Management Of Respiratory Distress Syndrome Research Articles

Vayu bubble continuous positive airway pressure is a promising solution with favorable treatment outcomes for respiratory distress syndrome in newborns: a qualitative study in Bangladesh.

According to Bangladesh Demographic and Health Survey (2022), neonatal mortality, comprising 67% of under-5 deaths in Bangladesh, is significantly attributed to prematurity and low birth weight (LBW), accounting for 32% of neonatal deaths. Respiratory distress syndrome (RDS) is a prevalent concern among preterm and LBW infants, leading to substantial mortality. The World Health Organization (WHO) recommends bubble continuous positive airway pressure (bCPAP) therapy, but the affordability and accessibility of conventional bCPAP devices for a large number of patients become major hurdles in Bangladesh due to high costs and resource intensiveness. The Vayu bCPAP, a simple and portable alternative, offers a constant flow of oxygen-enriched, filtered, humidified, and pressurized air. Our study, conducted in five health facilities, explores the useability, acceptability, and perceived treatment outcome of Vayu bCPAP in the local context of Bangladesh. A qualitative approach was employed in special care newborn units (SCANUs) of selected facilities from January to March 2023. Purposive sampling identified nine key informants, 40 in-depth interviews with service providers, and 10 focus group discussions. Data collection and analysis utilized a thematic framework approach led by trained anthropologists and medical officers. Service providers acknowledged Vayu bCPAP as a lightweight, easily movable, and cost-effective device requiring minimal training. Despite challenges such as consumable shortages and maintenance issues, providers perceived the device as user-friendly, operable with oxygen cylinders, and beneficial during referral transportation. Treatment outcomes indicated effective RDS management, reduced hospital stays, and decreased referrals. Though challenges existed, healthcare providers and facility managers expressed enthusiasm for Vayu bCPAP due to its potential to simplify advanced neonatal care delivery. The Vayu bCPAP device demonstrated useability, acceptability, and favorable treatment outcomes in the care of neonates with RDS. However, sustained quality service necessitates continuous monitoring, mentoring and retention of knowledge and skills. Despite challenges, the enthusiasm among healthcare providers underscores the potential of Vayu bCPAP to save lives and simplify neonatal care delivery. Development of Standard Operating procedure on Vayu bCPAP is required for systematic implementation. Further research is needed to determine how the utilization of Vayu bCPAP devices enhances accessibility to efficient bCPAP therapy for neonates experiencing RDS.

Respiratory distress syndrome is associated with increased morbidity and mortality in late preterm births

Respiratory Distress Syndrome (RDS) is strongly associated with prematurity, including late preterm births. RDS has been shown to be associated with certain neonatal morbidities and mortality, but these associations are not well described among late preterm births. We sought to determine the association between RDS and adverse neonatal outcomes among late preterm (34-36 weeks) born singleton neonates. This is a retrospective cohort study using California's linked vital statistics-patient discharge data (2008-2019). We included singleton, non-anomalous births with gestational age of 34-36 weeks. Outcomes of interest were interventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), neonatal sepsis, length of hospital stay, neonatal death and infant death. Chi-square and multivariable Poisson regression analyses were used to examine the association of RDS with outcomes at each gestational age. Adjusted risk ratios (aRR) and 95% confidence intervals (CI) were estimated. A total of 242,827 births were included, of which 11,312 (4.7%) had RDS. We found that among neonates with RDS, NEC was higher at 35 weeks (aRR= 3.97; 95% CI: 1.88, 8.41) and 36 weeks (aRR= 4.53; 95% CI: 1.45, 14.13). IVH, ROP, neonatal sepsis and length of hospital stay were significantly higher at 34-36 weeks' gestation in neonates with RDS. Neonatal death was significantly higher among neonates with RDS at 35 weeks (aRR=3.04; 95% CI: 1.58, 5.85) and 36 weeks (aRR=3.25; 95% CI: 1.59, 6.68). Infant death was also significantly higher at 35 weeks (aRR=2.27; 95% CI: 1.43, 3.61) and 36 weeks (aRR=2.60; 95% CI: 1.58, 4.28). We found that RDS was associated with IVH, ROP and sepsis at 34-36 weeks' gestation; while RDS was associated with neonatal death, infant death and NEC at 35 and 36 weeks. Clinicians should keep these outcomes in mind when making decisions about delivery timing and the potential benefits of antenatal steroids in pregnancies in the late preterm period as well as management of RDS in late preterm neonates.

Updated Clinical Practice Guidelines in Resuscitation and the Management of Respiratory Distress Syndrome in Extremely Preterm Infants during Two Epochs in Romania: Impact on Outcomes.

