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

GA: gestational age; HR: heart rate; bpm: beats per minute; ECG: electrocardiography; CPAP: continuous positive airway pressure; FiO₂: fraction of inspired oxygen; BG: blood gas.
* Refer to the UpToDate topic and algorithm on neonatal resuscitation for further details regarding interventions for infants who immediately after delivery are apneic or gasping with an HR<100 bpm.
¶ In our center, we use nasal CPAP as the preferred modality to provide noninvasive positive pressure. Other modalities include nasal intermittent positive pressure ventilation and high-flow nasal cannulae. Refer to UpToDate topics on prevention and treatment for neonatal respiratory distress syndrome for details on different noninvasive modalities that provide positive airway measure.
Δ Ventilation is provided as breaths through bag or mechanical ventilation.
◊ The targeted saturation oxygen level (SpO₂) is between 90 and 95% and the prespecified threshold of FiO₂ varies based on the technique used for surfactant administration. Refer to UpToDate topics on prevention and treatment for neonatal respiratory distress syndrome for details on the different measures of surfactant administration. If surfactant is administered through an endotracheal tube (ETT) after intubation, the threshold of FiO₂ ≥0.4 is used. If less invasive measures are used (eg, administration by thin intratracheal catheter), the prespecified FiO₂ threshold is typically lower (FiO₂ ≥0.3).
§ Additional surfactant therapy may be needed as discussed in the UpToDate topic on prevention and management of neonatal respiratory distress syndrome. This is dependent on oxygen saturation, BG results, and the prespecified FiO₂ threshold based on the technique used for surfactant administration.