What is the immediate treatment for Respiratory Distress Syndrome (RDS) in a newborn?

Immediate Treatment for Respiratory Distress Syndrome (RDS) in Newborns

For newborns with respiratory distress syndrome (RDS), the immediate treatment should be continuous positive airway pressure (CPAP) started at or soon after birth with subsequent selective surfactant administration as needed, particularly in preterm infants. 1

Initial Respiratory Support

Preterm Infants

• For spontaneously breathing preterm infants with respiratory distress, CPAP should be initiated immediately after birth as the first-line respiratory support 1
• CPAP helps prevent atelectasis in newborns and is especially helpful for preterm infants with breathing difficulty after birth or after resuscitation 1
• CPAP may reduce the risk of death or bronchopulmonary dysplasia in very preterm infants when compared with endotracheal intubation and positive pressure ventilation (PPV) 1
• For preterm infants requiring positive pressure ventilation, use positive end-expiratory pressure (PEEP) during initial ventilation to help prevent lung collapse 2

Surfactant Administration

• Preterm infants born at <30 weeks' gestation who need mechanical ventilation because of severe RDS should be given surfactant after initial stabilization 1
• Early rescue surfactant treatment (<2 hours of age) in infants with established RDS decreases the risk of mortality, air leak, and chronic lung disease 1
• Surfactant options include animal-derived surfactants such as poractant alfa (Curosurf) or beractant (Survanta), both of which are FDA-approved for rescue treatment of RDS in premature infants 3, 4

Treatment Algorithm for RDS in Newborns

Step 1: Initial Assessment and Stabilization

• Assess respiratory effort, heart rate, and oxygen saturation immediately after birth 2
• Provide warmth and dry the infant to prevent hypothermia 2

Step 2: Choose Initial Respiratory Support

• For spontaneously breathing preterm infants with respiratory distress:

  • Start with CPAP at 5-6 cm H₂O 1
  • Avoid excessive chest wall movement during ventilation 2

• For apneic or severely distressed infants:

  • Provide positive pressure ventilation with PEEP 1, 2
  • Use an initial inflation pressure of 20-25 cm H₂O for most preterm cases 2
  • A T-piece resuscitator is preferred as it delivers more consistent inflation pressures and maintains PEEP more effectively than bags 2

Step 3: Oxygen Management

• Start with the lowest effective FiO2 to maintain target oxygen saturation 1
• Titrate oxygen based on continuous pulse oximetry monitoring 2

Step 4: Surfactant Administration Decision

• For preterm infants on CPAP who show worsening respiratory distress:

  • Consider selective surfactant administration 1
  • The INSURE technique (Intubation, Surfactant administration, and Extubation to CPAP) may be used for surfactant delivery 1

• For infants requiring mechanical ventilation:

  • Administer surfactant as soon as possible after intubation 1, 3, 4
  • Dosing is typically 100 mg phospholipids/kg birth weight for beractant or 2.5 mL/kg for poractant alfa 3, 4

Special Considerations

Term Infants with RDS

• Term infants with RDS often have different underlying causes than preterm infants, including perinatal infections, cesarean delivery without labor, or meconium aspiration 5
• These infants may require more aggressive initial management including early mechanical ventilation and broad-spectrum antibiotics 5

Complications to Monitor

• Watch for persistent pulmonary hypertension, which commonly complicates RDS in term infants 5
• Monitor for air leaks (pneumothorax), which may occur more frequently with CPAP (9% versus 3% with intubation) 2
• Avoid high levels of PEEP (8-12 cm H₂O) which may reduce pulmonary blood flow 2

Common Pitfalls to Avoid

• Delaying initiation of CPAP in spontaneously breathing preterm infants 1
• Using unnecessarily high ventilation pressures that can cause lung injury 2
• Routine intubation and prophylactic surfactant without a trial of CPAP in preterm infants who are breathing spontaneously 1
• Prolonged mechanical ventilation when non-invasive support would be sufficient 6
• Failure to recognize and treat secondary causes of respiratory distress in term infants 5

Early use of non-invasive ventilation in preterm neonates with mild to moderate respiratory distress significantly reduces the need for intubation, mechanical ventilation, and associated complications 6, 7.