PURPOSE: To evaluate the relationship between radiographic findings after surfactant replacement therapy and prognosis in newborns with respiratory distress syndrome (RDS). MATERIALS AND METHODS: The chest radiographs and medical records of 78 infants [body weight 840-3600g, mean 1682g, gestational age 20 -38 (mean, 31) weeks] who had been treated with surfactant were retrospectively analysed. Surfactant was applied 1 -12 (mean, 5) hours after birth. By comparing pre-and post-surfactant radiographs, radiographi changes were graded as either uniform bilateral improvement (grade 1), asymmetrical unilateral improvement (grade 2), or no improvement (grade 3). Complications such as barotrauma, bilateral diffuse consolidation, or intracranial hemorrhage were tabulated. We correlated the prognosis with (a) the radiographic improvement pattern, (b) the time of surfactant application, and (c) the incidence of pulmonary complications, respectively. RESULTS: Forty-six (59%) of 78 infants survived, and 32 (41%) died. The survivors comprised 38 infants in group 1 (67%, n=57), six in group 2 (46%, n=13), and two in group 3 (25%, n=8) (p < 0.05). The survival rate did not correlate with the time of surfactant application (p> 0.05). Infants with barotrauma had a lower survival rate (42%, 10/24) than those not suffering from this condition (67%, 36/54) (p<0.05). The condition oc-curred in 12 (21%) of 57 infants in group 1, six (46%) of 13 in group 2, and six (75%) of eight in group 3 (p <0.05). Eleven(92%) of 12 infants with pulmonary hemorrhage, seven (100%) of seven with intracranial hemorrhage above grade 3, and seven (41%) of 17 with sepsis died. CONCLUSION: The radiographic changes occurring after surfactant replacement therapy correlated closely with the incidence of barotrauma and the prognosis of newborns with respiratory distress syndrome. Close observation of follow-up radiographic findings plays an important role in therapy and prognosis.