A DOUBLE BLIND, RANDOMIZED, CONTROLLED STUDY TO INVESTIGATE THE EFFICACY AND SAFETY OF SYNTHETIC SURFACTANT (CHF 5633) IN COMPARISON TO PORCINE SURFACTANT (PORACTANT ALFA, CUROSURF®) IN THE TREATMENT OF PRETERM NEONATES WITH RESPIRATORY DISTRESS SYNDROME
Phase: PHASE2
Conditions: Respiratory Distress Syndrome, Newborn
Sponsor: Chiesi Farmaceutici S.p.A.

CONFIDENTIAL
Page 1/62
CODE: CCD-5633AA1-02
A MULTICENTER, DOUBLE BLIND, RANDOMIZED, SINGLE 
DOSE, ACTIVE-CONTROLLED STUDY TO INVESTIGATE THE 
EFFICACY AND SAFETY OF SYNTHETIC SURFACTANT (CHF 
5633) 
IN 
COMPARISON 
TO 
PORCINE 
SURFACTANT 
(PORACTANT ALFA, CUROSURF®) IN THE TREATMENT OF 
PRETERM 
NEONATES 
WITH 
RESPIRATORY 
DISTRESS 
SYNDROME.
Version No.: 4.0
Date: 31st January 2018  
The information contained in this document is confidential and will not be disclosed to others without written 
authorization from Chiesi Farmaceutici S.p.A., except to the extent necessary to obtain informed consent from those 
persons to whom the drug may be administered or for discussions with local regulatory authorities, Ethics 
Committee/Investigational Review Boards, or people participating in the conduct of the study.
Chiesi Farmaceutici S.p.A.
Via Palermo 26/A
43122 Parma (Italy)
CLINICAL STUDY PROTOCOL 
IND No : 122619
ClinicalTrials.gov ID: NCT02452476

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 2/62
GENERAL INFORMATION
Sponsor:
Chiesi Farmaceutici S.p.A.
Via Palermo 26/A
43122 Parma (Italy)
Tel.: +39 0521 2791
Fax: +39 0521 774468
E-mail: info@chiesigroup.com
SPONSOR MEDICAL EXPERT
(Clinical Research Physician)
 
Chiesi Farmaceutici S.p.A.
Via Palermo 26/A
43122 Parma (Italy)
Clinical Project Manager:
Chiesi Farmaceutici S.p.A.
Via Palermo 26/A
43122 Parma (Italy)
Monitoring CRO:
Coordinating Investigator
Prof. Rangasamy Ramanathan, MD
Professor of Pediatrics
Division Chief of Neonatology
Program Director, NPM Fellowship Program
Associate Center Director, Center for Neonatal Medicine-
CHLA
Medical Director, NICU, LAC+USC Medical Center

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 3/62
Central Laboratory for Immunogenicity 
Evaluation:
     
 
Central Laboratory for Biomarker 
Evaluation:
    

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 4/62
VERSION HISTORY
Version 
Date 
Change History
1.0
25 May 2015
Original version
2.0
07 August 2015

Administrative change of the Sponsor’s name from 
Chiesi USA, Inc to Chiesi Farmaceutici S.p.A. (Italy);

Clarification of the procedures for re-dosing with 
study drug; 

Incorporation of a dynamic randomization method 
to assure the balance of the treatment groups by 
investigational site and gestational age group;

Clarification of the pharmacovigilance procedure 
for adverse events reporting/follow-up and CRO contact 
details;

Broadening of the safety assessment window for 
performance of cranial ultrasound from within 48 hours 
to within 7 days of life;

Delineation of the allowed time deviations from 
post-dose times;

Correction of minor typographical errors.
3.0
08 February 2017      
Administrative 
change 
of 
the 
SPONSOR 
MEDICAL EXPERT (Clinical Research Physician);

Clarification of the timings in hours for Phases 3 
(Section 7.1.3), 4 (Section 7.1.4), 5 (Section 7.1.5), 6 
(Section 7.1.6);

Correction of bronchopulmonary dysplasia (BPD) 
diagnosis in Section 7.1.9 to align it to the one contained 
in Appendix II;

Update and correction of the list of Morbidities or 
Complications of prematurity at study entry; 

Correction of minor typographical errors and 
further clarifications on some protocol definitions and 
procedures (i.e. Mortality/BPD rate, data collection at 
planned time points and for tracheal aspirates).
4.0
31 January 2018        
To replace the Coordinating Investigator;

To update the protocol template according to ICH 
Topic E6 (R2), CPMP/ICH/135/95, ‘Note for Guidance 
on Good Clinical Practice’, Step 4, November 2016.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 5/62
PROTOCOL OUTLINE
Study Title
A multicenter, double blind, randomized, single dose, active-
controlled study to investigate the efficacy and safety of synthetic 
surfactant (CHF 5633) in comparison to porcine surfactant (Poractant 
alfa, Curosurf ®) in the treatment of preterm neonates with 
respiratory distress syndrome.
Sponsor
Chiesi Farmaceutici S.p.A., Via Palermo 26/A, 43122 Parma (Italy)
Name of the Product
CHF 5633 Synthetic surfactant
Centers
Approximately 20 investigational sites will be involved. 
Indication 
Treatment of Respiratory Distress Syndrome (RDS).
Study design
Double blind, randomized, single dose, active-controlled study. 
Study phase
Proof of Concept (POC)/Phase II
Objectives
Main objectives of this study are: 

to investigate the short term efficacy profile of CHF 5633 vs. 
porcine surfactant (Poractant Alfa, Curosurf®) in terms of 
reduced oxygen requirement and ventilatory support 

to evaluate the mid-term efficacy profile in terms of reduced 
incidence of bronchopulmonary dysplasia (BPD) and 
mortality/BPD rate at 36 weeks post menstrual age (PMA), 
mortality rate at 28 days post-natal age (PNA) and 36 weeks 
PMA, RDS-associated mortality through 14 days of age and 
other major co-morbidities of prematurity.
Moreover, other objectives of the present study are: 

to evaluate the need for  re-dosing in the 2 treatment groups 
according the pre-defined criteria;

to 
evaluate 
the 
inflammatory 
status 
through 
the 
measurements of specific biomarkers of inflammation  in 
tracheal aspirates (in a subgroup of babies who require 
endotracheal intubation for mechanical ventilation when 
feasible);

to assess immunogenicity through the measurement of 
antibodies to SP-B analogue (CHF 5736.03) and SP-C 
analogue (CHF 4902.03) contained in CHF 5633.

to perform the evaluation of oxygenation status through 
invasive measurements [in a subgroup of babies who have 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 6/62
an arterial (umbilical, peripheral) access, when feasible]; 

to evaluate the safety profile in the two treatment groups  in 
terms of adverse events (AEs) and adverse drug reactions 
(ADRs), vital signs, hematology and biochemistry values.
Treatment duration
One intratracheal administration of CHF5633 200mg/kg or Poractant 
alfa (Curosurf®) 200 mg/kg within 24 hours from birth. If needed, up 
to two repeat doses of 100 mg/kg each may be administered at 
approximately 12-hour intervals with the same surfactant as the first 
dose, according to the double blind design and the below pre-defined 
criteria: 

lack of reduction in FiO2 >0.10  to keep arterial oxygen 
saturation (SpO2) between 88–95% or other clinical evidence 
of lack of efficacy within 12 hours after first/previous 
dosing;

babies mechanically ventilated with FiO2 ≥0.30 for babies 24 
to 26+6 weeks and FiO2 ≥0.35 for babies 27 to 29+6 weeks 
within 12 hours after first/previous dosing;

babies not mechanically ventilated with FiO2 ≥0.35 for 
babies 24 to 26+6 weeks and FiO2 ≥0.40 for babies 27 to 29+6 
weeks within 12 hours after first/previous dosing.
However, if a neonate still fails to show a clinical improvement after 
further re-dosing with the same surfactant as the first dose (e.g. 
FiO2>0.40 to maintain SatO2 88-95%, respiratory acidosis defined as 
pCO2 >65 mmHg/8.5 kPa and pH<7.20 on an arterial or capillary 
blood gas), he/she could receive an alternative surfactant treatment 
according to Investigator’s discretion.
Test product 
dose/route/regimen
CHF5633 200mg/kg synthetic surfactant sterile suspension in 3.0 ml 
glass vials with a total concentration of 80 mg/ml for intratracheal 
administration, 
containing 
the 
synthetic 
phospholipids: 
dipalmitoylphosphatidylcholine (DPPC), 1-palmitoyl-2-oleoyl-sn-
glycero-3-phosphoglycerol (POPG) and sodium salt, synthetic 
surfactant protein C analogue and synthetic surfactant protein B 
analogue [SP-C 1.5%, SP-B 0.2%, total phospholipids 98.3% 
(w/w)]. 
CHF5633 100 mg/kg will be used for further re-dosing when needed.
  
Reference product 
dose/route/regimen
Poractant alfa (Curosurf®) 200mg/kg sterile suspension in 3.0 ml  
glass vials with a total concentration of 80 mg/ml for intratracheal 
administration, standard natural surfactant prepared from porcine 

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 7/62
lungs and containing almost exclusively polar lipids, in particular 
phosphatidylcholine (about 70% of the total phospholipid content), 
and about 1% of specific low molecular weight hydrophobic 
proteins SP-B and SP-C.
Poractant alfa 100mg/kg will be used for further re-dosing when 
needed.
Number of patients
126 patients (63 in each treatment group) will be randomized in the 
study.
Study population
Preterm neonates with a gestational age of 24+0 weeks up to 29+6 
weeks with RDS
Inclusion/exclusion criteria
Inclusion Criteria 
Subjects must meet all the following inclusion criteria to be eligible 
for enrolment into the study: 
1. Written 
informed 
consent 
obtained 
by 
parents/legal
representative (according to local regulation) prior to any
study-related procedures
2. Inborn preterm neonates of either sex with a gestational age
of 24+0 weeks up to 29+6 weeks
3. Clinical course consistent with RDS
4. Requirement of endotracheal surfactant administration within
24 hours from birth
5. Fraction of inspired oxygen (FiO2) ≥0.30 for babies 24+0 to
26+6 weeks  and FiO2 ≥0.35 for babies 27+0 to 29+6 weeks to
maintain SpO2 between 88–95%
Exclusion Criteria
The presence of any of the following will exclude a subject from 
study enrolment:
1. Use of surfactant prior to study entry and need for
intratracheal administration of any other treatment (e.g. nitric
oxide)
2. Known genetic or chromosomal disorders, major congenital
anomalies (cardiac malformations, myelomeningocele etc)
3. Mothers with prolonged rupture of the membranes (>21 days
duration)
4. Strong suspicion of congenital pneumonia/infection, sepsis
5. Presence of air leaks if identified and known prior to study

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 8/62
entry
6. Evidence of severe birth asphyxia
7. Neonatal seizures prior to study entry
8. Any condition that, in the opinion of the Investigator, would 
place the neonate at undue risk
9. Participation in another clinical trial of any placebo, drug or 
biological substance conducted under the provisions of a 
protocol. 
Most 
relevant 
allowed 
concomitant treatments
Any concomitant medication required for the normal care of preterm 
neonates will be permitted during the study.
Most relevant forbidden 
concomitant treatments

Surfactant treatment prior to study entry 

Intratracheal administration of any other treatment (e.g. nitric 
oxide) prior to study entry

Other investigational drugs.
Efficacy variables (and/or 
pharmacokinetics 
variables)

Ratio of arterial oxygen saturation determined by pulse 
oximetry and  fraction of inspired oxygen (SpO2/FiO2) in the 
first 7 days post-treatment (at 30 minutes, at 1, 3, 6, 12, 18, 24 
hours, at Days 2, 3, 5 and 7), at Day 28±2 PNA, at discharge 
home and at 36 weeks PMA.

Fraction of inspired oxygen (FiO2) in the first 7 days post-
treatment (at 30 minutes, at 1, 3, 6, 12, 18, 24 hours, at Days 
2, 3, 5 and 7), at Day 28±2 PNA, at discharge home and at 36 
weeks PMA.

Respiratory Severity Score (RSS) [FiO2 corrected by mean 
airway pressure (MAP):  FiO2 x MAP] in the 2 days 
post-treatment (at 30 minutes, at 1, 3, 6, 12, 18, 24 hours and 
on Day 2); 

Oxygen Saturation Index (OSI) [ FiO2 x MAP x100/SpO2] in 
the 2 days post-treatment (at 30 minutes, at 1, 3, 6, 12, 18, 24 
hours and on Day 2); 

SpO2 in the first 7 days post-treatment (at 30 minutes, at 1, 3, 
6, 12, 18, 24 hours, at Days 2, 3, 5 and 7), at Day 28±2 PNA, 
at discharge home and at 36 weeks PMA.

Mean airway pressure (MAP), peak inspiratory pressure (PIP) 
and positive end-expiratory pressure (PEEP) in the first 7 
days of post-treatment

Mortality/BPD rate defined as the incidence of patients who 
are dead or alive with a diagnosis of BPD at 36-week PMA;

BPD incidence at 36-week PMA;

Mortality rate at Day 28 PNA and at 36-week PMA;

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 9/62

RDS-associated mortality rate through 14 days of age; 

Percentage of patients requiring at least one rescue surfactant 
dose;

Percentage of patients with at least one reading of FiO2=0.21 
(i.e. room air) within 24 hours from first dosing with test 
treatment;

Time (hours) to reach FiO2=0.21 (i.e. room air);

Duration of invasive mechanical ventilation (days), defined as 
the time until the first successful extubation lasting more than 
24 hours;

Duration of non-invasive ventilation (days), defined by nasal 
continuous positive airway pressure (nCPAP), Bi-level 
positive airway pressure (BiPAP), nasal intermittent positive 
pressure ventilation (NIPPV),  high flow nasal cannula 
(HFNC); 

Duration of oxygen alone, defined as receiving supplemental 
oxygen without invasive or non-invasive ventilator support;

Biomarkers of inflammation: CXCL8, Interleukin 1β (IL1β), 
Interleukin 6 (IL6), Tumor Necrosis Factor-alpha (TNF-α), 
myeloperoxidase (MPO), prior to study drug administration, 
at 24 hours and on Day 2 (48 hours) (in a subgroup of babies 
who 
require 
endotracheal 
intubation 
for 
mechanical 
ventilation when feasible). 

Alveolar–arterial (A-a) Oxygen gradient at 3, 6, 12, 18, 24 
hours and day 2 post treatment (in a subgroup of babies who 
have an arterial access, when feasible)

Oxygenation Index (OI) at 3, 6, 12, 18, 24 hours and day 2 
post treatment (in a subgroup of babies who have an arterial 
access, when feasible)
Safety variables

AEs and ADRs

Vital signs (systolic and diastolic blood pressure, heart rate) 
and SpO2 during administration

Incidence of major neonatal morbidities (for the list of 
neonatal morbidities and complications of prematurity see 
section 10.8)

Hematology and blood chemistry: full blood count (FBC), 
urea, creatinine and electrolytes (sodium, potassium, calcium, 
phosphorus), alanine aminotransferase (ALT), aspartate 
aminotransferase (AST), glucose, C-reactive protein     

Immunogenicity assessment will be carried out in one blood 
sample collected approximately 5 weeks after administration 
(with a window from 3 to 6 weeks)  

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 10/62

Bayley Scales of Infant Development at 24 months (±3 
months) corrected age. 

