactant.
improves lung compliance, and results in more homogeneous
ventilation (2–4).
Studies in preterm infants have mainly explored the effect of
exogenous surfactant on lung function in RDS and exclusively
during conventional ventilation. These studies also showed a pos-
itive effect of surfactant on FRC (5). However, data on the
changes in lung compliance have been less consistent, varying
from a reduction, to no change, to an increase in compliance
after surfactant treatment (6–13). This inconsistency may, in
part, be explained by the fact that most studies assessed the
effect of surfactant on lung function at different points in time
after treatment, ranging from 15 minutes to several hours. To
date, no study in preterm infants continuously measured the
acute changes in lung volume and mechanics during surfactant
administration. This is also true for the regional effects of sur-
factant on lung volume and ventilation.
This gap in knowledge is mainly caused by the limitations of
the available bedside lung function monitoring tools. This has
recently changed with the introduction of electrical impedance
tomography (EIT), a noninvasive bedside tool capable of contin-
uously measuring (regional) changes in lung impedance, which
are highly correlated with changes in gas volume (14). Studies
have shown that EIT measurements are also feasible in preterm
infants (15, 16). In this study, we used EIT to monitor (regional)
changes in lung volume and ventilation during and after surfac-
tant administration in high-frequency ventilated premature in-
fants with RDS. We hypothesized that exogenous surfactant
would increase and stabilize lung volume, improve compliance,
and result in a more homogeneous distribution of ventilation.
METHODS
A detailed description of the methodology is provided in the online sup-
plement.
The study was performed in the neonatal intensive care unit of the
Emma Children’s Hospital, Academic Medical Center (Amsterdam,
Miedema, de Jongh, Frerichs, et al.: Effect of Surfactant on Lung Function in Infants 101

