Respiratory Distress Syndrome Clinical Practice Guidelines (2019)

In 2019, an update to the European Consensus Guidelines on the Management of Respiratory Distress Syndrome, as developed by an expert panel backed by the European Society of Paediatric Research, was released.

Prenatal Care

For women at risk of preterm delivery, a single course of prenatal corticosteroids should be offered from the time the pregnancy is considered potentially viable up to 34 weeks' gestation (ideally, at least 24 hours prior to birth).
Prior to 32 weeks' gestation, in cases of threatened preterm birth, women may undergo a single repeat course of steroids, provided that administration of the first course occurred at least 1-2 weeks earlier.

In cases of imminent labor prior to 32 weeks' gestation, women should receive magnesium sulfate (MgSO₄).
In very preterm pregnancies, short-term use of tocolytic agents should be considered to permit completion of a corticosteroid course and/or safe in utero transfer to a perinatal center.

Stabilization in the Delivery Room

Umbilical cord clamping should be delayed for at least 1 minute to promote placento-fetal transfusion.
Using a mask or nasal prongs, continuous positive airway pressure (CPAP) of at least 6 cm H₂O should be used to stabilize spontaneously breathing babies. Because it provides no long-term benefit, sustained inflation should not be used. Infants who are persistently apneic or bradycardic should be treated with gentle positive-pressure lung inflation with 20-25 cm H₂O peak inspiratory pressure.
Only infants who do not respond to positive-pressure ventilation delivered through a face mask or nasal prongs should undergo intubation. Surfactant should be administered to babies in whom stabilization must be achieved through intubation.
During stabilization in the delivery suite, hypothermia risk in babies delivered at less than 28 weeks' gestation should be reduced via the use of plastic bags or occlusive wrapping, under radiant warmers.

Surfactant Therapy

An animal-derived surfactant preparation should be administered to infants with respiratory distress syndrome (RDS).

The use of early rescue surfactant should be standard policy, but occasions exist, including when intubation is required for stabilization, in which surfactant should be administered in the delivery suite.
In rescue therapy, an initial 200 mg/kg dose of poractant alfa is preferable to a 100 mg/kg dose of the drug or a 100 mg/kg dose of beractant.
When ongoing evidence of RDS, such as persistent high oxygen requirement, exists (with other problems having been excluded), a second and, occasionally, third dose of surfactant should be administered.

Noninvasive Respiratory Support

In all infants at risk of RDS, such as those born at less than 30 weeks' gestation, who do not need to be stabilized via intubation, CPAP treatment should begin at birth.
Although it is of little importance which CPAP administration system is used, the interface should consist of short binasal prongs or a mask with a starting pressure of approximately 6-8 cm H₂O.
Optimally, infants with RDS should be treated with CPAP with early rescue surfactant.

Mechanical Ventilation

After stabilization, infants in whom other respiratory support methods have failed should undergo mechanical ventilation (MV).
It is up to the clinical team to decide on the primary ventilation mode, but conventional MV, if employed, should involve the use of targeted tidal volume ventilation.
In infants who, after 1-2 weeks, are still on MV, consider facilitating extubation through a short tapering course of low- or very low–dose dexamethasone.
For infants in whom the risk of bronchopulmonary dysplasia is very high, inhaled budesonide can be considered.
It is not recommended that morphine or midazolam infusions routinely be used in ventilated preterm infants.

Persistent Ductus Arteriosus

Indomethacin, ibuprofen, or paracetamol can be employed in light of a decision to attempt therapeutic closure of a persistent ductus arteriosus.