European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update

Recommendations

• 1Mothers at high risk of preterm birth <28–30 weeks of gestation should be transferred to perinatal centres with experience in management of RDSB1
• 2In women with a singleton pregnancy and a short cervix in mid-pregnancy or previous preterm birth, vaginal progesterone treatment should be used to increase gestational age at delivery and reduce perinatal mortality and morbidityA1
• 3In women with symptoms of preterm labour, cervical length and accurate biomarker measurements should be considered to prevent unnecessary use of tocolytic drugs and/or antenatal steroidsB2
• 4Clinicians should offer a single course of prenatal corticosteroids to all women at high risk of preterm delivery, from when pregnancy is considered potentially viable up to 34 completed weeks of gestation, ideally at least 24 h before birthA1
• 5A single repeat course of steroids may be given in threatened preterm birth before 32 weeks of gestation if the first course was administered at least 1–2 weeks earlierA2
• 6MgSO4 should be administered to women with imminent delivery before 32 weeks of gestationA1
• 7Clinicians should consider short-term use of tocolytic drugs in very preterm pregnancies to allow completion of a course of prenatal corticosteroids and/or in utero transfer to a perinatal centreB1
• 1If clinical condition allows, defer clamping the umbilical cord for at least 60 s (A1). Only when DCC is not feasible, consider umbilical cord milking in infants with GA >28 weeksB2
• 2T-piece devices should be used rather than bag and maskB1
• 3Spontaneously breathing preterm infants should be stabilised using CPAP (A1). If apnoeic or bradycardic, start giving ventilation breaths. Expert consensus is to start with CPAP pressure at least 6 cm H2O and peak inspiratory pressures 20–25 cm H2OD2
• 4Oxygen for resuscitation should be controlled using a blender. Use an initial FiO2 of 0.30 for babies <28 weeks of gestation and 0.21–0.30 for those 28–31 weeks, 0.21 for 32 weeks of gestation and above. FiO2 adjustments up or down should be guided by pulse oximetry (B2). SpO2 of 80% or more (and heart rate >100/min) should be achieved within 5 minC2
• 5Intubation should be reserved for babies not responding to positive pressure ventilation via face mask or nasal prongsA1
• 6Plastic bags or occlusive wrapping under radiant warmers and humidified gas should be used during stabilisation for babies <32 weeks of gestation to reduce the risk of hypothermia. Hyperthermia should also be avoidedA1
• 1If a preterm baby <30 weeks of gestation requires intubation for stabilisation, they should be given surfactantA2
• 2Babies with RDS needing treatment should be given an animal-derived surfactant preparationA1
• 3LISA is the preferred method of surfactant administration for spontaneously breathing babies on CPAPA1
• 4Laryngeal mask surfactant may be used for more mature infants >1.0 kgB2
• 5An initial dose of 200 mg/kg of poractant alfa is better than 100 mg/kg of poractant alfa or 100 mg/kg beractant for rescue therapyA1
• 6Rescue surfactant should be given early in the course of the disease (A1). Suggested protocol would be to treat worsening babies with RDS when FiO2 > 0.30 on CPAP pressure ≥6 cm H2O or if lung ultrasound suggests surfactant needB2
• 7A 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 excludedA1
• 1In preterm babies receiving oxygen, the saturation target should be between 90 and 94%B2
• 2Alarm limits should be set to 89% and 95%D2
• 3Protocols for screening and treating preterm babies for ROP should be in placeA1
• 1CPAP or (s)NIPPV should be started from birth in all babies at risk of RDS, such as those <30 weeks of gestation who do not need intubation for stabilisationA1
• 2NIV with early rescue surfactant by LISA technique is considered optimal management for babies with RDSA1
• 3The 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 (A2). Ability to escalate to NIPPV will reduce the need for invasive MV in some infantsA1
• 4BIPAP devices confer no advantage over CPAP alone (A2). However, synchronised NIPPV, if delivered through a ventilator, can reduce need for ventilation or need for re-ventilation following extubation and may reduce BPDA2
• 5HFNC can be used as an alternative to CPAP for some babies, with the advantage of less nasal trauma, provided centres have access to CPAP or NIPPV for those failing this modeB2
• 1MV should be used in babies with RDS when other methods of respiratory support have failed (A1). Duration of MV should be minimisedB2
• 2Lung-protective modes such as VTV or high-frequency oscillation ventilation should be the first choice for babies with RDS who require MVA1
• 3When weaning from MV, it is reasonable to tolerate a modest degree of hypercarbia, provided the pH remains above 7.22 (B2). Avoid pCO2 < 4.7 kPa (35 mm Hg) when on MV to reduce brain injuryC1
• 5INO in preterm babies should be limited to a therapeutic trial for those in whom there is documented pulmonary hypertension with severe respiratory distress and stopped if there is no responseD2
• 4Caffeine (20 mg/kg loading, 5–10 mg/kg maintenance) should be used to facilitate weaning from MV (A1). Early caffeine can be considered for babies at high risk of needing MV such as preterm babies on NIVC1
• 5A short tapering course of low-dose dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1–2 weeksA2
• 6Opioids should be used selectively when indicated by clinical judgement and evaluation of pain indicators (D1). The routine use of morphine or midazolam infusions in ventilated preterm infants is not recommendedA1
• 1Core temperature should be maintained between 36.5°C and 37.5°C at all timesC1
• 2Most 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 (C2). Fluids must be tailored individually according to serum sodium levels, urine output, and weight lossD1
• 3Parenteral nutrition should be started from birth. Amino acids 1.5–2 g/kg/d should be started from day 1 and quickly built up to 2.5–3.5 g/kg/d (B2). Lipids 1–2 g/kg/d should be started from day 1 and quickly built up to 4.0 g/kg/day as toleratedC2
• 4Enteral feeding with mother's milk should be started from the first day if the baby is hemodynamically stableB2
• 5In infants with RDS, antibiotics should be used judiciously and stopped early when sepsis is ruled outD1
• 1Treatment of hypotension is recommended when there is evidence of poor tissue perfusion such as oliguria, acidosis, and poor capillary refill (C2). Treatment will depend on the cause.
• 2When a decision is made to attempt pharmacologic closure of hemodynamically significant PDA, indomethacin, ibuprofen, or paracetamol can be used with a similar efficacy (A2). Paracetamol is preferred when there is thrombocytopaenia or concerns about renal functionB2
• 3Thresholds for red blood cell transfusion in infants can be set at 12 g/dL (HCT 36%) for those with severe cardiorespiratory disease, 11 g/dL (HCT 30%) for those who are oxygen dependent, and 7 g/dL (HCT 25%) for stable infants beyond 2 weeks of ageA2
• Surfactant can be used for RDS complicated by congenital pneumoniaC2
• Surfactant therapy can improve oxygenation following pulmonary haemorrhageC1
• Surfactant can improve oxygenation in infants with severe meconium aspiration syndromeB2