Respiratory distress syndrome is a common condition among preterm neonates and . Assessing lung aeration assists in diagnosing the disease and helping to guide and monitor treatment. We aimed to identify and analyse the tools available to assess lung aeration in neonates with respiratory distress syndrome.A systematic review and narrative synthesis of studies published between 1 January 2004 and 26 August 2019 was performed using the OVID Medline, PubMed, Embase and Scopus databases.A total of 53 relevant papers were retrieved for the narrative synthesis. The main tools used to assess lung aeration were respiratory function monitoring, capnography, chest X-rays, lung ultrasound, electrical impedance tomography and respiratory inductive plethysmography. This paper discusses the evidence to support the use of these tools, including their advantages and disadvantages, and explores the future of lung aeration assessments within neonatal intensive care units.There are currently several promising tools available to assess lung aeration in neonates with respiratory distress syndrome, but they all have their limitations. These tools need to be refined to facilitate convenient and accurate assessments of lung aeration in neonates with respiratory distress syndrome.