Adequate perinatal management is essential in caring for extremely preterm (EP) infants. We aimed to evaluate and compare the impact of different protocols on short-term outcomes. A retrospective study was conducted on EP infants in a Romanian perinatal tertiary center during 2008-2012 and 2018-2022. Data on 270 EP infants (121 in period I, 149 in period II) were analyzed collectively and stratified into two subgroups by gestational age. Initial FiO2 administration (100% vs. 40%% p < 0.001), lung recruitment at birth (19.0% vs. 55.7% p < 0.001), early rescue surfactant administration (34.7% vs. 65.8%; p < 0.001), and the mechanical ventilation rate (98.3% vs. 58.4%; p < 0.001) were significantly improved during period II. Survival rates of EP infants significantly improved from 41.3% to 72.5%, particularly in the 26-28 weeks subgroup (63.8% to 83%). Compared to period I, the overall frequency of severe IVH decreased in period II from 30.6% to 14.1%; also, BPD rates were lower (36.6% vs. 23.4%; p = 0.045) in the 26-28 weeks subgroup. Despite improvements, there were no significant differences in the frequencies of NEC, sepsis, PVL, ROP, or PDA. Implementing evidence-based clinical guidelines can improve short-term outcomes.

A Survey of the Union of European Neonatal and Perinatal Societies on Neonatal Respiratory Care in Neonatal Intensive Care Units.

(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO2 is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO2 and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO2 and SpO2/FiO2 ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.

Preterm Birth: A Review of Its Early Diagnosis and Prevention

Preterm birth, a major global healthcare concern, is characterized by infants being born before completing 37 weeks of gestation. Accurate diagnosis and effective interventions are critical to managing this complex issue. This abstract provides an overview of the diagnosis and prevention of preterm birth, focusing on risk assessment, diagnostic techniques, and various interventions for mothers and newborns. The diagnostic process involves evaluating risk factors, clinical history, and the assessment of potential membrane rupture. Techniques such as speculum examination, the Nitrazine test, the Fern test, ultrasonography, and the Placental Alpha Microglobulin-1 test play vital roles in identifying membrane rupture and infection. Additional diagnostic markers include cervical ultrasonography and fetal fibronectin testing. Prevention strategies include lifestyle changes, maternal therapies, and antenatal interventions. Smoking cessation programs, low-dose aspirin, antenatal corticosteroid therapy, progesterone supplementation, magnesium sulfate, and antibiotic treatment are employed to reduce the risk of preterm birth. Cervical cerclage, another surgical intervention, is recommended in specific cases.&#x0D; For preterm newborns, immediate and effective care is vital. This includes thermal care, early breastfeeding, infection prevention, and respiratory distress syndrome management. These interventions are crucial in reducing infant mortality and morbidity associated with preterm birth. Efforts to diagnose and prevent preterm birth are essential in improving the well-being of both mothers and their newborns. A comprehensive approach, combining accurate diagnosis and effective interventions, can make a significant impact in reducing the burden of preterm birth on healthcare systems and families.&#x0D; Keywords: Preterm birth, infants, gestation, potential membrane rupture

European Consensus Guidelines on the Management of Respiratory Distress Syndrome, 2022 : What is New?

European Consensus Guidelines on the Management of Respiratory Distress Syndrome, 2022 : What is New?

Management of Respiratory Distress Syndrome: Clinical Implications from Recent European Consensus Guidelines

Respiratory distress syndrome (RDS) is the most common major morbidity in preterm infants. The recent 6th edition of European consensus guidelines (2023) on RDS gives comprehensive care pathways for management of this vulnerable population based on updated evidence until the end of 2022. The current update also aims to highlight the major updates from the previous version (2019) and to compare the surfactant and non-invasive respiratory support guidelines from the National Neonatology Forum, India.

Lung UltrasouNd Guided surfactant therapy in preterm infants: an international multicenter randomized control trial (LUNG study)

