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 ¹.

• 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 ¹. Non-invasive mechanical ventilation, including CPAP, plays a crucial role in the early management of RDS in premature infants (Iyer and Mhanna, 2014).
• Surfactant Therapy: Surfactant should be given to preterm babies who require invasive ventilation for stabilisation in the early postnatal period ¹. If a preterm baby does not need invasive ventilation, a minimally invasive administration technique should be used for surfactant ¹. 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 ¹. 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 ¹.
• Oxygen Therapy: Supplemental oxygen should be provided using nasal cannula or incubator oxygen ¹. Oxygen given at higher flow rates (2 litres per minute or more) should be humidified ¹. After initial stabilisation, the target oxygen saturation for preterm babies is 91% to 95% ¹. Continuous pulse oximetry is used to measure oxygen saturation, with arterial sampling if clinically indicated ¹. For clinically unstable preterm babies on invasive ventilation, transcutaneous oxygen monitoring may be considered ¹.
• 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 ¹.
  • Invasive Ventilation: If invasive ventilation is required, volume-targeted ventilation (VTV) combined with synchronised ventilation is the primary mode ¹. If VTV is ineffective, high-frequency oscillatory ventilation (HFOV) may be considered ¹. If VTV and HFOV are unavailable or unsuitable, synchronised intermittent mandatory ventilation (SIMV) can be considered ¹. 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 ¹.
• 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 ¹. If a low PCO2 is identified, minute ventilation should be reduced without delay, and PCO2 rechecked within an hour ¹.
  • 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 ¹.
• 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 ¹. When considering dexamethasone, the risk factors for BPD and the possible benefits and harms should be discussed with parents or carers ¹. It is important to be aware that dexamethasone increases the risk of gastrointestinal perforation in babies younger than 8 days old ¹. Dexamethasone should not be used with non-steroidal anti-inflammatory drugs (NSAIDs), and blood pressure should be monitored due to the risk of hypertension ¹.
  • 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 ¹.
  • 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 ¹.
  • Sedation and Analgesia: Morphine should not be routinely used for preterm babies on respiratory support ¹. However, it can be considered if the baby is in pain, with pain assessed using locally agreed protocols or guidelines ¹.

  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 ¹. Prematurity, particularly birth before 32 gestational weeks, is a factor that lowers the threshold for hospital admission for respiratory issues ².