Abstract: We included three small RCTs enrolling 79 participants. Two trials did not use a placebo in the control arms and the third trial used air placebo. Two included studies reported no mortality. We judged all three of the included studies to be at low risk or unclear risk across all risk of bias categories; we did not judge any of the studies to be at high risk of bias in any category. Our pooled analysis of the three trials revealed that duration of mechanical ventilation was not significantly different between the groups (mean difference (MD) -63.04, 95% confidence interval (CI) -130.43 to 4.35 hours) but duration of intensive care unit (ICU) stay was less in the surfactant group compared to the control group: MD -3.31, 95% CI -6.38 to -0.25 days. After excluding one trial which produced significant heterogeneity, the duration of mechanical ventilation and duration of ICU stay were significantly lower in the surfactant group compared to the control group: MD -28.99, 95% CI -40.10 to -17.87 hours; and MD -1.81, 95% CI -2.42 to -1.19 days, respectively. Use of surfactant had favourable effects on oxygenation and CO2 elimination. No adverse effects and no complications were observed in any of the three included studies. The level of evidence for duration of mechanical ventilation, duration of intensive care unit stay, oxygenation parameters, and carbon dioxide parameters was of moderate quality. Use of surfactant had favourable effects on duration of mechanical ventilation, duration of ICU stay, oxygenation, and CO2 elimination. However, the studies are few and small (n = 79) so available evidence is insufficient to establish the effectiveness of surfactant therapy for bronchiolitis in critically ill infants who require mechanical ventilation. There is a need for larger trials with adequate power and a cost-effectiveness analysis to evaluate the effectiveness of exogenous surfactant therapy for infants with bronchiolitis who require intensive care management.

Plain-language summary: The evidence is current to June 2015. Three small randomised controlled trials (RCTs) enrolling 79 participants were included in the review. All studies included children younger than 2.5 years with a diagnosis of bronchiolitis who required mechanical ventilation. Two studies did not include a placebo (a substance having no active effect) for comparison. None of the included studies provided a source of funding. Two included studies reported no mortality. Use of surfactant for mechanically ventilated infants and children with bronchiolitis did not decrease the duration of mechanical ventilation. However, the intervention decreased duration of stay in the intensive care unit and had favourable effects on oxygenation and carbon dioxide removal. No complications were observed in any of the three included studies. The level of evidence for duration of mechanical ventilation, duration of intensive care unit stay, oxygenation parameters, and carbon dioxide parameters was of moderate quality. The limited number of studies with small numbers of participants was the reason for moderate quality, and are limitations of this review. There is a need for larger trials to establish any benefits of surfactant for bronchiolitis in critically ill infants and children.