European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2025

Every year new evidence emerges about how best to care for babies with respiratory distress. We report the seventh version of "European Guidelines for the Management of RDS" by a panel of European neonatologists and a perinatal obstetrician based on available literature up to mid-2025. Optimising outcome involves collaboration with obstetricians to predict risk of preterm delivery, consideration of transfer to perinatal centres and perinatal optimisation including antenatal steroids. Delivery room protocols should include maintenance of normal body temperature whilst aiming to promote spontaneous breathing before clamping the umbilical cord, using non-invasive respiratory support where possible and considering early use of surfactant via thin catheter in an attempt to avoid intubation. Ongoing non-invasive respiratory support and judicious use of surfactant will improve outcomes. If mechanical ventilation is needed, lung protective strategies should be employed and ventilation continued for the shortest time possible to reduce risk of bronchopulmonary dysplasia. Protocols for supportive care are also reviewed. What is New? Prenatal management remains largely unchanged, perhaps with more emphasis on confirming preterm labour, to allow more judicious use of antenatal steroids. In the delivery room we suggest physiological based cord clamping rather than time based, with an emphasis on strategies for managing thermal care if equipment is available before the cord is cut. Starting FiO2 of 0.6 rather than 0.3 at birth should reduce bradycardia and need for chest compressions and adrenaline for infants born < 29 weeks' gestational age. Surfactant prophylaxis has reappeared for extremely preterm infants in the current era of Less Invasive Surfactant Administration (LISA), with an emphasis on use of videolaryngoscopy for LISA catheter placement or intubation because of greater first pass success for intubations. Nasal ventilation rather than CPAP now seems the most potent mode of non-invasive respiratory support, both after initial stabilisation and when coming off mechanical ventilation, although there is no unified approach as to how best to provide it. For babies who have not received prophylactic surfactant, the treatment thresholds of FiO2 0.3 are unchanged, but with more emphasis on using ultrasound where possible to diagnose RDS regardless of FiO2 requirements in babies with signs of respiratory distress.