Case presentation on

Approach to newborn case of Respiratory

Distress

Moderator:- •Presented by -:
Dr.Meenakshi Rawat •Akansha Verma 09
( Senior Resident ) •Akash Rawat 10
Department of paediatrics •Akhil Rana 11
VCSGGIMS&R Srinagar
•Akshay Kumar 12
Uttarakhand
DETAILED HISTORY
OF THE CASE
I am presenting case history of baby of Mrs Nikita, a 36 week gestation
age baby boy ,now 6 days old born to a 21 years old primigravida first
born of non consanguineous marriage ,Hindu by religion ,resident of
Sunderban , karanprayag.
Baby was born on 11 May 2024 at 8:30 am by vaginal delivery at HNB
Base Hospital.
Mothers LMP was on 2 September 2023 and EDD was on 8 June
2024.
Mrs Ankita ,who is the informant of the baby is his mother and her
reliability is good who belongs to lower middle class as per modified
BG Prasad scale .
The history was taken on 16 May 2024
 CHIEF COMPLAINT
Patient was presented to Paediatrics OPD on 11 may
2024 with chief complaint of:

• Difficulty in breathing since

birth.
• Inability to breastfeed.
 HISTORY OF PRESENT ILLNESS
•Baby of Nikita ,6 days old baby boy born on 11 may 2024 ,28
days before the expected date of delivery by vaginal delivery
with very low birth weight of 1.42 kg.
•At birth he was having difficulty in breathing, developed
immediately after birth which was sudden in onset
,continuous in nature associated with rapid breathing ,chest
retraction and lethargy.
•For this he was shifted to NICU on O2 support .
NEGATIVE HISTORY
• No history of cyanosis .
• No history of yellowish discolouration.
• No history of vomiting.
• No history of abdominal distension
• No history of fever and cold peripheries.
• No history of apnea.
• No history of chest and abdominal deformity.
COURSE DURING HOSPITAL STAY
• Patient was admitted to Paediatrics ward on 11 May 2024 for
complaint of difficulty in breathing and preterm care.
• Patient was kept on O2 support and IV medications were given.
• On 11 may 2024, surfactant was given to baby for respiratory
distress.
• Patient was started on trophic feed after 12 hr of birth with a
dose of 10ml/kg/day on Day1 then increased gradually after
every 6 hr to full feed at day 3, ie……90 ml/kg/day
• From Day 4 child was started on oral katori spoon breastfeed.
• USG cranium and USG abdomen were done on 14 May 2024.
• Ophthalmological examination on 16 may 2024 was done.
• Patient condition gradually improved and patient is withdrawn of
ANTENATAL HISTORY
Maternal age at conception - 20 years
Father’s age at conception- 23 years
Pregnancy was registered in ANC at 5th month .
First trimester
•Spontaneous conception.
•Pregnancy was confirmed by UPT at 6 weeks
•GPAL score – G1P0A0L0
•Pregnancy was not registered to ANC in 1st trimester.
•No Td dose given.
•No USG done in 1st trimester.
•No folic acid tablets were taken.
•No routine urine and serum investigations were done.
•No Routine antenatal investigation were done.
•No history of excessive vomiting.
•No h/o radiation exposure.
•No h/o of alcohol, tobacco use, substance abuse
•No complication in pregnancy was reported
•No h/o DM, Hypertension or any chronic illness.
•No h/o burning micturition, increased frequency of micturition,
•No h/o bleeding p/v.
•No h/o fever with rash and infection during antenatal period
Second trimester
•Quickening felt at 5th month.
•First ANC visit done at time of registration at 5 month.
•Iron Folic acid and Ca supplements were taken
•USG done at 20 weeks and was said to be normal.
•No history of headache, swelling of feet ,blurring of vision,
epigastric pain, polyuria, polydipsia or deranged glucose readings
•No history of burning micturition.
•2 Td dose given
•Routine investigation were done and found to be normal.
Third trimester
•Continued to perceive fetal movements.
•Fe and Ca supplements continued.
•USG at 7th and 8th month was done and found to be normal.
•No history of fever, bleeding or leaking PV, abdominal pain
,polyuria or polydipsia, blurring of vision.
•No history of blood transfusion.
•No history suggestive of UTI.
•No Corticosteroid were given for lung maturity.
BIRTH HISTORY
• Birth order – First
• Gender - Male
• Preterm baby boy born out of vaginal delivery ,the labour was spontaneous and not
drug induced , institutional delivery was done by a trained gynaecologist.
• Birth weight – 1.42 kg
• Cried immediately after birth and no resuscitation was required..
• History of NICU admission present.
• Amniotic fluid was not meconium stained and non foul smelling.
• Breastfed 12 hour after birth ..
• Passed urine and meconium within 24 hrs of birth.
 POST NATAL HISTORY
• Colostrum was fed after 1 day
• Patient admitted in NICU for .
• Meconium and urine passed within 24 hrs of birth.
• No history of yellowish discolouration of skin and mucous membrane
NUTRITIONAL HISTORY
Child is Exclusively breastfeed .
He is having mother’s milk every 2-3 hours
For 8-12 times /day
Average amount of each feed is 20 ml.
So total amount of mother’s milk consumed in
a day is 20*12 =240ml
IMMUNIZATION HISTORY
• Child is immunised according to NIS upto age as per mother.
• As per informant, last immunization was done on 3rd day after birth .
FAMILY HISTORY

