What is the appropriate management for a preterm infant presenting with nasal flaring and grunting due to respiratory distress?

Management of Preterm Infant with Nasal Flaring and Grunting

The appropriate initial management is D: Non-invasive ventilation and oxygen support, specifically CPAP started immediately at 5-8 cm H₂O, with surfactant administered selectively only if respiratory distress worsens despite CPAP. 1, 2

Initial Respiratory Support Strategy

Start with CPAP immediately rather than routine intubation. The American Academy of Pediatrics provides Level 1 evidence (Strong Recommendation) that CPAP initiated at or soon after birth with subsequent selective surfactant administration should be considered as the first-line approach for preterm infants with respiratory distress, as this results in lower rates of bronchopulmonary dysplasia and death compared to prophylactic surfactant therapy (RR 0.53,95% CI 0.34-0.83). 1, 2

CPAP Implementation Details:

• Deliver CPAP at 5-8 cm H₂O pressure using nasal prongs, nasopharyngeal tube, or mask 2
• Use blended oxygen and air guided by pulse oximetry, avoiding both hyperoxemia and hypoxemia 2
• For preterm infants <32 weeks' gestation, give blended oxygen judiciously rather than starting with 100% oxygen 2

When to Escalate to Surfactant Therapy

Surfactant (Option A) is not the initial management but becomes appropriate under specific conditions:

• Preterm infants born at <30 weeks' gestation who require mechanical ventilation because of severe RDS should receive surfactant after initial stabilization 1, 3, 2
• If surfactant is needed, use the INSURE strategy (Intubation, Surfactant, Rapid Extubation back to CPAP) rather than prolonged mechanical ventilation 3, 2
• Early rescue surfactant (<2 hours of age) is superior to delayed treatment if the infant fails CPAP, significantly decreasing mortality (RR 0.84; 95% CI 0.74-0.95) 3

Critical Success Data:

Approximately 50% of preterm infants managed with early CPAP will never require surfactant or mechanical ventilation, and many extremely preterm infants, even those as immature as 24-25 weeks' gestational age, can be successfully managed with CPAP alone. 2

Why Other Options Are Incorrect

Option B (Steroids): Antenatal steroids are given to the mother before delivery, not to the neonate presenting with respiratory distress. While antenatal steroids and postnatal surfactant work synergistically to reduce mortality and RDS severity, postnatal steroids are not part of acute RDS management. 1, 3

Option C (Indomethacin): This medication is used for patent ductus arteriosus closure, not for respiratory distress management. [@General Medicine Knowledge@]

Critical Pitfalls to Avoid

Avoid routine intubation with prophylactic surfactant as the first-line approach, as this is no longer recommended due to increased risk of complications and worse long-term outcomes. 2

Monitor for pneumothorax risk when using CPAP, particularly with:

• High CPAP pressures (≥8 cm H₂O) 2, 4
• High PCO₂ (>75 mm Hg) 4
• High FiO₂ (>0.6) as threshold for intubation 4

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. 2

Evidence Quality

This recommendation is based on Level 1 evidence from the American Academy of Pediatrics guidelines, supported by large multicenter randomized controlled trials including the SUPPORT trial (N=1,310) and COIN trial, which demonstrated that CPAP started immediately after birth resulted in less respiratory morbidity at 18-22 months corrected age compared to routine intubation and surfactant. 2