Health status questionnaire (health problems, illnesses, 
injuries, well-being, diet, respiratory assessment) at 24 
months (±3 months) corrected age.
Sample size calculation
According to the exploratory nature of this study, no formal sample 
size calculation was performed. A maximum number of sixty-three 
randomized neonates per treatment group (126 in total) is deemed 
sufficient to describe the efficacy and safety of CHF5633 compared 
to Poractant Alfa.
Statistical methods
Efficacy variables
•
SpO2/FiO2 will be analyzed using a linear mixed model for 
repeated measures (MMRM) including treatment, time point, 
treatment by time point interaction, investigational site and 
gestational age group as fixed effects and pre-dose ratio as 
covariate. The adjusted means in each treatment group, the 
adjusted mean difference between treatments and their 95% 
confidence intervals (CIs) at each time point and averaged over 
the first 24 hours will be estimated by the model.
SpO2/FiO2 will be compared between treatments at the 
remaining post-treatment time points (i.e., Days 2, 3, 5, 7, 28±2 
PNA, at discharge home and at 36 weeks PMA) using mixed 
model including treatment, investigational site and gestational 
age group as fixed effects and pre-dose ratio as covariate.
SpO2/FiO2 will be analyzed by subgroups based on ventilator 
support used.  
•
FIO2 will be analyzed at each time point and averaged over the 
first 24 hours post dose using the same model used for the 
SpO2/FiO2. Pre-dose FIO2 will be used as covariate.
FiO2 will be compared between treatments at additional post-
treatment time points (i.e., Days 2, 3, 5, 7, 28±2 PNA, at 
discharge home and at 36 weeks PMA) using linear mixed 
model including, treatment, investigational site and gestational 
age group as fixed effects and pre-dose FIO2 as covariate.
•
RSS will be analyzed at each time point and averaged over the 
first 24 hours post study drug intake using the same model used 
for the SpO2/FiO2.
RSS at day 2 will be analyzed using linear mixed model 
including, treatment, investigational site and gestational age 
group as fixed effects.

OSI will be analyzed at each time point and averaged over the 
first 24 hours post study drug intake using the same model used 
for the SpO2/FiO2.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 11/62
OSI at day 2 will be analyzed using linear mixed model 
including, treatment, investigational site and gestational age 
group as fixed effects.

SpO2, MAP, PIP, PEEP values as well as changes from baseline 
will be summarized by treatment group by means of descriptive 
statistics at each post-treatment timepoints.
•
Mortality/BPD rate at 36-week PMA will be compared by 
treatment by means of Cochran-Mantel-Haenszel (CMH), 
adjusting for stratification factors (i.e. GA group and 
investigational site). Relative risk (RR) and related 95% 
confidence interval will be provided.
•
The incidence of BPD at 36-week PMA will be compared by 
treatment as Mortality/BPD rate.

The mortality rate at 36-week PMA and at Day 28 will be 
compared by treatment as Mortality/BPD rate.

RDS-associated mortality rate through 14 days of age will be 
compared by treatment as for Mortality/BPD rate.
•
The percentage of patients requiring at least one rescue 
surfactant dose will be compared by treatment group by means 
of a Fisher’s exact test at 5% significance interval. Odds ratio 
(OR) and related exact 95% CI will be also provided. Patients 
with pulmonary hemorrhage will be excluded from this 
summary. 
•
The median duration time of invasive mechanical ventilation, 
oxygenation and non-invasive ventilation will be compared 
between groups by the Mann-Whitney U-test.
•
Percentage of patients with at least one reading of  FiO2 equal to 
0.21 (i.e. at room air) within 24 hours from first intake will be 
compared by treatment groups by means of a Fisher’s exact test 
at 5% significance interval. Odds ratio (OR) and related exact 
95% CI will be also provided. 
•
The median duration time to reach FiO2 equal to 0.21 will be 
compared between groups by the Mann-Whitney U-test.
•
Mean values of biomarkers of inflammation (i.e., CXCL8, IL1β, 
IL6, TNF-α, MPO) in the tracheal aspirates as well as change 
from baseline to 24 hours and on Day 2 (48 hours) will be 
summarized by treatment by means of descriptive statistics.
•
A–a gradient and OI values as well as change from baseline in 
the first 48 hours after the first surfactant intake (i.e., at 3, 6, 12, 
18, 24 hours and on day 2) will be summarized by treatment by 
means of descriptive statistics.
Safety variables
•
Incidence of AEs will be summarized by treatment group both 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 12/62
in term of frequency of neonates with at least one AE and in 
term of frequency of AEs (number of events). All AEs, related 
AEs, serious AEs, AEs leading to death will be summarized by 
SOC and PT. 
•
Major neonatal morbidities (see section 10.8) will be 
summarized by treatment group.
•
At each time point (at 0 -for HR only-, 30 minutes, at 1, 3, 6, 
12, 24 hours, Days 2, 3, 5, 7 and 28, discharge home and at 36 
weeks PMA), the absolute value and the change from baseline 
in vital signs (SBP, DBP and HR) will be summarized by 
treatment group using descriptive statistics. SpO2 during 
administration will be summarized as well.  
•
Hematology and chemistry parameters will be listed.
•
Immunogenicity titers will be listed. 

Bayley Scales of Infant Development assessed at 24 months (±3 
months) corrected age will be summarized by means of 
descriptive statistics. 

Health status questionnaire assessed at 24 months (±3 months) 
corrected age will be summarized by means of descriptive 
statistics.

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 13/62
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS
A-a
Alveolar-arterial
ADR
Adverse Drug Reaction
AE
Adverse Event
ALT
Alanine aminotransferase
AST
Aspartate aminotransferase
APGAR
Appearance, Pulse, Grimace, Activity, Respiration
BiPAP
Bi-level Positive Airway Pressure 
BPD
Bronchopulmonary Dysplasia
BW
Birth Weight
CPAP
Continuous Positive Airway Pressure
CRA
Clinical Research Associate
eCRF
electronic Case Report Form
CRO
Clinical Research Organization
DBP
Diastolic Blood Pressure
DPPC 
Dipalmitoylphosphatidylcholine
FBC
Full Blood Count
FiO2
Fraction of inspired Oxygen
GA
Gestational Age
GCP
Good Clinical Practice
HFOV
High Frequency Oscillatory Ventilation
HFNC
High-Flow Nasal Cannula
HR
Heart Rate
ICH
International Conference on Harmonization
EC
Ethics Committee
IRB
Institutional Review Board
IRT
Interactive Response Technology
ISMB
Independent Safety Monitoring Board
ITT
Intention to Treat
IVH
Intraventricular Hemorrhage
LSMs
Least Square Means
MAA
Marketing Authorization Application
MAP
Mean Airway Pressure
MedDRA
Medical Dictionary for Regulatory Activities
NEC
Necrotizing enterocolitis 
NICU
Neonatal Intensive Care Unit
NIPPV 
Nasal Intermittent Positive Pressure Ventilation 
NO
Inhaled nitric oxide
OI
Oxygenation Index
OSI
Oxygen Saturation Index
PCO2
Arterial Carbon Dioxide Tension
PDA
Patent Ductus Arteriosus
PEEP
Positive End-Expiratory Pressure
PIE
Pulmonary Interstitial Emphysema
PIP
Peak Inspiratory Pressure
PMA
Post-Menstrual Age
PNA 
Post-Natal Age
PP
Per-Protocol
PVL
Periventricular Leukomalacia
RDS
Respiratory Distress Syndrome
ROP
Retinopathy of Prematurity

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 14/62
RSS 
Respiratory Severity Score
SAE
Serious Adverse Event
SBP
Systolic Blood Pressure
SOP
Standard Operating Procedure
SmPC
Summary of Product Characteristics
SpO2
Arterial Oxygen Saturation by Pulse Oximetry
SUSAR
Suspected Unexpected Serious Adverse Reaction

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 15/62
CONTENTS
       Page
1.
BACKGROUND INFORMATION AND STUDY RATIONALE.....................................................................18
2.
STUDY OBJECTIVES...........................................................................................................................................21
2.1
PRIMARY OBJECTIVES......................................................................................................................................21
2.2
SECONDARY OBJECTIVES.................................................................................................................................21
3.
STUDY DESIGN.....................................................................................................................................................21
4.
SUBJECT SELECTION CRITERIA ...................................................................................................................23
4.1
SUBJECT RECRUITMENT...................................................................................................................................23
4.2
INCLUSION CRITERIA .......................................................................................................................................23
4.3
EXCLUSION CRITERIA ......................................................................................................................................23
4.4
SUBJECT WITHDRAWALS .................................................................................................................................24
5.
CONCOMITANT MEDICATIONS.....................................................................................................................24
5.1
PERMITTED CONCOMITANT MEDICATIONS.......................................................................................................24
5.2
NON-PERMITTED PREVIOUS AND CONCOMITANT MEDICATIONS ......................................................................24
6.
TREATMENT(S)....................................................................................................................................................25
6.1
APPEARANCE AND CONTENT............................................................................................................................25
6.2
DOSAGE AND ADMINISTRATION.......................................................................................................................25
6.2.1
Selection of doses in the study ..................................................................................................................25
6.2.2
Dosage ......................................................................................................................................................26
6.2.3
Administration...........................................................................................................................................26
6.2.4
Subject Training........................................................................................................................................27
6.3
PACKAGING......................................................................................................................................................27
6.3.1
Primary packaging....................................................................................................................................28
6.3.2
Secondary packaging................................................................................................................................28
6.4
LABELING.........................................................................................................................................................28
6.5
TREATMENT ALLOCATION................................................................................................................................28
6.6
TREATMENT CODE ...........................................................................................................................................28
6.7
TREATMENT COMPLIANCE................................................................................................................................29
6.8
DRUG STORAGE ...............................................................................................................................................29
6.9
DRUG ACCOUNTABILITY..................................................................................................................................29
6.10
PROVISION OF ADDITIONAL CARE.....................................................................................................................30
7.
STUDY PLAN.........................................................................................................................................................30
7.1
STUDY SCHEDULE............................................................................................................................................30
7.1.1
Phase 1 - On admission prior to study treatment administration (within first 24 hours of life) ..............32
7.1.2
Phase 2 - Up to 24 hours after test treatment administration ..................................................................32
7.1.3
Phase 3 - 2 days after test treatment administration (from  24hrs + 1min to 48hrs after dosing)...............33
7.1.4
Phase 4 - 3 days after test treatment administration (from 48 hrs+ 1 min to 72hrs after dosing) ...............34
7.1.5
Phase 5 - 5 days after test treatment administration (from 96 hrs to 120 hrs after dosing) ....................34
7.1.6
Phase 6 - 7 days after test treatment administration (from 144hrs to 168 hrs after dosing) ...................35
7.1.7
Phase 7 (Follow-up) – 28±2 days postnatal age (PNA)...........................................................................35
7.1.8
Phase 8 (Follow-up) – Discharge home ...................................................................................................36
7.1.9
Phase 9 (Follow-up) – 36-week PMA (from 36+0 to 36+6  weeks).............................................................36
7.1.10 Phase 10 – Clinical assessment at 24 months (±3 months) corrected age....................................................37
7.2
INVESTIGATIONS ..............................................................................................................................................37
7.2.1
Immunogenicity assessment......................................................................................................................37
7.2.2
Biomarkers of Inflammation .....................................................................................................................38
7.2.3
A-a oxygen gradient and Oxygenation Index............................................................................................39
7.2.4
Vital signs and Blood tests........................................................................................................................39
7.2.5
Bayley scale ..............................................................................................................................................40
8.
EFFICACY ASSESSMENTS ................................................................................................................................40

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 16/62
9.
SAFETY ASSESSMENTS.....................................................................................................................................41
10.
ADVERSE EVENTS REPORTING .....................................................................................................................42
10.1
DEFINITIONS.....................................................................................................................................................42
10.2
EXPECTEDNESS ................................................................................................................................................44
10.3
INTENSITY OF ADVERSE EVENT .......................................................................................................................44
10.4
CAUSALITY ASSESSMENT.................................................................................................................................44
10.5
ACTION TAKEN WITH STUDY DRUG DUE TO THE AE.........................................................................................45
10.6
OTHER ACTIONS TAKEN....................................................................................................................................45
10.7
OUTCOME.........................................................................................................................................................45
10.8
RECORDING ADVERSE EVENTS ........................................................................................................................45
10.9
REPORTING SERIOUS ADVERSE EVENTS TO THE SPONSOR...............................................................................47
10.10
REPORTING SERIOUS ADVERSE EVENTS TO REGULATORY AUTHORITIES/ETHICS COMMITTEES/IRB.............47
10.11
GENERAL NOTES..............................................................................................................................................48
10.12
INDEPENDENT SAFETY MONITORING BOARD...................................................................................................48
11.
DATA MANAGEMENT........................................................................................................................................49
12.
STATISTICAL METHODS ..................................................................................................................................49
12.1
SAMPLE SIZE....................................................................................................................................................49
12.2
POPULATIONS FOR ANALYSIS ...........................................................................................................................49
12.3
STATISTICAL ANALYSIS....................................................................................................................................50
12.3.1
Descriptive Statistics.................................................................................................................................50
12.3.2
Missing data..............................................................................................................................................50
12.3.3
Description of the population-description of baseline characteristics.....................................................50
12.3.4
Efficacy variables......................................................................................................................................50
12.3.5
Safety variables.........................................................................................................................................53
12.3.6
Interim Analysis ........................................................................................................................................54
13.
ETHICS COMMITTEE/INSTITUTIONAL REVIEW BOARD APPROVAL...............................................54
14.
REGULATORY REQUIREMENTS....................................................................................................................54
15.
INFORMED CONSENT........................................................................................................................................54
16.
DIRECT ACCESS TO SOURCE DOCUMENTS/DATA ..................................................................................55
17.
STUDY MONITORING ........................................................................................................................................55
18.
QUALITY ASSURANCE ......................................................................................................................................55
19.
INSURANCE AND INDEMNITY ........................................................................................................................55
20.
CONFIDENTIALITY ............................................................................................................................................56
21.
PREMATURE TERMINATION OF THE STUDY............................................................................................56
22.
CLINICAL STUDY REPORT ..............................................................................................................................56
23.
RECORD RETENTION ........................................................................................................................................56
24.
PUBLICATION OF RESULTS ............................................................................................................................57
25.
REFERENCES........................................................................................................................................................57
APPENDIX I.....................................................................................................................................................................59
APPENDIX II ...................................................................................................................................................................60
APPENDIX III..................................................................................................................................................................61

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 17/62
APPENDIX IV..................................................................................................................................................................62
APPENDICES
APPENDIX I      Approval of the protocol by the coordinating investigator        
APPENDIX IIOLE_LINK1    Approval of clinical study protocol by the principal investigator 
APPENDIX III   Minimum list of Source Data Required
APPENDIX IV   List of Study Definitions
        

