REVIEW ARTICLE Use of CPAP and Surfactant Therapy in Newborns with Respiratory Distress Syndrome Srinivas Murki & Ashok Deorari & Dharmapuri Vidyasagar Received: 8 October 2013 /Accepted: 5 March 2014 /Published online: 12 April 2014 # Dr. K C Chaudhuri Foundation 2014 Abstract Respiratory distress syndrome (RDS) is a major disease burden in the developing countries. Current evidence supports early continuous positive airway pressure (CPAP) use and early selective surfactant administration as the most efficacious interventions in the management of RDS, both in developed and developing countries. In developing coun- tries, it is recommended to increase institutional deliveries and increase the coverage of antenatal steroids in women in preterm labor as preventive measures. Establishing interven- tion of CPAP and surfactant therapies in the Level II special care newborn units (SCNUs) and Level III units requires focus on training nursing staff and pediatricians across the board. These approaches would pave the way in optimizing the care of the preterm infants with RDS and decrease their mortality and morbidity significantly. Keywords RDS . nCPAP . Surfactant . Developing country Introduction Respiratory distress is one of the commonest morbidities in babies admitted in sick newborn care units (SCNUs). Respiratory distress syndrome (RDS) is the commonest cause of respiratory distress in preterm infants. Lower the gestation, higher is the incidence of RDS, accounting for nearly 80 % incidence in preterm infants with gestation less than 28 wk. Surfactant deficiency is the major underlying cause of RDS [1]. Surfactant deficiency results in lower functional residual capacity, increased work of breathing and respiratory failure. In 1967, Gregory et al. reported the value of application of continuous positive airway pressure in the management of RDS [2]. Successful surfactant replacement therapy in RDS was reported by Fujiwara et al. [3]. Continuous positive airway pressure (CPAP) coupled with surfactant replacement therapy appears to be the ideal choice for the management of respiratory distress in preterm infants with RDS in low and middle income countries [4]. In RDS, CPAP prevents alveolar collapse, improves the functional residual capacity (FRC), brings the FRC above the closing volume, reduces the protein leak and conserves surfactant. As per Laplace law, the col- lapsing alveoli pressure is proportional to surface tension at air liquid interface in the alveoli and inversely proportional to the radii of the alveoli. CPAP works by improving the alveoli radii and surfactant by decreasing the surface tension. Surfactant a complex lipoprotein forms a monolayer on the air fluid inter- face in the alveolar membrane and thereby decreases the surface tension. Both surfactant and CPAP together would improve the FRC and homogenize lung expansion [5, 6]. As stated earlier RDS is primarily associated with prema- turity. It is well recognized that prematurity is a global issue, with large proportion of premature babies born in developing countries. In India, nearly 26 million infants are born every year. Assuming 10 % incidence of respiratory distress in newborn infants [7], nearly 2.6 million infants are at need of oxygen or CPAP for respiratory distress. Assuming 20 % of infants with oxygen need may require non invasive respiratory support (CPAP) for respiratory distress [8], nearly 5 lakhs (0.5 million) infants per annum require CPAP as a mode of respi- ratory support. As most of these infants either die or referred to S. Murki Department of Pediatrics, Fernandez Hospital, Hyderabad, India A. Deorari (*) Department of Pediatrics, Division of Neonatology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India e-mail: sdeorari@yahoo.com D. Vidyasagar Division of Neonatology, University of Illinois at Chicago, Chicago, IL, USA Indian J Pediatr (May 2014) 81(5):481–488 DOI 10.1007/s12098-014-1405-8