The Patient Experience Across the RDS Care Pathway
There are proven preventions and treatments for RDS. They encompass antenatal care at the PHC level and care in NICUs at higher levels of the health system. As part of antenatal care, health workers assess the baby’s gestational age, identify risk factors for preterm labor, and determine when treatment with antenatal corticosteroids is indicated. Preterm infants with RDS must be diagnosed immediately after birth, stabilized, and transferred to a NICU with CPAP therapy for them to survive. In LMICs, access to CPAP is often limited due to the lack of devices suitable for the settings there.
WHO Guidelines
The WHO’s Every Newborn Action Plan provides guidance for holistic care of preterm and low-birth-weight infants, including management of complications such as RDS.
Prevention
High-quality care for pregnant women at PHC facilities can help prevent RDS. Health workers there have opportunities during antenatal care visits to accurately assess the baby’s gestational age and identify risk factors for preterm labor, addressing them when possible. When pregnant women meet a set of criteria, including accurate gestational age assessment and imminent risk of preterm delivery, the WHO recommends treatment with antenatal corticosteroids. This treatment has been shown to lower the incidence and severity of RDS by speeding fetal lung development and increasing lung surfactant production.Challenges
In LMICs, fetal ultrasound for accurate gestational age assessment and antenatal corticosteroid treatment are not routinely available and typically not accessible at the PHC level. More broadly, women may not seek antenatal care because of a lack of awareness or feasibility.
Diagnosis
For preterm infants with RDS, symptoms begin immediately after birth and worsen over the first 48-72 hours. A skilled birth attendant, in a PHC facility or wherever a baby is delivered, can make the diagnosis of probable RDS based on these worsening symptoms. Diagnosis in LMICs is typically made using one of several scoring systems to measure the severity of respiratory distress based on observable clinical signs, such as the Downes Score or Silverman Anderson Retraction Score. RDS symptoms include visible and audible signs of increased breathing effort, including retraction, grunting, and nasal flaring. Decreased breath sounds and diminished peripheral pulses may also be present, along with hypoxemia detected in an arterial blood sample or non-invasively using a pulse oximeter.Challenges
Prompt identification of RDS is critical, but this may not routinely happen where and when a woman delivers.
Stabilization and Transfer to a NICU
Preterm infants with RDS must be medically stabilized and transferred to a NICU with CPAP therapy for them to survive. NICUs are typically located within district level hospitals and higher levels of care, and these infants will often require additional supportive measures that are not available at the PHC level.Challenges
Suitably trained health workers together with effective tools to stabilize preterm infants and enable their safe transfer to higher levels of care may not routinely be accessible where and when a woman delivers.
Treatment
The first-line treatment for infants with RDS is neonatal CPAP administered in NICUs. Most of these infants will stabilize with CPAP. For those needing more support, additional treatments include mechanical ventilation and surfactant delivered directly into their trachea by intubation.Challenges
Access to treatments beyond CPAP is limited in LMICs. Access to CPAP itself in NICUs is limited due to its cost and complexity of use and to the lack of devices fit for use in LMIC settings. When CPAP devices are unavailable, clinicians sometimes must use simpler versions that deliver oxygen not blended with air. This high (100%) oxygen concentration can cause retinopathy of prematurity, resulting in decreased vision or blindness. It also can increase the risk of lung damage, resulting in bronchopulmonary dysplasia, a chronic lung disease.
Lack of Access to CPAP is a Critical Gap in RDS Care
There are proven interventions to reduce neonatal deaths caused by RDS. It is estimated that CPAP therapy alone would avert approximately 70% of these deaths (Figure 1). Additional contributions are predicted from tools and treatments including lung surfactant, antenatal corticosteroids (ACS), and AI-supported point-of-care ultrasound (AI POCUS). There is limited access to all these interventions in LMICs, however, due to their cost and complexity of use. Innovation is needed to make these interventions suitable for effective, sustained use in LMIC settings, particularly CPAP.
CPAP Therapy has an Increasingly Outsized Role in RDS Care
