What is the management of Respiratory Distress Syndrome (RDS)?

From the Guidelines

Respiratory distress syndrome management should prioritize lung-protective ventilation strategies, including the use of higher positive end-expiratory pressure (PEEP) without lung recruitment maneuvers (LRMs) and limiting tidal volume to 4-8 mL/kg predicted body weight, as recommended by the American Thoracic Society guideline updated in 2024 1. The management of respiratory distress syndrome, particularly in adults with acute respiratory distress syndrome (ARDS), involves a multifaceted approach that includes mechanical ventilation, pharmacological interventions, and supportive care. Key components of this approach include:

• Mechanical ventilation strategies that limit tidal volume and inspiratory pressures, with the goal of preventing ventilator-induced lung injury 1.
• The use of higher PEEP without LRMs in patients with moderate to severe ARDS, as suggested by the 2024 American Thoracic Society guideline 1.
• Consideration of corticosteroids for patients with ARDS, although the certainty of evidence is moderate 1.
• The potential use of venovenous extracorporeal membrane oxygenation (VV-ECMO) in selected patients with severe ARDS, despite the low certainty of evidence 1.
• The use of neuromuscular blockers in patients with early severe ARDS, with the aim of improving ventilator synchrony, although the certainty of evidence is low 1. It is essential to tailor the management strategy to the individual patient's needs and to continuously monitor their response to therapy, adjusting the approach as necessary to optimize outcomes and minimize morbidity and mortality.

From the FDA Drug Label

In the event of accidental overdosage, and if there are clear clinical effects on the infant's respiration, ventilation, or oxygenation, aspirate as much of the suspension as possible and provide the infant with supportive treatment, with particular attention to fluid and electrolyte balance

A deficiency of pulmonary surfactant in preterm infants results in Respiratory Distress Syndrome (RDS) characterized by poor lung expansion, inadequate gas exchange, and a gradual collapse of the lungs (atelectasis). CUROSURF compensates for the deficiency of surfactant and restores surface activity to the lungs of these infants.

The clinical efficacy of CUROSURF in the treatment of established Respiratory Distress Syndrome (RDS) in premature infants was demonstrated in one single-dose study (Study 1) and one multiple-dose study (Study 2) involving approximately 500 infants.

The management of Respiratory Distress Syndrome (RDS) with poractant alfa (INH) involves:

• Administering CUROSURF to compensate for the deficiency of surfactant and restore surface activity to the lungs of preterm infants
• Providing supportive treatment, with particular attention to fluid and electrolyte balance, in the event of accidental overdosage
• Using CUROSURF as a single-dose or multiple-dose treatment, with the initial dose being 2.5 mL/kg (200 mg/kg) and subsequent doses being 1.25 mL/kg (100 mg/kg) 2

From the Research

Surfactant Therapy for Respiratory Distress Syndrome

• Surfactant therapy has been shown to decrease air leaks, neonatal and infant mortality, as well as cost among survivors 3.
• Natural surfactants derived from animal sources have been found to be more effective than synthetic surfactants in reducing mortality and improving outcomes in preterm infants with respiratory distress syndrome (RDS) 3, 4.
• Among natural surfactants, poractant alpha has been shown to result in significantly decreased mortality, decreased need for additional doses, faster weaning of oxygen, and reduced hospital costs compared to beractant and calfactant 3.

Timing and Mode of Surfactant Administration

• Early surfactant administration with brief mechanical ventilation has been found to be associated with a lower incidence of mechanical ventilation, air leak syndromes, and bronchopulmonary dysplasia (BPD) compared to later selective surfactant administration 5.
• Minimally invasive surfactant therapy (MIST) has been shown to be a safe and effective alternative to intubation for surfactant delivery in preterm infants with RDS, reducing the need for oxygen, mechanical ventilation, and surfactant 6.

Comparison of Surfactant Preparations

• Comparative studies have shown significant differences in outcome and cost among different natural surfactant preparations, with poractant alpha being the most effective 3.
• The differences in outcome may be due to differences in phospholipid and SP-B content, amount of antioxidant phospholipids, plasmalogens, anti-inflammatory properties, and viscosity among the surfactants 3.

Future Directions

• New types of surfactant, surfactant dosages, co-medication, and technical advances in the mode of administration are being investigated to further improve outcomes in preterm infants with RDS 7.