Abstract Respiratory distress syndrome (RDS) occurs predominantly in premature infants and is a direct consequence of surfactant deficiency. The incidence of RDS is inversely related to gestational age and the weight of the newborn. There are a multitude of risk factors for RDS which increase the incidence of the condition. The use of antenatal corticosteroids and early surfactant use along with more gentle modes of ventilation have all contributed to a dramatic improvement in the mortality and morbidity associated with RDS. Over the years our understanding of the pathophysiology of RDS has greatly increased and this has aided the advances in treatment of this condition. This article covers the most up to date and relevant information surrounding the pathophysiology of RDS.