Is a high pressure approach recommended for managing Respiratory Distress Syndrome (RDS) in neonates?

High Pressure Approach in RDS: Not Recommended

A high pressure approach is not recommended for managing RDS in neonates; instead, use the minimal inflation pressure necessary to achieve heart rate improvement or chest expansion, typically 20-25 cm H₂O for preterm infants and 30 cm H₂O for term infants, with CPAP at 5-6 cm H₂O as first-line therapy. 1, 2

Evidence Against High Pressure Ventilation

• There is no evidence supporting inflation pressures higher than those necessary to achieve improvement in heart rate or chest expansion 1
• In immature animals, ventilation with high tidal volumes and high peak inflation pressures for even a few minutes causes lung injury, impaired gas exchange, and reduced lung compliance 1
• Providers should specifically avoid creating excessive chest wall movement during ventilation of preterm infants immediately after birth, as this indicates excessive pressure delivery 1

Recommended Pressure Parameters

For Preterm Infants

• Initial inflation pressure of 20-25 cm H₂O is adequate for most preterm infants 1
• CPAP should be initiated at 5-6 cm H₂O immediately after birth for spontaneously breathing preterm infants with respiratory distress 2, 3
• If prompt improvement in heart rate or chest movement is not obtained, higher pressures may be needed, but should be titrated carefully 1

For Term Infants

• Initial inflation pressure of 30 cm H₂O is usually effective, though occasionally 30-40 cm H₂O may be necessary 1
• The minimal inflation required to achieve an increase in heart rate should be used 1

PEEP Considerations

• PEEP is beneficial during initial stabilization of apneic preterm infants requiring positive-pressure ventilation and should be used if suitable equipment is available 1
• High levels of PEEP (8-12 cm H₂O) may reduce pulmonary blood flow and increase the risk of pneumothorax 1
• There is increased pneumothorax risk when using CPAP pressure ≥8 cm H₂O 4

First-Line Management Strategy

• CPAP at 5-6 cm H₂O should be initiated immediately after birth as first-line respiratory support for spontaneously breathing preterm infants with respiratory distress 2, 3
• This approach with selective surfactant administration results in lower rates of bronchopulmonary dysplasia and death compared to routine intubation (RR 0.53,95% CI 0.34-0.83) 5
• Early CPAP reduces the need for mechanical ventilation from 100% to 46% and surfactant use from 77% to 38% in infants 25-28 weeks' gestation 1

When Mechanical Ventilation Is Required

• Use gentle ventilation strategies to minimize barotrauma and oxygen toxicity 3
• Monitor inflation pressure to help provide consistent inflations and avoid unnecessarily high pressures 1
• Expeditious changes in ventilator settings may be necessary after surfactant administration to minimize lung injury and air leak 5

Critical Pitfalls to Avoid

• Using unnecessarily high ventilation pressures that cause lung injury 2
• Routine intubation with prophylactic surfactant without a trial of CPAP in spontaneously breathing preterm infants 2, 5
• Creating excessive chest wall movement during ventilation 1, 2
• Delaying initiation of CPAP in spontaneously breathing preterm infants 2

Pneumothorax Risk Factors

• High CPAP pressure (≥8 cm H₂O) 4
• High partial pressure of carbon dioxide (PCO₂ >75 mmHg) 4
• High fraction of inspired oxygen (FiO₂ >0.6) as threshold for intubation while on CPAP 4
• CPAP use is associated with increased pneumothorax rate (9% versus 3% with intubation) 1