BackgroundThe management of respiratory distress syndrome (RDS) in premature newborns is based on different types of non-invasive respiratory support and on surfactant replacement therapy (SRT) to avoid mechanical ventilation as it may eventually result in lung damage. European guidelines currently recommend SRT only when the fraction of inspired oxygen (FiO2) exceeds 0.30. The literature describes that early SRT decreases the risk of bronchopulmonary dysplasia (BPD) and mortality. Lung ultrasound score (LUS) in preterm infants affected by RDS has proven to be able to predict the need for SRT and different single-center studies have shown that LUS may increase the proportion of infants that received early SRT.Therefore, the aim of this study is to determine if the use of LUS as a decision tool for SRT in preterm infants affected by RDS allows for the reduction of the incidence of BPD or death in the study group.Methods/designIn this study, 668 spontaneously-breathing preterm infants, born at 25+0 to 29+6 weeks’ gestation, in nasal continuous positive airway pressure (nCPAP) will be randomized to receive SRT only when the FiO2 cut-off exceeds 0.3 (control group) or if the LUS score is higher than 8 or the FiO2 requirements exceed 0.3 (study group) (334 infants per arm). The primary outcome will be the difference in proportion of infants with BPD or death in the study group managed compared to the control group.DiscussionBased on previous published studies, it seems that LUS may decrease the time to administer surfactant therapy. It is known that early surfactant administration decreases BPD and mortality. Therefore, there is rationale for hypothesizing a reduction in BPD or death in the group of patients in which the decision to administer exogenous surfactant is based on lung ultrasound scores.Trial registrationClinicalTrials.gov identifier NCT05198375. Registered on 20 January 2022.

Bocavirus and rotavirus co-infection in children with acute gastroenteritis and associated risk factors

Background: Both Viruses are the leading cause of acute gastroenteritis in infants and young children and are considered an important cause of mortality worldwide.   &#x0D; Objective: To estimate the rate of human bocavirus and rotavirus co-infection in children with acute gastroenteritis and determine any association with different risk factors.&#x0D; Patients and Methods: Stool samples were collected from one hundred children suffering from acute gastroenteritis at the Central Teaching Hospital of Pediatrics, Baghdad, Iraq, for the period from December 2021 to April 2022. Samples were stored at -20 °C until they were utilized by PCR and ELISA to identify the human bocavirus (HBoV) DNA and rotavirus antigen (RV-Ag), respectively.&#x0D; Results: This cross-sectional study showed that HBoV DNA was detected in 10 out of 100 samples (10%), while RV-Ag was detected in 22 out of 93 samples (23.66%), and the co-infection rate was 100% (All cases positive for HBoV were also positive for RV). None of the studied demographic data and risk factors showed a significant association with HBoV and/or rotavirus infection (P&gt;0.05).&#x0D; Conclusion: Most NICU deaths resulted from prematurity and respiratory distress syndrome. Enhancing healthcare personnel skills, standardizing protocols, and evidence-based practices for preterm and respiratory distress syndrome management can help reduce neonatal mortality rates in Iraq.

Bocavirus and rotavirus co-infection in children with acute gastroenteritis and associated risk factors

Background: Both Viruses are the leading cause of acute gastroenteritis in infants and young children and are considered an important cause of mortality worldwide. Objective: To estimate the rate of human bocavirus and rotavirus co-infection in children with acute gastroenteritis and determine any association with different risk factors. Patients and Methods: Stool samples were collected from one hundred children suffering from acute gastroenteritis at the Central Teaching Hospital of Pediatrics, Baghdad, Iraq, for the period from December 2021 to April 2022. Samples were stored at -20 °C until they were utilized by PCR and ELISA to identify the human bocavirus (HBoV) DNA and rotavirus antigen (RV-Ag), respectively. Results: This cross-sectional study showed that HBoV DNA was detected in 10 out of 100 samples (10%), while RV-Ag was detected in 22 out of 93 samples (23.66%), and the co-infection rate was 100% (All cases positive for HBoV were also positive for RV). None of the studied demographic data and risk factors showed a significant association with HBoV and/or rotavirus infection (P&gt;0.05). Conclusion: Most NICU deaths resulted from prematurity and respiratory distress syndrome. Enhancing healthcare personnel skills, standardizing protocols, and evidence-based practices for preterm and respiratory distress syndrome management can help reduce neonatal mortality rates in Iraq. Keywords: Human bocavirus, rotavirus, acute gastroenteritis, risk factors, co-infection

Feasibility, safety and efficacy of COVID-19 severe acute respiratory distress syndrome management without invasive mechanical ventilation.

COVID-19 acute respiratory distress syndrome (ARDS) is often managed with mechanical ventilation (MV), requiring sedation and paralysis, with associated risk of complications. There is limited evidence on the use of high flow nasal cannula (HFNC). We hypothesized that management of COVID-19 ARDS without MV is feasible. Included were all adult patients diagnosed with COVID-19 ARDS, with PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 at admission, and whose management was initially performed without MV. We evaluated need for intubation during ICU stay, mortality and hospital/ICU length of stay (LOS). Out of 118 patients, 41 were managed only with HFNC from hospital admission (and at least during first 24 hours in ICU) and had a PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 (72.9±13.0). 29/41 patients never required MV: 24 of them survived and were discharged home. Their median ICU LOS was 11 (7-17) days, and their hospital LOS was 29 (18-45) days. We identified PaO<inf>2</inf>/FiO<inf>2</inf> ratio at ICU admission as the only significant predictor for need for MV during ICU stay. We also identified age, length of non-invasive respiratory support before ICU admission, mean value of PaO<inf>2</inf>/FiO<inf>2</inf> ratio during first half and whole ICU stay as predictors of mortality. It is safe to monitor in ICU and use HFNC in patients affected by COVID-19 ARDS who initially present data suggesting an early need for intubation. The 41 patients admitted with a PaO<inf>2</inf>/FiO<inf>2</inf> ratio <100 and initially treated only with HFNC show a 22% mortality that is in the lower range of what is reported in recent literature.

