Clinical Scenario:
A 27-week preterm infant weighing 900 g develops severe respiratory distress syndrome shortly after birth. The infant receives surfactant but remains intubated because of persistent respiratory failure. The baby is hemodynamically stable, and chest radiography shows diffuse reticulogranular changes without air leak. You decide to use pressure-control ventilation.
Which of the following is the most appropriate initial ventilator strategy?
A. PIP 18–20, PEEP 5–6, FiO₂ titrated to SpO₂ 90–94%
B. PIP 30–35, PEEP 3, FiO₂ 1.0, SpO₂ 98–100%
C. PIP 12–14, PEEP 2–3, FiO₂ titrated to SpO₂ 85–89%
D. PIP 25–30, PEEP 10–12, FiO₂ titrated to SpO₂ 98–100%
E. PIP 35–40, PEEP 5, FiO₂ titrated to SpO₂ 98–100%
Correct answer & Explanation:
Explanation
Correct answer: A. PIP 18–20, PEEP 5–6, FiO₂ titrated to SpO₂ 90–94%
In pressure-control ventilation, PIP and PEEP are set by the clinician, while the delivered tidal volume depends on the infant’s lung compliance, airway resistance, inspiratory time and the pressure difference between PIP and PEEP.
A preterm infant with RDS has poorly compliant lungs and requires sufficient PEEP to maintain functional residual capacity while avoiding excessive inspiratory pressure. After surfactant administration, lung compliance can improve rapidly; therefore, the PIP should be reassessed frequently because the same pressure may subsequently deliver a larger tidal volume and increase the risk of volutrauma.
The principle is lung-protective ventilation: use the lowest effective pressures that provide adequate ventilation and oxygenation, and avoid excessive PIP and PEEP. Current European RDS guidelines recommend volume-targeted ventilation as the preferred invasive mode when mechanical ventilation is required because it automatically reduces inspiratory pressure as compliance improves.
For oxygen therapy, the 2025 guideline recommends an SpO₂ target of 90–94% in preterm infants <28 weeks receiving oxygen, with alarm limits of approximately 89–95%.
Reference
Sweet DG, Carnielli V, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2025. Neonatology. 2026; online ahead of print.
