Neonate Respiratory Distress Syndrome

1. Respiratory Distress Syndrome (RDS)
or
Hyaline Membrane Disease (HMD)
Prepared by
Om Prakash Choudhary
1/6/2021
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2. We will discuss
 Introduction & Definition
 Epidemiology
 Etiology
 Pathogenesis & Pathophysiology
 Clinical manifestation
 Diagnosis
 Management
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3. Introduction
 Neonatal respiratory distress syndrome (NRDS), also called
hyaline membrane disease; the commonest respiratory disorder
among preterm neonates.
 It is a syndrome caused in premature neonates by
developmental insufficiency of ‘surfactant’ production and
structural immaturity in the lungs.
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4. Definition
“It is defined as an acute lung disease of the newborn (especially the
premature newborn), lungs cannot expand because of a wetting
agent is lacking, characterized by rapid shallow breathing and
cyanosis and the formation of a glassy hyaline membrane over the
alveoli.”
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Medical dictionary 2015

5. Epidemiology:
 RDS affects 40,000 infants each year in the US and accounts
for approximately 20% of neonatal deaths.
 RDS affects 50,000 infants each year in the India and accounts
for approximately 28.5% of neonatal deaths.
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Kumar A et al. indian J pediatr.1996

6. Epidemiology Cont…
 RDS typically affects infants <35 weeks gestational age (GA)
but may affect older infants who have delayed lung maturation.
 Approximately 50% of the neonates born at 26-28 weeks of
gestation develop RDS
 <30% of premature neonates born at 30-31 weeks develop
RDS.
Fanaroff and Martin’s Neonatal-Perinatal medicine,2013
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7. Etiology
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8. Etiology Contd…
 There are many factor involve in developing NRDS:
1. Prematurity
2. Low birth weight
3. Genetic factor
4. Contributing factors
5. Secondary surfactant deficiency
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9. Etiology Contd….
24-25 weeks gestation 95-100% get RDS
26-27 weeks gestation 50-70% get RDS
28-30 weeks gestation 20-40% will get RDS
31-36 weeks gestation
10-20% will get RDS
Term neonates < 1%
1. Prematurity or Young gestational age
Canberra Hospital Neonatal Intensive Care1/6/2021
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Incidence of RDS α 1 .
gestational ageType
equation here.

10. Etiology Contd…
2. low birth weight :
 71% incidence in infants of 500g -750g
 54% incidence in infants of 750g –1000g
 36% incidence in infants of 1000g-1250g
 22% incidence in infants of 1250g -1500g
Fanaroff M et al, Neonatal-Perinatal medicine. 20131/6/2021
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Incidence of RDS α 1 .
Low birth weight

11. Etiology Contd…
3. Genetic factor
Genetic
factor
White race
History of
RDS in
sibling
Male
gender
Surfactant
production
disorder
Mutation
of gene
Anadkat j S et al.2014
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12. Increased risk for respiratory distress among white, male, late
preterm and term infants
In this study white race and sex in infants with (GA) 34 to 42
weeks, (n=286 454) within 12 hospitals in the California.
Conclusion: Male sex and White race independently increase risk
for RDS in late preterm and term infants.
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Anadkat J S et al. Journal of Perinatology.2012

13. Etiology Contd…
Contributing
factors
Maternal
diabetes
Fetal
asphyxia
Cesarean
delivery
without
preceding
labor
Second
of twins
4. Contributing factors
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• high insulin levels decrease surfactant production
• increased fetal blood glucose results in increased
fetal insulin production
Birth asphyxia is a condition of impaired gas exchange
occuring during labor leading to progressive hypoxia
associated with carbon dioxide retention and significant
metabolic acidosis

14. Etiology Contd…
Secondary
surfactant
deficiency
Pulmonary
infections
Meconium
aspiration
pneumonia
Oxygen
toxicity
Congenital
diaphragmatic
hernia
5. Secondary surfactant deficiency
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15. Phases of Lung Development and
surfactant
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16. What is Surfactant ???
 Complex lipoprotein
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Phosphatidylcholine
65%
Natural lipids
10%
Phosphatidylglycerol
5%
Phosphatidylethanolamine
5%
Phosphoatidylnositol
5%
SP-A
2%
SP-B
2%
SP-C
2%
SP-D
2% Other protein
2%