•No history of consanguineous marriage.

•No history of similar episodes in family.
•No history of congenital and genetic diseases in family.
FAMILY PEDIGREE
SOCIO ECONOMIC HISTORY
•Child belongs to lower middle class family
according to modified BG Prasad scale
•Joint family of 9 members
•Family per capita income – Rs 20000
•Father is graduate.
•Mother is housewife.
SUMMARY
Baby of Mrs Nikita, a 36 week gestation age baby boy ,now 6 days old ,
first order child born out of non consanguineous marriage with vaginal
delivery ,having very low birth weight, cried immediately after birth,
belonging to lower middle class family according to modified BG Prasad
scale.Patient is exclusively breastfed.

He has presented to paediatric department with complaint of difficulty in

breathing immediately after birth and inability to breastfeed.
DIAGNOSIS
Preterm/SGA/VD/CIAB/RDS
DIFFERENTIAL DIAGNOSIS
Respiratory distress syndrome
Transient tachypnea of newborn
Meconium aspiration syndrome
Congenital heart disease
Early onset neonatal sepsis
Congenital anomalies
 NEWBORN
EXAMINATION
 GENERAL PHYSICAL EXAMINATION
Consent was taken from mother before examination.
Child was examined on NICU ward.
Child was conscious(at stage 4), alert and playful.

Vitals:

Heart Rate-:138 beats/min,regular and rhythmic

Respiratory rate-:56 breaths/min, abdominothoracic
Temperature:97.7 f measured in right axilla for 3 min.
Saturation:98% at room air.
Capillary filling time:<3 secs
BP-;80/42 by neonatal cuff

General physical examination:

Pallor: absent
Icterus: absent
Cyanosis: absent
Lymphadenopathy: absent
 EXPANDED NEW BALLARD SCORE(ENBS)

Acc. To ENBS -
Range of
gestation-34-36
weeks.
Total score- 26
 APGAR SCORE

APGAR SCORE — At 1 min -7

— At 5min - 8
 SILVERMAN ANDERSON
SCORE
1.Score <5 - mild
respiratory distress.
2.Score 5-7- moderate
respiratory distress
3.Score >7 - Severe
respiratory distress

Interpretation-: score is
1
 ANTHROPOMETRY
PARAMETE OBSERVED EXPECTED INFERENCE
R

Weight for age 1.42kg 2.5kg Below 3

percentile

length 41cm 46 cm Between 3-10

percentile

Head 29cm 32cm Between 3-10

circumference percentile

Chest 26cm 33cm CC<HC

circumference
 HEAD TO TOE EXAMINATION
Head: normal shape and symmetry, anterior fontanelle open, posterior fontanelle
open
Eyes: no pallor; no icterus
Ears: normal shape and size and at normal level,no discharge.
Nose: nasal flaring absent ; no scar sinus or deformity
Face: no facial asymmetry
Oral cavity: normal mucosa ;no cleft-lip and cleft palate
Neck: normal ;no distended veins
Nails: normal shape
Abdomen: no distension ;normal shape.umblicus not stained.
External genitalia: normal
Spine: central
Skin: peeling of skin ;no hyperpigmentation, rashes ,eruptions.
RESPIRATORY SYSTEM-:

Upper respiratory tract:

1.nose: normal shape, nasal flaring absent,no septal deviation,no discharge,

no blockage.
2.oropharynx: mucosa normal,no tonsillar enlargement
3.ears: normal shape and size, no external deformity, no discharge,no sinus.

