When Avery and Mead1 first described surfactant deficiency as being responsible for hyaline-membrane disease, it seemed as if the therapeutic implications would be simple: Because we knew that pulmonary surfactant was made up primarily of phosphatidyl choline, perhaps administering a solution or aerosol of this readily available lipid to the surfactant-deficient lung should solve the problem. Unfortunately, this simplistic approach did not work regardless of whether surfactant was delivered to humans2 or animals.3 Improving the spreading characteristics by adding alcohols or altering the physical preparation improved the function somewhat,4,5 but the first dramatic effect on pulmonary function and survival was shown only with modified natural surfactants that had been extracted from lung minces6,7 and airway washes of animal lungs.8 Various head-to-head trials of natural versus synthetic surfactants have consistently favored the natural preparations.9 Accordingly, although 2 synthetic surfactant preparations (Exosurf and Pumactant) were approved for commercial distribution in the United States and Britain, respectively, Exosurf is no longer readily available in the United States, and Pumactant was recently removed from the market in Britain. The search for a synthetic preparation that is equivalent or superior to the animal-derived surfactants has continued, because there has always been concern about the potential antigenic and infectious complications that might be associated with animal-derived … Address correspondence to John Kattwinkel, MD, Department of Pediatrics, University of Virginia, Charlottesville, VA 22908. E-mail: jk3f{at}virginia.edu