What is the course of Respiratory Distress Syndrome (RDS) in neonates?

Course of Respiratory Distress Syndrome (RDS) in Neonates

Respiratory Distress Syndrome (RDS) in neonates typically begins shortly after birth and can be effectively managed with early CPAP followed by selective surfactant administration, which significantly reduces mortality and respiratory morbidity compared to routine intubation with prophylactic surfactant. 1, 2

Pathophysiology and Presentation

• RDS results from surfactant deficiency in preterm infants, leading to poor lung expansion, inadequate gas exchange, and gradual collapse of the lungs (atelectasis) 3
• Symptoms typically present immediately or shortly after birth with increased work of breathing, tachypnea, grunting, nasal flaring, and retractions 2
• Without treatment, RDS can rapidly progress to respiratory failure requiring mechanical ventilation 1

Initial Management

• Early initiation of CPAP at or soon after birth is recommended as the first-line treatment for preterm infants with RDS 1
• CPAP helps maintain functional residual capacity, prevents alveolar collapse, and may reduce the need for mechanical ventilation 4
• Early CPAP with selective surfactant administration results in lower rates of bronchopulmonary dysplasia (BPD) and death compared to prophylactic surfactant therapy 1

Surfactant Administration

• Surfactant should be administered selectively to infants who show worsening respiratory distress despite CPAP support 1, 2
• Preterm infants born at <30 weeks' gestation who need mechanical ventilation because of severe RDS should receive surfactant after initial stabilization 1
• Early rescue surfactant treatment (within 2 hours of birth) decreases mortality, air leak, and chronic lung disease compared to delayed treatment 2, 5
• The INSURE technique (Intubation, Surfactant administration, and Extubation to CPAP) can be used to minimize the duration of mechanical ventilation 2, 5

Complications and Monitoring

• Transient adverse reactions during surfactant administration may include bradycardia, hypotension, endotracheal tube blockage, and oxygen desaturation 3
• Common complications of RDS include pneumothorax (21-36%), pulmonary interstitial emphysema (21-38%), bronchopulmonary dysplasia (18-22%), and intracranial hemorrhage (51-64%) 3
• After surfactant administration, ventilator settings may need adjustment to prevent lung injury and air leak 2, 3
• Infants should not be suctioned for 1 hour after surfactant instillation unless signs of significant airway obstruction occur 3

Disease Progression and Outcomes

• With appropriate treatment, many infants show rapid improvement in oxygenation and lung compliance within hours after surfactant administration 3, 6
• Early CPAP with selective surfactant administration is associated with shorter duration of oxygen therapy (3±2 days vs 4.5±2 days) and hospitalization (30±10 days vs 43±12 days) compared to conventional management 6
• Mortality is significantly reduced with CPAP and selective surfactant therapy (RR 0.53,95% CI 0.34 to 0.83) 4
• Long-term follow-up of infants treated with surfactant shows similar developmental outcomes compared to controls when evaluated at 1,2, and 5.5 years of age 3

Special Considerations

• Antenatal steroids and postnatal surfactant work synergistically to reduce mortality, severity of RDS, and air leaks in preterm infants 1, 2
• Secondary surfactant deficiency from conditions such as meconium aspiration syndrome, pneumonia/sepsis, or pulmonary hemorrhage may also benefit from rescue surfactant therapy 1, 2
• Personalized approaches using tools such as lung ultrasound can help optimize the timing of surfactant administration based on individual patient needs 7

Pitfalls and Caveats

• Routine intubation with prophylactic surfactant is no longer recommended as the first-line approach for preterm infants with RDS 1, 2
• CPAP is associated with an increased risk of pneumothorax (RR 2.48,95% CI 1.16 to 5.30) and requires careful monitoring 4
• Surfactant administration should be performed by personnel with technical and clinical expertise to manage potential complications 1, 3
• Redosing of surfactant should not be needed more frequently than every 12 hours unless surfactant is being inactivated by infection, meconium, or blood 2