the Netherlands). Preterm infants (, 37 wk) were included if they TABLE 1. PATIENT CHARACTERISTICS
failed nasal continuous positive airway pressure (nCPAP) and needed
high-frequency oscillatory ventilation (HFOV) for a suspected diagno- 5-min
sis of RDS within 72 hours after birth. All patients were ventilated in Subject No. GA (wk) Weight (g) Apgar Score Age (h) mOI
the supine position and were not sedated or paralyzed. The study was 1 27.6 1,000 8 4 9.76
approved by the institutional board and written informed consent was 2 28.3 1,070 8 2 7.17
obtained from both parents. 3 29.4 1,200 9 8 4.44
HFOV was used as a primary mode and combined with an open lung 4 25.3 750 6 3 4.49
ventilation strategy using oxygenation as an indirect marker for lung vol- 5 28.1 760 9 4 4.53
ume. Briefly, the continuous distending pressure (CDP) was increased 6 26.9 960 9 16 9.52
stepwise (1–2 cm H2O) until oxygenation no longer improved or frac- 7 28.0 720 8 3 8.70
tional inspired oxygen (FIO2) was less than or equal to 0.25 (CDPo). 8 26.4 750 7 4 8.99
Next, CDP was decreased with 1- to 2-cm H2O steps until oxygenation 9 28.6 820 7 33 3.48
deteriorated (CDPc). Finally, the lung was once more recruited (CDPo) 10 29.3 1,095 8 2 3.08
and then stabilized with a CDP 2 cm H2O above CDPc (CDPopt). 11 28.7 1,220 8 14 3.45
Previous studies have shown that this open lung approach is feasible 12 28.7 880 8 24 6.67
13 31.9 1,080 9 4 10.63
in the majority of preterm infants with RDS and does not lead to
14 29.6 1,000 7 10 5.27
hemodynamic instability (17, 18).
15 26.3 1,020 9 2 11.36
Surfactant was then administered as a bolus via a closed system cath-
Median 28.3 1,000 8 4 6.67
eter. After a stabilization period of 10 minutes, the CDPc, CDPo, and
CDPopt were once more determined. If CDPc could be successfully Definition of abbreviations: CDP ¼ continuous distending pressure; GA ¼ ges-
reduced to 8 cm H2O without oxygenation compromise, the procedure tational age; mOI ¼ modified oxygenation index at the start of recruitment using
was stopped and this pressure was designated as CDPopt. the following equation: CDP 3 FIO2/SpO2; SpO2 ¼ oxygen saturation as measured
Changes in lung impedance (DZ) were continuously recorded by pulse oximetry.
during the above-described procedures, using a scan rate of 44 Hz.
Relative DZ was calculated for each decremental pressure step before This volume increase was reached after a median time of 241
and after surfactant treatment using a 30-second reference period at (interquartile range [IQR], 118–300) seconds. The median ven-
the start of recruitment and just before surfactant administration, re-
tral to dorsal ratio in lung volume changed significantly from 1.16
spectively. All DZ values were normalized setting the DZ at presurfac-
tant CDPo at 100%. Using the pressure/impedance pairs, individual (IQR, 0.79–1.89) before to 0.81 (IQR, 0.40–0.96) after surfactant
pre- and postsurfactant deflation limbs were plotted according to administration, whereas the right to left ratio remained un-
Venegas and colleagues, and the upper inflection points (UIPs), max- changed (Table 2).
imum compliance of the respiratory system (Crsmax), and pressure at The fitting curves of the deflation limbs before and after sur-
Crsmax were calculated (19). The immediate effect of surfactant on lung factant could be constructed in all patients with a mean goodness
volume was assessed by calculating the increase in DZ after adminis- of fit (R2) of 0.98 6 0.03 and 0.97 6 0.05, respectively. The UIP
tration and the stabilization time. The above-described analyses were after surfactant (10.4 6 2.4 cm H2O) was significantly lower com-
performed for the whole chest cross-section as well as for the ventral, pared with the UIP before surfactant (16.4 6 3.1 cm H2O) (P ,
dorsal, right, and left lung regions. The regional effect of surfactant on
0.01) (Table 2). Crsmax increased significantly from a median of
lung volume was assessed by calculating the ventral/dorsal and right/
left ratios at presurfactant CDPopt, directly after surfactant but before
6.9 (IQR, 4.9–8.1) %/cm H2O before to 9.0 (IQR, 8.3–11.8) after
the first decremental pressure step and at postsurfactant CDPopt. surfactant administration. The pressure at which Crsmax was
At these same time points the effect of surfactant treatment on oscillation reached also changed from 12.0 (IQR, 8.8–13.2) before to 7.2
volume was calculated using band-pass filtering (600 6 15/min). In (IQR, 4.7–7.8) cm H2O after surfactant treatment (Table 3).
addition, the ventral to dorsal and left to right distribution of the These changes were also observed in the different analyzed lung
normalized oscillatory DZ was calculated using functional images (20, regions.
21). The area under the curve and geometrical centers (area under the
curve ventral ¼ dorsal) were calculated for the ventral, dorsal, left, and
Surfactant Effect on Ventilation
right regions.
Nonlinear regression was used to plot the deflation limbs. For com- Compared with the presurfactant time point (¼ 100%), the me-
parative analyses the Mann-Whitney or Wilcoxon rank test was used for dian oscillation volume decreased significantly to 73.6% (IQR,
skewed data and the Student t test for a normal distributed data. A 62.1–80.6) immediately after surfactant treatment followed by
P value less than 0.05 was considered statistically significant. an increase to 85.2% (IQR, 75.2–91.4) at optimal postsurfactant
inflation (Table 2). Transcutaneous carbon dioxide pressure ini-
RESULTS tially increased after surfactant administration but reached sig-
nificantly lower values at optimal inflation, despite the fact that
Fifteen newborn infants were included in the study and com- the mean oscillation pressure amplitude decreased from 20.4 6
pleted the recruitment procedure and surfactant administration 2.6 cm H2O before to 18.5 6 3.5 cm H2O after surfactant treat-
without complications (Table 1). The mean CDP at the start of ment (Table 3).
lung recruitment (CDPst) was 8.3 6 1.7 cm H2O with a mean In general, oscillatory ventilation showed a slight asymmetri-
FIO2 of 0.73 6 0.27. The mean CDPo, CDPc, and CDPopt before cal distribution favoring the ventral lung regions along the ver-
surfactant treatment were, respectively, 19.3 6 1.7, 11.0 6 1.6, tical axis (Table 2 and Figure 2). Furthermore, oscillatory
and 13.0 6 1.6 cm H2O, with a mean FIO2 of 0.26 6 0.04. Sur- ventilation was more ventrally located in the right lung com-
factant was administered in a mean dose of 136 6 27 mg/kg, after pared with the left lung. Surfactant administration did not
which CDP could be decreased in all patients to 8.0 cm H2O, with change this regional distribution (Table 2, Figures 2 and 3).
a mean FIO2 of 0.21.
DISCUSSION
Surfactant Effect on Lung Volume To our knowledge, this is the first study that continuously mea-
Lung volume increased in all patients after surfactant adminis- sured regional lung volume changes during and after surfactant
tration with a mean increase of 61 6 39% expressed as per- treatment in preterm infants with RDS. Up to now, the effect of
centage of the presurfactant lung volume at CDPo (Figure 1). exogenous surfactant on lung volume has only been determined
102 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
in conventionally ventilated preterm infants, using different tech-
niques to measure lung volume changes and different time points
after administration (5–10, 13). These studies showed that surfac-
tant increased FRC by 20 to 100% (4, 12, 13). In the present study,
surfactant was administered during HFOV and after a lung re-
cruitment procedure. The main reason for recruiting the lung
before surfactant treatment was to minimize ventilation-
induced lung injury as much as possible during the presurfactant
ventilation period. Surfactant administration under these condi-
tions is different from the studies using conventional ventilation
in which surfactant also plays an important role in lung recruit-
ment. Despite these differences, we found a comparable increase
in lung volume (60%) in preterm infants on HFOV. But more
importantly, we were able to show that this volume increase was
VOL 184 2011
Figure 1. The individual pres-
sure/impedance relationship of
the deflation limb before (solid
circles) and after (open circles)
surfactant administration. The
relative impedance change
(DZ) at the end of recruitment
procedure was set at 100%.
CDP ¼ continuous distending
pressure.
completed in the majority of infants within 5 minutes after sur-
factant administration. To our knowledge, this observation has
not been previously reported.
In addition to measuring the changes in lung volume in the
whole chest cross-section after surfactant treatment, EIT also pro-
vided regional information on these changes, which ideally should
be homogenously distributed. Our study shows that the increase in
lung volume was most prominent in the dorsal lung region (i.e., in
the dependent lung parts). This finding seems to support previous
animal experimental data suggesting that gravity plays an impor-
tant role in the distribution of exogenous surfactant (22).
The observed increase in lung volume can be caused by either
alveolar/saccular distension or recruitment. Considering the fact
that the lungs of these preterm infants were already recruited
Miedema, de Jongh, Frerichs, et al.: Effect of Surfactant on Lung Function in Infants 103

