As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Department of Child Health Queen's University Belfast and Royal Maternity Hospital Belfast United Kingdom

Department of Neonatology Polytechnic University of Marche and Azienda Ospedaliero Universitaria Ospedali Riuniti Ancona Ancona Italy

Department of Neonatology Rigshospitalet and University of Copenhagen Copenhagen Denmark

Department of Obstetrics and Gynecology University Medical Centre Utrecht The Netherlands

Department of Paediatrics University of Oxford Medical Sciences Division Newborn Services John Radcliffe Hospitals Oxford United Kingdom

Department of Pediatric Research Oslo University Hospital Rikshospitalet University of Oslo Oslo Norway

Department of Pediatrics and Adolescence Oulu University Hospital and PEDEGO Research Unit Medical Research Center University of Oulu Oulu Finland

Department of Pediatrics and Neonatal Research Unit Health Research Institute La Fe University and Polytechnic Hospital La Fe Valencia Spain

Department of Pediatrics Marmara University Medical Faculty Istanbul Turkey

Department of Pediatrics University Children's Hospital Würzburg Germany

Division of Neonatology Department of Obstetrics and Gynecology General Faculty Hospital and 1st Faculty of Medicine Charles University Prague Czechia

Division of Pediatrics CHUV and University of Lausanne Lausanne Switzerland

Leiden University Medical Centre Leiden The Netherlands

Regional Neonatal Unit Royal Maternity Hospital Belfast United Kingdom

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