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

Treatment of Respiratory Distress Syndrome in Neonates

The treatment of respiratory distress syndrome (RDS) in neonates should begin with continuous positive airway pressure (CPAP) immediately after birth with subsequent selective surfactant administration for preterm infants showing signs of respiratory distress. 1

Initial Respiratory Support

• 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 and is especially beneficial for preterm infants with breathing difficulty after birth or following resuscitation 1
• CPAP may reduce the risk of death or bronchopulmonary dysplasia in very preterm infants compared to immediate intubation and mechanical ventilation 1

Surfactant Administration

• Preterm infants born at <30 weeks' gestation who need mechanical ventilation because of severe RDS should receive surfactant after initial stabilization 2
• Both animal-derived and synthetic surfactants with SP-B–like activity decrease respiratory morbidity and mortality in preterm infants with RDS 2
• Early rescue surfactant treatment (<2 hours of age) in infants with established RDS decreases the risk of mortality, air leak, and chronic lung disease 2, 3
• Poractant alfa (CUROSURF) at a dose of 2.5 mL/kg (200 mg/kg) is FDA-approved for rescue treatment of RDS in premature infants and reduces mortality and pneumothoraces 4

Treatment Algorithm for RDS in Neonates

Step 1: Initial Assessment and Stabilization

• Assess respiratory effort, heart rate, and oxygen saturation immediately after birth 1
• Provide initial stabilization as needed 2

Step 2: Choose Initial Respiratory Support

• For spontaneously breathing preterm infants with respiratory distress, start with CPAP at 5-6 cm H₂O 1
• Using CPAP immediately after birth with subsequent selective surfactant administration is strongly recommended as an alternative to routine intubation with prophylactic surfactant 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 1

Step 4: Surfactant Administration Decision

• For preterm infants <30 weeks' gestation who require mechanical ventilation due to severe RDS, administer surfactant after initial stabilization 2
• Consider selective surfactant administration for preterm infants on CPAP who show worsening respiratory distress 1
• The INSURE technique (Intubation, Surfactant administration, and Extubation to CPAP) may be used for surfactant delivery 1
• Rescue surfactant may be considered for infants with hypoxic respiratory failure attributable to secondary surfactant deficiency (e.g., meconium aspiration syndrome, sepsis/pneumonia, pulmonary hemorrhage) 2

Step 5: Multiple Dose Consideration

• Multiple doses of surfactant may be more effective than single-dose therapy in reducing mortality 4
• Clinical trials have shown that multiple-dose surfactant treatment (initial dose of 2.5 mL/kg followed by up to two 1.25 mL/kg doses) resulted in lower mortality (13% vs 21%) compared to single-dose treatment 4

Special Considerations

• Antenatal steroids and postnatal surfactant replacement independently and additively reduce mortality, severity of RDS, and air leaks in preterm infants 2
• Surfactant treatment improves oxygenation and reduces the need for ECMO without increasing morbidity in neonates with meconium aspiration syndrome 2
• Surfactant treatment of infants with congenital diaphragmatic hernia does not improve clinical outcomes 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 1
• Routine intubation and prophylactic surfactant without a trial of CPAP in preterm infants who are breathing spontaneously 1
• Preterm and term neonates receiving surfactant should be managed by personnel with technical and clinical expertise to administer surfactant safely and manage multisystem illness 2
• Inexperienced providers should wait for the transport team to arrive rather than attempting surfactant administration without proper expertise 2