What is the primary treatment for pediatric patients with Respiratory Distress Syndrome (RDS)?

Primary Treatment for Pediatric Respiratory Distress Syndrome (RDS)

Surfactant replacement therapy is the cornerstone of RDS treatment in preterm infants, combined with continuous positive airway pressure (CPAP) as the initial respiratory support strategy. 1, 2, 3

Initial Respiratory Support Strategy

Start with CPAP immediately at or soon after birth for spontaneously breathing preterm infants with respiratory distress, using 5-6 cm H₂O pressure. 4, 2 This approach:

• Prevents alveolar collapse and maintains functional residual capacity 2
• Reduces the combined outcome of death or bronchopulmonary dysplasia compared to routine intubation with prophylactic surfactant (mortality RR 0.53,95% CI 0.34-0.83) 2
• Should be the first-line treatment before considering surfactant administration 1, 4

When to Administer Surfactant

Give selective surfactant to infants who show worsening respiratory distress despite CPAP support. 1, 2 Specific indications include:

• Preterm infants <30 weeks' gestation requiring mechanical ventilation due to severe RDS should receive surfactant after initial stabilization 1, 2
• Early rescue surfactant (<2 hours of age) decreases 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, 2
• Animal-derived surfactants are superior to first-generation synthetic surfactants, showing lower mortality (RR 0.86,95% CI 0.76-0.98) and fewer pneumothoraces (RR 0.63,95% CI 0.53-0.75) 2

Surfactant Administration Technique

Use the INSURE technique (Intubation, Surfactant administration, Extubation to CPAP) for surfactant delivery. 4, 2 This approach:

• Significantly reduces the need for mechanical ventilation (RR 0.67,95% CI 0.57-0.79) 2
• Decreases oxygen requirement at 28 days 2
• Requires careful monitoring during administration for transient airway obstruction, oxygen desaturation, and bradycardia 2, 3

Oxygen Management

• Start with the lowest effective FiO₂ to maintain target oxygen saturation 4
• Titrate oxygen based on continuous pulse oximetry monitoring 4
• Avoid excessive oxygen exposure while maintaining adequate oxygenation 4

Ventilation Strategy if Mechanical Ventilation Required

After surfactant administration, expeditious changes in ventilator settings are necessary to minimize lung injury: 2

• Avoid excessive chest wall movement during ventilation 4
• Adjust settings promptly to prevent air leak and barotrauma 2

Critical Pitfalls to Avoid

Do not routinely intubate and give prophylactic surfactant without first attempting CPAP in spontaneously breathing preterm infants. 4, 2 This outdated approach increases complications and is no longer recommended. 2

Additional pitfalls include:

• Delaying CPAP initiation in spontaneously breathing preterm infants 4
• Using unnecessarily high ventilation pressures that cause lung injury 4
• Administering surfactant too late (>2 hours) when early rescue is indicated 1, 2

Synergistic Treatments

Antenatal steroids and postnatal surfactant work synergistically to reduce mortality, severity of RDS, and air leaks. 1, 2 Ensure maternal antenatal steroid administration when possible, as this independently and additively improves outcomes. 1

FDA-Approved Surfactant

Poractant alfa (CUROSURF) is FDA-approved for rescue treatment of RDS in premature infants, reducing mortality and pneumothoraces associated with RDS. 3 The safety and effectiveness have been established specifically in premature infants. 3