What is the treatment for Respiratory Distress Syndrome (RDS) in preterm infants and adults?

Treatment of Respiratory Distress Syndrome

Preterm Infants with RDS

For preterm infants with RDS, initiate CPAP at 5-6 cm H₂O immediately after birth as first-line therapy, followed by selective surfactant administration (poractant alfa 200 mg/kg or beractant) if respiratory distress worsens or mechanical ventilation becomes necessary. 1, 2, 3

Initial Respiratory Support Strategy

• Start CPAP (5-6 cm H₂O) at or immediately after birth for all spontaneously breathing preterm infants with respiratory distress rather than routine intubation 2, 3
• Early CPAP with selective surfactant reduces bronchopulmonary dysplasia and death compared to prophylactic surfactant (RR 0.53,95% CI 0.34-0.83) 2, 4
• CPAP prevents alveolar collapse by maintaining functional residual capacity and reduces the combined risk of death or bronchopulmonary dysplasia 3, 4

Common Pitfall: Routine intubation with prophylactic surfactant is no longer recommended as first-line therapy, as it increases complications without additional benefit when CPAP is used 2

Surfactant Administration Protocol

When to Give Surfactant:

• Administer surfactant to preterm infants <30 weeks gestation who require mechanical ventilation with FiO₂ ≥0.30 due to severe RDS 2, 3
• Give early rescue surfactant within 1-2 hours of birth if respiratory distress worsens on CPAP 1, 2
• Early rescue (<2 hours) 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) compared to delayed treatment 1, 2

Surfactant Choice and Dosing:

• Use animal-derived surfactants (poractant alfa or beractant) as they demonstrate lower mortality (RR 0.86; 95% CI 0.76-0.98) and fewer pneumothoraces (RR 0.63; 95% CI 0.53-0.75) compared to synthetic surfactants 1, 2
• Initial dose: poractant alfa 2.5 mL/kg (200 mg/kg) via endotracheal tube 5
• Repeat dosing: Up to 2 additional doses of 1.25 mL/kg (100 mg/kg) if infant continues requiring mechanical ventilation with FiO₂ ≥0.30 5
• Administer repeat doses no more frequently than every 12 hours 1, 2, 5
• Multiple-dose poractant alfa reduces 28-day mortality (13% vs 21%, p=0.048) and pneumothorax (9% vs 17%, p=0.03) compared to single-dose 5

INSURE Technique (Intubation-Surfactant-Extubation)

• The INSURE strategy significantly reduces need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79) and oxygen requirement at 28 days 1, 2
• Intubate, administer surfactant, then rapidly extubate to CPAP for spontaneously breathing infants 2, 3

Mechanical Ventilation Management

• Use minimal inflation pressures necessary to achieve heart rate improvement or chest expansion 3
• Preterm infants: Initial pressure 20-25 cm H₂O with PEEP 5-6 cm H₂O 3
• Make expeditious ventilator setting changes after surfactant administration to minimize lung injury and air leak 1, 2
• Avoid excessive pressures that cause lung injury 3

Critical Monitoring: Surfactant administration may cause transient airway obstruction, oxygen desaturation, bradycardia, and alterations in cerebral blood flow requiring immediate ventilator adjustments 1, 2

Synergistic Therapies

• Antenatal corticosteroids and postnatal surfactant work synergistically to reduce mortality, RDS severity, and air leaks more than either alone 1, 2, 4
• Administer caffeine therapy early to reduce apnea and facilitate extubation 6

Term and Late-Preterm Infants with Secondary Surfactant Deficiency

Consider rescue surfactant therapy for term and late-preterm neonates with secondary surfactant deficiency from meconium aspiration syndrome, pneumonia/sepsis, or pulmonary hemorrhage, as it improves oxygenation and reduces ECMO requirements. 1, 2

Specific Conditions

• Pneumonia/sepsis: Surfactant improves oxygenation and reduces ECMO requirements, though evidence is less robust than for primary RDS 2
• Meconium aspiration syndrome: Surfactant replacement may be beneficial 1
• Infection and meconium can inactivate surfactant, potentially requiring more frequent redosing than the standard 12-hour interval 2

Contraindication: Do not use surfactant for congenital diaphragmatic hernia, as it has not shown improved outcomes 1, 2

Adult Respiratory Distress Syndrome (ARDS)

The evidence provided focuses exclusively on neonatal RDS. For adult ARDS, surfactant therapy has not demonstrated the same efficacy as in neonates, and management centers on lung-protective mechanical ventilation strategies, treatment of underlying causes, and supportive care. The pathophysiology differs fundamentally from neonatal surfactant deficiency RDS.

Administration Requirements

• Surfactant must be administered by or under supervision of clinicians experienced in intubation, ventilator management, and care of premature infants 2
• Requires specialized expertise in neonatal intensive care 2