seminar on respiratory distress syndrome

1. Dr. Yesmin Tanjin Jahan ( Y-1 )
Dr. Rumman ( Y- 4 )

2. S/O of Nupur , 1st issue of non
consanguinous parents, inborn got admitted
at 15 min of age with the complaints of
prematurity, Low Birth Weight & respiratory
distress soon after birth. At 29 weeks of
gestation mother delivered a male baby
weighing 920 gm by LUCS due to fetal
distress baby cried just after birth & she
received single dose of corticosteroid

3. 5 hour prior to delivery. But Baby developed
respiratory distress soon after birth .On
examination , vitals are normal except tachypnea
RR-75/Min . Downe’s score 3 . On Respiratory
system examination baby was tachypneic, chest
indrawing & grunting present . Other systemic
examination reveals no abnormality.

4.  What we think about ?
 What is our next plan ?

5. Respiratory distress
in Preterm Newborn

6. Outline
 Introduction
 What is Respiratory distress ?
 Incidence
 Some physiology
 Aetiology
 How to approach ?
 Laboratory evaluation

7. Outline
 Management
 Monitoring for & management of
complication
 Prevention

8. • Respiratory distress is one of the most common
reasons a neonate is admitted to the NICU. 15%
of term infant & 29% of preterm infants admitted to
the NICU develop significant respiratory morbidity,
this is even higher for newborn born before 34 wks
gestation.
Pediatr Rev. 2014 oct ; 35 (10) : 417 – 429 .
Introduction

9. What is Respiratory distress ?
According to the National Neonatal
Perinatal Database (NNPD) respiratory
distress is defined as, presence of any two
of the following features
 Respiratory rate>60/min
 Subcostal/intercostal recessions
 Expiratory grunting/groaning

10. In addition to the above features,
 nasal flaring,
 suprasternal retraction,
 decreased air entry on auscultation of the
chest

11. Incidence
 Almost 2.2-3.3% of the life born
infant.according to the NNPD data(2002-2003)
 5.8% of the life born infants had respiratory
morbidites.
 inversely proportional to the gestatinal age
and birth wt. in a prospective study it was found
that,almost 58% of the ELBW

14. Parenchymal
-
Extraparen
chymal
Pulmonary
Respiratory distress - Aetiology

15. Heart
Metabolic
Brain
Blood
Abdominal
Non pulmonary

16. RD in Newborn – Causes
Pulmonary
Parenchymal Extraparenchymal
* RDS (HMD) * Upper airway obstruction
* TTN (RDS II) (Cloanal atresia, stenosis)
* Aspiration (Blood * Pneumothorax
meconium) * Pleural effusion
* PPHN * Cong. Diaph. hernia
* Pneumonia * Diaphragmatic paralysis
* Pulm. hemorrhage
* Pulm. hypoplasia
AIIMS PROTOCOL

17. RD in Newborn – Causes
Extrapulmonary
Heart Metabolic Brain Blood Abdominal
CCF - Met. Acidosis - Haemorrhage - Hypovolemia - NEC
PDA - Hypoglycemia Edema Hyperviscosity - Pneumo
CCHD - Hypothermia - Drugs - Acute blood peritonium
Vascular - Sepsis Pain loss - Large mass
AIIMS PROTOCOL

18.  Tracheo-esophageal fistula
 Diaphragmatic hernia
 Lobar emphysema
 Pierre -Robin syndrome
 Choanal atresia
Surgical causes of respiratory distress

19. Respiratory distress
Preterm Term
<6 hrs old >6 hrs old <6 hrs old >6 hrs old
HMD
Pneumonia
Lung anatomy
Shock
Pneumonia
CHD
Pulmonary
haemorrhage
TTN
MAS PPHN
Asphyxia
Shock
Lung anatomy
Pneumonia
Polycythaemia
CHD
Mathai ss et al ,MJAFI 2007; 63 : 269-272

20. Preterm – Possible aetiology
 Early progressive - Respiratory distress
syndrome or hyaline
membrane disease
 Early transient - Asphyxia,
metabolic
 Anytime - Pneumonia

