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

Abstract

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.

Keywords: continuous positive airway pressure (CPAP); low resource; low- and middle-income countries; prematurity; respiratory distress syndrome (RDS); surfactant; treatment.

Figure 1

Essential therapies for respiratory distress syndrome (RDS) in resource limited settings along the time course of preterm birth. Important fundamental premature care includes thermoregulation, nutrition, and management of infection. CPAP, continuous positive airway pressure.

Figure 2

Scoring systems for respiratory distress syndrome. Downes and Silverman Andersen scores assign 0–2 points for each of five categories of respiratory distress (19, 20). Part of figure reprinted with permission from (25).

Figure 3

Forest plot of comparison of CPAP plus minimally invasive surfactant administration via thin catheter or laryngeal mask airway (LMA) vs. CPAP only. The outcome of interest was CPAP failure as determined by need for intubation. These minimally invasive techniques are associated with a 47% risk reduction in CPAP failure (–144, 150).