In a preterm newborn with nasal flaring and grunting, what is the appropriate immediate management?

Management of Preterm Infant with Nasal Flaring and Grunting

The appropriate immediate management is non-invasive ventilation with CPAP at 5-6 cm H₂O, NOT 100% oxygen, and surfactant should be reserved for selective use only if the infant fails CPAP. 1, 2

Initial Respiratory Support Strategy

Start with CPAP immediately as first-line therapy for this spontaneously breathing preterm infant showing signs of respiratory distress (nasal flaring and grunting). 3, 1, 4

• CPAP should be initiated at 5-6 cm H₂O pressure using nasal prongs, nasopharyngeal tube, or mask. 1, 2, 4
• Begin with blended oxygen (21-30%) guided by pulse oximetry, NOT 100% oxygen, as high oxygen concentrations cause harm in preterm infants without benefit. 1
• This CPAP-first approach results in lower rates of bronchopulmonary dysplasia and death (RR 0.53; 95% CI 0.34-0.83) compared to routine intubation with prophylactic surfactant. 1, 4

Why CPAP First, Not Prophylactic Surfactant

The evidence strongly favors a CPAP-first strategy over routine surfactant administration:

• Early CPAP with subsequent selective surfactant is superior to prophylactic surfactant therapy based on Level 1 evidence from the American Academy of Pediatrics. 3, 4
• Approximately 50% of preterm infants managed with early CPAP will never require surfactant or mechanical ventilation, making prophylactic surfactant unnecessary and potentially harmful. 4
• Prophylactic surfactant in infants receiving CPAP actually increases the risk of death or chronic lung disease (RR 1.13; 95% CI 1.02-1.25). 3

When to Escalate to Surfactant Therapy

Surfactant should be administered selectively, not prophylactically, only when specific failure criteria are met:

• Requirement of FiO₂ ≥ 0.30-0.50 to maintain target oxygen saturations despite adequate CPAP. 1
• Persistent or worsening work of breathing (continued grunting, retractions, nasal flaring). 1
• Need for escalation to mechanical ventilation due to severe RDS. 1
• For infants <30 weeks gestation who require mechanical ventilation, surfactant should be given after initial stabilization. 3, 1, 4

Surfactant Administration Technique (If Needed)

If surfactant becomes necessary, use the INSURE strategy (Intubation, Surfactant, Rapid Extubation back to CPAP) rather than prolonged mechanical ventilation:

• This approach reduces the need for mechanical ventilation (RR 0.67; 95% CI 0.57-0.79) compared to delayed rescue surfactant. 3
• Early rescue surfactant (within 2 hours) 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). 3

Why the Other Options Are Incorrect

Steroids (Option B): Postnatal steroids are not indicated for initial management of respiratory distress syndrome; they are reserved for later phases or specific indications, not acute RDS treatment. 1

Indomethacin (Option C): This medication is used for patent ductus arteriosus closure and has no role in acute respiratory management of RDS. 1

100% Oxygen (Part of Option D): Starting with 100% oxygen is contraindicated and causes harm in preterm infants; oxygen should be blended at 21-30% and titrated upward only as needed. 1

Critical Pitfalls to Avoid

• Do not delay CPAP initiation in spontaneously breathing preterm infants with respiratory distress. 2, 4
• Do not routinely intubate for prophylactic surfactant without first attempting CPAP. 3, 4
• Monitor for pneumothorax, as CPAP carries a higher pneumothorax rate (9% vs 3% with intubation), though overall respiratory outcomes remain superior. 2, 4
• Avoid excessive CPAP pressures (8-12 cm H₂O), which may reduce pulmonary blood flow and increase pneumothorax risk. 2, 4
• Grunting indicates severe disease and impending respiratory failure, requiring urgent intervention with continuous cardiorespiratory monitoring. 1