21. Term – Possible aetiology
 Early well looking - TTNB, polycythemia
 Early severe distress - MAS, asphyxia,
- malformations
 Late sick with - Cardiac
hepatomegaly
 Late sick with shock - Acidosis
 Anytime - Pneumonia

22. RR (bpm
Aspiration cong. Pneumonia, sev. HMD ,CDH
cardiac malformation
Approx. 6 Hours of age
Normal
60
Course of Neonatal Tachypnoea : Etiologic possibilities
Source : Baurn DJ, Birth Risks, Nastle Nutrition Workshop,
1993
TTNB
HMD

23. How to approach ?

24. Delivery room and emergency
assessment
Obstructive airway:
Gasping
Choking
Striodor
Insufficient breathing:
Apnea
Poor respiratory effort

25. Delivery room and emergency
assessment
Circulatory collapse:
Bradycardia
Hypotension
Poor perfusion
Poor oxygenation :
Cyanosis

26. Relevant history in a Neonate with
Respiratory distress
Fever
/UTI
Diabtes
mellitus
Poly/ Oligo
hydramnion
APH
Fetal
assessment
Rh -
isoimmuniation
ANC
H/O
Consanguinity
Antenatal

27. PPROM
/PROM
Chorioamnionitis
/fever
Meconium stained
fluid
Birth trauma
Detail of
resuscitation
Natal

28. Post natal
Gestational
age
Postnatal
age
Onset Course of distress
Malfeeding
Choking & coughing
during feeding

29. Does the NB have spontaneous cough?
 Spont. Cough, always abnormal in NB
 Causes of cough in NB : CRADLE
C cystic fibrosis
R respiratory infection
A aspiration (reflux, TE fistula)
D dyskinesia of cilia

30. L lung, airway, vascular malformation
E edema (heart failure, BPD)
Fletcher MA, 1998, Physical diagnosis in neonatology

31.  Signs of prematurity
 Features of
IUGR
Look for

32. Colour
 Cyanosis

33.  Dusky red
 Pale

34. Perfusion
 Capillary Refill Time (CRT)
 Blood Pressure

35. As
Sd
Q
As
Cd
Fr
M
 Vital signs
 Oxygen saturation

36. Nm
 Scaphoid abdomen
 Meconium staining
 Single umbilical artery
 Dysmorphic facies

37. Physical characteristics
 Flat nasal bridge, Simian crease,
recessed chin, low set ears

38.  Extra digit
 Gastroschisis

39.  Muscular
Hyoptonia vs Hypertonia
 Skeleton
Choanal Atresia, Osteogenesis
Imperfecta
 Others
Hepatomegaly, situs inversus

40. Respiratory system examination
Vb
 Respiratory rate
 Asymmetry of chest shape/ movement
ension pneumothorax, pleural effusion,H,
Diaphragmatic paralysis, PIE.
A As
Inspection
Tension pneumothorax, Pleural effusion

41. Respiratory system examination
Vb
Increased A-P diameter of chest
 Pneumothorax, effusion or CDH
Features of respiratory distress

42.  Air entry
 Breath sound
 Added sound , such as crepitation
Auscultation
 Early, coarse crackles
Pneumonia & HMD
 Late crackles

43. Feature Score 0 Score 1 Score 2
Cyanosis None In room air In 40% FiO2
Retractions None Mild Severe
Grunting None Audible with
stetho.
Audible
without stetho.
Air entry Normal Decreased Barely audible
RR < 60 60-80 > 80 or apnea
Score > 4 = Clinical respiratory distress
Score> 7= Impending respiratory failure
Downe’s score

44. Score Upper
chest
retraction
Lower
chest
retraction
Xiphoid
retraction
Nasal
dilatation
Grunt
0 None None None None None
1 Lag-
inspiration
Just
visible
Just
visible
Minimal Stethos
cope
only
2 See-Saw Marked Marked Marked Naked
ear
Score > 4 Clinical respiratory distress
Scpre> Impending respiratory failure
Silverman score

