If the initial response to surfactant therapy wanes in a premature infant with IRDS, what should the clinician consider?

• A. Escalate FiO2
• B. Re-administer the medication
• C. Place the patient prone
• D. Start ECMO

Answer: (B)

Surfactant works by lowering surface tension and re-expanding alveoli, so after an initial dose the lungs can open up and oxygenation improves. If that improvement fades, it suggests there are still alveoli that didn’t receive enough surfactant or have re-collapse, or new lung tissue areas now require surfactant.

Re-administering the medication replenishes the surfactant pool, helping to restore alveolar stability, reduce work of breathing, and lower oxygen or ventilator requirements. This approach directly addresses the deficit rather than just tightening the oxygen mask or changing positioning. ECMO is considered only if maximal conventional support fails, so repeating surfactant is the appropriate next step when the response wanes.