Lower respiratory tract:

1.Inspection :

Shape of chest –,bilaterally symmetrical

Chest movements-bilaterally symmetrical
Mild retraction present and use of accessory muscles not visible
Trachea-central
2.Palpation:

All inspectory findings confirmed.

No local rise of temperature.
Trachea is central.
Chest expansion is equal on both sides
Apical impulse at 4th intercostal space ,in mid clavicular line.
Vocal fremitus could not be performed.
3.Percussion: could not be performed
4.Ascultation-:normal vesicular sounds were heard.
 SYSTEMIC EXAMINATION
Cardio vascular system:

1.Inspection:
chest shape and normal movements
No scar, sinus ,or deformity.
No apex beat visible

2.Palpation:
no local rise of temperature.
Apex beat felt in 4th intercostal space in mid-clavicular line.
Trachea central
No parasternal heave

3.Percussion:
could not be performed.

4.Auscultation:
Gastro-intestinal tract:

1.Inspection: no scar, symmetrical movements,

umblicus inverted
No discharge, no inflammation,
no nodule,no visible engorged veins
No localised or gernalised distension seen.

2.Palpation: soft, no tenderness, normal temperature,

no mass, no pulsations
no rigidity,no guarding.

3.Percussion: could not be performed.

4.Auscultation:normal bowel sounds heard.

Central nervous system:

1.Level of consciousness: Baby is conscious.

2.Cry and habituation: normal[cries on stimulus and consolable]
3.Posture: no abnormal posture.
4.Tone :
Passive tone Active tone

neck normal normal

Upper limbs normal normal

shoulder normal normal

Lower limbs normal normal

 5.Cranial nerve
examination:
Cranial nerve inference
olfactory intact
optic intact
oculomotor intact
trochlear intact
trigeminal intact
abducens intact
facial intact
Vestibulo-cochlear intact
glossopharyngeal intact
vagus intact
Spinal accessory intact
hypoglossal intact
6. Primitive
reflexes
Rooting reflex- present

Sucking reflex- present but poor

Moro reflex- incomplete but symmetrical (extension and abduction complete

not followed by proper flexion and adduction )

Asymmetric tonic neck reflex- absent

Grasp reflex- present

Babinski reflex - present

Glabellar tap reflex - present

PRIMITIVE REFLEXES ONSET FULLY DEVELOPED DISAPPEARS

1.Rooting reflex 32 weeks 34 weeks At 1 month post natal age

2.palmer grasp 16 weeeks 25-26 weeks 3-4months after birth

3.moro reflex 28-32 weeks 37 weeks 5-6 month after birth

4.ATNR 35 weeks 1 month after birth 6-7 months after birth

 DIFFERENTIAL DIAGNOSIS
—Respiratory distress syndrome
— Transient tachypnea of newborn
— meconium aspiration syndrome
— congenital heart disease
— Early onset neonatal sepsis
— congenital anomalies
DIFFERENTIAL DIAGNOSIS POINT IN FAVOUR POINT IN AGAINST

Preterm, respiratory distress since

Respiratory distress syndrome -
birth

respiratory distress since birth Vaginal birth (normally found in

Transient tachypnea of newborn Respiratory distress settles within 24 LSCSand diabetic mother)
hr,preterm VLBW,preterm

No cyanosis,no desaturation,no
Congenital heart disease Respiratory distress,preterm
murmur

Early onset neonatal sepsis Onset within 72 hrs of birth ,preterm No h/o maternal sepsis

Preterm (normally found in post

Meconium aspiration syndrome Respiratory distress termwith IUGR,no MSAF
history,umbilical cord not stained

No excess frothing from mouth,no

Congenital anomalies Respiratory distress
dystrophic faces
Investigations
1) Blood examination of the patient

