This document provides guidance on managing a neonate with respiratory distress, including defining the severity, identifying the etiology, initial management with oxygen therapy and supportive care, and the various modes of respiratory support including CPAP, NIV, HHHFNC, IMV, and HFOV. The goal of respiratory support is to optimize oxygenation and ventilation while avoiding lung injury through use of the lowest effective pressures and tidal volumes. Clinical assessment and arterial blood gases are important to monitor the adequacy of respiratory support and make adjustments as needed.

1. Management of a Neonate with
Respiratory Distress
Soumya Ranjan Parida

2. • Defining Respiratory Distress
• Identifying the severity
• Etiology
• Clinical Clues for Diagnosis
• Investigations
• Monitoring
• Management (O2/
CPAP/NIV/HHFNC/IMV/HFOV)

3. Defining Respiratory Distress
Presence of 2 of the following
• Tachypnea
• Retractions (intercostal and/or Subcostal)
• Grunt
Ensure baby is quite, normothermic before
counting Respiratory rate ( count RR for 1min)

4. • Respiratory Distress: increase in work of
breathing
• Respiratory Failure: ineffective ventilation or
oxygenation or both. Associated worsening
sensorium, slow or fast breathing
• Respiratory Arrest: No spontaneous breathing,
cyanosis, unresponsiveness

5. Knowing the severity
• Downe’s Score
• Silverman-Anderson Score
• WHO Classification of respiratory distress

6. Silverman-Anderson Score

7. Downe’s Vidyasagar Score

8. WHO Classification of Respiratory Distress

9. WHO Classification of Respiratory Distress

10. Etiology Based on Gestation and Age Of Onset
Preterm
RDS
Cong.Pneumonia
TTN
Pneumothorax
Lung
malformations
Cong.Pneumonia
Aspiration Syndromes
PDA
Shock
CHD-duct Dependant
Lung Malformations
Pneumothorax
Acquired Pneumonia
Aspiration Syndromes
PDA
Shock
CHD-Duct Dependant
Lung Malformations
Pneumothorax
Pulmonary
Haemorrhage
< 6 hrs 6-24 hrs > 24 HRS

11. Etiology Based on Gestation and Age Of Onset
Term
TTN
Cong.Pneumonia
Asphyxial Lung
Aspiration Syn
Malformations
Pneumothorax
Rds
Aspiration Syn
Cong.Pneumonia
CHD-duct Dep.
Shock
Lung Malfor.
Pneumothorax
Acquired Pneumonia
Shock
Chd-duct Dependant
Lung Malformations
Pneumothorax
Pulmonary Haemorrhage
< 6 hrs 6-24 hrs > 24 hrs

12. Risk factor Based Approach to
Respiratory Distress
Ask for risk factors Suggestive of
Worsening on bag & mask ventilation CDH, Air Leak
Prolonged labor, difficult labor, assisted
delivery, fetal distress, MSAF
Asphyxia Lung disease, MAS, Birth Injury
Elective Caeserian Section TTNB
Maternal Fever, Foul Liquor, prolonged
labour, multiple PV examinationPPROM,
PROM >12hrs, Assisted Delivery
Congenital pneumonia
No antenatal Steroid to mother, infant of
diabetic mother, Rh Issoimmunisation,
Perinatal Asphyxia
RDS
Polyhydramnios CDH, TEF
Oligohydramnios MAS, Pulmonary Hypoplasia

13. Risk factor Based Approach to
Respiratory Distress
Ask for risk factors Suggestive of
Maternal Hypertension, Preeclampsia Asphyxia, MAS
Placenta Previa or abruption Shock
Family h/o unexplained neonatal deaths,
still births
RDS, IDM, CHD, IEM
Post Feed worsening GERD, Isolated Cleft Palate, TEF, IEM
Relationship with Crying Crying worsens cyanosis (CHD)
Crying relieves cyanosis (Choanal atresia)
Chronic course, O2 dependency BPD, CHD (TAPVC), Atypical
Infection(CMV, Fungus, Chlamydia),
Recurrent aspiration (GER, Pharyngeal
incordination, H shaped TOF), Osteopenia
of Prematurity