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 18/62
1.
BACKGROUND INFORMATION AND STUDY RATIONALE
Neonatal respiratory distress syndrome (RDS) is the most common respiratory disease of premature 
neonates and its incidence is directly proportional to the degree of prematurity. It occurs especially 
in extremely preterm infants, as illustrated in a study of the National Institute of Child Health and 
Human Development Neonatal Research Network, that showed an incidence of RDS of 93% in a 
cohort of 9575 extreme premature infants with gestational age (GA) of 28 weeks or below, born 
between 2003 and 2007 (1). Despite a constant improvement of neonatal care, RDS still represents 
one of the major causes of mortality in preterm infants, as confirmed by a very recent American 
review (64 deaths per 1000 live births) (2).
The clinical features of RDS start appearing soon after birth. RDS is characterized by tachypnea 
(rapid breathing), expiratory grunting, subcostal and intercostal retractions, cyanosis, nasal flaring, 
apnea and/or hypothermia in extremely immature neonates. In the pre-surfactant era, the disease led 
rapidly to progressive respiratory failure in the first 2-3 days of life (Error! Reference source not found.) and, 
in the most severe cases, to the death of premature babies. Moreover, RDS can be followed by 
respiratory complications, such as bronchopulmonary dysplasia (BPD), most commonly in those 
infants who required ventilatory support and/or oxygen therapy for RDS treatment (8). 
The pathophysiology of RDS has been correlated to lung immaturity and surfactant deficiency. 
Surfactant, a macro-aggregate composed by highly organized lipids and specific proteins, is 
produced by type 2 cells in the alveoli and covers the air liquid interface. It mainly reduces surface 
tension and prevents alveolar collapse, particularly at end-expiration, so that adequate gas exchange 
is maintained throughout the ventilatory cycle (5,8). In preterm babies, RDS develops mostly for the 
deficiency of surfactant production, but different kinds of insults may deteriorate surfactant function 
(inhibition, inactivation, dysfunction, degradation).
Surfactant therapy has become the standard of care in management of preterm neonates with RDS 
and is commonly accepted as being crucial in management of RDS (8). Surfactant treatment of 
babies with or at risk of RDS reduces mortality and the incidence of pulmonary air leaks such as 
pneumothorax by about 50% (7). 
Natural surfactants (containing SP-B and SP-C) derived from animal sources (porcine or bovine) 
and synthetic surfactants have been evaluated extensively in preterm neonates. The natural 
surfactants commonly available worldwide include Survanta® (beractant), InfasurfTM (calfactant; 
licensed in the US and Israel but not in the EU), Curosurf® (poractant alfa), Alveofact® (bovactant; 
national European authorization). They produce better results than synthetic, protein-free 
preparations (8) and overall poractant alfa (Curosurf®) has been regarded as the gold standard for the 
treatment of RDS (6). There have been several attempts over the years to replace animal-derived 
surfactants with more effective synthetic surfactants (9-10). The first-generation synthetic surfactants, 
no longer commercially available, contained only phospholipids and no surfactant proteins. The 
superiority of animal surfactants over these first protein-free synthetic preparations was due to the 
presence of the hydrophobic proteins SP-B and SP-C (11). The functional importance of the 
surfactant proteins SP-B and SP-C in the phospholipid monolayer encouraged attempts to improve 
the function of synthetic surfactants by the addition of human analogues of both surfactant proteins 
SP-B and SP-C. An effective synthetic surfactant should comprise both these peptides. Synthetic 
new-generation surfactants consisting of peptide and lipids may have several advantages over the 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 19/62
current natural surfactants: less infectious risk, less batch-to batch variability and no ethnographic 
issues.
Among the new-generation synthetic surfactants (containing SP-B and/or SP-C analogues) only 
lucinactant (proposed name Surfaxin®) reached the stage of being used in comparative clinical 
trials in preterm neonates (12-13). Surfaxin was approved by FDA in March 2012 for the prevention 
of RDS in high risk, premature infants and it was launched in the US in November 2013.  Unlike all 
available animal-derived surfactants, Surfaxin contains only one surfactant synthetic peptide 
(sinapultide/KL4).  Since CHF 5633 contains two synthetic peptides and has a proposed indication 
for treatment of RDS, surfaxin would not represent a good comparator for CHF 5633 both in terms 
of chemical characteristics and therapeutic indication. Surfaxin also requires high volume of 
administration (5.8 mL per kg) and a cumbersome preparation procedure in the neonatal intensive-
care unit (NICU) setting, which makes it a less-than-ideal candidate for comparison in a CHF 5633 
trial.
The new synthetic surfactant CHF 5633 is the first fully synthetic surfactant in which the lipid 
phase is enriched by both peptide analogues to human SP-B and SP-C, proteins that are of crucial 
importance for lung surface activity. Moreover, CHF 5633 contains a suitable phospholipid 
composition of phosphatidylglycerol and phosphatidylcholine, optimized to maintain integrity over 
a large range of surface tension, with enhanced adsorption and spreading characteristics. It is 
presented as a sterile suspension for intratracheal administration as a single dose and the intended 
indication is treatment of RDS in premature neonates. 
The in vitro and in vivo non-clinical studies showed that CHF 5633 displays at least similar 
surfactant activity to animal derived surfactant.
The in vitro experiments showed that CHF 5633 reduces surface tension at the air/liquid interface as 
efficiently as animal derived surfactant. The dynamic surface response/spreading data illustrated 
that CHF 5633 results in reduction of surface tension very close to that achieved by Curosurf®. 
Moreover it was as fast as Curosurf® in promoting spreading at the interface (14).
The in vivo efficacy of CHF 5633 as surfactant replacement was evaluated in preterm newborn 
rabbits. This model is regarded as an appropriate and sensitive experimental benchmark for neonatal 
respiratory distress syndrome (15). It closely resembles the conditions of premature babies affected 
by RDS in the sense that the lungs of these animals are not yet able to produce their own surfactant 
but can undertake gas exchange and they can expand in response to exogenous surfactant 
administration. Curosurf® was used as reference standard. Intratracheal administration of CHF 5633 
resulted in a marked improvement of lung expansion and the response was not statistically different 
from that of the animal-derived surfactant Curosurf® (16). As CHF 5633 contains the essential 
surface active components of natural human pulmonary surfactant required for treatment of RDS, it 
is anticipated that this new surfactant has the potential to offer an increased benefit to risk balance 
over the existing therapies for the life threatening and potentially debilitating consequences of RDS 
in preterm neonates. This concept is supported by the current experience with natural and artificial 
surfactants, and by the activity of the product itself, that has been demonstrated, as described above, 
both in in vitro models and in a relevant in vivo disease model. 
Based on these results it is anticipated that CHF 5633 will restore the functional surfactant film in 
the lungs of newborns with RDS. The anticipated improved therapeutic potential of this product is 
related to an improved safety profile. Most importantly the modified amino acid sequence of the 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 20/62
SP-B and SP-C peptide analogues improves resistance to degradation. This might result in overall 
enhanced efficacy with potentially fewer patients requiring repeated administrations.
In a first-in-human Phase I study (17) conducted in European Countries (Germany, UK and Czech 
Republic) mainly aimed at investigating the safety and tolerability of intratracheal administration of 
two different escalating single doses of CHF 5633 (100 and 200 mg/kg) in preterm neonates with 
RDS from 27+0 to 33+6 weeks  gestational age. 
The primary aim of this study was the evaluation of the safety and tolerability of intratracheal 
administration of two doses of CHF5633, 100 and 200 mg/kg, in preterm neonates with RDS, in 
terms of adverse events (AE) and adverse drug reactions (ADR), haematology and biochemistry 
values, incidence of major neonatal morbidities and mortality. The secondary objectives of this 
study were to explore the effect of the drug on oxygenation and ventilatory requirements and need 
for rescue surfactant treatment. Moreover, the immunogenicity through the measurement of 
antibodies to SP-B analogue (CHF 5736.03) and SP-C analogue (CHF 4902.03) contained in CHF 
5633 as well as the extent of systemic exposure were evaluated. 
CHF 5633 demonstrated a good safety profile and also an encouraging preliminary efficacy profile 
at both 100mg/kg and 200 mg/kg. Only one adverse drug reaction was  reported  following drug 
administration at 200 mg/kg:  obstruction of the endotracheal tube ) with no persistent effects on  
oxygen requirement or ventilatory support. The  main objective of the present Phase 2 proof-of-
concept (POC) study is to provide a proof-of-efficacy profile of CHF 5633 in comparison with 
Poractant Alfa (Curosurf®) in the same clinical procedural setting to sustain (or not) further clinical 
development.
Inflammation seen during RDS may be associated with the course of RDS and the promotion of 
bronchopulmonary dysplasia (BPD) (18). A synthetic surfactant may provide a less potent 
immunological stimulus than an animal product.  An exploratory examination of whether the nature 
and extent of the inflammatory response during RDS is related to the administered surfactant will 
be performed in a subgroup of centers and babies in this study. The good safety profile of CHF 
5633 obtained in the European FIH study will be further evaluated in the present study in 
comparison to Curosurf® administered to extremely preterm and very preterm neonates, the 
potential target population of a surfactant replacement therapy nowadays. This trial will be 
conducted in compliance with the Declaration of Helsinki (1964 and amendments), the current 
Good Clinical Practices and all other applicable laws and regulations.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 21/62
2.
STUDY OBJECTIVES
2.1 Primary Objectives
Main objectives of this study are:

to investigate the short term profile of CHF 5633 vs. porcine surfactant (Poractant Alfa, 
Curosurf®) in terms of reduced oxygen requirement and ventilatory support

to evaluate the mid-term profile in terms of incidence of BPD and mortality/BPD rate at 36-
week post menstrual age (PMA), mortality rate at 28 days PNA and at 36 weeks PMA, 
RDS-associated mortality through 14 days of age and other major co-morbidities of 
prematurity. 
2.2 Secondary Objectives
•
To evaluate the need for re-dosing in the two treatment groups;
•
to evaluate the inflammatory status through the measurements of specific biomarkers of 
inflammation  in tracheal aspirates (in a subgroup of babies who require endotracheal 
intubation for mechanical ventilation, when feasible);
•
to assess immunogenicity through the measurement of antibodies to SP-B analogue (CHF 
5736.03) and SP-C analogue (CHF 4902.03) contained in CHF 5633
•
to perform the evaluation of invasive measurements of ventilator support (in a subgroup of 
babies when feasible); 
•
to evaluate the safety profile in the two treatment groups  in terms of adverse events (AEs) 
and adverse drug reactions (ADRs), vital signs, hematology and biochemistry values.
3.
STUDY DESIGN
This is a multicenter, double blind, randomized, single dose, active-controlled study. Efficacy and 
safety assessments will be performed in the 24 hours following study treatment administration (at 
minutes 30, at hours 1, 3, 6, 12, 18 and 24), in the next 6 days (at days 2, 3, 5 and 7) and in the 
follow-up periods [(at days 28±2 postnatal age (PNA), discharge home and at 36 weeks 
postmenstrual age (PMA)]. Moreover, a further clinical assessment will be performed at 24 months 
(±3 months) corrected age to check the neurological and general health status related to the 
condition of prematurity (Table 1). 

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 22/62
 TABLE 1: TIMETABLE 
Time
Within
24 hours
0
30’
1h
3h
6h
12h
18h
24h
2
days
3
days
5
days
7   
days
28 
days 
PNA
Dischar
ge home
36 wks
PMA
24 -
month 
clinical 
assess.
Phase
1
2
3
4
5
6
7
8
9
10
Randomisation 
and Test treatment 
administration
End of the trial
The end of the trial will correspond to the date of discharge home of the last baby from the 
approved investigational sites (recruiting sites) or from another hospital where the treated baby 
could have been transferred from the original recruiting site for continuation of clinical care. 
In case the last baby is discharged home prior to 36-week PMA, the end of the trial will correspond 
to a clinical assessment at 36-week PMA (on-site visit or phone call).
The approved investigational site is responsible for the proper follow-up, data collection and 
documentation of the primary and secondary outcomes until the baby is discharged home. The 
investigator of the recruiting site will have to keep contacts and provide the continuing care site 
with written instruction about management of the above as well as for the reporting of serious AE, 
if any.
On admission
prior to study 
treatment
TREATMENT A 
CHF5633 (synthetic surfactant) 200 mg/kg (re-dosing if needed with CHF5633 100mg/kg)
TREATMENT B 
Poractant Alfa (porcine surfactant) 200 mg/kg (re-dosing if needed with Poractant Alfa 
100mg/kg)

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 23/62
4.
SUBJECT SELECTION CRITERIA
4.1 Subject Recruitment
The study population consists of premature neonates with RDS. Up to one hundred and twenty-six 
(126) patients of either sex with clinical finding of RDS (63 in each treatment arm) are expected to 
be randomized in the study. In this trial the eligible neonates will be drawn from those born in the 
collaborating centers (inborn neonates), who meet all the inclusion and none of the exclusion 
criteria. No limitation by ethnic origin, gender or social status will be used. RDS is defined in the 
study population by the presence of respiratory symptoms and signs in the first 24 hours of life, 
associated to the need for increased inspired oxygen requirements.  
4.2 Inclusion Criteria 
Subjects must meet all the following inclusion criteria to be eligible for enrolment into the 
study: 
1. Written informed consent obtained by parents/legal representative (according to local 
regulation) prior to any study-related procedures
2. Inborn preterm neonates of either sex with a gestational age of 24+0 weeks up to 29+6 
weeks 
3. Clinical course consistent with RDS
4. Requirement of endotracheal surfactant administration within 24 hours from birth
5. Fraction of inspired oxygen (FiO2) ≥0.30 for babies 24+0 to 26+6 weeks and FiO2 ≥0.35 
for babies 27+0 to 29+6 weeks to maintain SpO2 between 88–95%.
4.3 Exclusion Criteria
The presence of any of the following will exclude a subject from study enrollment:
1. Use of surfactant prior to study entry and need for intratracheal administration of any other 
treatment (e.g. nitric oxide)
2. Known genetic or chromosomal disorders, major congenital anomalies (cardiac 
malformations, myelomeningocele etc)
3. Mothers with prolonged rupture of the membranes (>21 days duration)
4. Strong suspicion of congenital pneumonia/infection, sepsis
5. Presence of air leaks if identified and known prior to study entry
6. Evidence of severe birth asphyxia
7. Neonatal seizures prior to study entry
8. Any condition that, in the opinion of the Investigator, would place the neonate at undue risk
9. Participation in another clinical trial of any placebo, drug or biological substance conducted 
under the provisions of a protocol.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 24/62
4.4 Subject Withdrawals
Parents/legal representative have the right to withdraw the subject from the study at any time for 
any reason. 
The Investigator has also the right to withdraw the subjects from the study in the event of:

An adverse event which is considered intolerable by the Investigator prior to or after 
surfactant administration

An abnormal laboratory test result that the Investigator considers clinically significant and 
warranting the withdrawal of the subject prior to surfactant administration. 