17. Surfactant Metabolism
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18. Pulmonary Surfactant
Structure of lung surfactant
Protein 10% of lung surfactant
Consists of small proteins
 Hydrophobic protein
SP-B and SP-C
 Hydrophilic proteins
SP-A and SP-D
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19. Pulmonary Surfactant Contd…
SP-B
 Required for normal pulmonary function
 Abnormal expression of SP-B Can cause severe lung disease that is
lethal in perinatal period
SP-C
 Promotes formation of phospholipid film
 SP-C deficiency do not cause respiratory distress at birth
Hydrophilic SP-A and SP-D
 They are host defense of the lung
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20. Pulmonary surfactant
The timing of lung surfactant or (Lecithin) production
 At 32-34 weeks fetal cortisol increase
 Stimulate Type II pneumocyte cells
 By 34-36 weeks sufficient amount of Lecithin secreted into
alveolar lumen
 Excreted into the amniotic fluids
 Lecithin concentration in amniotic fluid indicate lung maturity
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21. Function of surfactant
Decrease the surface tension.
To promote lung expansion
during inspiration.
To prevent alveolar collapse
and loss of lung volume at the
end of expiration.
Facilitates recruitment of
collapsed alveoli.
www.medscape.com 20:10,18.08.2015 1/6/2021
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22. The Laplace Relationship
Explains the relationship between intra-alveolar pressure (P)needed
to counteract the tendency of the alveoli to collapse under the force
of surface (wall) tension (ST) and the radius (r ).
The pressure (P)needed to stabilize the respiratory system from
within is directly proportional to twice the surface tension (ST)and
inversely proportional to the radius (r)of the structure
H2O molecules
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D Henry et al 2003
P = 2 x ST
r

23. Cont….
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24. Pathogenesis of hyaline membrane disease
.
Prematurity<36wk
Multiple
pregnancy
Maternal diabetes
Caesarean section
Amniotic fluid
aspiration
Immature & damage type-II pneumocytes
Low level of
surfactant
Lungs collapse
Hypoxia
Pulmonary
vasoconstriction
Endothelial
damage
Fibrin hyaline
membrane
Alveolar lining
cell damage
.
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Manual NNF 2013

25. Cont…
PREMATURITY
Reduced surfactant synthesis, storage and release
Decreased alveolar surfactant
Increased alveolar surface tension
Atelectasis
Uneven perfusion Hypoventilation
Hypoxemia and CO2 retention
Acidosis
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26. Cont…
Acidosis
Pulmonary vasoconstriction
Pulmonary Hypertension
Endothelial damage Epithelial damage
Plasma leak into alveoli Fibrin and necrotic
cells (hyaline membrane)
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Manual NNF 2013

27. Pathophysiology in RDS
Dismissed
surfactant
Progressive
atelectasis
Hypoventila
tion
(disturbed
V/Q)
Pco2 ,
Po2, pH
Hypotension
”shock”
Pulmonary
vasoconstriction
Alveolar hypo
perfusion
Impaired
cellular
metabolism
Transient tachypnea
Asphyxia
Hypothermia
apnea
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28. Clinical manifestations
 C = Cyanosis
 H = Hypoxia
 I = Intercostal retractions/ subcostal retraction
 L = low body temperature ( Hypothermia)
 D= Difficulty breathing (birth) progressively worse
 I = Immature neonates (apnea)
 N = Nasal flaring
 T = Tachypnea
 E = Expiratory grunting ( partial closure of glottis)
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NNF manual 2003
We can make a
mnemonic
“CHILD IN TroubleE”

29. Chest wall Retractions
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30. Diagnosis of RDS
 Good history
 Assess by assessment scales
 Clinical presentation
 CXR
 ABG
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31. Prenatal Diagnosis Contd….
 History of premature delivery( perinatal )
 Concentration of lecithin in amniotic fluids
 Ratio of lecithin/sphingomyelin
 Lecithin indicate lung maturity
 Sphingomyelin remains constant during pregnancy
 L/S ratio 2:1 indicate lung maturity
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32. Prenatal Diagnosis Contd….
 Blood gases ( PCo2, Po2 )
 Pulse Oximetry (Spo2<87%)
 Complete blood count
 Electrolytes, glucose, renal and liver function
 Blood Culture to rule out sepsis
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33. Prenatal Diagnosis Contd….
Assessment of severity of the respiratory Distress in two methods
A. Downe’score
Parameter 0 1 2
RR(per min) <60 60-80 >80
Cynosis Absent In room air In 40%O2
Grunt Absent Audible with a
Stethoscope
Audible with a
nacked ear
Retraction Absent Mild Moderate –
sever
Air entry Good Diminished Barely Audible
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NNF NNP data base 2003
A score of >6 indicates impending respiratory
failure and warrants mechanical ventilation

34. B. Silverman –Anderson score
A score of >6 indicates impending respiratory failure and warrants mechanical
ventilation 1/6/2021
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NNF NNP data base 2003
A score of >6 indicates impending respiratory
failure and warrants mechanical ventilation

35. Prenatal Diagnosis Contd….
 Ground glass appearance
 Symmetrical
 Air bronchograms
 Reduced lung volume
CXR-FEATURES
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36. Respiratory Disorders in the Newborn:
Identification and Diagnosis
 Radiographically in HMD lungs demonstrate the typical
“ground glass” appearance that represents diffuse atelectasis
and “air bronchograms” bronchograms”that reflect the
contrast of the relatively airless parenchyma against the air-
filled bronchi.
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Aly H, Article of neonatology, 2004