14. Physical Assessment
• Sensorium
• Color
• Tone, posture
• Response to touch
• Cry
• Gestation
• Weight
• Vital Parameters (Temp,
HR, RR, BP, SPO2)
• Work of Breathing
(Downe’s or silverman
score)
• Perfusion (HR, Color, core-
axillary temp, CRT, urine
output, BP)
• Danger Signs

15. Systematic Evaluation
SGA MAS, Asphyxia, Polycythemia
LGA Birth Trauma, Asphyxia, Polycythemia,
RDS, CHD, Hypoglycemia
Potter Facies Hypoplastic Lungs
Barrel chest MAS
Large caput or bruises Difficult or prolonged Labour
Frothing at Mouth TEF
Meconium staining MAS
Pallor Anemia, Shock
Plethora Polycythemia
Cyanosis CHD, Severe Luung disease, Shunt,
abnormal Hb, Air Leak

16. Systematic Evaluation
Murmur, Hepatomegaly, cardiomegaly,
abnormal pulses, differential cyanosis
CHD, Shunt
Fever, hypothermia, Cold Stress, Umbilical
sepsis, foul smell, pustules, petechiae,
bleeding tendency, sclerema
Sepsis, pneumonia
Twins Twin to twin transfusion
Inbility to pass orogastric tube TEF
Isolated Cleft palate Aspiration syndrome
Scaphoid abdomen, distal heart sounds,
shift of heart sounds, ipsilateral
decreased air entry
CDH
Absent femorals Coarctation of Aorta
Cardiomegaly CHD, Cardiomyopathy

17. Identifying the Lung pathology
• Isolated Tachypnea: CHD, Metabolic acidosis,
anemia, hypoglycemia, temp instability, renal
failure
• Grunt: Alveolar Lung disease (RDS,
Pneumonia, MAS)
• Stridor: Upper airway obstruction, Laryngo
tracheomalacia
• Cyanosis: CHD, severe lung disease, abnormal
Hb, CNS dysfunction

18. Respiratory vs Cardiac cause
Resp System CVS System
Breathing Retractions Tachypnea
Cardiac evaluation Normal Gallop, weak pulses,
hepatomegaly, absent
femorals
Second Heart Sound Split Single
X ray Chest Parenchymal lesion Abnormal shape, size of
heart
Abnormal pulmonary
vasculature
pCO2 High Low
Pulse Oxymeter Improvement with O2 Not much improvement
with O2, differential
cyanosis
Hyperoxia Test PaO2 >300mmHg rules out
cardiac disease
PaO2 does not rise

19. Clues to congenital Heart Disease
• Cyanosis disproportionate to clinical status
• Differential cyanosis (UL > LL saturation)
• Single S2
• Murmur
• Isolated Hepatomegaly
• Sudden deterioration
• Lack of response to O2
• Cardiomegaly

20. Investigations
• Hb
• RBS
• Sepsis Screen
• Blood Culture
• X ray Chest
• ABG
• Imaging (USG Chest, CT Thorax, MRI Chest, 2D
ECHO)

21. Radiological Signs & Etiology
Radiological Signs Etiology
Low Lung volume RDS, Pulmonary hypoplasia
High Lung Volume MAS, TTNB, Hyperventilation,
Air Bronchogram RDS, Pneumonia
Diffuse parenchymal infiltrates MAS, Pneumonia
Lobar Consolidation Pneumonia, CLE, CCAM
Pleural effusion Pneumonia, pulmonary Lymphagiectasia
Reticular granular pattern RDS, Pneumonia
Hyperinflation MAS, Pulmonary lymphagiectasia
Fluid accumulation in interlobar space TTN, pulmonary Lymphagiectasia
Cystic Mass CCAM, CDH, Pulmonary sequestration
Pneumothorax, pneumomediastinum Spontaneous, MAS, RDS, pneumonia