[Interpretation of the key updates in the 2022 European guideline on the management of neonatal respiratory distress syndrome].

With the deepening of clinical research, the management of neonatal respiratory distress syndrome (RDS) needs to be optimized and improved. This article aims to introduce the 2022 European guideline on the management of neonatal RDS, focusing on its key updates. The guide has optimized the management of risk prediction for preterm birth, maternal referral, application of prenatal corticosteroids, application of lung protective ventilation strategies, and general care for infants with RDS. The guideline is mainly applicable to the management of RDS in neonates with gestational age greater than 24 weeks.

Reverse diastolic flow of the fetal middle cerebral artery associated with placental chorangiomatosis and asymptomatic concealed placental abruption

Reverse diastolic flow of the fetal middle cerebral artery is a rare, yet ominous finding which has been associated with adverse perinatal outcomes including: intracranial hemorrhage, growth restriction, fetal-maternal hemorrhage, severe anemia, hydrops, hepatic anomaly, subsequent stillbirth, and early neonatal death. We report a case in which following notation of a nonreassuring fetal heart rate at 32 weeks' gestation, sonographic documentation of persistent reverse diastolic flow of the fetal middle cerebral artery was noted in association with sonographic findings of vascular placental dysmorphology and an asymptomatic concealed placental abruption. Subsequent fetal heart rate tracing consistent with uteroplacental insufficiency led to immediate Cesarean birth of an anemic yet nonacidotic, nonhypoxic neonate, who did well following management of respiratory distress syndrome and partial exchange transfusion. Placental abruption was confirmed at delivery. Histopathology of the placenta confirmed the presence of localized chorangiomatosis ("wandering" chorangioma). The association of reverse diastolic flow of the fetal middle cerebral artery, placental chorangiomatosis and placental abruption has not been reported previously. We conclude that in the presence of prenatal sonographic findings of placental dysmorphology and or placental abruption, insonation of the fetal middle cerebral artery should be performed to assess the possibility of increased peak systolic velocity and possible reverse diastolic flow, both associated with fetal anemia and increased likelihood of an adverse perinatal outcome.

[Trends in the management of respiratory distress syndrome in very preterm infants transferred to the Clinical Center of the University of Debrecen].

Although in utero transport is recommended in the case of threatening preterm delivery, it is not always possible. Management during postnatal transport may influence neonatal outcomes. The aim of this study was to investigate the trends in patient characteristics, respiratory management and outcomes in very preterm infants requiring postnatal transfer between 2008 and 2021. We conducted a retrospective study. Data were collected from both written and electronic medical records. Trends were assessed using joinpoint regression analysis and summarized as annual percentage changes (APC). A total of 177 infants were included. The number of transfers per year showed non-significant increase over time (APC = 6.8%, p = 0.087). The proportion of time above 60 minutes for care provided by the transport team at the referral site significantly increased (APC = 7.4%, p = 0.016). Between 2008 and 2010, the use of mechanical ventilation during transports increased (APC = 36.4%, p = 0.578), then it showed a decreasing trend during the rest of the study period (APC = -7.2%, p = 0.068). The use of oxygen concentrations above 40% significantly decreased (APC = -9.5%, p = 0.043). The proportion of surfactant doses less than 150 mg/kg showed a decreasing trend (APC = -7.65%, p = 0.162), while doses above 180 mg/kg significantly increased over time (APC = 8.5%, p = 0.031). Neonatal long-term outcome indicators showed improving trends. We observed relevant trends toward non-invasive approaches and improving outcomes. Our study can facilitate the ongoing change of approach to care during postnatal transport, promote the development of relevant protocols and guidelines, which together can improve the outcome of preterm infants born outside tertiary care centers. Orv Hetil. 2023; 164(15): 571-576.

Respiratory management in the premature neonate

Introduction : Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-premies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. Areas covered : Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. Expert opinion : Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.

Diagnosis and management of neonatal respiratory distress syndrome in Japan: A national survey.