45. Test Method result diagnosis
Hyperoxia 100 % fio2 5-10
min
Pao2 increases
to > 100 torr
Pao2 increases
by < 20 torr
Parenchymal
lung disease
PPHN / CCHD
Hyperoxia-
hypervetilation
MV 100 % fio2
& VR 100-150 /
min
Pao2 increases
to > 100 torr
w HV
Pao2 increases
at critical Pco2
No increase in
Pao2 with HV
Parenchymal
lung disease
PPHN
CCHD
Hyperoxia test

46. RD in Newborn – Clinical Differences
Symptoms &
signs
Pulm.
disorder
CVS
disorder
CNS
disorder
Metabolic
disorder
Tachypnea + + + or apnea +
I/C Recession +++ ± - ±
Expiratory
grunt
+ - - -
Cyanosis + ++++ + -
Hepatomegaly + +++ - -
History Prematurity
PROM,
Polyhydra
mnion.
Rubella Breech
Hypotonia
birth asphyxia
Preterm
increase
protein intake
Seizures Rare Absent May occur Common
Auscultation ± Murmur - -
RD in newborn – Clinical difference

47. Laboratory Evaluation for Respiratory
Distress in the Newborn
• Chest radiography
• Arterial blood gas
• Pulse oximetry
• Blood glucose
• Complete blood count with differential
• Blood culture
• Lumber puncture
• Echocardiography and
• CT of thorax

48. Chest radiography
• Indication:
• For initial diagnosis of the cause of
respiratory distress
• To check the position of tubes
• Respiratory deterioration
• When not to do ?

49. • Lungs
– Lung Volume
– Expansion
– Densities
• Fluid/ collapse (atelectasis)>>white
• Free Air>>dark
• Mass
• Heart shape and size
– Boot shaped
– Egg or Oval shaped
– cardiomegaly

50. Roentgen Finding in RD in the Neonate
Pulmonary infiltrates Aeration e/o PAL
Distributio
n
Characteristis
Hyaline
membrane
disease
Diffuse Fine reticulogranula
pattern with air
bronchograms
Hypoaeration Present usually
as a complication
of respirator
therapy
Transient
tachypnoea
Diffuse Symmetrical stringy
perihilar infiltration
Hypoaeration Uncommon
Meconium
aspiration
syndrome
Usually
diffuse
Bilat patchy, course
infiltrate & atelectasis
alternating with areas
of alveolar
emphysema
Hypoaeration Often seen in the
absence of
respiratory
therapy
Neonatal
pneumonia
Variable but
usually
asymmetrica
l & localized
Variable pattern
ranges from localized
to diffuse alveolar or
interstitial disease
Mild
hyperaeration
Uncommon

51. X-ray - RDS

53. X-ray - MAS

54. MAS

55. MAS

56. X-ray- TTNB

57. X-ray – Congenital pneumonia

58. X-ray - Pneumothorax

59. Pneumonia/ Sepsis

60. Pneumothorax

61. PneumothoraxRight lateral decubitus
view of pneumothorax

62. Pneumopericardium

63. Pulse oximetry
• Effective non invasive monitoring of
oxygen therapy
• Ideally must for all sick neonates and
those requiring oxygen therapy
• Maintain SaO2 between 90 – 93 %

66. Shake test
• Take a test tube
• Mix 0.5 ml gastric aspirate +
0.5 ml absolute alcohol
• Shake for 15 seconds
• Allow to stand 15 minutes for
interpretation of result

67. RD in Newborn – Differential Diagnosis
Condition Gestation History Clinical signs
RDS PT>FT APH/IDM asphyxia Retractions, grunt
Pneumoni
a
Any PROM, smelly
liquor, fever in
mother
Hypo/hyperthermia
leukocytosis or
neutropenia
MAS FT NSAF, asphysia
MA
Distended chest
Meconium staining
TTNB FT>PT C section Tachypnoea ++
PPHH Usually
FT
Asphyxia Profound cyanosis
CVS normal

68. Management
Basic principle of treatments are:
• Supportive care
• Respiratory support
• Monitoring for and Mx of complication

69. Supportive therapy
Thermal care
Maintain normal glucose level
Monitoring vital sign and
Scoring of respiratory distress