22. Indicators of Gas Exchange
Alveolar-arterial O2 gradient(A-aDO2)
• PAO2-PaO2 = FIO2 (PBAR – PH2O) – PACO2/RQ-PaO2
• normal range in newborn-5-15
• abnormal -15-40
• Definitely abnormal >40
a/A ratio (Ratio of PaO2 to PAO2)
• >0.8 is normal
• <0.6 –Needs Oxygen Therapy
• <0.15-severe Hypoxemia
Oxygen Index (OI)=(MAP X FiO2)/PaO2
• 25-45-severe Respiratory Failure, mortality risk 50-60%
• >40-mortality risk>80%

23. Initial Management Of A Neonate with Respiratory Distress
Administer O2,attach To Pulse Ox
Maintain Airway In Sniffing Position
,Clear Secretions
Examine For Features Of Respiratory
Distress
Assess Circulation
{skin Color,perfusion,pulses,crt}
PLACE VASCULAR
ACESS,ABG
LOCATE THE
PATHOLOGY,SCORE,
SEND CALL FOR CXR
APPLY SUCTION
TITRATE FIO2 TO
SAO2
SUPPORTIVE MEASURES LIKE
TEMP,SUGAR,FLUID AND ELECTROLYTE

24. Supportive Measures
• Thermal care
• Nursing
• IV Fluids
• Nutrition
• Antibiotics
• Inotropes
• Infection control
• Pain reducing Measures
• Monitoring

25. Preterm <34wks Near Term/Term
EARLY CPAP
IF RDS
SUSPECTED,EARLY
SURFACTANT
CONSIDER SENDING
BLOOD CULTURE
AND START
ANTIBIOTICS
 Poor Respiratory Efforts
 Worsening Shock
 PPHN
 Massive Pulmonary
Haemorrhage
 Malformations(CDH}
 Collapse With Apnea And
Failure To Respond To Bag
And Mask Ventilation
MECHANICAL
VENTILATION
START CPAP
(5-7cm H2O)
• worsening resp
distress
•metaolic
acidosis{ph,7.2
with BE>-10}
•respiratory
acidosis or
worsening ABG
FAILURE OF
CPAP
No
Yes

26. Oxygen therapy
• Judicious use of O2
• Administer appropriate O2 conc by using air-O2
blender or indigenous air-O2 mixing
• Target O2 saturations 90-95%
• Avoid Hypo or Hyperoxia
• Use O2 analyser to check FiO2 when O2 is given
• Set Pulse Oximeter alarms
• Use prewarmed & humidified Oxygen specially at
flow rate >2l/min
• Through nasal canula, nasal prongs,
nasopharyngeal prongs, O2 hoods

27. O2 Delivery Systems
Type Landmark for
depth of
insertion
Recommended
flow
rate(L/min)
FiO2 at
an avg
RFR
Complications Remarks
Nasal
Canula
Nares to inner
margin of eye
brow
1-2 25-45 Crausting,
nasal trauma,
erosion,
inadvertent
PEEP
Alternate between
nares every 12hrs
Nasop
haryng
eal
Canula
Alae nasi to
Tragus
1-2 45-60 Crausting,
nasal trauma,
erosion,
inadvertent
PEEP
Alternate between
nares every 12hrs
Nasal
Prong
1-2 25-45 Crusting,
erosion
Short binasal prongs
recommended
O2
Hood
4 30-70 RFR should be at least
4 times that of minute
vol. Lesser flow rate
risk of CO2 retention

28. SpO2 85-89% Vs 91-95 %
BPD 25%
ROP 50%
Mortality 20%

29. Julius Comroe (1945)
“The clinician must bear in
mind that oxygen is a drug
and must be used in
accordance with well
recognized pharmacologic
principles; i.e., since it has
certain toxic effects and is
not completely harmless (as
widely believed in clinical
circles) it should be given
only in the lowest dosage or
concentration required by
the particular patient.”

