Management of Preterm Infant with Nasal Flaring and Grunting
The appropriate initial management is D: Non-invasive ventilation and oxygen support, specifically CPAP (continuous positive airway pressure), with subsequent selective surfactant administration only if the infant fails to stabilize or requires mechanical ventilation. 1, 2
Initial Respiratory Support Strategy
Begin with nasal CPAP immediately rather than routine intubation for preterm infants presenting with respiratory distress signs like nasal flaring and grunting. 1, 3
The American Academy of Pediatrics provides Level 1 evidence (Strong Recommendation) that using CPAP immediately after birth with subsequent selective surfactant administration should be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants. 1, 2
Early initiation of CPAP with subsequent selective surfactant administration in extremely preterm infants results in lower rates of bronchopulmonary dysplasia (BPD) and death when compared with prophylactic surfactant therapy. 1
The SUPPORT trial (N=1,310) and COIN trial demonstrated that CPAP started immediately after birth resulted in less respiratory morbidity at 18-22 months corrected age compared to routine intubation and surfactant. 1
When to Escalate to Surfactant Therapy
Surfactant should be reserved for selective use when the infant meets specific failure criteria on CPAP:
Preterm infants born at <30 weeks' gestation who require mechanical ventilation because of severe RDS should be given surfactant after initial stabilization (Level 1 evidence, Strong Recommendation). 1
Consider intubation and surfactant if the infant demonstrates high oxygen requirements (FiO₂ >0.6), elevated PCO₂ (>75 mmHg), or persistent severe respiratory distress despite adequate CPAP support. 4
If surfactant is needed, use the INSURE strategy (Intubation, Surfactant, Rapid Extubation back to CPAP) rather than prolonged mechanical ventilation. 3, 2, 5
CPAP Administration Details
Deliver CPAP at approximately 5-8 cm H₂O pressure using nasal prongs, nasopharyngeal tube, or mask. 1, 3
Start with blended oxygen and air, guided by pulse oximetry, avoiding both hyperoxemia and hypoxemia. 1
For preterm infants <32 weeks' gestation, blended oxygen should be given judiciously rather than starting with 100% oxygen. 1
Monitor closely for pneumothorax risk, which increases with CPAP pressures ≥8 cm H₂O. 1, 4
Critical Pitfalls to Avoid
Do not routinely intubate and give prophylactic surfactant to all preterm infants with respiratory distress:
Approximately 50% of preterm infants managed with early CPAP will never require surfactant or mechanical ventilation. 1
Many extremely preterm infants, even those as immature as 24-25 weeks' gestational age, can be successfully managed with CPAP alone. 2
The COIN trial showed that while CPAP had a higher pneumothorax rate (9% vs 3%), it resulted in shorter duration of ventilation and less long-term respiratory morbidity. 1
Avoid high CPAP pressures and delayed intervention:
High CPAP pressures (8-12 cm H₂O) may reduce pulmonary blood flow and increase pneumothorax risk. 1
If the infant is failing CPAP support (persistent high oxygen needs, rising PCO₂, increasing work of breathing), do not delay intubation and surfactant administration. 4
Why Other Options Are Incorrect
Steroids (Option B) are not indicated for acute respiratory distress management in the delivery room or immediate postnatal period. 1
Indomethacin (Option C) is used for patent ductus arteriosus closure, not for initial respiratory distress management. 1
Surfactant therapy alone (Option A) without first attempting CPAP represents outdated practice that increases exposure to mechanical ventilation and its associated lung injury. 1, 2