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Backgrounds/Aims: The World Health Organization estimates the annual worldwide incidence of death by drowning to be about 400,000. Deaths from drowning are more common in young children, representing 27% of deaths at 1–4 years from unintentional injury in the US.Drowning victims develop hypoxaemia related to the acute lung injury as a result of surfactant disruption. The severe lung dysfunction leads to alveolar collapse, atelectasis and intrapulmonary shunting and often progresses to acute respiratory distress syndrome (ARDS). Surfactant replacement therapy has been shown to reduce mortality and complications in prematures and neonates with severe respiratory distress syndrome(RDS). Administration of surfactant to adults with ARDS has received great attention and specific patients may benefit from surfactant treatement; however more studies are needed.This Case report describes our experience with a 18 months child affected by a severe ARDS from freshwater near-drowning and treated with a single dose of surfactant (Curosurf). Methods: While she was unatended, a little 18 months girl fell in a big basin full of freshwater. Her face remained under water for 3–5 min. Her parents rescued her and started a basic CPR. They transported her to the nearest hospital where she was intubated and ventilated. Medical staff continued CPR and started acidosis correction, noradrenaline infusion (0,1 mcg/kg/min), antibiotics and corticosteroids therapy. Finally both pupils reacted to light. The patient had severe combined acidosis whith pH 7.09, but normal electrolytes. On ICU admission, 270 min after the submersion, her GCS was 8, BP 100/60mmHg, HR 120. A chest X-Ray showed bilateral infiltrates, subatelectasis and an increased cardiothoracic ratio.The rectal temperature was almost normal.The pulse oximetry revealed a saturation 100% with FiO2 =1. After repeated suctioning and recruitment manoevres a 240 mg dose of Surfactant (Cursurf) in volume of 50 ml of normal saline was injected intratracheally during a fiberoptic broncoscopy (mg/5ml). The ET tube was connected to the pressure controlled ventilation. The patient was also treated with antibiotics (ceftriaxone and amikacin), corticosteroids (desametasone), ranitidine, phenobarbital, fluids therapy and rewarming. Results: The first blood gas 3 hours after surfactant administration showed PaO2/FiO2 ratio of blood gas analysis 0h (144) -3 h (407), 6h (431), 12h (471), -18h (474).and chest X-Rays were checked at 6–12-18 hours and revealed a rapid improvement of oxygenation and respiratory distress. Electroencephalography and neurological evaluation were normal. An Echocardiography revealed normal ventricular function and minor ventricular septal decreased contractility. Conclusions: The key pathophysiological feature in drowning is hypoxia. In our experience surfactant replacement had drammatically improved oxygenation. Prompt resuscitation is crucial for optimal survival: that means good neurological outcome.