Parameter On 17/05/2024 Normal range

WBC count 6380/uL 3000-21600/ uL Normal

Lymphocytes 53.2% 15-75% Normal

Neutrophils 17.8% 15-78% Normal

Monocytes 25.9% 1-14% Increased

Eosinophil 2.6% 0-5% Normal

Basophil 0.5% 0-2% Normal

Blood examination of the patient
Parameter On 17/05/24 Range Inference

RBC count 5.42x 10^6/uL 4-5.5 × 10^6/uL Normal

Hb 18.6 15-24 g/dl Normal

MCV 104.2 95-125 fL Normal

MCH 34.3 26-41 pg Normal

MCHC 32.9 25.8-33.6 g/dl Normal

Hct 56.5% 44-70% Normal

Platelet 156x10^3 u/L 150-400x10^3u/L Normal

Blood examination report

• Inference
• Monocytosis
• (Monocytosis in newborn defined as
increases in number of monocytes in
blood, can be caused by various
conditions.
• Some of them are - -
Causes of monocytosis

• 1)- infection- neonatal infections either bacterial or viral, can

lead to increase in monocytes as necrotising
enterocolitis(NEC)
• 2)-inflamatory condition- congenital inflamatory condition
• 3)- infection acquired in uterus-
CMV,toxoplasmosis,syphilis,rubella
• 4)- Stress response- birth stress,including hypoxia and birth
asphyxia
2) Biochemical investigations(11/05/24)

• KFT( kidney function test)

Value Range Inference

Blood urea 13 12-40 mg/dl Normal

S. Creatinine 0.8 0.3-1 mg/dl Normal

• Serum electrolytes

Electrolytes Values Range Inference

S. Calcium 1.27 1.1-3.5 mmol/L Normal

S. Sodium 136 135-145mmol/L Normal

S. Potassium 6.1 3.5-7.2 mmol/L Normal

• LFT(liver function test)

Value Range Inference

S. Bilirubin(total) 1.8 - Normal

S. Bilirubin(direct) 0.3 - Normal

S. Protein(total) 6.5 4.6-7 mg/dl Normal

S. Albumin 4.0 2.0-4.0 g/dl Normal

SGPT(ALT) O/S 5-40 U/L -

SGOT(AST) 68 9-80 U/L Normal

S. Alkaline 227 110-398 U/L Normal

phosphatase
Biochemical investigation

• Inference

• Reports are normal.

•
3)-Stool examination(13/05/2024)

• Physical examination-
• Color- greenish
• Consistency- Semi solid
• Mucous- absent

• Microscopic examination:-
• Ova- Not seen
• Cyst- Not seen
• Pus cell- (0-1) pus Cell/ HPF
• Occult blood test- weakly positive
4)-Urine examination report(13/05/24)
• Physical examination

Value Range

Color Watery Pale yellow

Appearance Clear Clear

PH 5.0 4.6-8.0

SP. Gravity 1.010 1.003-1.035

• Microscopic examination

Value Range

Pus cell 0-1 0-5/ HPF

RBC Nil Nil

Epithelial cells 0-1 0-8/ HPF

5) Serological
investigation(11/05/24)

Investigations Report

CRP Negative
Serological investigations

• Reposts are normal.

5)- x-ray(post surfactant)

• Post surfactant therapy x-ray

appear to be normal

• No any granular opacities

• No hyperinflation of lung
• No any pleural fluid is seen
• No any subtle interstitial marking.
• RDS

• White out lungs/ ground glass

appearance
• Air bronchogram sign- air enter into
patent bronchi and appears black
• TTN( transient tachypnoea in
newborn)

• Perihilar streaks / sun burst

appearance- fluid in
bronchopulmonary structures and
fluid in interlobar fissure
• Prominent interlobar fissure
• Prominent vascular marking
• MAS( meconium aspiration
syndrome) –

• Due to intrauterine stress

meconium is swallowed and
aspirated, partial block of main
airway~ hyperinflation in CXR.
• Asymmetrical patchy infiltrate
• Pneumonia –

• Chest x- ray show

asymmetrical
parenchymal patchy
infiltrate
 6)- Ultrasound report

• USG cranium- within normal

limit
• USG abdomen-within normal
limit
 Summary

• Monocytes- increased
• CRP-negative
• Normal LFT & KFT
• Post surfactant CXR - normal
• USG cranium - normal
• USG abdomen- normal
Management
RESPIRATORY DISTRESS
Respiratory distress is defined as the presence of tachypnea
(RR >60 per min), with chest retractions, grunting, and cyanosis.

Respiratory Distress Syndrome (RDS)

• RDS is common in neonates of less than 34 weeks of

gestation.

• The overall incidence is 10-15% but can be as high as 80%

in neonates <28 weeks.