TABLE 2. CHANGES IN LUNG VOLUME, OSCILLATION VOLUME DISTRIBUTION, AND FRACTIONAL VENTILATION DISTRIBUTION DIRECTLY
AFTER SURFACTANT INSTILLATION AND AT THE OPTIMAL PRESSURE POSTSURFACTANT
Optimal Pressure Postsurfactant before the First Optimal Pressure
Presurfactant Decremental Pressure Step Postsurfactant

Ventral to dorsal ratio 1.16 (0.79–1.89) 0.84 (0.60–1.49) 0.81 (0.40–0.96)*,†

Right to left ratio 1.07 (0.73–1.39) 0.94 (0.86–1.17) 0.97 (0.83–1.21)
DZosc, % 100 73.6 (62.1–80.6)‡ 85.2 (75.2–91.4)‡,x
TcPCO2, kPa 6.9 (5.7–8.0) 7.3 (6.3–8.1)‡ 6.3 (5.7–7.4)*,†
AUCven, total matrix, % 53.8 6 9.0 54.0 6 7.8 53.5 6 7.4
AUCven, right half, % 57.7 6 8.7 56.7 6 6.8 56.0 6 7.3
AUCven, left half, % 49.3 6 9.9k 51.1 6 9.9k 50.5 6 8.5k
Geometric center, whole matrix, % 48.1 6 4.2 47.9 6 3.7 48.3 6 3.5
Geometric center, right half, % 46.0 6 4.1 46.4 6 3.3 46.8 6 3.7
Geometric center, left half, % 50.5 6 4.7k 49.4 6 4.8*,k 49.8 6 3.8k

