In 1959 Avery and Mead suggested internationally that respiratory failure in premature infants is due to lack of surfactant. Surfactant is a phospholipid protein complex that is synthesised and stored in alveolar type II pneumocytes in the lungs. The main function of surfactant is to reduce surface tension in the lungs and make respiratory effort easier. Since 1959 much of scientific work has been done in this field, and there is now increasing evidence to support the theory that surfactant is important for normal lung function. Therefore surfactant insufficiency plays a major role in acute respiratory failure of any etiology. In this paper we focus on other possible indications for surfactant replacement therapy, and describe a patient with meconium aspiration syndrome which was treated successfully with exogenous natural surfactant.