Respiratory distress syndrome (RDS) is characterized by a lack of lung surfactant; therefore, biochemical evidence of surfactant deficiency is needed to diagnose RDS. European guidelines recommend surfactant administration when patients need fraction of inspired oxygen exceeding 0.3 on continuous positive airway pressure or intubation. We hypothesized that the European guidelines for surfactant administration were not adopted in Japan because of the lack of RDS diagnosis. This study aimed to investigate neonatologists' attitudes and practices regarding the diagnosis and management of RDS in Japan. A mail-based survey regarding the diagnosis and management of RDS was conducted at 111 level III or ΙV neonatal intensive care units in Japan. The questionnaire was completed by the person in charge of each unit. The overall response rate for the questionnaire was 91% (101/111 centers). All respondents referred to chest radiography, and the majority (83%) of respondents referred to stable microbubble rating (SMR) for establishing the diagnosis of RDS. Surfactant administration was chiefly based on clinical conditions, chest radiography, and/or SMR. Most units in Japan do not adopt the European criteria for surfactant administration. In Japan, chest radiography and/or SMR are commonly used for the diagnosis of RDS and as the rationale for surfactant administration. Further studies from other countries are required to establish the ideal criteria for surfactant administration.

Prevalence and Outcome of Management of Respiratory Distress Syndrome: A Systematic Review

The main goal of this review is about Respiratory distress syndrome, which starts within hours of delivery, is really a major cause of neonatal respiratory distress; it remains a leading cause of morbidity and mortality in preterm infants. The following search databases were used PubMed, the Web of Science, Science Direct, EBSCO, and the Cochrane Library. Utilizing Rayyan QCRI, studies papers were screened by title and abstract before being subjected to a full-text evaluation. This review invest

Lung ultrasound to guide the administration of exogenous pulmonary surfactant in respiratory distress syndrome of newborn infants: A retrospective investigation study.

Respiratory distress syndrome (RDS) is a common disease that seriously endangers the life and safety of newborns, especially premature infants. Exogenous pulmonary surfactant (PS) is the specific agent for the treatment of neonatal RDS. Lung ultrasound (LUS) has been successfully used in the diagnosis of RDS, but its value in guiding the application of PS is still unclear. This paper explored whether the application of PS under LUS monitoring has some advantages, including (1) decreasing the misdiagnosis rate of RDS and decreasing probability of using PS, and (2) reducing the dose of PS without reducing the therapeutic effect. This study included two parts. Part 1: To decide whether the LUS is good to differentiate RDS from other lung diseases in the premature infants. All patients who were diagnosed with RDS and required PS treatment based on conventional criteria were routinely examined by LUS. Then, according to LUS findings, we decided whether they needed to receive PS treatment. Part 2: To see the dose reduction of surfactant is applicable. In RDS patients diagnosed based on LUS presentation and treated with Curosurf (Chiesi Pharmaceutical, Parma, Italy), the dose of Curosurf was compared with that recommended by the European RDS management guidelines. (1) Since March 2017, 385 newborn infants admitted to our neonatal intensive care unit met the traditional diagnostic criteria of RDS. Of these, only 269 cases were diagnosed with RDS and needed PS treatment according to LUS manifestations. The other 116 infants who did not meet the criteria for ultrasound diagnosis of RDS did not receive PS supplementation but obtained good outcomes, that is LUS findings decreased a misdiagnosis rate of RDS by 30.1% and subsequently resulted in a 30.1% reduction in PS use. (2) Among the 269 RDS patients diagnosed based on LUS findings, 148 were treated with Curosurf (another 121 RDS infants who received domestic PS treatment were not included in the study group), and the average dose was 105.4 ± 24.3 mg/kg per time, which is significantly lower than the dose of 200 mg/kg per time recommended by the European RDS guidelines. (3) The mortality rate of RDS patients was 0%, and no patients had ventilator-associated pneumonia or bronchopulmonary dysplasia in this study. LUS can decrease the misdiagnosis rate of RDS, thereby decreasing the probability of using PS and decreasing the dose of PS, and can help RDS infants to achieve better outcomes.

Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022.

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.

New developments in neonatal respiratory management.

Respiratory distress syndrome (RDS) is the major cause of respiratory failure in preterm infants due to immature lung development and surfactant deficiency. Although the concepts and methods of managing respiratory problems in neonates have changed continuously, determining appropriate respiratory treatment with minimal ventilation-induced lung injury and complications is crucially important. This review summarizes neonatal respiratory therapy's advances and available strategies (i.e., exogenous surfactant therapy, noninvasive ventilation, and different ventilation modes), focusing on RDS management.