An intercurrent clinical condition/disorder/anomaly that necessitates pharmacological 
treatment with a drug which interacts in any way with the test treatment prior to surfactant 
administration

The development of any exclusion criterion prior to surfactant administration.
The Investigator is responsible for the optimal individual treatment for the subject. The Investigator 
must fill in the “Study Termination” page in the electronic case report form (eCRF) explaining the 
main reason for withdrawal.   
5.
CONCOMITANT MEDICATIONS
Subjects may be treated with other medications as needed in the critical care situation. The treating 
physician will manage neonates as he/she deems to be in their best interests. Concomitant 
medications will be recorded in the CRF.
5.1 Permitted concomitant Medications
Any concomitant medication required for the normal care of preterm neonates will be permitted 
during the study.
5.2 Non-permitted previous and concomitant Medications
1.
Surfactant treatment prior to study entry 
2.
Intratracheal administration of any other treatment (e.g. nitric oxide) prior to study entry
3.
Other investigational drugs.
6.
TREATMENT(S)
6.1 Appearance and Content 
The drug product CHF 5633 is a sterile suspension, with a pH of 6.0 compatible with the 
physiologic one in the lungs' and designed specifically for endotracheopulmonary instillation. The 
suspension contains a combination of two phospholipids and two peptides, in a sterile saline 
solution at the final concentration of 80 mg/ml. The drug product is filled in sealed 3.0 ml glass 
vials under nitrogen atmosphere. The composition is reported in the table below.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 25/62
Table 2.4/5: Drug Product composition
Ingredients
Quantity per mL
(mg)
Function
CHF 4902.03 (SP-C analogue)
1.2
Surfactant’s co-
adjuvant agent
CHF 5736.03 (SP-B analogue)
0.16
Surfactant’s co-
adjuvant agent
CHF 5300.00 (DPPC)
39.32
Surfactant
CHF 5301.02 (POPG, sodium salt)
39.32
Surfactant
0.9% sodium chloride sterile solution for injection 
q.s. to1.0 mL
Suspending agent
1% sterile acetic acid to pH
q.s to pH
pH adjustment agent
1.4% sodium bicarbonate sterile solution qs to pH
q.s to pH 
pH adjustment agent
 Sterile nitrogen flow is used to flush bottle’s head space.
Poractant Alfa (Curosurf®) is a standard natural surfactant treatment prepared from porcine lungs 
for intratracheal administration and containing almost exclusively polar lipids, in particular 
phosphatidylcholine (about 70% of the total phospholipid content), and about 1% of specific low 
molecular weight hydrophobic proteins SP-B and SP-C, with a total concentration of 80 mg/ml. The 
drug product is filled in sealed 3.0 ml glass vials.
Chiesi Farmaceutici S.p.A. will supply the study medication and also provide the 
Pharmacist/Investigator with appropriate certificates of analytical conformity.
6.2 Dosage and Administration 
6.2.1
Selection of doses in the study
Surfactant doses used in the study follow the recommendations approved in the USA SmPC for the 
administration of Poractant Alfa (Curosurf®), determined as 200 mg/kg for the first dose and 100 
mg/kg for additional doses. For this reason, CHF 5633 will be initially administered at the dosage of 
200 mg/kg (total drug substance components).
Pharmacodynamic studies, both in vitro and in vivo in premature newborn rabbits (16), showed that 
200 mg/kg of CHF 5633 has a profile comparable to that of approved naturally derived surfactants 
(Survanta® and Poractant Alfa, Curosurf®).
In the FIH trial (17) a lower dose of 100 mg/kg was included for safety reasons and showed to be safe 
and effective. The same positive profile was demonstrated for the upper dose of 200 mg/kg. 
Extreme preterm neonates’ lungs present very immature features, such as simplified saccular 
airways, no true alveoli and wide interstitial spaces, making them very susceptible to lung injury 
(18). Given the vulnerability of this population, the higher dose of 200 mg/kg has been chosen to 
achieve a clear efficacy signal and the possible greatest beneficial effect. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 26/62
6.2.2
Dosage
CHF 5633 2.5 ml/kg (200 mg/kg) sterile suspension in one single intratracheal administration 
within 24 hours from birth.
CHF 5633 1.25 ml/kg (100 mg/kg) will be used for further re-dosing when needed (up to two repeat 
doses).
Poractant Alfa (Curosurf®) 2.5 ml/kg (200 mg/kg) sterile suspension in one single intratracheal 
administration within 24 hours from birth. . 
Poractant Alfa 1.25 ml/kg (100 mg/kg) will be used for further re-dosing when needed (up to two 
repeat doses).
6.2.3
Administration
Before the administration of CHF 5633 or Poractant Alfa, the condition of the neonate should be 
stabilized, correcting any acidosis, hypotension, anaemia or hypothermia. The following modes and 
techniques for surfactant administration are the ones to be used in the present study:
a. Disconnecting endotracheally intubated neonates from the ventilator, leaving the endotracheal 
tube
Disconnect the infant momentarily from the ventilator and administer the suspension, as a single 
bolus, directly into the lower trachea via the endotracheal tube. Perform approximately one 
minute of hand-bagging and then reconnect the infant to the ventilator at the same settings as 
before administration. 
b. Without disconnecting endotracheally intubated neonates from the ventilator 
Administer the suspension, as a single bolus, directly into the lower trachea by passing a catheter 
through the suction port into the endotracheal tube or using an endotracheal tube with a side port. 
c. Infants stabilized on nasal continuous positive airway pressure (nCPAP) may also receive 
surfactant via an endotracheal tube solely introduced for the purpose of surfactant administration 
or with brief ventilation and rapid extubation. The tube is withdrawn after surfactant 
administration, and the infant is put on CPAP.  If the condition of the baby worsens, standard of 
care measures could be applied at the discretion of the investigator
The CHF 5633 suspension will be withdrawn from the vial using a sterile syringe through a large-
gauge needle (e.g., at least 20 gauge) and the effective dose calculated on the basis of the weight of 
the neonate could be administered as a single bolus dose or as two half bolus doses into the lower 
part of the trachea, positioning the neonate on each side as each bolus is being administered.
Since both test treatments will be refrigerated, each vial must be warmed up slowly to room 
temperature e.g. by placing it in an incubator for about 1 hour or keeping it in hands for 5-10 
minutes and gently turned upside down, without shaking, avoiding the formation of foam. Artificial 
warming methods should not be used. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 27/62
Re-treatment will be undertaken according to the criteria reported in Section 7.1 The exact time of 
the rescue treatment will be noted in the appropriate section of the eCRF. 
No suctioning of the airways should be performed for two hours after each surfactant instillation 
unless the treating physician deems this appropriate, in which case this will be noted in the 
appropriate section of the eCRF.  
All used vials will be retained at the site until the conclusion of the trial. Each vial is for single use 
only. Any leftover medication is to be retained for drug accountability. And any need for re-dosing 
will require a new vial to be issued via IRT (see Section 6.6).
After surfactant administration, the specific method of respiratory support (mechanical ventilation 
or non-invasive support) will be provided at the discretion of the investigator
6.2.4
Subject Training
Not Applicable.
6.3 Packaging
Chiesi Farmaceutici S.p.A. will supply both test treatments. A central depot will be in charge of 
clinical trial supplies’ distribution to the Investigational sites.
Glass vials containing the study treatment will be packed in double blind condition. An initial 
supply containing single vials of 3 ml each of CHF5633/Poractant Alfa for both initial dosing and 
possible re-dosing will be provided to the investigational sites and will be packed in an outer box. 
Each vial is for single use only. Any need for re-dosing will require a new vial to be issued via IRT 
(see Section 6.6).
6.3.1
Primary packaging
Glass vial of 3 ml volume at a concentration of 80 mg/ml for both initial dosing and possible re-
dosing. The actual volume of instilled test treatment will be reported in the relevant section of the 
eCRF. 
6.3.2
Secondary packaging
A holder containing one glass vial of 3 ml volume.
6.4 Labeling 
All labeling will be in English and according to US law and FDA regulatory requirements in 
compliance with Annex 13 and GMPs.
6.5 Treatment allocation
A dynamic randomization method will be used to balance the treatment groups by investigational 
site and gestational age group (i.e. from 24+0 to 26+6 weeks and from 27+0 to 29+6 weeks). Patients 
will be centrally assigned to one of the two treatment arms on admission through an IRT system 
(Interactive Response Technology, combination of voice and web response system and also referred 
as IVRS/IWRS).

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 28/62
The IRT will allocate the patient to a certain treatment group using the Pocock and Simon 
minimization algorithm (19) and assign the study medication kit number corresponding to the 
patients’ treatment group. IRT specifications will be fully described in a specific document. The 
IRT will also generate a confirmation after every IRT transaction is performed.
The Investigator will call the IRT on admission to receive the patient number, and before treatment 
administration to randomize the patient and to obtain the medication kit number. Detailed 
instructions for use of IRT will be provided to the site.
The patient will be identified by a unique number of six digits: the country will be the first digit, the 
investigational site number will be the second two digits and the following three digits will be the 
progressive numbering of the patient within each site (e.g. 101001, 101002 etc.). 
6.6 Treatment Code
The medication list will be provided to the labeling facility but will not be available to patients, 
Investigators, monitors or employees of the center involved in the management of the trial before 
unblinding of the data, unless in case of emergency.
The Sponsor’s clinical team will also be blinded during the study as they will not have direct access 
to the randomization list nor to the medication list.
In case of emergency, unblinding of the treatment code will be done through IRT. The treatment 
group will be disclosed and confirmation will follow (by fax and/or notification email). The IRT 
will be designed to send a confirmation (by fax and/or notification email) to the site for every 
transaction performed by the Investigators. The Investigator will be provided with usernames and 
passwords for randomization purposes and to unblind the study treatment in case of emergency 
situation, where he/she considers essential to know what treatment the patient was taking. The IRT 
will promptly notify the Sponsor and the Clinical Monitor whenever a treatment code is unblinded. 
Users from Chiesi Global Pharmacovigilance will have their own passwords to unblind patients in 
case of SUSARs to be reported to the competent Regulatory Authorities and Ethic Committees/IRB. 
6.7 Treatment compliance
Each CHF 5633 or Poractant Alfa vial will be designated by code number and medication number 
according to the medication list and the actual volume of instilled test treatment will be noted in the 
hospital chart and on the eCRF of the study. The residual volume in each vial will have to be 
checked by the study monitor with the support of the Investigator or the hospital pharmacist during 
the monitoring visits, and all the residual vials will be maintained until the end of the study.
Moreover, also the code and medication number of the surfactant (CHF 5633 or Poractant Alfa) 
vials used as rescue treatment as well as the actual volume instilled will be recorded in the hospital 
chart, in the eCRF of the study and in the relevant surfactant accountability form and will be 
checked by the clinical monitor at the study visits. The completely or partially used vials will be 
kept in a sealed labelled plastic box/envelop with patient’s screening number/initials until the end of 
the study for final accountability.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 29/62
 
6.8 Drug Storage 
The Pharmacist/Investigator will be responsible for the safe storage of all medications assigned to 
this study, in a secure place with restricted access, and maintained within the appropriate ranges of 
temperature.
CHF 5633 and Poractant Alfa will have to be stored between 2˚ and 8˚C, protected from light (see 
CTS instruction leaflet) 
6.9 Drug Accountability
The Investigator or pharmacist is responsible for the management of all the test treatments to be 
used for the study. Test treatments should be stored in a locked, secure storage facility with access 
limited to those individuals authorized to dispense the study drugs.
An inventory will be maintained by the Investigator or pharmacist (or other nominated individual), 
to include a signed account of all the test treatment(s) received, dispensed and returned by each 
subject at the planned visits. 
At the conclusion or termination of the study, the Investigator or the pharmacist shall conduct and 
document a final drug supply (used and unused) inventory. An explanation will be given for any 
discrepancies.
No surfactant material supplied for this trial is to be used for any other purpose. 
In addition a signed account shall be kept of all test treatments administered to each patient. 
All the test treatments supplied, used or unused, will be returned to the Sponsor or to the designated 
CRO under Sponsor’s responsibility or destroyed directly by the Pharmacy of the involved 
investigational site upon provision of destruction certificate and documentation assuring the 
occurred destruction according to standard procedures and filed both at investigator’s site file and at 
Sponsor/CRO trial master file.   
6.10
Provision of additional care
At study completion, it is the Investigator’s responsibility to prescribe appropriate treatment for the 
patient. 
7.
STUDY PLAN
7.1 Study Schedule
As described in Section 3. Study Design, this study will be conducted in phases and follow-up 
periods: on admission to the study (within the first 24 hours of life), study treatment administration 
and up to 24 hours after receiving it (at 30 min., 1, 3, 6, 12, 18, 24 hours), 2, 3, 5 and 7 days after 
initial treatment, and follow-up periods (28±2 days PNA, discharge home and 36 weeks PMA). 
Moreover, a further clinical assessment will be performed at 24 months (±3 months) corrected age 
to check the neurological and general health status related to the condition of prematurity.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 30/62
If needed, up to two repeat doses of 100 mg/kg each may be administered at approximately 12-hour 
intervals with the same surfactant as the first dose, according to the double blind design and the below 
pre-defined criteria: 
•
lack of reduction in FiO2 ≥0.10 to keep arterial oxygen saturation (SpO2) between 
88–95% or other clinical evidence of lack of efficacy within 12 hours after 
first/previous dosing;
•
babies mechanically ventilated with FiO2 ≥0.30 for babies 24+0 to 26+6 weeks and 
FiO2 ≥0.35 for babies 27+0 to 29+6 weeks within 12 hours after first/previous dosing;
•
babies not mechanically ventilated with FiO2 ≥0.35 for babies 24+0 to 26+6 weeks and 
FiO2 ≥0.40 for babies 27+0 to 29+6 weeks within 12 hours after first/previous dosing.
However, if a neonate still fails to show a clinical improvement after further re-dosing with the 
same surfactant as the first dose (e.g. FiO2>0.40 to maintain SatO2 88-95%, respiratory acidosis 
defined as pCO2 >65 mmHg/8.5 kPa and pH<7.20 on an arterial or capillary blood gas), he/she 
could receive an alternative surfactant treatment according to Investigator’s discretion. Such 
treatment would need to be appropriately documented as a concomitant medication in the CRF. 
The study phases and follow-up periods are detailed in the following sections and summarized in 
the following flow chart (Table 2):

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 31/62
TABLE 2 - FLOW-CHART 
MINUTES/HOURS/DAYS
DAYS/WEEKS
ASSESSMENT
ON ADMISSION 
prior to study 
treatment within 
first 24 hours of 
life (Day -1)
0
30’ 
(±5’)
1-h 
(±10’)
3-h 
(±30’)
6-h 
(±30’)
12-h 
(±30’)
18-h 
(±30’)
24-h 
(±30’)
Day 2 Day 3 Day 5 Day 7
Day 
28±2 
PNA
Discharge 
home
36-
WEEK
PMA
24-month 
clinical 
assess.
Randomization/Study treatment 
administration
X
Parental Informed Consent (1)
X
Inclusion/Exclusion Criteria
X
Complications during pregnancy
X
Demographic data
X
X
Apgar Score
X
Neonatal complications
X
Vital signs
X
X(+)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Chest x-ray
   X(*)
 X(*)
Cranial sonography
   X(*)
X (**)
(X)*
Haematology and Biochemistry
X
Arterial Oxygen Saturation (SpO2)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Ventilator settings 
(FiO2, PIP, MAP, PEEP) (2)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
A-a Oxygen gradient and OI (3)
X
X
X
X
X
X
X
Duration of oxygen alone 
X
X
X
X
X
X
X
X
Neonatal Concomitant Medications
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Immunogenicity assessment in serum
X
(X)***
Tracheal aspirates (3)
X
X
X
Assessment of BPD
X
Adverse Events/Adverse Drug Reactions
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Bayley Scales
X
Health status questionnaire
X
1. Signature of Parental Informed Consent can be obtained prior to birth or after birth;   2. PIP, MAP, PEEP to be monitored and collected until Day 7; 3. In a subgroup of babies when feasible;  (X)+ Only heart rate at time 0 
within 5 min from study drug administration; (X)* When applicable, at discretion of the Investigator ; (X)** At least one cranial ultrasound within the first 7 days of life; (X)*** The blood sampling has to be taken with a 
window of 3 to 6 weeks from administration. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 32/62
7.1.1
Phase 1 - On admission prior to study treatment administration (within first 24 hours 
of life) 
The study will be explained to the parents of a potentially eligible baby prior to birth, if 
possible, giving the parents the maximum time to make an informed choice. Once their written 
informed consent has been obtained either prior to or after birth, the neonate’s eligibility to take 
part in the study will be assessed according to the post-birth inclusion and exclusion criteria. If 
the baby becomes eligible, then the medical history of the mother, the complications during 
pregnancy and the prenatal use of corticosteroids will be collected.  
If the baby becomes eligible, then the following information will be collected:

birth weight; 

Apgar score;

neonatal complications and concomitant medications; 

clinical signs of  RDS (Chest X-ray when applicable, at discretion of the Investigator);