30. • In preterm baby receiving O2, the saturation
target should be 90-94%
• To achieve this, suggested alarm limits should
be 89-95%

31. Respiratory Support General Principles
A. The aims of respiratory support are to maintain
adequate oxygenation and ventilation, to reduce
respiratory work and to prevent lung injury.
B. With mechanical ventilation, use small or normal tidal
volumes and the lowest effective ventilator pressures.
Both large tidal volumes and high pressures cause
lung injury and inflammation, especially in preterm
infants.
C. PEEP is critical for maintenance of FRC. PEEP is the
main factor that influences PAW, a major determinant
of oxygenation.

32. Adequacy of Respiratory Support
• Comfortable baby
• Minimal retraction, no grunt
• Normal capillary refill, BP
• Normal saturations: 87% - 93%
• Normal ABG
(PaO2 60-80, PaCO2 40-60, pH 7.35-7.45, BE±2)

33. Modes of Respiratory Support
Non Invasive
• CPAP
• NIV
• HHHFNC
Invasive
• IMV/SIMV
• HFOV

34. The Best Ventilator: Least Lung Injury

35. What’s the Target of Respiratory
Support
• Optimise Oxygenation and Ventilation
• Correct V/Q mismatch
• Comfortable Baby
• Lung Recruitment
• Avoid Lung Hyperinflation & Lung Injury

36. Evidences of hyperinflation
• Lung expansion > 6 ribs anteriorly or > 8 ribs
posteriorly
• Flattening of diaphragms
• Increased lucency of lungs
• Air under the heart or herniation of lung to
other side
• Ribs more horizontal

37. Stable Alveoli

38. Unstable Alveoli

39. HFOV

40. Abnormal Gas Exchange
• Hypoxemia can be
due to:
– hypoventilation
– V/Q mismatch
– shunt
– diffusion
impairments
• Hypercarbia can be
due to:
– hypoventilation
– V/Q mismatch

41. CO2 elimination is determined by
 Recruit maximal alveoli
 Minimize alveolar dead space
No collapse / over-distension
 Minimize external dead space
 Tidal volume
 Reduce resistance & obstruction of airways
 Expiratory time and rates

42. • High CO2 - Cerebral Vasodilation---------------
risk of IVH
• Low CO2 –Cerebral Vasoconstriction----------
risk of PVL

43. Clinical assessment
• Appearance – color, posture, comfort
• Vitals – HR, RR, CRT,SaO2, NIBP, IBP,
• Respiratory – RDS, effort, retractions, alae nasi,
breath sounds, air entry, symmetry, ABG
• Circulatory – HR, CFT, BP, UO
• Abdomen- AG, feeds, orogastric tube, bowel sounds
• Neurological- state, activity, tone, posture, pain relief

44. CPAP
• Application of continuous distending pressure
through out the respiratory cycle in a
spontaneously breathing infant

45. CPAP machine
• Bubble CPAP
• Ventilator CPAP
• Infant Flow Driver

47. Indications of CPAP
• Respiratory distress syndrome
• Transient tachypnoea of
newborn
• Post Extubation
• Apnea of prematurity
• MAS
• Pneumonia
• Laryngo/ Tracheo/Broncho
malacia
• Spontaneously breathing
• Haemodynamically stable
• No upper airway
anomalies
• Not in severe respiratory
failure

48. • CPAP from birth in all babies at risk of RDS
• System delivering CPAP is of little importance,
however the interface should be short binasal
prongs
• CPAP start at 5-6cm H2O and then
individualise depending on clinical condition,
oxygenation and perfusion

