Question of the Week

Question :
Posted On : 13 Feb 2020
Q a 1.2 kg born at 30 wks develops moderate respiratory distress with chest retractions and grunting 6 hrs after birth. What is d next logical step?
a}warm humidified oxygen
b}nasal cpap
c}surfactant and ventilation
d}mechanical ventilation

Very confused between b and c. because according to cloherty`s manual indication of CPAP is mild res. distress and for starting surfactant we need other criteria like Fio2 which whr not mentioned in dis question. Should we start surfactant for this children? which develops after 6 hrs of birth.
Expert Answer :
The most probable diagnosis in this case scenario seems to be Respiratory Distress Syndrome due to Hyaline Membrane Disease. A chest X-ray would be helpful here.
Among the options listed, warm humidified oxygen will not help and is not recommended.
The decision to administer surfactant depends on the clinical condition and oxygen requirement to maintain the SpO2 in the range of 87-93 percent.
In my opinion, this baby should be started on nasal CPAP {either bubble CPAP or by normal ventilator through a nasopharyngeal tube} with a CPAP setting of 6 cm of H2O and gradually adjust FiO2 up to ~50 percent as per requirement. If one is in an experienced setting, upto 60 percent FiO2 can be accepted.
If the baby`s SpO2 is not maintained with upto 50-60 percent of FiO2 in the range mentioned above, I would intubate the baby and put on a mechanical ventilator followed by surfactant therapy. This should be followed with a steady and rapid reduction in the FiO2 settings and early weaning of the PIP settings depending upon the tidal volume that the baby is receiving which should be ~ 5 ml, kg and not exceeding 6 ml, kg so as to avoid volutrauma. A volume guarantee {VG} function in the ventilator if available can be helpful to steadily bring down the PIP setting automatically. The aim should be to extubate the baby to nasal CPAP as soon as possible after the surfactant provided the required settings have reduced significantly and a repeat CXR after ~ 6 - 8 hours of the surfactant shows good aeration of the lung fields. A blood gas analysis atleast every 8 hours on day 1 and 2 is usually required to assess the ventilation status.
Only mechanical ventilation without surfactant is no longer recommended as this will only prolong ventilation and predispose to ventilator associated lung injury {VLI} which can then lead to chronic lung disease.
Answer Discussion :
Rutul Patel
In my opinion , first you have to put on CPAP and see distress ..if oxygen requirement increase more than 30-40 % than give surfactant by INSURE mothod if baby otherwise stable.
4 years ago
masoud nawzadi
we moslty do b
4 years ago
Veron Yala
I work in a rural area whereby we have limited resources. In this situation, with this Preterm baby having respiratory distress, I always use a nasal CPAP
4 years ago
Dee Johnson
surfactant and ventilation
4 years ago
Ahmed Yaseen
Surfactant and ventilation
4 years ago

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