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate);

Respiratory support (invasive or non-invasive), ventilatory settings (PIP, FiO2, PEEP, 
MAP), OSI and RSS;

Invasive oxygen measurements (A-a oxygen gradient, OI), when feasible, in a subgroup of 
infants 

400 µL blood sample for immunogenicity assessments in serum ;

Cranial ultrasound when applicable, at discretion of the Investigator;

Tracheal aspirates for the evaluation of inflammatory biomarkers to be shipped to a central 
laboratory for analysis, when feasible, in a subgroup of patients;

Any adverse events occurring after the Informed Consent Form Signature, in the AE Form 
of the eCRF. If the abnormality starts prior to the study drug administration and it is listed 
among the Morbidities or Complications of Prematurity (see Section 10.8) which are 
clinically expected outcomes in preterm neonates aged between 24+0 and 29+6 weeks, it 
should be recorded in the dedicated form. 
In the event that multiple measurements are available, the measurements closest to the required 
time point are to be collected.
7.1.2
Phase 2 - Up to 24 hours after test treatment administration
Once the neonate’s eligibility to take part in the study is confirmed, the Investigator will have to 
call/check the IRT to receive the kit number to be used and then the test treatment will be 
administered within 24 hours from birth. The tear-off sticker from the medication box will be 
applied in the appropriate section of the surfactant accountability log.
At the administration (Time 0) the following information will be collected:

SpO2 and heart rate within 5 min from study drug administration;
Then, after the administration, the following information will be collected:

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 33/62

SpO2 and vital signs (systolic and diastolic blood pressure, heart rate) at 30 min, 1 hour, 3, 6, 
12, 18 and 24 hours after test treatment administration; 

ventilator settings (PIP, FiO2, PEEP, MAP), RSS and OSI at 30 min, 1 hour, 3, 6, 12, 18 and 
24 hours after test treatment administration. Mechanical ventilation will be monitored and 
any change in invasive and non-invasive ventilation will be recorded with its date and time; 

Invasive oxygen measurements (A-a oxygen gradient, OI), when feasible, in a subgroup of 
infants at 3, 6, 12, 18 and 24 hours after treatment;

Use of oxygen alone (supplemental oxygen without invasive or non-invasive ventilator 
support) will be monitored and any occurrence will be recorded with its date and time of 
start and end;

Blood tests within  24 hours after test treatment administration, defined as full blood count 
(FBC), urea, creatinine and electrolytes (sodium, potassium, calcium, phosphorus), alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), glucose, C-reactive protein;

RDS or other respiratory anomalies ’s diagnosis confirmation (Chest X-ray when applicable, 
at discretion of the Investigator);

At least one cranial ultrasound within the first 7 days of life;

Tracheal aspirates for the evaluation of inflammatory biomarkers to be shipped to a central 
laboratory for analysis, when feasible, in a subgroup of patients;

new neonatal concomitant medications and adverse events as well as changes in those 
already reported.
In the event that multiple measurements are available, the measurements closest to the required 
time point are to be collected.
7.1.3
Phase 3 - 2 days after test treatment administration (from  24hrs + 1min to 48hrs after 
dosing) 
The following information will be collected:

SpO2

vital signs (systolic and diastolic blood pressure, heart rate) 

ventilator settings (PIP, FiO2, PEEP, MAP) and RSS;

Oxygen Saturation Index (OSI); 

any change in non-invasive/invasive ventilation with the relevant dates and times; 

Invasive oxygen measurements (A-a oxygen gradient, OI), when feasible, in a subgroup of 
infants;

Use of oxygen alone (supplemental oxygen without invasive or non-invasive ventilator 
support) will be monitored and any new occurrence will be recorded with the relevant dates 
and times;

At least one cranial ultrasound within the first 7 days of life;

Tracheal aspirates for the evaluation of inflammatory biomarkers to be shipped to a central 
laboratory for analysis, when feasible, in a subgroup of patients;

new neonatal concomitant medications and adverse events as well as changes in those 
already reported.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 34/62
In the event that multiple measurements are available, the measurements closest to the required time 
point are to be collected.
7.1.4
Phase 4 - 3 days after test treatment administration (from 48 hrs+ 1 min to 72hrs after 
dosing)
The following information will be collected:

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate); 

ventilator settings (PIP, FiO2, PEEP, MAP); 

any change in non-invasive/invasive ventilation with the relevant dates and times; 

Use of oxygen alone will be monitored and any new occurrence will be recorded with the 
relevant dates and times;

At least one cranial ultrasound within the first 7 days of life;

new neonatal concomitant medications and adverse events as well as changes in those 
already reported.
In the event that multiple measurements are available, the measurements closest to the required time 
point are to be collected.
7.1.5
Phase 5 - 5 days after test treatment administration (from 96 hrs to 120 hrs after 
dosing)
The following information will be collected:

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate);

ventilator settings (PIP, FiO2, PEEP, MAP); 

any change in non-invasive/invasive ventilation with the relevant dates and times; 

use of oxygen alone will be monitored and any new occurrence will be recorded with the 
relevant dates and times;

At least one cranial ultrasound within the first 7 days of life;

new neonatal concomitant medications and adverse events as well as changes in those 
already reported.
In the event that multiple measurements are available collect the measurements closest to the 
required time point.
7.1.6
Phase 6 - 7 days after test treatment administration (from 144hrs to 168 hrs after 
dosing)
The following information will be collected:

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate); 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 35/62

ventilator settings (PIP, FiO2, PEEP, MAP);

any change in non-invasive/invasive ventilation with the relevant dates and times;

use of oxygen alone will be monitored and any new occurrence will be recorded with the 
relevant dates and times;

At least one cranial ultrasound within the first 7 days of life;

new neonatal concomitant medications and adverse events as well as changes in those 
already reported.
In the event that multiple measurements are available, the measurements closest to the required time 
point are to be collected.
7.1.7
Phase 7 (Follow-up) – 28±2 days postnatal age (PNA) 
The following information will be collected:

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate); 

FiO2;

any change in non-invasive/invasive ventilation  with the relevant dates and times;

use of oxygen alone will be monitored and any new occurrence will be recorded with the 
relevant dates and times; 

cranial sonography when applicable at phases 7 or 8 or 9 just before discharge home.

new neonatal concomitant medications and adverse events as well as changes in those 
already reported

400 µL blood sample for immunogenicity assessments in serum when applicable at Phase 7 
or 8 or 9 (to be taken only once), approximately 5 weeks after administration (with a 
window from 3 to 6 weeks).
In case the baby was discharged home prior to 28 days of life, the baby should be recalled for an 
on-site clinic visit at the recruiting site. If not feasible, any effort should be made to collect 
information about the occurrence of any adverse events as well as about any change in concomitant 
medications. The Investigator should contact the family pediatrician to collect the relevant 
information.
In case the treated baby was transferred to and discharged home by a continuing care site prior to 28 
days of life or still hospitalized there, the baby should be recalled at the recruiting site for the visit. 
If this is not feasible, the visit can be replaced by a contact/phone call by the Investigator to the 
physician of the continuing care site or to the family pediatrician to check the occurrence of any 
other adverse event as well as of any change in concomitant medications. 
In the event that multiple measurements are available, the measurements closest to the required time 
point are to be collected.
7.1.8 Phase 8 (Follow-up) – Discharge home 
The following information will be collected:

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 36/62

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate);

FiO2;

any change in non-invasive/invasive ventilation  with the relevant dates and times;

use of oxygen alone will be monitored and any new occurrence will be recorded with the
relevant dates and times;

cranial sonography if not already performed at phases 7 or 9;

new neonatal concomitant medications and adverse events as well as changes in those
already reported;

400 µL blood sample for immunogenicity assessments in serum if not already taken at day
28 PNA or 36 weeks PMA, according to what described in paragraph 7.2
The discharge home can occur whenever deemed appropriate by the investigator according to the 
clinical condition of the baby. In case the baby is transferred to a continuing care site, the recruiting 
site is responsible for the proper continuation of data collection and documentation of the primary 
and secondary outcomes. The investigator of the recruiting site should keep contacts and provide 
the continuing care site with written instruction about management of the above as well as for the 
reporting of serious AE, if any. The recruiting site should receive a discharge letter clarifying as 
much detailed information as possible the progress in patient’s conditions. 
Routine clinical safety data included in the discharge home summary letter should be sought to 
complete data collection and register the end of the trial, if applicable. 
If the discharge home coincides with the 36 wks PMA follow-up, only the assessments foreseen at 
36 wks PMA will be performed and reported in the eCRF.
In the event that multiple measurements are available, the measurements closest to the required time 
point are to be collected.
7.1.9
Phase 9 (Follow-up) – 36-week PMA (from 36+0 to 36+6  weeks)
The following information will be collected:

SpO2 along with vital signs (systolic and diastolic blood pressure, heart rate);

FiO2;

any change in non-invasive/invasive mechanical ventilation with the relevant dates and
times;

use of oxygen alone (supplemental oxygen without invasive or non-invasive ventilator
support) will be monitored and any new occurrence will be recorded with the relevant dates
and times;

cranial sonography if not already performed at phases 7 or 8;

new neonatal concomitant medications and adverse events as well as changes in those
already reported;

BPD diagnosis (see definition in Appendix II) ;

400 µL blood sample for immunogenicity assessments in serum if not already taken at day
28 PNA or at Discharge home, according to what described in paragraph 7.2;

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 37/62
In case the baby was discharged home or transferred to a continuing care site prior to this phase, the 
baby should be recalled as soon as possible for an on-site clinic visit at the recruiting site. If not 
feasible, any effort should be made to collect information about the occurrence of BPD, adverse 
events as well as any change in concomitant medications. The investigator should therefore contact 
the physician of the continuing care site or the family pediatrician to collect the relevant 
information.
In the event that multiple measurements are available, the measurements closest to the required time 
point are to be collected.
 
7.1.10 Phase 10 – Clinical assessment at 24 months (±3 months) corrected age 
A further clinical assessment will be performed at 24 months (±3 months) corrected age by 
physicians of participating study centers. This clinical assessment will be based on:

Demographic data

Vital signs

Bayley Scales of Infant Development (see Section 7.2.5)

Health status questionnaire (health problems, illnesses, injuries, well-being, diet, respiratory 
assessment).
7.2 Investigations
7.2.1
Immunogenicity assessment
An immunogenicity assessment in serum will be carried out in about 400 µL blood sample 
additionally collected prior to test treatment administration and approximately at 5 weeks after 
administration (with a window from 3 to 6 weeks).In case there is no possibility to obtain the blood 
sample pre-dose without delaying the baby clinical care, a window of maximum 2 hours is allowed 
after surfactant administration.
 
To obtain serum, after collection the blood is allowed to clot by leaving it undisturbed at room 
temperature. This usually takes 15-30 minutes. The clot is than removed by centrifugation at 1,000-
2,000 x g for 10 minutes in a refrigerated centrifuge and serum is the resulting supernatant.
It is important to immediately transfer the liquid component (serum) into a clean polypropylene 
tube using a Pasteur pipette. The samples should be maintained at 2-8°C while handling and then 
stored below –65°C until shipped to the central laboratory (
) for the immunogenicity assay. A 
laboratory manual will be provided to the clinical sites by 
.
In case the treated baby is transferred to another hospital site, the blood sample will be taken by a 
trained study team member of the original site in which the baby received the study treatment and 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 38/62
transported back to the original site in refrigerated (not frozen) condition within maximum two 
hours, to be processed according to the above procedures.
The measure of anti-SP-B and anti-SP-C antibodies will be evaluated by a titration versus a positive 
control serum (GP) diluted in buffer solution. The titer is expressed as the dilution at which the 
sample exhibited a 0.050 absorbance (background). The entire range of dilutions will be plotted 
versus optical density. If a sigmoidal profile of the curve will be observed, it will show that the 
serum contains a significant level of antibodies.
 is allocated as reference laboratory in charge for 
this assessment and the samples will be shipped to the following address:
     
7.2.2
Biomarkers of Inflammation
CXCL8, Interleukin 1β (IL1β), Interleukin 6 (IL6), Tumor Necrosis Factor-alpha (TNF-α), 
myeloperoxidase (MPO) will be collected prior to study drug administration, at 24±1 hours and on 
day 2 (48±1 hours) (in a subgroup of babies who require endotracheal intubation for mechanical 
ventilation, when feasible). In case the baby is extubated earlier than 24 or 48 hours and when 
feasible, the tracheal aspirate can be collected at any time closest to the above time points. 
The suggested procedure to collect the tracheal aspirates is the following:

After instillation of 0.5 ml of 0.9% saline through the endotracheal tube, a 5 F catheter is 
inserted slightly beyond the distal tip of the endotracheal tube and all the secretions are 
aspirated. The tracheal secretions are collected through a Luken’s trap. Three to five 
manual or ventilator breaths are given between instillation of saline and suctioning. 

The whole procedure is then repeated.

The suction catheter is then flushed with 0.5mL of normal saline to collect the residual 
sample in the catheter. The final volume should be 1 ml.
The infant’s heart rate, respiratory rate and oxygen saturation will be monitored and allowed to 
stabilize during the suctioning procedure. 
The collected tracheal aspirate need to be immediately chilled in ice bath and centrifuged at 2000 x 
g for 15 min within 1 h. The supernatant will be recovered, divided into aliquots and kept below -65 
°C until shipment to the central laboratory for analysis. Further details will be described in the 
laboratory manual that will be provided to each clinical site.
 is allocated as reference laboratory in charge for this assessment and the 
samples will be shipped to the following address:

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 39/62
7.2.3
A-a oxygen gradient and Oxygenation Index
Alveolar-arterial (A–a) oxygen gradient is a measure of the difference between the alveolar 
concentration of oxygen and the arterial concentration of oxygen obtained from the following 
equation: 
Oxygenation Index (OI) is defined as the ratio of RSS and partial pressure of oxygen in arterial 
blood (PaO2). 
Both OI and A-a gradient require an arterial blood gas analysis to calculate PaO2. Given the 
challenges to placing arterial catheters in pre-term neonates, these parameters will be measured at 3, 
6, 12, 18, 24 and 2 days post treatment (only in a subgroup of babies when feasible). 
7.2.4
Vital signs and Blood tests

Heart rate and SatO2 are measured by pulse oximetry 

Systolic and diastolic blood pressures are measured in a non-invasive way 

Blood tests can be performed with an arterial, capillary or venous sample. 
The following blood tests are to be performed: FBC, urea, creatinine, electrolytes, glucose, ALT, 
AST, CRP:  1-3 ml (depending on centers’ assays). 
7.2.5
Bayley scale
Bayley Scales of Infant Development is a standard series of measurements used primarily to 
assess the motor (fine and gross), language (receptive and expressive), and cognitive development 
of infants and toddlers, aged 0-3. This measure consists of a series of developmental play tasks 
and takes between 45 - 60 minutes to administer. Raw scores of successfully completed items are 
converted to scale scores and to composite scores. These scores are used to determine the child's 
neurodevelopmental performance compared with norms taken from typically developing children 
of their age (in months). Completed by the parent or caregiver, this questionnaire establishes the 
range of adaptive behaviors that the child can currently achieve and enables comparison with age 
norms.
8.
EFFICACY ASSESSMENTS

SpO2/FiO2 at 30 minutes, at 1, 3, 6, 12, 18, 24 hours, at Days 2, 3, 5, 7, 28±2 PNA, at 
discharge home and at 36 weeks PMA. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 40/62

Fraction of inspired oxygen (FiO2) at 30 minutes, at 1, 3, 6, 12, 18, 24 hours, at Days 2, 3, 5, 
7, 28±2 PNA, at discharge home and at 36 weeks PMA; 

Respiratory Severity Score (RSS) will be calculated from ventilator setting as FiO2 x MAP 
in the 2 days post treatment (at 30 minutes, at 1, 3, 6, 12, 18, 24 hours and on day 2); 

Oxygen Saturation Index (OSI) will be calculated as FiO2 x MAP x 100 / SpO2 in the 2 days 
post treatment (at 30 minutes, at 1, 3, 6, 12, 18, 24 hours and on day 2); 

Arterial oxygen saturation determined by pulse oximetry (SpO2) at 30 minutes, at 1, 3, 6, 12, 
18, 24 hours, at Days 2, 3, 5, 7, 28±2 PNA, at discharge home and at 36 weeks PMA;

Mean airway pressure (MAP) at 30 minutes, at 1, 3, 6, 12, 18, 24 hours, on Days 2, 3, 5, 7;

Peak inspiratory pressure (PIP) at 30 minutes, at 1, 3, 6, 12, 18, 24 hours, on Days 2, 3, 5, 7; 

Positive end-expiratory pressure (PEEP) at 30 minutes, at 1, 3, 6, 12, 18, 24 hours, on Days 
2, 3, 5, 7

Alveolar-arterial (A–a) at 3, 6, 12, 18, 24 hours and 2 days post treatment (only in a 
subgroup of babies when feasible). 