49. Contraindications of CPAP
• Progressive respiratory failure and unable to maintain
oxygenation, PaCO2 >60 mm Hg and/or pH 7.25 or less
• Congenital malformations: congenital diaphragmatic
hernia, tracheoesophageal fistula, choanal atresia, cleft
palate, gastroschisis
• Infants with severe cardiovascular instability
(hypotension, poor ventricular function)
• Neonates with poor or unstable respiratory drive
(frequent apnea, bradycardia, and/or oxygenation
desaturation) that is not improved by CPAP

51. DEVICE ADVANTAGE DISADVANTAGE
Ventilator
CPAP
• No need of a separate equipment
•Can be easily switched over to
Mechanical ventilation, if CPAP fails
• Expensive
• Standard flow of 5-8L/ min may be
insufficient in the presence of high
leak
• Difficult to know if the set flow is
sufficient or not (insufficient flow can
lead to increased WOB)
Bubble CPAP • Simple and inexpensive
• Oscillations produced by
continuous bubbling might
contribute to gas exchange (akin to
HFV)
• Can identify large leaks at the
nares
(bubbling stops)
• Flow has to be altered to ensure
proper
bubbling
• It is difficult to detect high flow
which can ead to over distension of
the lungs
Variable Flow
Device
• Maintains more uniform pressure
•Might decrease the WOB
• Recruits lung volume more
effectively
• Expensive
• Requires more technical expertise

52. Flow, PEEP and FiO2• PEEP
– 5 cms
– Chest recessions, air entry, CXR
• FiO2 50%
• Flow
– 2 to 5 liters
– Minimum to ensure continuous bubbling
– High flow- check for leaks (open mouth)
Rule of 5

53. How do we know when to change CPAP
pressure?
• Clinical signs only – little research
1. Observe grunting / chest wall retraction
– If obvious ? need more pressure
2. How much oxygen?
– - high FiO2 ? Need more pressure
3. Observe the chest x-ray
• - very granular ? Need more pressure
– May need pressures > 5 cm H2O

54. Methods of weaning preterm babies <30 weeks gestation off CPAP:
a multicentre randomized controlled trial
Stability criteria( all 8 criteria for > 12hrs) Criteria for failed Trial Off (at least 2 of
Following)• CPAP 4-6cm H2O
• O2 requirement < 25% and not
increasing
• RR < 60
• No significant chest recession
( sternal/diaphragmatic)
• <3 episodes of self reverting
apneas/bradycardia/desaturation
s in 1hr for previous 6hrs
• Avg SpO2 > 86% most of time or
PaO2/TcPO2 >45mm Hg
• Not currently treated for
PDA/Sepsis
• Tolerated time off CPAP during
cares up to 15min
• Increase work of breathing
with RR> 75
• Increased
apnoea/bradycardia/desaturat
ions > 2 in 1 hr for previous
6hr period
• Increase O2 requirement >
25% to maintain SpO2 >86%
and/or PaO2/TcPO2 >45mm
Hg
• PH < 7.2
• PaCO2/ Tc PcO2 > 65 mm Hg
• Major apnea/ bradycardia
requiring Resuscitation
Arch Dis Child Fetal Neonatal Ed July 2012 Vol 97 No 4

55. When has CPAP failed?
• Apnoea
• Respiratory failure =
PaCO2 rising >60 mmHg
(pH<7.20)
• Or FiO2 is rising above
??? 60%
• Worsening of respiratory
distress
• Agitation not relieved by
simple measures
But only after you have
checked
– The prongs are in the nose
– They are the right size
– The nose has been cleared
– Place baby prone
– The mouth is closed
– The neck slightly extended
– You have tried higher
pressures (?? ~ 10 cm H2O
or more.)

56. HHHFNC
(F&P)

57. HHHFNC oxygen therapy: definition
Optimally warmed and humidified respiratory gases
delivered by nasal cannula at flow rates between 2
and 8 L/min.

