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

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: January 18, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Management of Preterm Infant with Nasal Flaring and Grunting

The appropriate management is D: Non-invasive ventilation (specifically CPAP at 5-8 cm H₂O) with blended oxygen guided by pulse oximetry—NOT 100% oxygen—with subsequent selective surfactant administration only if the infant fails CPAP and requires mechanical ventilation. 1

Initial Respiratory Support Strategy

Start with CPAP immediately, not intubation or prophylactic surfactant. The American Academy of Pediatrics provides Level 1 evidence (Strong Recommendation) that CPAP initiated immediately after birth with subsequent selective surfactant administration should be considered as the primary approach rather than routine intubation with prophylactic surfactant in preterm infants. 1 This strategy results in lower rates of bronchopulmonary dysplasia and death compared to prophylactic surfactant therapy. 1

CPAP Administration Details

  • Deliver CPAP at 5-8 cm H₂O pressure using nasal prongs, nasopharyngeal tube, or mask 1
  • Use blended oxygen and air guided by pulse oximetry—avoid starting with 100% oxygen in preterm infants <32 weeks' gestation 1
  • The goal is to avoid both hyperoxemia and hypoxemia 1

Why CPAP First Works

  • Approximately 50% of preterm infants managed with early CPAP will never require surfactant or mechanical ventilation 1
  • Even extremely preterm infants as immature as 24-25 weeks' gestational age can be successfully managed with CPAP alone 1
  • Meta-analysis shows CPAP reduces treatment failure (death or need for assisted ventilation) with RR 0.64 (95% CI 0.50-0.82), reduces mechanical ventilation use (RR 0.72), and reduces overall mortality (RR 0.53) 2

When to Escalate to Surfactant (Option A)

Surfactant is NOT first-line but becomes appropriate when CPAP fails. 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

INSURE Strategy

  • If surfactant is needed, use Intubation, Surfactant, Rapid Extubation back to CPAP rather than prolonged mechanical ventilation 1, 3
  • This approach is preferable to prolonged ventilation when respiratory support is needed 3

Why Other Options Are Incorrect

Option B (Steroids)

  • Not mentioned in any guideline as initial management for acute respiratory distress in preterm infants
  • Steroids have a role in prevention (antenatal) or chronic lung disease management, not acute presentation

Option C (Indomethacin)

  • This is used for patent ductus arteriosus closure, not respiratory distress management
  • Completely unrelated to the clinical scenario of nasal flaring and grunting

Option D Caveat: The 100% Oxygen Component Is Wrong

  • While non-invasive ventilation (CPAP) is correct, 100% oxygen is contraindicated 1
  • For preterm infants <32 weeks' gestation, blended oxygen should be given judiciously rather than starting with 100% oxygen 1
  • High oxygen concentrations increase risk of retinopathy of prematurity and oxidative injury

Critical Clinical Pitfalls

Pneumothorax Risk

  • CPAP increases pneumothorax risk (RR 2.48,95% CI 1.16-5.30) compared to spontaneous breathing 2
  • The COIN trial showed CPAP had 9% pneumothorax rate vs 3% with intubation, but resulted in shorter duration of ventilation and less long-term respiratory morbidity 1
  • High CPAP pressures (8-12 cm H₂O) may reduce pulmonary blood flow and increase pneumothorax risk—stay in the 5-8 cm H₂O range 1

Recognition of Severity

  • Nasal flaring and grunting indicate moderate to severe respiratory distress requiring hospitalization 4
  • These signs are statistically associated with hypoxemia and increased severity of lower respiratory tract disease 4
  • Monitor for treatment failure indicators: persistent work of breathing, increasing oxygen requirements, or apnea

Algorithmic Approach

  1. Preterm infant with nasal flaring and grunting arrives → Recognize this as respiratory distress 4, 5
  2. Initiate CPAP at 5-8 cm H₂O with blended oxygen (NOT 100%) guided by pulse oximetry 1
  3. Monitor for CPAP success (decreased work of breathing, stable oxygen saturations, no apnea) 1
  4. If CPAP fails (persistent severe distress, requiring mechanical ventilation) → Intubate, give surfactant, rapidly extubate back to CPAP (INSURE) 1, 3
  5. If CPAP succeeds → Continue CPAP, wean as tolerated 1

References

1
Guideline

Management of Preterm Infant with Respiratory Distress

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Extubation Criteria for Extreme Preterm Neonates

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Differential Diagnosis for Nasal Congestion in Infants

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Research

Newborn Respiratory Distress.

American family physician, 2015

Related Questions

What is the initial management for a newborn with grunting and respiratory distress?
What is the best course of treatment for a 5-month-old infant presenting with respiratory distress?
What is the next step in management for a 33-week preterm neonate with respiratory distress, grunting, and chest retraction?
What is the most likely diagnosis for a 33-week preterm baby, born via cesarean section (CS) to a diabetic mother, presenting with grunting, respiratory distress, and cyanosis?
What is the likely diagnosis for a 33-week premature baby, delivered by cesarean section (CS) to a diabetic mother, presenting with grunting, respiratory distress, and cyanosis?
What is the role of platelet-rich plasma (PRP) therapy in treating knee osteoarthritis in older adults with a history of joint trauma, obesity, or repetitive strain, and comorbidities such as diabetes or cardiovascular disease?
What is the recommended dose of Xarelto (rivaroxaban) for a patient with atrial fibrillation and impaired renal function?
What is the appropriate management and treatment for a patient suspected of having meningitis, considering their immune status and past medical history?
Can cortical atrophy be visualized on a CT scan in a patient with severe bilateral cortical atrophy and impaired renal function?
What is the initial dose of Cogentin (benztropine) for an adult patient with schizophrenia experiencing Extrapyramidal Symptoms (EPS) as a side effect of antipsychotic therapy?
What is the recommended duration of treatment with nepafenac (nepafenac ophthalmic suspension) eye drops for a patient after cataract surgery?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question