Oxygenation Index (OI) at 3, 6, 12, 18, 24 hours and 2 days post treatment (only in a 
subgroup of babies when feasible). 

Mortality/BPD rate defined as the incidence of patients who are dead or alive with a 
diagnosis of BPD at 36-week PMA;

BPD incidence at 36-week PMA;

Mortality rate at Day 28 PNA and 36-week PMA;

RDS-associated mortality rate through 14 days of age, defined as deaths associated with 
RDS through the first 14 days of life, resulting from severe respiratory failure, from 
pulmonary hemorrhage if the RDS had not resolved before the development of this 
complication, or from air leaks that occurred in the presence of severe RDS;

Percentage of patients requiring at least one surfactant rescue dose;

Percentage of patients with at least one reading of FiO2=0.21 (i.e. room air) within 24 hours 
from first dosing with test treatment;

Time (hours) to reach FiO2=0.21 (i.e. room air);

Duration of invasive mechanical ventilation, defined as the time until the first successful 
extubation lasting more than 24 hours (days);

Duration of non-invasive ventilation, defined by nasal continuous positive airway pressure 
(nCPAP), Bi-level positive airway pressure (BiPAP), nasal intermittent positive pressure 
ventilation (NIPPV),  or high flow nasal cannula (HFNC) (days);

Duration of oxygen use alone, defined as receiving supplemental oxygen without invasive or 
non-invasive ventilator support, at 24 hours after first surfactant dosing, at Days 2, 3, 5, 7, at 
Day 28±2 PNA, at discharge home and at 36 weeks PMA

Biomarkers of inflammation in tracheal aspirates: CXCL8, Interleukin 1β (IL1β), Interleukin 
6 (IL6), Tumor Necrosis Factor-alpha (TNF-α), myeloperoxidase (MPO), prior to study drug 
administration, at 24 hours and on day 2 (48 hours) (in a subgroup of babies who require 
endotracheal intubation for mechanical ventilation when feasible). 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 41/62
The following time deviations from theoretical post-dose times will be allowed:
Post-dose time assessments 
Allowed deviations 
30 minutes 
+ 5 minutes 
1 hour
+ 10 minutes
3, 6, 12, 18 and 24 hours 
+ 30 minutes 
28 days PNA
+ 2 days
9.
SAFETY ASSESSMENTS
The following clinical and laboratory assessments will be performed to explore the safety of the 
study drug:

AEs and ADRs

Vital signs (systolic and diastolic blood pressure, heart rate) and SpO2 during administration

Incidence of major neonatal morbidities (for the list of neonatal morbidities and 
complications of prematurity see section 10.8)

Hematology and blood chemistry

Immunogenicity assessment in serum will be carried out in samples collected at baseline 
prior to test treatment administration and approximately at 5 weeks after administration 
(with a window from 3 to 6 weeks)

Bayley Scales of Infant Development at 24 months (±3 months) corrected age

Health status questionnaire (health problems, illnesses, injuries, well-being, diet, respiratory 
assessment) at 24 months (±3 months) corrected age.
The following time deviations from theoretical post-dose times will be allowed:
Post-dose time assessments 
Allowed deviations 
30 minutes 
+ 5 minutes 
1 hour
+ 10 minutes
3, 6, 12,18 and 24 hours 
+ 30 minutes 
28 days PNA
+ 2 days
10. ADVERSE EVENTS REPORTING
10.1
Definitions
An Adverse Event is, “any untoward medical occurrence in a patient or clinical trial subject 
administered a medicinal (investigational or non-investigational) product and which does not 
necessarily have a causal relationship with this treatment.” An adverse event can therefore be any 
unfavourable and unintended sign (including abnormal laboratory finding), symptom, or disease 

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 42/62
temporally associated with the use of a medicinal (investigational or non-investigational) product, 
whether or not considered related to the medicinal (investigational or non-investigational) product.
An Adverse Drug Reaction is an, “untoward and unintended response to an investigational 
medicinal product related to any dose administered.”
All adverse events judged by either the reporting Investigator or the Sponsor as having a reasonable 
causal relationship to a medicinal product qualify as adverse reactions. The expression, “reasonable 
causal relationship,” means to convey in general that there are facts (evidence) or arguments meant 
to suggest a causal relationship.
The definition covers also medication errors and uses outside what is foreseen in the protocol, 
including misuse and abuse of the product.
A Serious Adverse Event (SAE)/Serious Adverse Drug Reaction is any untoward medical 
occurrence or effect that at any dose falls in one or more of the following categories:
-
Results in death
Death is not an adverse event but an outcome. It is the cause of death that should be regarded as
the adverse event. The only exception to this rule is, “sudden death,” where no cause has been
established; in this latter instance, “sudden death,” should be regarded as the adverse event and,
“fatal,” as its reason for being serious.
-
Is life-threatening
Life-threatening refers to an event in which the subject was at risk of death at the time of the
event (e.g., aplastic anaemia, acute renal failure, and anaphylaxis). The term does not refer to
an event which hypothetically might have caused death if it were more severe.
-
Requires hospitalisation or prolongation of existing hospitalization
Hospitalization refers to a situation whereby an AE is associated with unplanned overnight
admission into hospital, usually for purpose of investigating and/or treating the AE.
Hospitalization for the treatment of a medical condition that occurs on an, “elective,” or,
“scheduled,” basis or for a pre-existing condition that did not worsen during the study should
not necessarily be regarded as an AE. Complications that occur during the hospitalization are
AEs. If a complication prolongs hospitalization, the event is an SAE.
Emergency room visits that do not result in a formal admission into hospital should be
evaluated for one of the other seriousness criteria (e.g., life-threatening; persistent or significant
disability or incapacity; medically significant).
-
Results in persistent or significant disability or incapacity.
The term significant disability should be viewed as any situation whereby an AE has a
clinically important effect on the subject’s physical or psychological well-being to the extent
that the subject is unable to function normally.
-
Is a congenital anomaly or birth defect (not applicable for this study)
-
Is a medically significant adverse event

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 43/62
This criterion allows for any situations in which important adverse events/reactions that are not 
immediately life-threatening or do not result in death or hospitalization may jeopardize the 
subject’s health or may require intervention to prevent one of the above outcomes.
Examples of such events are: intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization; or 
development of drug dependency or drug abuse.
Medical and scientific judgment should be exercised in deciding whether an event is serious 
because medically significant.
Any suspected transmission via a medicinal product of an infectious agent is also considered a 
serious adverse reaction.
A Non-Serious Adverse Event/Non-Serious Adverse Drug Reaction is an adverse event or 
adverse drug reaction that does not meet the criteria listed above for a serious adverse event/serious 
adverse drug reaction. 
10.2
Expectedness
An expected adverse reaction is an adverse reaction, the nature or severity of which is consistent 
with the applicable Reference Safety Information (Investigator’s Brochure for CHF 5633 and 
Summary of Product Characteristics for Curosurf®), otherwise it is considered unexpected. 
Reports which add significant information on specificity or severity of a known, already 
documented serious adverse drug reaction constitute unexpected events. For example, an event 
more specific or more severe than described in the Investigator’s Brochure would be considered as 
“unexpected”. General examples of such events are: (a) acute renal failure as a labelled ADR with a 
subsequent new report of interstitial nephritis and (b) hepatitis with a first report of fulminant 
hepatitis.
10.3
Intensity of Adverse Event
The investigator is asked to assess the intensity of all the adverse events and to report them in the 
eCRF.
The intensity (severity) of a specific event is defined as mild, moderate, or severe; the event itself, 
however, may be of relatively minor medical significance (such as severe headache).  This is not the 
same as "serious," which is based on patient/event outcome or action criteria usually associated 
with events that pose a threat to a participant's functioning.  Seriousness (not severity) serves as a 
guide for defining regulatory reporting obligations.
Each Adverse Event must be rated on a 3-point scale of increasing intensity:
Mild: The event causes a minor discomfort, or does not lead to establishment of a correcting 
treatment.
Moderate: The event perturbs the usual functioning of the subject. The event leads to the 
establishment of a correcting treatment.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 44/62
Severe:  The event prevents any usual functioning of the subject.
10.4
Causality Assessment 
The following “binary” decision choice will be used by the Investigator to describe the causality 
assessment with the study medication:
-
Reasonable possibility of a relatedness 
-
No reasonable possibility of relatedness 
The expression “reasonable possibility of relatedness” is meant to convey, in general, that there are 
facts (evidence) or arguments meant to suggest a causal relationship. 
The Investigator will be asked to consider the following before reaching a decision on causality 
assessment:
-
Time relationship between study drug intake and event’s onset;
-
Medical history;
-
Lack of efficacy/worsening of existing condition;
-
Study treatment(s);
-
Mechanism of action of the study drug;
-
Class effects;
-
Other treatments-concomitant or previous;
-
Erroneous treatment with study medication (or concomitant);
-
Protocol related process.
10.5
Action taken with study drug due to the AE
Since patients will receive a single dose of study drug, “action taken with study drug” will be not 
applicable.
10.6
Other actions taken
-
Specific therapy/medication
-
(Prolonged) Hospitalization
-
Surgical/medical procedure
10.7
Outcome
Each Adverse Event outcome must be described by choosing among:
-
Recovered/resolved
-
Recovering/resolving
-
Not recovered/not resolved
-
Recovered with sequelae/resolved with sequelae
-
Fatal
-
Unknown
10.8
Recording Adverse Events
All AEs occurring during the course of the study must be documented in the Adverse Event page of 
the eCRF. Moreover, if the Adverse Event is serious, the Serious Adverse Event Form must also be 
completed. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 45/62
It is responsibility of the Investigator to collect all adverse events (both serious and non-serious).
As a general rule, the recording period for Adverse Events is the period starting from the Informed 
Consent signature until the subject’s study participation ends.
However, the complications of prematurity, listed below, are clinically expected outcomes in 
preterm neonates aged between 24+0 and 29+6 weeks. Therefore, if started before drug 
administration, they haven’t to be reported as AEs but in the relevant section of the eCRF. 
While the occurrence or worsening of these complications of prematurity after test 
treatments’ administration must be recorded as an AE in the case report form.
Morbidities or Complications of prematurity
•
Air leaks (pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum);
•
anemia of prematurity;
•
apnea of prematurity;
•
necrotizing enterocolitis (NEC); 
•
patent ductus arteriosus (PDA);
•
pneumonia; 
•
pulmonary interstitial emphysema (PIE); 
•
pulmonary hemorrhage;
•
germinal matrix/intraventricular hemorrhage (GMH/IVH); 
•
cerebral parenchymal haemorrhage;
•
neonatal jaundice;
•
periventricular leukomalacia (PVL); 
 
•
sepsis and/or meningitis;
•
Presence of the following abnormal laboratory values:
o hypoglycaemia
o hyperglycaemia
o hypocalcaemia
o hypercalcaemia
o hyponatraemia
o hypernatraemia
o hypokalaemia
o hyperkalaemia. 
For study definitions see appendix II and its references.
The investigator should carefully check inclusion and exclusion criteria because some of these 
morbidities may not allow the neonate to be randomized.
If a clinically significant abnormal laboratory finding or other abnormal assessment detected during 
the study period meets the definition of an AE, then the AE eCRF page must be completed, as 
appropriate. A diagnosis, if known, or clinical signs and symptoms if diagnosis is unknown, rather 
than the clinically significant abnormal laboratory finding, should be reported on the AE eCRF 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 46/62
page. If no diagnosis is known and clinical signs and symptoms are not present, then the abnormal 
finding should be recorded.
For pharmacovigilance purposes, all SAEs should be followed-up in order to elucidate as 
completely and practically as possible their nature and/or causality until resolution of all queries, 
clinical recovery is complete, laboratory results have returned to normal, stable condition is reached 
or until the subject is lost to follow-up. Follow-up may therefore continue after the subject has left 
the study. In this case, the follow-up will continue with no timelines for related SAEs, while for 
unrelated SAEs the type and extent of follow-up undertaken will be determined for each individual 
case and will depend upon the nature (e.g. events with poor prognosis or which do not resolve), 
severity and medical significance of the event.
Follow-up may therefore continue after the patient has been discharged from the NICU.
10.9
Reporting Serious Adverse Events to the Sponsor
The Investigator must report all Serious Adverse Events to the 
 Safety Contact within 24 
hours of awareness. The information must be sent by providing the completed Serious Adverse 
Event form. At a later date, the 
Safety Contact will report all information to Chiesi Global 
Pharmacovigilance, the Clinical Project Manager and the Clinical Research Physician. 
Name and Title
Telephone no.
Fax no.
E-mail
 
 
 
Global Pharmacovigilance
Chiesi Farmaceutici S.p.A., 
Parma (Italy)
 
 
 