• In addition to prematurity,asphyxia, acidosis, maternal

diabetes, and cesarean section can increase the risk of
Chest X-ray show
depicts low-volume lungs,
reticulogranular pattern, ground
glass opacity, and air
bronchogram The lungs become
white out in severe disease.
Etiopathogenesis
• Surfactant production starts around 20 weeks of life and peaks at
35 weeks gestation

• Therefore, any neonate less than 35 weeks is prone to develop

RDS. The primary abnormality is surfactant deficiency

• Surfactant, produced by type Il alveolar cells, comprises

lipoprotein containing phospholipids and proteins.

• The surfactant prevents the alveoli from deflating at the end of

expiration by lowering surface tension within them
• In the absence of surfactant, the alveoli tend to collapse during
expiration, and the neonate has to exert additional to open the
collapsed alveoli again.

• Increased work of breathing and hypoxemia causes acidosis, which

results in pulmonary vasoconstriction, right-to-left shunting across
the foramen ovale, and consequent hypoxemia

• Ischemic damage to the alveoli causes the transudation of proteins

forming a hyaline membrane.
MANAGEMENT OF RDS
• The goal of management for respiratory distress is to ensure a
patent airway and provide necessary support for adequate
oxygenation of the blood and removal of co2

• Continuous positive airway pressure (CPAP) is generally enough

for mild to moderate disease.

• Exogenous surfactant replacement therapy(SRT) is

recommended as the treatment of choice for moderate to
severe RDS.
 CPAP in newborn
• Continuous positive airway pressure (CPAP) provides respiratory support to
preterm neonates breathing spontaneously with respiratory distress
• CPAP generates a positive pressure of 5 to 8 cm H2O at the nostril level, and
it is delivered through an interphase of either a binasal prong or nasal mask.
• Preterm neonates do not have adequate functional residual capacity (FRC)
due to a compliant chest wall. The lung alveoli tend to collapse at the end of
expiration, making breathing difficult and impairing the gas exchange
• CPAP prevents the collapse of the alveoli and helps in better recruitment of
alveoli resulting in optimal FRC.
Component of CPAP system
The CPAP system has the following elements:

• Gas source provides a continuous supply of

warm, humidified, and blended gases, i.e. air
and oxygen. The blender can provide desired
oxygen concentration varying from 21 to 100%.

• Pressure generator creates a positive pressure

in the circuit. In the most commonly used
bubble CPAP machine, the expiratory limb of
the circuit is dipped in a water column to
generate the desired pressure. CPAP DEVICE
• Patient interface connects the CPAP circuit to
the infant's airway
COMMON INDICATION
• Respiratory distress in preterm neonates due to respiratory distress
syndrome (RDS), transient tachypnea, and pneumonia

• Apnea of prematurity despite methylxanthine therapy

• Following extubation in preterm VLBW infants

• Airway instability such as laryngomalacia, tracheomalacia and

bronchomalacia
COMPLICATION
• Nasal injury
• Pulmonary air leaks
• Decreased cardiac output
• Increased pulmonary vascular resistance (with excessive CPAP)
• Gastric distension (CPAP belly syndrome)
SURFACTANT REPLACEMENT THERAPY
• Exogenous surfactant replacement therapy (SRT) is recommended as the
treatment of choice for moderate to severe RDS

• SRT can be given as rescue therapy to treat established RDS or

prophylactic therapy in neonates less than 28 weeks.

• SRT has a synergistic action with CPAP. A preterm neonate with

respiratory distress is treated initially with CPAP. The SRT is administered,
if the RDS is severe enough to require FiO2 of 40% or greater while on
CPAP.

• SRT decreases the duration and level of respiratory support in neonates

and improves outcomes.
Transient Tachypnea of Newborn (TTN)
• Transient tachypnea of the newborn (TTN) is a benign self-limiting
disease usually occurring in term neonates

• TTN is due to delayed lung fluid clearance, leading to impaired gas

exchange and hypoxia at birth

• Elective cesarean section before 39 weeks of gestation and prematurity

are major risk factors.

• These neonates have tachypnea, which is often silent without much

respiratory distress
• Chest X-ray may show high-volume lung fields,
prominent vascular marking, and prominent
interlobar fissure.

• Supportive treatment with oxygen therapy is

often adequate, but some may need CPAP
therapy. The prognosis is excellent.

