Respiratory Medications in the NICU: What Every Nurse Should Know

Caring for critically ill infants in the NICU often means becoming familiar with a wide range of medications—many of which are specific to the neonatal population. Respiratory medications are among the most frequently used, given how vulnerable preterm and critically ill infants are to lung disease and respiratory instability. Knowing not only what these medications do, but also how to explain them to parents and integrate them into care safely, is a vital part of NICU nursing. Below, we’ll walk through the most common respiratory medications you’ll see, how they work, and the important details to keep in mind.

Surfactant

Surfactant is used for premature infants who lack adequate surfactant production, leading to respiratory distress syndrome. It works by reducing surface tension in the alveoli, keeping them from collapsing and improving oxygen exchange. It is administered directly into the endotracheal tube, often followed by positive pressure ventilation to distribute it evenly. Side effects may include transient bradycardia, desaturation, or pulmonary hemorrhage.
One detail to remember: explaining to parents that surfactant isn’t a daily medication but a one-time or limited therapy to help “jump-start” the lungs can ease anxiety about its role in their baby’s care.

Caffeine Citrate

Caffeine is a mainstay for infants with apnea of prematurity. It works by stimulating the central nervous system and increasing respiratory drive. Typically given intravenously or orally, the standard dosing is a loading dose followed by daily maintenance. Side effects may include tachycardia, irritability, or feeding intolerance.
A helpful teaching point for parents is framing it as a “breathing reminder” medicine can help them understand its importance.

Inhaled Nitric Oxide (iNO)

iNO is given to infants with persistent pulmonary hypertension of the newborn (PPHN). It works as a selective pulmonary vasodilator, improving oxygenation without lowering systemic blood pressure. It is administered via inhalation through the ventilator circuit. Side effects can include methemoglobinemia and rebound pulmonary hypertension if weaned too quickly.
When discussing with families, it’s useful to explain that iNO is not oxygen itself but a gas therapy that relaxes the blood vessels in the lungs so oxygen can work more effectively.

Sildenafil

Sildenafil is sometimes used for chronic pulmonary hypertension in infants. By inhibiting phosphodiesterase-5, it promotes pulmonary vasodilation. It can be given orally or intravenously, though oral is most common. Doses are carefully titrated, and side effects include hypotension and flushing.
A key point for nurses: sildenafil is often continued long-term after NICU discharge, meaning parent education around monitoring breathing and blood pressure is essential. This is a medication used for BPD patients.

Racemic Epinephrine

Racemic epinephrine is typically used for acute airway swelling or post-extubation stridor. It works as a bronchodilator and vasoconstrictor, helping reduce upper airway edema. It is given via nebulization, and side effects may include tachycardia, hypertension, or rebound stridor.
Parents often fear when their baby suddenly develops stridor—explaining that racemic epi is a fast-acting rescue medication for airway swelling can help normalize what may otherwise feel alarming.

Albuterol

Albuterol is used in infants with bronchospasm, bronchopulmonary dysplasia (BPD), or wheezing. It acts as a beta-2 agonist, relaxing smooth muscle in the airways. It is usually given via nebulization, and side effects include tachycardia, jitteriness, and hypokalemia. Tachypnea is something to pay attention to after this medication is given.
An unusual but important point: in neonates, albuterol is often trialed to see if it helps, as not all infants respond. Nurses play a key role in observing whether there is clinical improvement.

Systemic Steroids (Dexamethasone, Prednisolone)

Steroids are used in severe BPD or to help facilitate extubation. They work by reducing inflammation and improving lung compliance. Administration may be oral or intravenous, with dosing regimens varying based on indication. Side effects include hyperglycemia, hypertension, and risk of neurodevelopmental concerns with prolonged use.
A critical parent conversation is balancing risks and benefits—explaining that steroids may help the baby get off the ventilator but are not without long-term considerations.

Lasix (Furosemide)

Lasix is a diuretic commonly given to infants with pulmonary edema or fluid overload contributing to respiratory distress. It works by inhibiting sodium and chloride reabsorption in the kidneys, reducing fluid volume. It can be given IV or orally, with side effects including electrolyte imbalances, dehydration, and ototoxicity with high doses.
Parents often understand Lasix best when explained as a medication that “helps the baby pee off extra fluid so the lungs can work better.”

Hydrocortisone

Hydrocortisone may be used for infants with evolving BPD, adrenal insufficiency, or refractory hypotension. As a glucocorticoid, it reduces inflammation and supports blood pressure. It is usually administered intravenously. Side effects include hyperglycemia, hypertension, and possible gastrointestinal perforation in preterm infants.
A nursing pearl: always monitor for feeding intolerance in preemies receiving hydrocortisone, as gut complications—though rare—can be severe.

Final Thoughts

Respiratory medications in the NICU are complex, highly specific to neonatal physiology, and often carry unique side effects and considerations. As nurses, our role extends beyond safe administration—we are educators, observers, and advocates for both infants and their families. When we understand the “why” behind each medication, we not only strengthen our own practice but also empower parents to feel more confident in their baby’s care. Whether it’s surfactant in the first hours of life or diuretics for chronic lung disease, these medications can change the trajectory of an infant’s hospitalization.