58. Mechanism of action
• Reduce dead space
making minute
ventilation more
efficient.
Dead space
washout
• Exceeds inspiratory
flow thus
eliminating nasal
resistance.
Reduce
inspiratory work
of breathing
• Warmed,
humidified gas has
been shown to
improve lung
compliance.
Improved lung
mechanics
• Attenuates the
energy and water
loss associated with
conditioning
inspiratory gas.
Decreases
metabolic work
• Flow generates
some positive
distending pressure,
It can be helpful in
lung recruitment.
Provision of mild
distending
pressure
• Ideal humidification
of the inspired gas
has been shown to
restore mucocilliary
function.
Improve
secretion
mobilization

59. Clinical use of HHHFNC
As a mode of
weaning from
ventilation/NCPAP
support
Alternative to
NCPAP in
mild/moderate
respiratory distress
Treatment or
prevention of
apnoea of
prematurity
Babies with nasal
trauma from
NCPAP
Infants with
Chronic Lung
Disease
Supportive growth
optimisation???

60. How to use HHHFNC

61. Recommended Guidelines for Intubation From Optimized
Noninvasive Respiratory Support with nCPAP or HHFNC
Support
Apnea
• Apnea despite 30 seconds of PPV
• Heart rate ,100 beats per minute and not increasing
despite 30 seconds of PPV
• Frequent or severe apnea and bradycardia
• More than 1 apnea event per 12-hour period requiring
PPV
Cardiovascular collapse
• Heart rate <60 beats per minute
• Shock
Pediatrics 2013;131:e1482–e1490

62. Recommended Guidelines for Intubation From Optimized
Noninvasive Respiratory Support with nCPAP or HHFNC Support
Marked respiratory distress
• Persistent marked/severe retractions
• Suspected airway obstruction (despite adequate suctioning)
High O2 requirement
• FIO2 .0.6 to maintain SpO2 >88%
ABG
• Severe metabolic acidosis (arterial base deficit > -10)
• Severe respiratory acidosis (arterial pCO2 >65 mm Hg)
Pediatrics 2013;131:e1482–e1490

63. Invasive Ventilation
Disease PIP PEEP Ti Frequency Flow
RDS 16-18 5-6 0.3-0.35 60 7-8
Pneumonia 14-16 3-4 0.35-0.4 50-60 6-8
MAS 14-16 3-4 0.35-0.4 40-50 5-7
Apnea 12-14 3 0.35 20-30 5-6
Air leak 14-16 3 0.3-0.35 60 5-6
BPD 15-20 4-5 0.4-0.7 20-40 5-6

64. Adjustments
• To affect
oxygenation, adjust:
–FiO2
–PEEP
–I time
–PIP
• To affect
ventilation, adjust:
–Respiratory Rate
–Tidal Volume

65. Weaning from Invasive Ventilation
• Clinically & Hemodynamically stable
• Effective respiratory efforts
• Basic Lung pathology/disease improving
• Associated illnesses (active Sepsis, PDA)
improving
• Optimum blood gases
• Principle of weaning ( decrease the most harmful
parameter first, limit change to one parameter at
a time, avoid changes of a large magnitude)

66. High Frequency Ventilation
• Indications
• Failure of conventional ventilation (high PIP
requirement 22-25 in preterm, 25-28 in term
to maintain normal blood gases in conditions
including HMD, Pneumonia, MAS, Pulmonary
Hypoplasia)
• Air Leak
• PPHN not responding to conventional
ventilation

67. Surfactant therapy
• Prophylactic therapy
a. Neonates with gestation less than 30 weeks of gestation
b. Surfactant given within 15 minutes of birth before a
diagnosis of RDS is made
• Early Rescue therapy
a. Neonate with RDS (confirmed clinically ,radiologically).
b. Surfactant given within first 2 hours of life
• Late Rescue therapy
a. Neonate with RDS and requiring ventilation with a MAP
of at least 8cms of water and/or an FiO2 > 30% or
(a/A ratio < 0.22)
b. Surfactant given after 2 hours of birth