Definition of abbreviations: AUCven ¼ area under the curve of the ventral lung region; DZosc ¼ relative oscillation impedance change; TcPCO2 ¼ transcutaneous carbon
dioxide pressure.
Values are shown as mean 6 SD or median (IQR, 25–75).
* Indicates a significant change in contrast to optimal pressure before surfactant, P , 0.05.
y
Indicates a significant change in contrast to directly after surfactant treatment, P , 0.01.
z
Indicates a significant change in contrast to optimal pressure before surfactant, P , 0.01.
x
Indicates a significant change in contrast to directly after surfactant treatment, P , 0.05.
k
Indicates a significant difference in contrast to the right half of the chest, P , 0.01.

before surfactant administration, it is most likely that the observed
volume increase after surfactant administration was, for the larger
part, caused by distension. The fact that we observed only a small
improvement in oxygenation after surfactant treatment (FIO2 from
0.26 to 0.21) supports this assumption, as only alveolar recruit-
ment and not distension will improve oxygenation.
To assess the effect of surfactant on lung mechanics, we
mapped the deflation limb of the pressure/impedance curve be-
fore and after treatment. As indicated by the significant de-
crease in the UIP of the deflation limb, surfactant stabilized
lung volume at much lower pressures compared with the
surfactant-deficient lung. Surfactant treatment also resulted
in a significant increase in Crsmax and a reduction of the air-
way pressure at which the maximal compliance was reached.
Both the stabilization of lung volume and the increase in com-
pliance are consistent with previous animal studies (4, 13).
Studies in preterm infants have mainly focused on the changes
in compliance and showed conflicting results (5, 11, 13, 23).
Besides differences in the timing and method (static versus
dynamic) of compliance measurement, the present study
seems to suggest that part of this inconsistency can be
explained by the fact that some studies failed to reduce airway
pressures after surfactant treatment and therefore did not de-
tect the surfactant-induced increase in compliance (3, 4, 13).
Only one study mapped the deflation limb of the pressure/
volume curve in paralyzed preterm infants before and 30
minutes after surfactant treatment, using a tracer gas washout
technique (7). Bjorklund and colleagues also found a surfac-
tant-induced increase in Crsmax at lower airway pressures (7).
In addition, the presented deflation limbs suggested a stabiliz-
ing effect of surfactant on lung volume, although more objec-
tive variables, such as UIPs, were not provided. In contrast to
our study, FRC and TLC showed no increase 20 to 40 minutes
after surfactant administration. As noted by the authors, this
discrepancy with our study may be, in part, explained by the fact
that presurfactant FRC was overestimated by applying repeated
deep inflations before each measurement.
By filtering the impedance data in the 10-Hz domain, we were
able to establish the effect of surfactant on oscillatory ventila-
tion. Immediately after surfactant administration, the oscillation
volume decreased, probably as a result of airway obstruction.
Over time the oscillation volume improved as airway pressures
were reduced and surfactant moved into the periphery of the lung.
The fact that the oscillation volumes did not return to presurfac-
tant values after completing the postsurfactant recruitment proce-
dure is probably best explained by the reduction in the pressure
amplitude. Despite this decrease in pressure amplitude and oscil-
lation volume, transcutaneous carbon dioxide pressure levels were
lower after surfactant, indicating improved alveolar ventilation as
also shown in previous studies in premature infants (5, 11–13).
Analysis of the regional distribution of the oscillatory volume
showed that ventilation was more prominent in the right and ven-
tral lung region. This (novel) finding is probably best explained
by the anatomical position of the heart, resulting in less lung

TABLE 3. CHANGES IN THE DEFLATION LIMB CHARACTERISTICS BEFORE AND AFTER SURFACTANT TREATMENT
Deflation Limb before Surfactant Deflation Limb after Surfactant

Global Ventral Dorsal Global Ventral Dorsal

UIP, cm H2O 16.4 6 3.1 15.7 6 2.8 16.2 6 3.8 10.4 6 2.4* 10.5 6 2.8* 10.5 6 3.2*
Crsmax, %/cm H2O 6.9 (4.9–8.1) 3.6 (2.7–4.4) 3.7 (2.8–5.9) 9.0 (8.3–11.8)† 4.9 (4.1–6.0) 5.3 (3.6–8.3)
Pressure at Crsmax, cm H2O 12.0 (9.3–12.9) 10.0 (8.6–12.2) 11.4 (8.3–12.6) 7.2 (4.7–7.7)* 6.7 (5.0–7.5)* 6.7 (4.7–7.6)†

