What is the treatment for Respiratory Distress Syndrome (RDS)?

Treatment of Respiratory Distress Syndrome (RDS)

Surfactant replacement therapy is the cornerstone of RDS treatment, significantly reducing mortality and respiratory morbidity in preterm infants with surfactant deficiency. 1

Primary Treatment Approaches

Surfactant Replacement Therapy

• Animal-derived surfactants (beractant, calfactant, poractant alfa) are more effective than first-generation synthetic surfactants, showing lower mortality rates (RR 0.86; 95% CI 0.76–0.98) and fewer pneumothoraces (RR 0.63; 95% CI 0.53–0.75) 1
• Poractant alfa (Curosurf) is FDA-approved for rescue treatment of RDS in premature infants, reducing mortality and pneumothoraces associated with RDS 2
• Multiple doses of surfactant are more effective than single doses for ongoing respiratory insufficiency, showing decreased risk of pneumothorax (RR 0.51; 95% CI 0.30-0.88) and improved survival 3

Timing of Surfactant Administration

• Early rescue surfactant (within 1-2 hours of birth) is superior to delayed treatment (≥2 hours), significantly decreasing mortality (RR 0.84; 95% CI 0.74-0.95), air leak (RR 0.61; 95% CI 0.48-0.78), and chronic lung disease (RR 0.69; 95% CI 0.55-0.86) 1
• The INSURE strategy (Intubation, Surfactant administration, and Extubation to CPAP) significantly reduces the need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79) and oxygen requirement at 28 days 1

Respiratory Support Strategies

• Continuous Positive Airway Pressure (CPAP) is recommended as initial respiratory support in preterm infants with RDS, with surfactant administered if respiratory distress worsens 4
• For infants requiring mechanical ventilation, expeditious changes in ventilator settings may be necessary after surfactant administration to minimize lung injury and air leak 1
• Clinicians with expertise in surfactant administration should be responsible for the procedure to minimize complications 1

Surfactant Administration Techniques

• Surfactant is traditionally administered through an endotracheal tube either as a bolus, in smaller aliquots, or by infusion 1
• The optimal method of administration remains unclear, as clinical trials show no significant differences in outcomes between bolus and infusion techniques 1
• Standard dosing for poractant alfa (Curosurf) is 2.5 mL/kg (200 mg/kg) for initial dose, with up to two additional doses of 1.25 mL/kg (100 mg/kg) if needed 2

Treatment for Non-RDS Respiratory Disorders

• Surfactant therapy may benefit late-preterm and term neonates with secondary surfactant deficiency from conditions such as: 1
  • Meconium aspiration syndrome - improves oxygenation and reduces need for ECMO (RR 0.64; 95% CI 0.46-0.91) 1
  • Pneumonia/sepsis - may improve gas exchange and reduce ECMO need, though evidence is limited 1
  • Pulmonary hemorrhage - theoretically beneficial as blood inhibits surfactant function, but limited evidence 1

Monitoring and Complications

• Surfactant administration may cause transient airway obstruction, oxygen desaturation, bradycardia, and alterations in cerebral blood flow 1
• Rapid improvement in lung compliance after surfactant administration requires careful monitoring and adjustment of ventilator settings to prevent lung injury 1
• Redosing should not be needed more frequently than every 12 hours unless surfactant is being inactivated by infection, meconium, or blood 1

Special Considerations

• Antenatal steroids and postnatal surfactant work synergistically to reduce mortality and respiratory morbidity 4
• Surfactant therapy is not recommended for infants with congenital diaphragmatic hernia, as it has not shown improved outcomes 1
• For extremely premature infants (<26 weeks gestation), the approach should be individualized, balancing the benefits of early CPAP versus prophylactic surfactant 4