What are the recommended management strategies for a premature infant diagnosed with RDS, including the use of surfactant therapy?

For a premature infant diagnosed with respiratory distress syndrome (RDS), recommended management strategies focus on respiratory support, surfactant therapy, and careful monitoring NICE NG124.

• Initial Respiratory Support: When stabilising preterm babies who need respiratory support soon after birth and before admission to the neonatal unit, continuous positive airways pressure (CPAP) should be used where clinically appropriate, rather than invasive ventilation NICE NG124. Non-invasive mechanical ventilation, including CPAP, plays a crucial role in the early management of RDS in premature infants Iyer & Mhanna 2014.
• Surfactant Therapy: Surfactant should be given to preterm babies who require invasive ventilation for stabilisation in the early postnatal period NICE NG124. If a preterm baby does not need invasive ventilation, a minimally invasive administration technique should be used for surfactant NICE NG124. If minimally invasive techniques are not feasible due to lack of facilities or trained staff, endotracheal intubation can be used to administer surfactant, followed by early extubation NICE NG124. Surfactant instillation in spontaneously breathing preterm infants has been systematically reviewed Rigo et al. 2016. While being treated with surfactant is a risk factor for bronchopulmonary dysplasia (BPD), this often reflects the severity of the baby's condition, and surfactant use is appropriate when clinically indicated NICE NG124.
• Oxygen Therapy: Supplemental oxygen should be provided using nasal cannula or incubator oxygen NICE NG124. Oxygen given at higher flow rates (2 litres per minute or more) should be humidified NICE NG124. After initial stabilisation, the target oxygen saturation for preterm babies is 91% to 95% NICE NG124. Continuous pulse oximetry is used to measure oxygen saturation, with arterial sampling if clinically indicated NICE NG124. For clinically unstable preterm babies on invasive ventilation, transcutaneous oxygen monitoring may be considered NICE NG124.
• Ventilation Techniques:
  • Non-invasive Ventilation: For preterm babies needing non-invasive ventilation, nasal CPAP or nasal high-flow therapy should be considered as the primary mode of respiratory support NICE NG124.
  • Invasive Ventilation: If invasive ventilation is required, volume-targeted ventilation (VTV) combined with synchronised ventilation is the primary mode NICE NG124. If VTV is ineffective, high-frequency oscillatory ventilation (HFOV) may be considered NICE NG124. If VTV and HFOV are unavailable or unsuitable, synchronised intermittent mandatory ventilation (SIMV) can be considered NICE NG124. Synchronised pressure-limited ventilation types, such as assist control (AC), synchronised intermittent positive pressure ventilation (SIPPV), patient-triggered ventilation (PTV), pressure support ventilation (PSV), or synchronised time-cycled pressure-limited ventilation (STCPLV), should not be used NICE NG124.
• Monitoring:
  • Carbon Dioxide: For preterm babies on invasive ventilation, the aim for carbon dioxide partial pressure (PCO2) is 4.5 kPa to 8.5 kPa on days 1 to 3, and 4.5 kPa to 10 kPa from day 4 onwards NICE NG124. If a low PCO2 is identified, minute ventilation should be reduced without delay, and PCO2 rechecked within an hour NICE NG124.
  • Blood Pressure: Hypotension in preterm babies should not be treated based solely on specific blood pressure thresholds; other factors like poor tissue perfusion should be considered, with the aim of treatment being to improve perfusion NICE NG124.
• Other Management Considerations:
  • Corticosteroids: Dexamethasone may be considered to reduce the risk of BPD for preterm babies who are 8 days or older and still require invasive ventilation for respiratory disease NICE NG124. When considering dexamethasone, the risk factors for BPD and the possible benefits and harms should be discussed with parents or carers NICE NG124. It is important to be aware that dexamethasone increases the risk of gastrointestinal perforation in babies younger than 8 days old NICE NG124. Dexamethasone should not be used with non-steroidal anti-inflammatory drugs (NSAIDs), and blood pressure should be monitored due to the risk of hypertension NICE NG124.
  • Inhaled Nitric Oxide: Inhaled nitric oxide should not be routinely used for preterm babies needing respiratory support for RDS, unless there are other indications such as pulmonary hypoplasia or pulmonary hypertension NICE NG124.
  • Patent Ductus Arteriosus (PDA): A PDA in a preterm baby should not be treated unless it causes a significant clinical problem, such as difficulty weaning the baby from a ventilator NICE NG124.
  • Sedation and Analgesia: Morphine should not be routinely used for preterm babies on respiratory support NICE NG124. However, it can be considered if the baby is in pain, with pain assessed using locally agreed protocols or guidelines NICE NG124.

  Parents and carers have the right to be involved in planning and making decisions about their baby's health and care, and should be provided with information and support to facilitate this NICE NG124. Prematurity, particularly birth before 32 gestational weeks, is a factor that lowers the threshold for hospital admission for respiratory issues NICE CKS.