Definition of abbreviations: Crsmax ¼ maximal compliance of the respiratory system; UIP ¼ upper inflection point.
Values are shown as mean 6 SD or median (IQR, 25–75).
* Indicates a significant change in contrast to the deflation limb before surfactant, P , 0.01.
y
Indicates a significant change in contrast to the deflation limb before surfactant, P , 0.05.
104 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 184 2011

Figure 2. Distribution of the

normalized oscillation amplitude
(DZ in percentage) in 32 ante-
rior to posterior slices at optimal
pressure before (left panel ), after
(middle panel ), and at the opti-
mal pressure after surfactant ad-
ministration (right panel). The
slices were denoted by setting
the most anterior part to 0%
and the most posterior part to
100%. Data are presented as
mean values 6 SD.

tissue and thus oscillatory ventilation in the left ventral region.
This finding seems to support the validity of the presented EIT
data. It was interesting to observe that surfactant treatment did
not change the distribution of oscillatory ventilation. Although
this finding might suggest a homogenous surfactant distribution,
other explanations should also be considered. First, surfactant
treatment in an already recruited, and thus homogeneously aer-
ated lung might not impact ventilation distribution even if surfac-
tant distribution is heterogeneous. Second, the oscillatory volumes
may be too small to pick up more subtle changes in ventilation
distribution. This might be different during conventional mechan-
ical ventilation, although a recent animal study does not seem to
support this explanation (2).
This study has several limitations that need to be addressed.
First, EIT only monitored lung volume changes in one transver-
sal “slice” of the lung. RDS is suggested to be a homogenous
lung disease, making it highly likely that the presented findings
are representative for the entire lung. Second, although not
essential, this study did not provide information on the absolute
changes in lung volume as the calibration of the EIT signal has,
so far, not been feasible. Third, all the patients in this study
were treated with open lung HFOV. The results may be differ-
ent during conventional (tidal) ventilation, during which surfac-
tant also plays an important role in lung recruitment. However,
the similar findings on FRC and compliance in animal and hu-
man studies using conventional ventilation seem to be reassur-
ing (2, 7). Finally, surfactant was administered relatively late
(. 2 h) after birth, which may have reduced its efficacy. This
delay is probably best explained by the fact that all patients in
our unit are started on nCPAP (1). The fact that many clinicians
have adopted the use of early nCPAP makes our study results
clinically relevant.
Despite these limitations, our study has important implica-
tions for clinical practice. First, this study shows that surfactant
treatment during high-frequency ventilation increases lung vol-
ume comparable to treatment during conventional (tidal) venti-
lation. Second, based on the stabilizing effect of surfactant on
lung volume, clinicians should reduce the airway pressures after
treatment to avoid possible overdistension and to profit from the
increased compliance. Third, this reduction in pressure should be
started within 5 minutes after surfactant therapy. Finally, rescue
surfactant treatment in a recruited lung seems to result in a rel-
atively homogenous distribution, although there is a possible
gravity-dependent tendency for surfactant to move to the more
dependent lung parts. This latter finding suggests that body po-
sitioning might be an effective way to augment regional surfac-
tant deposition in heterogeneous lung disease.
In conclusion, this study shows that rescue surfactant treat-
ment in open lung high-frequency ventilated preterm infants
with RDS causes a rapid increase (minutes) and subsequent sta-
bilization of lung volume, which is most prominent in depen-
dent lung regions. In addition, surfactant treatment increases
maximal compliance, but at lower airway pressures. Ventilation
distribution is relatively homogeneous and not affected by
surfactant.
Author Disclosure: M.M. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. F.H.d.J. was an expert
witness for Teva Pharmaceutical. I.F. received travel accommodations from Car-
dinal Health. M.B.v.V. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. A.H.v.K. received
grant support from Chiesi Pharmaceuticals.

Figure 3. Summarized frac-

tional regional oscillation dis-
tribution in 32 anterior to
posterior slices of the right
and left halves of the chest de-
termined at optimal pressure
before (left panel), after (middle
panel), and at optimal pressure
after surfactant administration
(right panel ). The numbers in
the left and right corners of
these diagrams specify the
fractional ventilation in the
right and left thoracic cross-
sections, respectively. Data are
presented as mean values 6
SD. D ¼ dorsal; L ¼ left; R ¼
right; V ¼ ventral.
Miedema, de Jongh, Frerichs, et al.: Effect of Surfactant on Lung Function in Infants
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