Reporting of SAEs from the investigator site is from the time of subject’s signature of 
informed consent and until the subject’s study participation ends. Moreover, even after the 
end of the study, if the investigator becomes aware of an SAE and deems it as related to study 
drug, he/she should report this SAE. 
Up to the closure of the recruiting site, these SAE reports should be reported to the CRO 
Safety Contact. All related SAEs occurring after the recruiting site is closed should be directly 
reported to the Sponsor Safety Contact.
10.10 Reporting Serious Adverse Events to Regulatory Authorities/Ethics Committees/IRB
The Sponsor or designated CRO will report adverse events to the regulatory authorities in 
compliance with the timelines and standards of reporting according to local regulations (Guidance 
for industry and Investigators-Safety Reporting Requirements for INDs and BA/BE studies, 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 47/62
December 2012). All suspected unexpected serious adverse reactions (SUSARs), which occur with 
the investigational medicinal product or marketed active comparator, within or outside the 
concerned clinical trial, will be reported by the Sponsor or designated CRO to regulatory 
authorities, as required, as well as to the Investigators and Central IRB, if applicable, by 
MedWatch/CIOMS form. The Investigator (or Sponsor/CRO where required) must inform the IRB 
per Sponsor instruction upon receipt of the SUSAR notification. An IND and/or NDA Safety 
Report will be submitted to regulatory authorities unblinded. Participating Investigators and IRB 
will receive a blinded IND Safety Report, unless otherwise specified. 
10.11 General Notes
-
In case of death, a comprehensive narrative report of the case should be prepared by the 
Investigator and provided to the 
 Safety Contact together with the Serious Adverse 
Event form, retaining a copy on site;
-
If an autopsy is performed, copy of autopsy report should be actively sought by the 
Investigator and provided to the 
 Safety Contact as soon as available, retaining a 
copy on site;
-
If a baby is transferred to a continuing care site prior to discharge home, the investigator 
should ensure that the receiving hospital site is aware that the baby is participating to the 
present study and communication should be maintained in order to record any adverse 
event. Moreover, the investigator of the recruiting site will have to provide the continuing 
care site with written instruction about management and reporting of SERIOUS AE. After 
discharge home from the continuing care site a copy of the discharge summary letter 
should be requested in order to cross reference any adverse events and to determine if the 
baby is suffering from BPD. 
10.12 Independent Safety Monitoring Board  
An Independent Safety Monitoring Board (ISMB) will be established to ensure the safety of study 
subjects on an on-going basis. The involvement of independent expert advisors will provide an 
unbiased evaluation of the overall safety in the study, with particular regard to the incidence of 
major adverse outcomes (i.e. Serious Adverse Events) following study treatment administration.
The ISMB will be composed by independent Clinicians and one independent Biostatistician.
The ISMB will have periodical face-to face or telephone meetings, as appropriate, and a Safety 
Assessment Report will be issued after each meeting.
The Sponsor (and other study personnel) may be involved in some parts of the ISMB meetings, 
however, they will never have access to unblinded data and/or unblinded/coded comparisons.
All ISMB members will keep as confidential all information and data deriving from the ISMB 
activity, without disclosing them to others.
The complete ISMB guidelines including details regarding the members, duties and responsibilities, 
work and communication processes, frequency of meetings will be established by the ISMB 
members during the first meeting and reported in a separate charter.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 48/62
11. DATA MANAGEMENT
An electronic case report form (eCRF) to be filled in by the investigator and/or his/her designee will 
be used. 
Front-end edit checks will run at the time of data collection and back-end edit checks will be run by 
the Data Manager to check for discrepancies and to ensure consistency and completeness of the 
data. 
Complications of prematurity, procedures and adverse events will be coded using the MedDRA 
dictionary; medications will be coded using the WHO Drug dictionary and Anatomical Therapeutic 
Chemical classification (ATC). The same dictionaries will be used to code mother’s medical 
history, complications during pregnancy and mother’s prenatal medications.
External data (Immunogenicity and Biomarkers of Inflammation) will be processed centrally and 
reconciled against data recorded in the eCRF as part of cleaning activities.
Laboratory normal ranges will be collected prior to FPFV at each site and provided to CRO data 
management that will enter them in the eCRF. Laboratory results will be entered in the eCRF by the 
investigator.
After cleaning of data, a review meeting will be held to determine the occurrence of any protocol 
violation and to define the patient populations for the analysis. 
Once the database has been declared to be complete and accurate, it will be locked, the 
randomization codes will be opened and the planned statistical analysis will be performed. Only 
authorised and well-documented updates to the study data are possible after database lock. 
A CD-ROM of the patient data will be sent after database lock at the investigational site for 
archiving.
The 24-month clinical assessment data will be collected by a paper CRF and recorded in a separate 
database.
12. STATISTICAL METHODS
12.1
Sample Size
According to the exploratory nature of this this study, no formal power calculation was performed.
A maximum number of sixty-three (63) randomized neonates per treatment group (126 in total) is 
deemed sufficient to describe the efficacy and safety profile of CHF5633 compared to Poractant 
Alfa.
12.2
Populations for analysis
The following populations will be considered for the analysis:

Intention-to-Treat population (ITT): all randomized patients who received at least 
one dose of study medication and with at least one available evaluation of efficacy 
after the baseline.

Safety population: all randomized patients who took at least one dose of study 
medication.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 49/62
The efficacy analyses population will be performed in the ITT population. The Safety population 
will be used in the analysis of all safety variables. 
In case of deviation between as-randomized treatment and treatment actually received, the 
treatment actually received will be used in the safety analyses (i.e. an as-treated analysis will be 
performed).
12.3
Statistical analysis
A detailed statistical analysis plan (SAP) will be described in a separate document. The plan might 
be reviewed and updated as a result of the blind review of the data and will be finalized before 
breaking the blind. 
12.3.1 Descriptive Statistics 
General descriptive statistics for numeric variables will include the n (number of observed values), 
the mean, the standard deviation, 95% CI, the median, the minimum, and the maximum values. For 
categorical variables, the number and percent of subjects with a specific level of the variable will be 
presented.
12.3.2 Missing data
Details on dealing with missing data, along with the handling of possible outliers, will be described 
in the SAP. Critical missing data, if any, will be discussed during the review of the data. Decisions 
will be fully documented in the Data Review Report.
12.3.3 Description of the population-description of baseline characteristics
Demographics and baseline variables will be summarized by treatment group using descriptive 
statistics for the ITT population.
The following variables will be summarized by treatment group and overall in order to describe the 
study population: neonate baseline characteristics and demographics (birth weight, gestational age, 
sex, race, APGAR score), maternal history including the mother’s age, race, medical and pregnancy 
history, current and pre-birth medications and delivery conditions.
12.3.4 Efficacy variables
Arterial Oxygen Saturation and Ventilator settings 
SpO2/FiO2
SpO2/FiO2 will be analyzed using a linear mixed model for repeated measures (MMRM) 
including treatment, time point, treatment by time point interaction, investigational site and 
gestational age group as fixed effects and pre-dose SpO2/FiO2 as covariate. The adjusted 
means in each treatment group, the adjusted mean difference between treatments and their 
95% confidence intervals (CIs) at each time point and averaged over the first 24 hours will be 
estimated by the model. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 50/62
Time profile plot of mean SpO2/FiO2 in the first 24 hours post-treatment will be presented by 
treatment group.
SpO2/FiO2 will be compared between treatments at the remaining post-treatment time points  
(i.e., Days 2, 3, 5, 7, 28±2 PNA, at discharge home and at 36 weeks PMA) using mixed model 
including treatment, investigational site and gestational age group as fixed effects and pre-
dose SpO2/FiO2 as covariate.
SpO2/FiO2 will be analyzed by subgroups based on ventilator support used.  
FiO2
FiO2 will be analyzed at each time point and averaged over the first 24 hours post dose using 
the same model used for the SpO2/FiO2. Pre-dose FiO2 will be used as covariate.
Time profile plot of mean FiO2 in the first 24 hours after treatment will be presented by 
treatment group.
FiO2 will be compared between treatments at the remaining post-treatment time points (i.e., 
Days 2, 3, 5, 7, 28±2 PNA, at discharge home and at 36 weeks PMA) using linear mixed 
model including, treatment, investigational site and gestational age group as fixed effects 
and pre-dose FiO2 as covariate.
Percentage of patients with at least one reading of FiO2 equal to 0.21 (i.e. at room air) within 
24 hours from first intake will be compared by treatment group by means of a Fisher’s exact 
test at 5% significance interval. Odds Ratio (OR) and related exact 95% CI will be also 
provided. 
The median duration time to reach FiO2 equal to 0.21 will be compared between treatment 
groups by the Mann-Whitney U-test.
Respiratory Severity Score
RSS, calculated from ventilator settings as MAP x FiO2, will be analyzed at each time point 
and averaged over the first 24 hours post study drug intake using the same model used for 
the SpO2/FiO2.
Time profile plot of mean RSS in the first 24 hours after treatment will be presented by 
treatment group.
RSS will be compared between treatments at day 2 using linear mixed model including, 
treatment, investigational site and gestational age group as fixed effects.
Oxygen saturation index
OSI, will be calculated as MAP x FiO2 x 100/ SpO2 and analyzed at each time point and 
averaged over the first 24 hours post study drug intake using the same model used for the 
SpO2/FiO2.
Time profile plot of mean OSI in the first 24 hours after treatment will be presented by 
treatment group.
OSI will be compared between treatments at day 2 using linear mixed model including, 
treatment, investigational site and gestational age group as fixed effects.

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 51/62
SpO2

SpO2 values as well as changes from baseline will be summarized at any post-treatment time
point by treatment group by means of descriptive statistics.
MAP, PIP, PEEP

MAP, PIP, PEEP values as well as changes from baseline will be summarized at any post-
treatment time point by treatment group by means of descriptive statistics.
Duration of ventilation/oxygen use
The median duration time (days) of invasive mechanical ventilation, oxygenation, non-
invasive ventilation will be compared between treatment groups by using the Mann-Whitney
U-test.
Mortality and BPD
•
Mortality/BPD rate at 36-week PMA will be compared by treatment by means of Cochran-
Mantel-Haenszel (CMH), adjusting for stratification factors (i.e. GA group and investigational
site). Relative Risk (RR) and related 95% confidence interval will be provided.
•
The incidence of BPD at 36-week PMA will be compared by treatment as for Mortality/BPD
rate.

The mortality rate at 36-week PMA and at Day 28 will be compared by treatment as for
Mortality/BPD rate.
•
RDS-associated mortality rate through 14 days of age will be compared by treatment as for
Mortality/BPD rate.
Rescue surfactant use
The percentage of patients requiring at least one rescue surfactant dose will be compared by 
treatment group by means of a Fisher’s exact test at 5% significance interval. Odds ratio (OR) and 
related exact 95% CI will be also provided. Patients with pulmonary haemorrhage will be excluded 
from this summary. 
Biomarkers of inflammation
Mean values of biomarkers of inflammation (i.e., CXCL8, IL1β, IL6, TNF-α, MPO) in the tracheal 
aspirates as well as change from baseline to 24 and day 2 (48 hours) will be summarized by 
treatment by means of descriptive statistics.
Alveolar-arterial gradient and Oxygenation Index
A–a gradient and OI values as well as change from baseline in the first 48 hours (i.e., to 3, 6, 12, 18, 
24 hours and to day 2) be summarized by treatment by means of descriptive statistics.
12.3.5 Safety variables

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 52/62
Adverse Events 
Incidence of AEs, related AEs (ADRs), serious AEs and AEs leading to death will be summarized 
by treatment group both in term of frequency of neonates with at least one AE and in term of 
frequency of AEs (number of events). All the aforementioned categories of AEs will be 
summarized by System organ Class (SOC) and Preferred Term (PT). 
Major neonatal morbidities (see section 10.8) will be summarized separately by treatment group in 
term of frequency of neonates with at least one complication and in term of number of 
complications.
Vital Signs and SpO2
At each time point (at 0 -for HR only-, 30 minutes, at 1, 3, 6, 12, 18, 24 hours, Days 2, 3, 5, 7 and 
28 PNA, discharge home and at 36 weeks PMA), the absolute value and the change from baseline 
in vital signs (SBP, DBP and HR) will be summarized by treatment group using descriptive 
statistics.
SpO2 during administration (time 0) will be summarized as well.
Time curve of the mean change from baseline in the first week of life will be presented by treatment 
group.
Laboratory data
Hematology and chemistry parameters will be listed together with their normal ranges when 
available.
Immunogenicity data
The levels of antibodies in serum will be listed.
Bayley Scales
Bayley Scales of Infant Development measured at 24 months (±3 months) corrected age will be 
summarized by treatment by means of descriptive statistics.
Health status questionnaire
Health status questionnaire (health problems, illnesses, injuries, well-being, diet, respiratory 
assessment) assessed at 24 months (±3 months) corrected age will be summarized by treatment by 
means of descriptive statistics.
12.3.6 Interim Analysis
No formal interim analysis is planned in this study.
13. ETHICS COMMITTEE/INSTITUTIONAL REVIEW BOARD APPROVAL 
The study proposal will be submitted to the Ethics Committee/Institutional Review Board in 
accordance with the requirements of each country. 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 53/62
The EC/IRB shall give its opinion in writing -clearly identifying the study number, study title and 
informed consent form approved-, before the clinical trial commences.
A copy of all communications with the EC/IRB will be provided to the Sponsor.  
The Investigator should provide written reports to the EC/IRB annually or more frequently if 
requested on any changes significantly affecting the conduct of the trial and/or increasing risk to the 
subjects (according to the requirements of each country).
14.  REGULATORY REQUIREMENTS
The study will be notified to the Health Authorities (or authorized by) according to the legal 
requirements in each participating country.  
Selection of the subjects will not start before the approval of the Ethics Committee/Institutional 
Review Board has been obtained and the study notified to Health Authorities (or authorized by).
The study will be conducted in accordance with the Declaration of Helsinki, with the Good Clinical 
Practices guidelines and following all other requirements of local laws.
15. INFORMED CONSENT 
It is the responsibility of the Investigator to obtain written consent from each subject’s parent or the 
parents’ legal representative prior to any study related procedures taking place.
If the subject’s parents or the parents’ legal representative are unable to read, the informed consent 
will be obtained in the presence of an impartial witness, e.g. a person independent of the study who 
will read the informed consent form and the written information for the parents.
Consent must be documented by the dated signature. The signature confirms that the consent is 
based on information that has been understood. Moreover, the Investigator must sign and date the 
informed consent form.
Each signed informed consent must be kept on file by the Investigator. One copy must be given to 
the subject.
16. DIRECT ACCESS TO SOURCE DOCUMENTS/DATA
The Investigators must permit trial-related monitoring, audits, Ethics Committee/Institutional 
Review Board review or regulatory inspection, providing direct access to source data/documents.
17.  STUDY MONITORING
Monitoring will be performed by the CRO 
, who has been designated by Chiesi 
Farmaceutici S.p.A..
It is understood that the monitor(s) will contact and visit the Investigator/center before the study, 
regularly throughout the study and after the study had been completed, and that they will be 
permitted to inspect the various study records: case reports form, Investigator study file and source 
data (source data is any data that is recorded elsewhere to the case report forms), provided that 
subject confidentiality is respected.

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 54/62
The purposes of these visits are:
to assess the progress of the study;
to review the compliance with the study protocol;
to discuss any emergent problem;
to check the eCRFs for legibility, accuracy and completeness;
to validate the contents of the CRFs against the source documents;
to assess the status of drug storage, dispensing and retrieval.
Prior to each monitoring visit, the Investigator or staff will record all data generated since the last 
visit on the eCRF. The Investigator and/or study staff will be expected to be available for at least a 
portion of the monitoring visit to answer questions and to provide any missing information.
It is possible that the Investigator site may be audited by Sponsor personnel or regulatory national 
and/or international regulatory agencies during and after the study has been completed.
18. QUALITY ASSURANCE
The R&D Quality Assurance Department of the Sponsor may perform an audit at any time 
according to the Sponsor’s Standard Operating Procedures, in order to verify whether the study is 
being conducted in agreement with Good Clinical Practices. 
19. INSURANCE AND INDEMNITY
Chiesi Farmaceutici S.p.A. holds and will maintain an adequate insurance policy covering damages 
arising out of Chiesi’s sponsored clinical research studies.
Chiesi Farmaceutici S.p.A.  will indemnify the Investigator and hold him/her harmless for claims 
for damages arising out of the investigation, in excess of those covered by his/her own professional 
liability insurance, providing that the drug was administered under his/her or deputy’s supervision 
and in strict accordance with accepted medical practice and with the study protocol.
The Investigator must notify Chiesi Farmaceutici S.p.A. immediately upon notice of any claims or 
lawsuits. 
20. CONFIDENTIALITY
All study documents are provided by the Sponsor in confidence to the Investigator and his/her 
appointed staff. None of this material may be disclosed to any party not directly involved in the 
study without written permission from Chiesi Farmaceutici S.p.A..
The Investigator must assure the subject’s anonymity will be maintained. The Investigator will keep 
a separate list with at least the initials, the subject’s study numbers, names, addresses and (optional) 
telephone numbers. The Investigator will maintain this for the longest period of time allowed by 
his/her own institution and, in any case, until further communication from Chiesi Farmaceutici 
S.p.A..

