What is the treatment for a newborn with Neonatal Respiratory Distress Syndrome (NRDS)?

Treatment for Neonatal Respiratory Distress Syndrome (NRDS)

For spontaneously breathing preterm infants with NRDS, initiate CPAP at 5-6 cm H₂O immediately after birth as first-line therapy, followed by selective surfactant administration if respiratory distress worsens despite CPAP support. 1, 2

Initial Respiratory Support Strategy

For Spontaneously Breathing Preterm Infants

• Start CPAP at 5-6 cm H₂O immediately at or soon after birth as the primary intervention for preterm infants with respiratory distress 1, 2
• CPAP prevents atelectasis and reduces the risk of death or bronchopulmonary dysplasia compared to routine intubation with mechanical ventilation 3, 1
• Early CPAP reduces the need for mechanical ventilation and surfactant use in infants 25-28 weeks' gestation (RR 0.53,95% CI 0.34-0.83) 1
• This CPAP-first approach with selective surfactant results in lower rates of bronchopulmonary dysplasia and death compared to prophylactic surfactant therapy 2

For Non-Breathing or Apneic Preterm Infants

• Initiate positive pressure ventilation (PPV) with PEEP at 5-6 cm H₂O 3
• Use initial inflation pressure of 20-25 cm H₂O for most preterm infants 1
• Use the minimal inflation pressure necessary to achieve heart rate improvement or chest expansion 1

For Term Infants

• Initial inflation pressure of 30 cm H₂O is usually effective, though occasionally 30-40 cm H₂O may be necessary 1
• No specific recommendation exists for PEEP use in term infants due to insufficient data 3

Surfactant Therapy

Indications for Surfactant Administration

• Preterm infants <30 weeks' gestation who require mechanical ventilation due to severe RDS should receive surfactant after initial stabilization 1, 2
• Administer selective surfactant to infants on CPAP who show worsening respiratory distress (typically requiring FiO₂ ≥0.30) 2, 4
• Early rescue surfactant (<2 hours of age) significantly 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) 2

Surfactant Dosing Protocol

• Initial dose: 2.5 mL/kg (200 mg/kg) of poractant alfa administered intratracheally 4
• Repeat doses: Up to two additional doses of 1.25 mL/kg (100 mg/kg) if the infant continues to require mechanical ventilation with FiO₂ ≥0.30 4
• Administer repeat doses no more frequently than every 12 hours 2, 4
• Plan for up to 3 additional doses in the first 48 hours if needed 2

Surfactant Administration Technique

• The INSURE technique (Intubation, Surfactant administration, and Extubation to CPAP) significantly reduces the need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79) 2
• Surfactant should be administered by or under supervision of clinicians experienced in intubation and ventilator management 2
• After surfactant administration, expeditious changes in ventilator settings may be necessary to minimize lung injury and air leak 2

Oxygen Management

• Start with the lowest effective FiO₂ to maintain target oxygen saturation 1
• Titrate oxygen based on continuous pulse oximetry monitoring 1
• Avoid excessive oxygen delivery that can cause lung injury 1

Mechanical Ventilation (When Required)

• Use minimal inflation pressures necessary to achieve heart rate improvement or chest expansion 1
• Avoid excessive chest wall movement during ventilation 1
• High levels of PEEP (8-12 cm H₂O) may reduce pulmonary blood flow and increase pneumothorax risk 1

Common Pitfalls to Avoid

• Do not routinely intubate with prophylactic surfactant as first-line approach – this increases complications compared to CPAP-first strategy 2
• Do not delay CPAP initiation in spontaneously breathing preterm infants, as early intervention is critical 1, 2
• Do not use unnecessarily high ventilation pressures that can cause barotrauma and lung injury 1
• Monitor for pneumothorax – CPAP use is associated with increased pneumothorax rate (9% versus 3% with intubation), requiring careful pressure management 1
• Do not administer surfactant more frequently than every 12 hours unless surfactant is being inactivated by infection, meconium, or blood 2

Monitoring During Treatment

• Surfactant administration may cause transient airway obstruction, oxygen desaturation, bradycardia, and alterations in cerebral blood flow 2
• Careful monitoring and adjustment of ventilator settings are required to prevent lung injury 2
• Continuous assessment of respiratory effort, heart rate, and oxygen saturation is essential 1

Synergistic Therapies

• Antenatal steroids and postnatal surfactant work synergistically to reduce mortality, severity of RDS, and air leaks more than either alone 2
• The combination provides additive benefits for reducing respiratory morbidity 2