Initial interventions to prevent or reduce severity of neonatal respiratory distress syndrome (RDS) in at-risk preterm infants (GA <32 weeks)

bpm: beats per minute; CPAP: continuous positive airway pressure; ETT: endotracheal tube; FiO₂: fraction of inspired oxygen; GA: gestational age; HFNC: high-flow nasal cannula; HR: heart rate; INSURE: INtubate, instill SURfactant, then Extubate; MIST: minimally invasive surfactant therapy; NIPPV: nasal intermittent positive pressure ventilation; NRP: neonatal resuscitation program; PaCO₂: partial pressure of carbon dioxide; PPV: positive pressure ventilation; SpO₂: peripheral oxygen saturation; VPT: very preterm.

* Refer to separate UpToDate content for details of neonatal resuscitation in the delivery room.

¶ In our center, we use nasal CPAP as the preferred initial modality for respiratory support in VPT infants. CPAP is typically initiated at 5 cm H₂O; if needed, it can be increased up to 6 to 8 cm H₂O depending on work of breathing and oxygenation. Other modalities for noninvasive positive airway pressure include NIPPV and HFNC. Refer to UpToDate topics on RDS for additional details on these modalities and the choice between them.

Δ VPT neonates who are managed initially with noninvasive ventilatory support should be monitored for a period of time before deciding whether additional interventions are warranted (eg, intubation, surfactant). However, the optimal duration of monitoring is uncertain. Surfactant therapy is most effective when given within the first 2 hours after birth. However, the potential benefits of timely administration of surfactant must be balanced with allowing time for an adequate trial of CPAP.

◊ If, despite efforts to optimize noninvasive support, the neonate develops any of the following signs of inadequate gas exchange, we typically intubate and initiate invasive mechanical ventilation:

• pH <7.20, with PaCO₂ >65 mmHg
• Requiring FiO₂ >0.5 to achieve SpO₂ >90% despite maximal noninvasive support
• Multiple apneic episodes per hour associated with desaturations and bradycardia or >1 episode requiring PPV within a few hours

We rely mostly on these objective measures of gas exchange to define failure of noninvasive support. However, the thresholds are not hard set, and these parameters should be interpreted in conjunction with other clinical findings. For neonates with signs of labored breathing, hemodynamic instability, or persistent metabolic acidosis, we generally use a lower threshold for transitioning to invasive mechanical ventilation. Refer to UpToDate topic on mechanical ventilation in VPT infants for additional details.

§ For neonates managed with noninvasive support (eg, CPAP), criteria for surfactant therapy are based on the FiO₂ required to maintain SpO₂ 90 to 95%. The threshold differs slightly depending on which method is used for administration:

• If surfactant will be administered using MIST technique: The threshold is a requirement of FiO₂ ≥0.30
• If surfactant will be administered using INSURE technique: The threshold is a requirement of FiO₂ ≥0.40

¥ The techniques used for surfactant administration vary between centers, and even between clinicians within a single center. Refer to UpToDate topic on prevention and treatment for neonatal RDS for details on the different methods of surfactant administration.