2019 Updated guideline on management of respiratory distress syndrome

A European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018, have released the fourth update of European Guidelines for the management of respiratory distress syndrome (RDS). It contains recommendations on prenatal care, surfactant therapy, delivery room stabilization, oxygen supplementation beyond stabilization, mechanical ventilation (MV) strategies, non-invasive respiratory support, monitoring and supportive care, and managing blood pressure and perfusion.

The recommendations, published in the journal Neonatology, are as follows:

Prenatal care

• Mothers at high risk of preterm birth <28–30 weeks’ gestation should be transferred to perinatal centers with experience in the management of RDS.


• Clinicians should offer a single course of prenatal corticosteroids to all women at risk of preterm delivery from when pregnancy is considered potentially viable until 34 weeks’ gestation ideally at least 24 h before birth.


• A single repeat course of steroids may be given in threatened preterm birth before 32 weeks’ gestation if the first course was administered at least 1–2 weeks earlier.


• MgSO₄ should be administered to women in imminent labor before 32 weeks’ gestation.


• In women with symptoms of preterm labor, cervical length and fibronectin measurements should be considered to prevent unnecessary use of tocolytic drugs and/or antenatal steroids.


• Clinicians should consider short-term use of tocolytic drugs in very preterm pregnancies to allow completion of a course of corticosteroids and/or in utero transfer to a perinatal center.

Delivery Room Stabilisation

• Delay clamping the umbilical cord for at least 60 s to promote placento-fetal transfusion.


• In spontaneously breathing babies, stabilize with continuous positive airway pressure (CPAP) of at least 6 cm H₂O via a mask or nasal prongs. Do not use SI as there is no long-term benefit. Gentle positive pressure lung inflations with 20–25 cm H₂O peak inspiratory pressure (PIP) should be used for persistently apnoeic or bradycardic infants.


• Oxygen for resuscitation should be controlled using a blender. Use an initial FiO₂ of 0.30 for babies <28 weeks’ gestation and 0.21–0.30 for those 28–31 weeks, 0.21 for 32 weeks’ gestation and above. FiO₂ adjustments up or down should be guided by pulse oximetry.


• For infants <32 weeks’ gestation, SpO₂ of 80% or more (and heart rate >100/min) should be achieved within 5 min.


• Intubation should be reserved for babies not responding to positive pressure ventilation via face mask or nasal prongs. Babies who require intubation for stabilization should be given surfactant.


• Plastic bags or occlusive wrapping under radiant warmers should be used during stabilization in the delivery suite for babies <28 weeks’ gestation to reduce the risk of hypothermia.

Surfactant Therapy

• Babies with RDS should be given an animal-derived surfactant preparation.


• A policy of early rescue surfactant should be standard, but there are occasions when surfactant should be given in the delivery suite, such as when intubation is needed for stabilization.


• Babies with RDS should be given rescue surfactant early in the course of the disease. A suggested protocol would be to treat babies who are worsening when FiO₂ >0.30 on CPAP pressure of at least 6 cm H₂O.


• Poractant alfa at an initial dose of 200 mg/kg is better than 100 mg/kg of poractant alfa or 100 mg/kg of beractant for rescue therapy.


• LISA (less invasive surfactant administration) is the preferred mode of surfactant administration for spontaneously breathing babies on CPAP, provided that clinicians are experienced with this technique.


• A second and occasionally a third dose of surfactant should be given if there is ongoing evidence of RDS such as persistent high oxygen requirement and other problems have been excluded.

Oxygen Supplementation beyond Stabilisation

• In preterm babies receiving oxygen, the saturation target should be between 90 and 94%.


• Alarm limits should be set to 89 and 95%.

Non-Invasive Respiratory Support

• CPAP should be started from birth in all babies at risk of RDS, such as those <30 weeks’ gestation who do not need intubation for stabilization.


• The system delivering CPAP is of little importance; however, the interface should be short binasal prongs or mask with a starting pressure of about 6–8 cm H₂O. Positive end-expiratory pressure (PEEP) can then be individualized depending on clinical condition, oxygenation, and perfusion.


• CPAP with early rescue surfactant is considered optimal management for babies with RDS.


• Synchronized nasal intermittent positive pressure ventilation (NIPPV), if delivered through a ventilator rather than BIPAP device, can reduce extubation failure but may not confer long-term advantages such as a reduction in BPD.


• During weaning, a high-flow nasal cannula (HFNC) can be used as an alternative to CPAP for some babies with the advantage of less nasal trauma.

Mechanical Ventilation (MV) Strategies

• After stabilization, MV should be used in babies with RDS when other methods of respiratory support have failed. Duration of MV should be minimized.


• The primary choice of ventilation mode is at discretion of clinical team; however, if conventional MV is used, targeted tidal volume ventilation should be employed.


• Caffeine should be used to facilitate weaning from MV. Early caffeine should be considered for babies at high risk of needing MV such as those on non-invasive respiratory support.


• Opioids should be used selectively when indicated by clinical judgment and evaluation of pain indicators. The routine use of morphine or midazolam infusions in ventilated preterm infants is not recommended.


• Inhaled budesonide can be considered for infants at very high risk of bronchopulmonary dysplasia (BPD).

Monitoring and Supportive Care

• Core temperature should be maintained between 36.5 and 37.5°C at all times.


• Most babies should be started on intravenous fluids of 70–80 mL/kg/day in a humidified incubator, although some very immature babies may need more. Fluids must be tailored individually according to serum sodium levels, urine output, and weight loss.


• Parenteral nutrition should be started from birth. Amino acids 1–2 g/kg/day should be started from day one and quickly built up to 2.5–3.5 g/kg/day. Lipids should be started from day one and built up to a maximum of 4.0 g/kg/day if tolerated.


• Enteral feeding with mother’s milk should be started from the first day if the baby is hemodynamically stable.

Managing Blood Pressure and Perfusion

• Treatment of hypotension is recommended when it is confirmed by the evidence of poor tissue perfusions such as oliguria, acidosis and poor capillary return rather than purely on numerical values.


• If a decision is made to attempt therapeutic closure of the PDA then indomethacin, ibuprofen or paracetamol can be used.


• Haemoglobin (Hb) concentration should be maintained within acceptable limits. Hb thresholds for infants with the severe cardiopulmonary disease are 12 g/dL (HCT 36%), 11 g/dL (HCT 30%) for those who are oxygen dependent and 7 g/dL (HCT 25%) for stable infants beyond 2 weeks of age.

For detailed guideline follow the link: https://doi.org/10.1159/000499361