70. Respiratory support
Supplemental oxygen
CPAP
Mechanical ventilation

72. Indications for oxygen therapy
• The treatment of documented
hypoxia/hypoxaemia as determined by SpO2 or
inadequate blood oxygen tensions (PaO2).
• Achieving targeted percentage of oxygen
saturation (as per normal values unless a
different target range is specified on the
observation chart.)
• Shock
• convulsion

73. • The treatment of an acute or emergency situation
where hypoxaemia or hypoxia is suspected, and if
the child is in respiratory distress manifested by:
– dyspnoea, tachypnoea, apnoea
– pallor, cyanosis
– lethargy or restlessness
– use of accessory muscles: nasal flaring, intercostal
or sternal recession
• Short term therapy e.g. post anaesthetic or surgical
procedure

74. Indications of CPAPA
• Recently delivered premature infant with
minimal respiratory distress and low
supplemental oxygen requirement
• Respiratory distress and requirement of FiO2
above 0.30 by hood
• FiO2 above 0.40 by hood
• Clinically significant retractions and/ or
distress after recent extubation
• Apnoea of prematurity

75. Indication of mechanical ventilation:
• Absolute indications:
• Sudden collapse with apnoea, bradycardia & failure to
establish satisfactory ventilation after a short period of bag
mask ventilation.
• Failure to establish adequate spontaneous ventilation in
the labour ward after prompt and active resuscitation
• Prolonged apnoea
• PaO2 below 50 mm Hg or FiO2 above 0.80. this indication
may not apply to the infant with cyanotic congenital heart
disease.
• Paco2 above 60 mm Hg with persistent academia.
• General anesthesia.

76. • Relative indications:
• Frequent intermittent apnoea unresponsive to
drug therapy.
• Early treatment when use of mechanical
ventilation is anticipated because of deteriorating
gas exchange.
• Relieving WOB in an infant with signs of
respiratory difficulty.
• Administration of surfactant therapy in infants
with RDS.

77. Selection of ventilation mode:
•When the patient is first intubated or during periods of instability
A/C mode is customarily utilized because it provide maximal
ventilatory assistance.
•When the patient is being evaluated for removal of machine
support, pressure support ventilation, SIMV, CPAP or combination of
these modes are employed.
Initial conventional M/V settings
* Congenital myopathy, fractured cervical spine, severe neurological depression due to birth asphyxia, drugs
or preterm babies with recurrent apnoea
Normal lungs*
Abnormal
lungs
RDS MAS BPD
PIP 15 18-20 20-25 Higher (22) 20-30
PEEP 3 3 4-5 3-5 5-6
Rate 20-30 60 20-40 Faster (<50) 10-15
Inspiratory time 0.35-0.4 0.3-0.4 0.3 lower 0.4-0.5
FiO2 0.21-0.3 0.6-0.8 0.4-1.0

78. Pharmacological respiratory support
and surfactant
• Bronchodilators and respiratory stimulants
• Anti inflammatory agents
• Inhaled gas mixtures
• Other medications
• Sedatives and paralyzing agents

79. Indication of surfactant therapy
• PROPHYLACTIC
• (Administration after initial resuscitation but within 10 to 30 minutes
after birth)
• Babies born ≤26 weeks gestation
• Babies <28 weeks gestation and/or mother not given steroid
• All preterm Babies who require intubation during
resuscitation/stabilisation
• RESCUE SURFACTANT THERAPY
• Babies with RDS should be given rescue surfactant early (within 2hours)
• 1.Babies <26 weeks’ gestation when FiO 2 requirements >0.30
• 2.Babies >26 weeks when FiO 2 requirements >0.40 and
Clinical and radiographic evidence of RDS

80. Monitoring for and management of
complication
Worsening of disease
Hemodynamic instability
PPHN
Complications of mechanical ventilation

82. Prevention
• Regular antenatal check up
• Antenatal corticosteroid in preterm delivery
• Institutional delivery
• Proper management of complications at
birth
• Infection control
• Early identification and prompt cost effective
treatment

83. THANK YOU