68. Before Surfactant 1 hr after Surfactant
SURFACTANT Therapy

69. Surfactant use
1. Prophylactic therapy
a. Neonates with gestation less than 30 weeks of gestation
b. Surfactant given within 15 minutes of birth before a
diagnosis of RDS is made
2. Early Rescue therapy
a. Neonate with RDS (confirmed clinically ,radiologically).
b. Surfactant given within first 2 hours of life
3. Late Rescue therapy
a. Neonate with RDS and requiring ventilation with a MAP of
at least 8cms of water and/or an FiO2 > 30% or (a/A ratio <
0.22)
b. Surfactant given after 2 hours of birth

70. Exogenous Surfactants in use Worldwide
I. Organic solvent extracts of Minced animal lung tissue:
Bovine: Surfactant-TA, Survanta
Porcine: Curosurf, HL-10
Goat surfactant
II. Organic solvent extracts of Lavaged animal lung surf:
Alveofact (SF-R1-1), BLES, Infasurf
III. Synthetic (protein-free):
ALEC, Exosurf
IV. Peptide-containing synthetic:
Surfaxin (KL-4)
V. Surfactant with Recombinant apoproteins:
Recombinant SP-C surfactant (Venticute)

71. Types of natural surfactant
name source Phospholipid
(mg/ml)
protein Dose
(mg/kg)
Dose
vol(ml/kg)
Survanta
(beractant)
bovine 25 (DPPC50%) SP B,SP C 100 4
Infasurf
(calfactant)
bovine 35 (DPPC74%) SP B,SP C 100 3
Curosurf
(poractant
alfa)
Porcine 80
(DPPC70%)
SP B,SP C 100-200 1.25-2.5
Alveofact
(bovactant)
bovine 50 SP B,SP C 50-100 1-2
BLES
(bovine lipid
extract
surfactant)
NEOSURF
bovine 27 SP B,SP C 135 5

72. Types of synthetic surfactant
Trade name preparation protein Phosphplipid
conc mg/ml
Dose ml/kg
Exosurf DPPC 9%
hexadecanol,6
% tyloxapol
no 13.5 5
Surfact DPPC no 13.5 5
pumactant DPPC,PG no 40 1.2
surfaxin
Trade name preparation protein Phosphplipid
conc mg/ml
Dose ml/kg
Exosurf DPPC 9%
hexadecanol,6
% tyloxapol
no 13.5 5
Surfact DPPC no 13.5 5
pumactant DPPC,PG no 40 1.2
Surfaxin
(lucinactant)
DPPC,POPG Kl 4 peptide as
SP B
(sinapultide)
30 5.8
venticute DPPC,POPG r SP C 50 Not studied in
neonates

73. Technique of administration
• INSURE
• LISA or MIST

74. Surfactant in other conditions
• Meconium aspiration syndrome
– Bolus
– Lavage - better improvement in oxygenation in
some studies
• Neonatal bacterial pneumonia -? Role
• Pulmonary hemorrhage
• Congenital diaphragmatic hernia – no benefit
• Chronic lung disease
Expanded Use of Surfactant Therapyin NewbornsThierry Lacaze-
Masmonteil.
Clin Perinatol 34 (2007) 179–189.

75. Surfactants
• 2 types - synthetic & natural
• Natural > synthetic
• Prophylactic strategy > rescue
• Early rescue > late rescue
• Multiple doses > single dose
• ANCS + surfactant > either alone
• Useful in MAS
• Newer surfactants are being evaluated

76. Supportive Management
• Bronchodilation
• Chest Physiotherapy
• Sedation & Analgesia
• Nutritional Support

77. Summary
• Quantify Respiratory Distress
• Judicious O2 use
• Target O2 saturation 90-94%
• Lung Recruitment
• Avoid Ventilation Induced Lung Injury
• Supportive Care

78. THANK YOU