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 55/62
21. PREMATURE TERMINATION OF THE STUDY
Both the Sponsor and the Investigator reserve the right to terminate the study at any time. Should 
this be necessary, the procedures for an early termination or temporary halt will be arranged after 
consultation by all involved parties.
The Sponsor should submit a written notification to the Regulatory Authority concerned and Ethics 
Committee/Institutional Review Board providing the justification of premature ending or of the 
temporary halt.
22. CLINICAL STUDY REPORT
The clinical study report, including the statistical and clinical evaluations, shall be prepared and sent 
to the coordinating Investigator for agreement and signature.
At the end of the trial a summary of the clinical study report will be provided to all Ethics 
Committees/Institutional Review Boards, to the Competent Authority of each participating Country 
and to the Investigators.
23. RECORD RETENTION
After completion of the study, all documents and data relating to the study will be kept in an orderly 
manner by the Investigator in a secure study file. 
Regulations require that essential documents must be retained for at least two years after the final 
marketing approval in an ICH region or until two years have elapsed since the formal interruption 
of the clinical development of the product under study.
It is the responsibility of the Sponsor to inform the Investigator of when these documents can be 
destroyed. The Investigator must contact Chiesi Farmaceutici S.p.A.  before destroying any trial-
related documentation. In addition, all subjects’ medical records and other source documentation 
will be kept for the maximum time permitted by the institution.
24. PUBLICATION OF RESULTS
Chiesi Farmaceutici S.p.A. is entitled to publish and/or present any results of this study at scientific 
meetings, and to submit the clinical trial data to national and international Regulatory Authorities. 
Chiesi Farmaceutici S.p.A.  furthermore reserves the right to use such data for industrial purposes. 
In the absence of a Study Steering Committee, Investigators will inform Chiesi Farmaceutici S.p.A.  
before using the results of the study for publication or presentation, and agree to provide the 
Sponsor with a copy of the proposed presentation. Data from individual study sites must not be 
published separately.
Negative as well as positive results should be published or otherwise made publicly available.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 56/62
25. REFERENCES 
1.
Stoll BJ, Hansen NI, Bell EF, et al; Eunice Kennedy Shriver National Institute of Child 
Health and Human Development Neonatal Research Network. Neonatal outcomes of 
extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010 
Sep;126 (3):443-56. doi: 10.1542/peds.2009-2959. Epub 2010 Aug 23. 
2.
Patel RM, Kandefer S, Walsh MC, et al; Eunice Kennedy Shriver National Institute of Child 
Health and Human Development Neonatal Research Network. Causes and timing of death in 
extremely premature infants from 2000 through 2011. N Engl J Med. 2015 Jan 22;372 
(4):331-40. doi: 10.1056/NEJMoa1403489.
3.
Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, Saugstad OD, Simeoni U, 
Speer CP, Vento M, Visser Gerard H.A.  Halliday HL; European Association of Perinatal 
Medicine. European consensus guidelines on the management of neonatal respiratory distress 
syndrome in preterm infants--2016 update. Neonatology. 2017;111 :107-125. doi: 
10.1159/000448985. Epub 2016 September 21 31 
4.
Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med. 2001 
Jun;163 (7):1723-9. 
5.
 Jobe AH. Pulmonary surfactant therapy. N Engl J Med 1993; 328: 861-8.
6.
Ramanathan R. Choosing a right surfactant for respiratory distress syndrome treatment. 
Neonatology 2009; 95: 1-5.
7.
Halliday HL. Surfactants: Past, present and future. J Perinatol 2008; 28: S47–S56. 
8.
Soll R, Blanco F. Natural surfactant extract versus synthetic surfactant for neonatal 
respiratory distress syndrome. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. 
No.: CD000144. DOI: 10.1002/14651858.CD000144.
9.
Moya F. Synthetic surfactants: where are we? Evidence from randomized, controlled clinical 
trials. J Perinatol 2009; 29: S23–S28.
10.
Curstedt T, Johansson J. New synthetic surfactant - basic science. Biol Neonate 2006; 89: 
257-258.
11.
Kattwinkel J. Synthetic surfactants: the search goes on. Pediatrics 2005; 115: 1075-1076.
12.
Moya F, Gadzinowski J, Bancalari E et al.  A multicenter, randomized, masked, comparison 
trial of lucinactant, colfosceril palmitate, and beractant for the prevention of respiratory 
distress syndrome among very preterm neonates. Pediatrics 2005; 115: 1018-29.
13.
Sinha S, Lacaze-Masmoneil T, Valls-i-Soler A et al. A randomized, controlled trial of 
lucinactant versus poractant alfa in very premature neonates at high risk for respiratory 
distress syndrome. Pediatrics 2005;115:1030–8.
14.
Chiesi Investigators’ Brochure on CHF 5633 –Synthetic Surfactant; CCD-IB-0019. Version 1. 
2011
15.
Robertson B. Experimental models for evaluation of exogenous surfactants. In Surfactant 
therapy for lung disease, Ed. B Robertson, HW Taeusch, Marcel Dekker Ed, New York 1995; 
238-97.

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 57/62
16.
CHF5633 - Dose-response curve in pre-term newborn rabbits (fixed concentration). Chiesi
Farmaceutici SpA; 2011 April. Report No.: PRECLI-RP-0325.
17.
A First in Human Clinical Study on the Safety and Tolerability of Two Escalating Single
Doses of CHF 5633 (Synthetic Surfactant) in Preterm Neonates with Respiratory Distress
Syndrome. Clinical Study No.: CCD-1011-PR-0059. Chiesi Farmaceutici S.p.A. Data on file.
18.
Jobe AH, Ikegami M. Lung development and function in preterm infants in the surfactant
treatment era. Annu Rev Physiol 2000; 62:825-846.
19.
Pocock SJ, Simon R. Sequential treatment assignment with balancing for prognostic factors in
the controlled clinical trial. Biometrics. 1975 Mar;31(1):103-15.
20.
Greenough A.  Air leaks.  In:  Neonatal Respiratory Disorders, 2nd Ed, Greenough A and
Milner AD (Eds), London:  Edward Arnold, 2003, pp 311-33.
21.
Fanaroff &Martin’s. Neonatal-Perinatal Medicine Disease of the Fetus and Infant. 10th
Edition Richard J. Martin, Avroy A. Fanaroff, Michele C. Walsh.  Elsevier Saunders, chapter
88 page 1299-1300.
22.
Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant
death syndrome, and home monitoring. Pediatrics. 2003;111(4 Pt 1):914.
23.
Jobe A, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001; 163:
1723-9.
24.
Papile L, Burstein J, Burstein R, Koffler H.  Incidence and evolution of subependymal and
intraventricular hemorrhage: a study of neonates with birth weights less than 1500 gm. J
Pediatr 1978;92:529-34.
25.
Bell MJ, Ternberg JL, Feigin RD et al. Neonatal necrotizing enterocolitis. Therapeutic
decision based upon clinical staging. Ann Surg. 1978;187:1-7.
26.
The Committee for the Classification of Retinopathy of Prematurity. An international
classification of retinopathy of prematurity. Arch Ophthalmol. 1984;102:1130-1134.

Clinical Study Protocol No.: CCD-5633AA1-02
Version No.: 4.0
IND No.: 122619  
Date: 31st January 2018 
CONFIDENTIAL 
Page 58/62
APPENDIX I
APPROVAL OF THE PROTOCOL BY THE COORDINATING 
INVESTIGATOR
A MULTICENTER, DOUBLE BLIND, RANDOMIZED, SINGLE DOSE, ACTIVE-
CONTROLLED STUDY TO INVESTIGATE THE EFFICACY AND SAFETY OF 
SYNTHETIC 
SURFACTANT 
(CHF 
5633) 
IN 
COMPARISON 
TO 
PORCINE 
SURFACTANT (PORACTANT ALFA, CUROSURF®) IN THE TREATMENT OF 
PRETERM NEONATES WITH RESPIRATORY DISTRESS SYNDROME.
Product: CHF 5633 Synthetic surfactant
Pharmaceutical Form:  sterile suspension
Approval of Clinical Study Protocol by the Coordinating Investigator:
I have carefully read this protocol and I agree that it contains all the necessary information required 
to conduct the study and I agree to conduct it as described.
I understand that this trial will not be initiated without Ethics Committee/Institutional Review 
Board approvals and that the administrative requirements of the governing body of the institution 
will be fully complied with.
Informed written consent will be obtained from all participating subjects and appropriately 
documented, prior to their enrolment in the study. 
The undersigned agrees that the trial will be carried out in conformity with the Declaration of 
Helsinki (attention being drawn to Section concerning freely given consent; copy appended), Good 
Clinical Practices and with all the other local laws and regulations relevant to the use of new and 
approved therapeutic agents in patients.
Coordinating Investigator’s Name: Prof. Rangasamy Ramanathan, MD
Professor of Pediatrics
Division Chief of Neonatology
Medical Director, NICU, LAC+USC Medical Center
Los Angeles, CA, USA
Centre No. : 
___________________________________           _______________  
Signature
Date
Chiesi Farmaceutici S.p.A.
Via Palermo 26/A
43122 Parma (Italy)

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 59/62
APPENDIX II
APPROVAL OF CLINICAL STUDY PROTOCOL BY THE PRINCIPAL 
INVESTIGATOR
A MULTICENTER, DOUBLE BLIND, RANDOMIZED, SINGLE DOSE, 
ACTIVE-CONTROLLED STUDY TO INVESTIGATE THE EFFICACY 
AND SAFETY OF SYNTHETIC SURFACTANT (CHF 5633) IN 
COMPARISON TO PORCINE SURFACTANT (PORACTANT ALFA, 
CUROSURF®) IN THE TREATMENT OF PRETERM NEONATES 
WITH RESPIRATORY DISTRESS SYNDROME.
Product:  CHF 5633 Synthetic surfactant
Pharmaceutical Form:  sterile suspension
Approval of Clinical Study Protocol by the Principal Investigator:
I have carefully read this protocol and I agree that it contains all the necessary information required 
to conduct the study and I agree to conduct it as described.
I understand that this trial will not be initiated without Ethics Committee/Institutional Review 
Board approvals and that the administrative requirements of the governing body of the institution 
will be fully complied with.
Informed written consent will be obtained from the parents/legal representative of all participating 
subjects and appropriately documented, prior to the enrolment in the study. 
The undersigned agrees that the trial will be carried out in conformity with the Declaration of 
Helsinki (attention being drawn to Section concerning freely given consent; copy appended), Good 
Clinical Practices and with all the other local laws and regulations relevant to the use of new and 
approved therapeutic agents in patients.
Principal Investigator’s Name: ____________________________________________________
                                               
Centre No. : 
      __________________
                                                          _________________________           _______________  
                                                                    Signature
                     Date
Chiesi Farmaceutici S.p.A.
Via Palermo 26/A
43122 Parma (Italy)

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 60/62
APPENDIX III
MINIMUM LIST OF SOURCE DATA REQUIRED
-
Demographic data
-
Study number
-
Patient identity/number
-
Randomization number
-
Complications during pregnancy
-
Neonatal complications
-
Neonatal Concomitant Medications
-
Date of informed consent signature
-
Date of specific study visits
-
Labels of study drugs
-
Examination or assessments carried out during the study (please refer to table 2. Flow Chart)
-
Laboratory reports (including haematology and biochemistry, chest x-rays and cranial sonography)
-
Adverse events / serious adverse events
-
24-month clinical assessment (Bayley scales, health status questionnaire)
-
If subject is withdrawn, reason for withdrawal.

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 61/62
APPENDIX IV
      LIST OF STUDY DEFINITIONS
Air leaks will be documented by evidence of pneumothorax, pneumomediastinum, 
pneumopericardium, pneumoperitoneum on radiograph (20). 
Anemia of prematurity is defined by a haemoglobin or haematocrit value that is more than 
two standard deviation below the mean for age (21)
Apnoea of prematurity is defined as pause in breathing > 20 sec, or <20 sec if accompanied 
by bradycardia and/or cyanosis (22)
Bronchopulmonary dysplasia (BPD) is defined according to the diagnostic criteria recently 
proposed by the NICHD / NHLBI / ORD Workshop (23): 

Time point of assessment and general criterion - 36 weeks postmenstrual age (PMA) or 
discharge home, whichever comes first; treatment with oxygen > 21% for at least 28 
days plus the below reported additional criteria: 

Additional criteria: 
Mild BPD = breathing room air at 36 weeks PMA or at discharge; 
Moderate BPD = need for < 30% oxygen at 36 weeks PMA or at discharge;
Severe BPD = need for >30% oxygen and/or positive pressure at 36 weeks PMA or at 
discharge.
Hypercalcaemia: Ca tot > 11 mg/dl
Hyperglycaemia: > 175 mg/dl (in 2 separate occasions at least 6 hours apart)
Hyperkalaemia: K+>6,0 mmol/l 
Hypernatraemia: > 150 mEq/l (operational value > 155 or an increasing trend)
Hypocalcaemia: Ca tot < 7,0 mg/dl
Hypoglycaemia: < 40 mg/dl (operational values < 45 in day 1st and 50 further days)
Hypokalaemia: K+<3 mmol/l 
Hyponatraemia: < 135 mEq/l (operational value < 130 or a decreasing trend)
Germinal matrix haemorrhage and Intraventricular haemorrhage will be determined 
according to Papile’s classification of cranial ultrasound findings of echodensity in the 

Clinical Study Protocol No.: CCD-5633AA1-02
                                         Version No.: 4.0
IND No.: 122619  
                                                                  Date: 31st January 2018 
CONFIDENTIAL 
Page 62/62
germinal matrix or ventricular extension (24).  
Cerebral parenchymal haemorrhage will be determined according to the cranial ultrasound 
finding of an echogenic lesion that fans out from the ventricular wall into the brain substance, 
associated to a GMH/IVH 
Necrotizing enterocolitis is defined as stage 2 or higher as per modified Bell’s criteria (25).
Neonatal jaundice is defined as elevated total serum/plasma bilirubin (TB) levels, which 
results in yellowish discoloration of the skin, and/or conjunctiva caused by bilirubin deposition
Patent ductus arteriosus will be documented by echocardiography or if medically treated / 
surgically ligated / haemodinamically significant. 
Periventricular leukomalacia will be defined by development of periventricular cysts 
identified by cranial ultrasound. 
Pneumonia will be clinically diagnosed as the presence of infected tracheal aspirate in a 
neonate with deteriorating oxygenation or chest x-ray appearances of consolidation.
Pulmonary haemorrhage will be diagnosed when significant amounts of blood from the 
endtroacheal tube, mouth and nose together with deterioration in oxygenation.
Pulmonary interstitial emphysema will be diagnosed on chest X-ray appearance.
Retinopathy of prematurity will be defined as per the International Classification (26).
Sepsis will be diagnosed by a positive blood culture or suggestive clinical and laboratory 
presentation resulting in a clinical decision to treat with antibiotics despite the absence of a 
positive blood culture. 
24+0 TO ≤ 29+6 WEEKS GA: 24 weeks and 0 days to 29 weeks and 6 days. Gestational age 
is determined based on certain dates of last menstrual period or early ultrasound scan (i.e. 
performed at < 20 weeks). If a discrepancy of more than 2 weeks exists choose the early 
ultrasound scan.