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

Management of Preterm Infant with Nasal Flaring and Grunting

Immediately initiate nasal CPAP at 5-8 cm H₂O pressure as first-line respiratory support, with selective surfactant administration only if the infant subsequently requires mechanical ventilation. 1

Initial Respiratory Support Strategy

• Start CPAP immediately using nasal prongs, nasopharyngeal tube, or mask at 5-8 cm H₂O pressure rather than routine intubation 1
• Use blended oxygen guided by pulse oximetry, avoiding both hyperoxemia and hypoxemia 1
• For preterm infants <32 weeks' gestation, begin with 21-30% oxygen and titrate upward as needed rather than starting with 100% oxygen 1
• This approach has Level 1 evidence (Strong Recommendation) from the American Academy of Pediatrics as an alternative to routine intubation with prophylactic surfactant 2, 1

Why CPAP First Works

• Early CPAP with selective surfactant results in lower rates of bronchopulmonary dysplasia and death compared to prophylactic surfactant therapy 1
• Approximately 50% of preterm infants managed with early CPAP will never require surfactant or mechanical ventilation 1
• The SUPPORT trial (N=1,310) demonstrated that CPAP started immediately after birth resulted in less respiratory morbidity at 18-22 months corrected age compared to routine intubation 2, 1
• Mean duration of ventilation is shorter with initial CPAP (3 days vs 4 days with immediate intubation) 2

When to Escalate to Surfactant

Administer surfactant if the infant requires mechanical ventilation despite CPAP, particularly for preterm infants <30 weeks' gestation with severe RDS 2, 1

Use the INSURE Strategy:

• Intubate the infant
• Administer Surfactant (animal-derived preferred over synthetic)
• Rapidly Extubate back to CPAP 2, 1, 3

This approach significantly reduces the need for prolonged mechanical ventilation (RR 0.67; 95% CI 0.57-0.79) 2

Timing Matters:

• If surfactant is needed, give it as early rescue within 1-2 hours rather than delayed treatment 2
• Early rescue surfactant decreases mortality (RR 0.84), air leak (RR 0.61), and chronic lung disease (RR 0.69) compared to delayed administration 2

Critical Pitfalls to Avoid

• Do not routinely intubate without first attempting CPAP - this increases complications without improving outcomes 1
• Be aware that CPAP carries a higher pneumothorax risk (9% vs 3% with intubation), but results in better long-term respiratory outcomes 2, 1
• Avoid excessive CPAP pressures (8-12 cm H₂O) as these may reduce pulmonary blood flow and increase pneumothorax risk 1
• Do not withhold surfactant if mechanical ventilation becomes necessary - these infants have true surfactant deficiency requiring replacement therapy 4
• Many extremely preterm infants, even those as immature as 24-25 weeks' gestational age, can be successfully managed with CPAP alone 1

Monitoring Requirements

• Continuous pulse oximetry (preferably preductal on right hand/wrist) 4
• Continuous respiratory rate, heart rate, and blood pressure monitoring 4
• Serial assessment for increased work of breathing, worsening retractions, or apnea indicating CPAP failure 5
• Blood gas measurement if clinical deterioration occurs 5