In a preterm neonate with respiratory distress manifested by nasal flaring and grunting, what is the appropriate initial management?

Management of Preterm Neonate with Nasal Flaring and Grunting

The appropriate initial management is non-invasive ventilation with CPAP (continuous positive airway pressure), NOT 100% oxygen, with subsequent selective surfactant administration if respiratory distress worsens despite CPAP support. 1

Initial Respiratory Support Strategy

Start with CPAP at 5-6 cm H₂O immediately for this spontaneously breathing preterm infant presenting with respiratory distress (nasal flaring and grunting). 1, 2, 3

• Nasal flaring and grunting are classic signs of respiratory distress syndrome (RDS) in preterm infants, indicating the infant is attempting to maintain functional residual capacity through auto-PEEP. 3, 4
• Grunting specifically signals severe disease and impending respiratory failure requiring urgent intervention, making immediate respiratory support critical. 3
• CPAP prevents alveolar collapse by maintaining functional residual capacity and has been shown to result in lower rates of bronchopulmonary dysplasia/death (RR 0.53; 95% CI 0.34-0.83) compared to routine intubation with prophylactic surfactant. 1, 2

Oxygen Management - Critical Pitfall

Do NOT use 100% oxygen as initial therapy. 3

• For preterm infants, begin with 21-30% oxygen and titrate upward based on pulse oximetry readings to maintain appropriate saturations. 3
• Using 100% oxygen initially is associated with harm in term and late-preterm infants and should be avoided. 3
• Monitor oxygen saturation continuously with pulse oximetry on the right hand/wrist to guide oxygen titration. 3

When to Administer Surfactant

Surfactant should be given selectively, not prophylactically, based on the infant's response to CPAP. 1, 2

• Administer surfactant if the infant shows worsening respiratory distress despite CPAP support, typically indicated by:

  • Requiring FiO₂ ≥0.30-0.50 to maintain adequate saturations
  • Persistent or worsening work of breathing
  • Need for mechanical ventilation 1, 2, 3

• Early rescue surfactant (within 1-2 hours) is superior to delayed treatment, significantly decreasing 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

• For preterm infants <30 weeks gestation requiring mechanical ventilation due to severe RDS, surfactant should be given after initial stabilization. 1

The INSURE Technique

If surfactant becomes necessary, consider the INSURE strategy (Intubation, Surfactant administration, Extubation to CPAP), which significantly reduces the need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79). 2, 4

Why the Other Options Are Incorrect

Option A (Surfactant therapy alone): While surfactant is effective, current evidence shows that starting with CPAP and giving surfactant selectively results in better outcomes than routine prophylactic surfactant administration. 1

Option B (Steroids): Postnatal steroids are not indicated for initial management of respiratory distress. Antenatal steroids given to the mother are preventive, but postnatal steroids in the immediate newborn period are not part of initial RDS management. 1

Option C (Indomethacin): This medication is used for patent ductus arteriosus closure, not for respiratory distress management. 1

Option D (100% oxygen): This is explicitly contraindicated as initial therapy and is associated with harm. Oxygen should be titrated starting at 21-30% for preterm infants. 3

Monitoring Requirements

• Continuous cardiorespiratory monitoring is essential, as infants requiring FiO₂ ≥0.50 to maintain saturation >92% need ICU-level monitoring capabilities. 3
• Monitor for complications including oxygen desaturation, bradycardia, and need for escalation of support. 2
• Maintain temperature between 36.5°C and 37.5°C, as hypothermia shows dose-dependent increase in mortality. 3