Caption
Meconium Aspiration Syndrome (MAS)
• Neonates born through MSAF can aspirate
meconium into the lungs and develop
respiratory distress (meconium aspiration
syndrome; MAS)

• Aspirated meconium can block the large and

small airways causing areas of atelectasis and
emphysema, which can result in air leaks like
pneumothorax.
Caption
• Chest X-ray show- Asymmetric patchy infiltrate
with hyperinflation

• Such neonates need supportive care by

providing thermal protection,IV fluids,and
monitoring. CPAP, and mechanical ventilation
Neonatal sepsis/pneumonia
• Pneumonia is a common cause of respiratory
distress in term and preterm neonates. It is a
form of sepsis with a pathogen profile such as
E. coli, S. aureus.

• The affected neonate has features of sepsis in

addition to respiratory distress.

• Chest X-ray shows assymmetric patchy

parenchymal opacities. Caption

• Treatment includes supportive care and specific

antibiotic therapy for sepsis.
 Preterm baby : delivery room

<34-35 weeks with breathing difficulty <28 weeks of gestation

Suspected RDS
Prophylactic surfactant to prevent RDS

Start CPAP (continuous positive

airway pressure) ————>keep alveoli open and
prevents its collapse

Termed as : early delivery room CPAP with

selective surfactant
 If baby develop RDS ,after shifting to the ICU

ICU

Silverman scoring

<5 mild RDS 5-7 Moderate RDS >7 severe RDS

CPAP Mechanical ventilation + endotracheal

Warm humidified O2
surfactant therapy

Initial pressure :5cm H2O

Target spo2 level : 90-95% pressure and O2 concentration Standard :INSURE technique .
can be adjusted according to Incubation —>surfactant
response in the baby —>extubation
Treatment during hospital stay
 Frequenc
Date Drug Dose Route Duration
y

(Loading
11/05/2024 inj Capnea IV OD 1day
dose) 30mg

(Maintaining
inj capnea dose)7.1mg IV OD 1day

Surfactant
Single dose - - -
given
 Date Drug Dose Route Frequency Duration

Orogastric
12/05/2024 2ml Oral 2hourly 1day
feed

Inj
70mg IV BD 1day
Ampicillin

inj
5.6mg IV OD 1day
Gentamycin

IVF+inj
calcium 3.43ml IV hourly -
gluconate
 Frequen
Date Drug Dose Route Duration
cy

Katori
13/05/2024 spoon 10ml Oral 2 hourly 1day
feeding

inj
70mg IV BD 1day
Ampicillin

Inj
Gentamyci 5.6mg IV OD 1day
n
 Frequenc
Date Drug Dose Route Duration
y

Katori spoon
14/05/2024 12ml Oral 2hourly 1day
feeding

Inj
70mg IV BD 1day
Ampicillin

Inj
5.6mg IV OD 1day
Gentamycin
 Date Drug Dose Route Frequency Duration

Ks
15/05/2024 feed+Alternat - Oral 2hourly -
e DBF

Inj
70mg IV BD 1day
Ampicillin

Inj
5.6mg IV BD 1day
Gentamycin

Multivitamin
1ml Oral OD 1day
s drop+Zn

Syrup
2.5ml Oral TDS 1day
ostocalcium
Drop
vitamin D3 1ml Oral OD 1day
(400:1)
Prevention of RDS
Antenatal prevention of RDS :
• corticosteroids to mothers who deliver at 24 - 34 weeks.
• Betamethasone : 12 mg/dose, 2 doses 24 hours apart.
• Dexamethasone: 6 mg /dose, 4 doses l2 hours apart (common in
India)

Benefits: Decreases incidence of

• Respiratory distress syndrome.
• Necrotizing enterocolitis.
• Intra ventricular hemorrhage in preterm babies.
• overall neonatal mortality..
RECENT ADVANCES
Non invasive/less invasive.
MIST: minimally Invasive surfactant therapy. Done using feeding tube or tracheal catheter
LISA : Less Invasive Surfactant Administration.

Early rescue surfactant therapy:

Baby with moderate RDS → Start CPAP → No response → Start surfactant therapy → Decreases
the need for mechanical ventilation.

Indications for surfactant therapy in a newborn :

• severe RDS.
• moderate RDS with no response to CPAP to decrease need for mechanical ventilation.
Thank you