37. Prenatal Diagnosis Contd….
Pulmonary Function
 Compliance decrease
 Functional residual capacity is reduced
 Hypoxemia secondary to mismatch of ventilation,
 Alveolar ventilation is decreased
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38. Management of RDS
1. Prevention
2. Medical management
3. Nursing management
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39. Management of RDS Cont…
1.Prevention of RDS
A. Prevent premature delivery
• Adequate bed rest
• Administer tocolytic agent as prescribe by physician
B. Determine lung maturity to plan delivery by
• Biochemical tests
• Biophysical tests
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40. Management of RDS Cont…
 Biochemical tests to determine lung maturity:
• Lecithin/sphingomyelin (L/S) ratio: Ratio >2 indicates low risk
for RDS.
• Phosphatidylglycerol
• Fluorescence polarization test
 Biophysical test to determine lung maturity :
• Foam stability index
• Lamellar body count
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41. Management of RDS Cont…
C. Antenatal Corticosteroids(ACS) Use
 Leads to improvement in neonatal lung function by:
• Enhancing maturation changes in lung architecture.
• Induction of lung enzymes leading to biochemical maturation.
 Types of ACS Used:
• Betamethasone 12mg IM q 24hrs X 2 doses
• Dexamethasone 6mg IM q 6hrs X 4 doses.
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F Brownfoot et al.2013

42. Management of RDS Cont…
 ACS should be given to all women at high risk for preterm
delivery at < 34 weeks unless impending delivery is anticipated.
Benefits accrue within few hours of administration.
 Multiple course of ACS is not encouraged, however rescue
therapy may be considered if several wks have elapsed since
initial course and GA is still <28-30 wks.
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43. Management of RDS Cont…
• Multiple weekly dosing is not encouraged.
• ACS is recommended despite presence of prolonged ROM at
GA 24-32 wks when there is no evidence of chorioamnionitis.
• ACS is not recommended before 24 wks or after 34 wks GA.
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44. Management of RDS Cont…
Benefits of ACS
For GA 24 -34 wks, ACS result in:
 Reduction in severity of RDS
 Reduction incidence of intraventricular haemorrhage
 Reduction in mortality
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45. Stimulation of fetal lung maturation with
dexamethasone in unexpected premature labour.
This study include 150 pregnant women which delivered before 37
week of gestation.
CONCLUSION
Dexamethasone accelerates maturation of fetal lungs, decrease
number of neonates with respiratory distress syndrome and
improves survival in preterm delivered neonates. Optimal
gestational age for use of dexamethasone therapy is 31 to 34 weeks
of gestation.
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Grgic G et all. Article in Bosnian 2013

46. Antenatal corticosteroids promote survival of extremely
preterm infants born at 22 to 23 weeks of gestation
Conclusions:-ACS exposure improved survival of extremely
preterm infants. ACS treatment considered for threatened preterm
birth at 22 to 23 weeks of gestation.
Rintaro M. Article of neonatology, 2011
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47. 2.Medical management
A. Respiratory support
B. Surfactant through ET
C. ABG Analysis do for ventilation status
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48. Cont…
B. Respiratory support
 Supplemental oxygen provide by
 Nasal Cannula
 Nasal CPAP by prongs or mask
• Bubble CPAP
• Ventilator CPAP
 Endotracheal intubation to keep O2 saturations above 87 % on
pulse Oximetry.
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49. Cont…
Indication of CPAP
 In delivery room for babies at risk of RDS
 Babies on low flow oxygen with respiratory distress
 Mechanical ventilation
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CJ morley et al med. 2008

50. Cont…
Bubble CPAP :-This CPAP device using soon after delivery.

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51. Cont…
Ventilator CPAP:- This CPAP device using for maintenance phase and
long term ventilation
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52. Continuous Positive Airway Pressure in Preterm Neonates: An Update of
Current Evidence and Implications for Developing Countries
 Conclusions: CPAP, if used early and judiciously, is an effective
intervention and need immediate scaling-up in resource-limited
settings.
Kumar P et al, indian paediatrics,2015
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53. Assisted ventilation for hyaline membrane
disease
 Results: Survival on assisted ventilation improved from initial
22.2% in 1989 to 77.8% in 1993. Of 19 babies weighing
between 750-1000g, 8 survived. 12 of 27 babies with a gestation
of less than 28 weeks survived. Survival rates in babies with
gestation of more than 33 weeks was 94%.
Singh M et al, IJP 1995
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54. Cont…
C. Surfactant through ET
 Prophylactic surfactant is given within 20 minutes of delivery
( GA < 30-32 Weeks ).
 Reduces incidence of
i. Pneumothorax
ii. Mortality in those <30 wks
 Early surfactant is given within 2 hrs of delivery.
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55. Available in market
.
Medicine
(Brand)
Volume
Conc.
(per ml)
Dosage
(recom)
Inter
b/w
Max.
doses
MRP
Neosurf
(CIPLA)
5ml &
3 ml
1ml=27mg
135 mg
per kg
12 hrs. 2
5 ml=8000
3 ml=4900
Survanta
(ABBOT)
8 ml &
4 ml
1ml=25mg
100mg
per kg
6 hrs. 2
8ml=12000
4 ml=7260
Curosurf
(NICHOLAS)
1.5 ml 1ml=80mg
200mg per
kg (first)
100mg per
kg (repeat)
12 hrs. 2 1.5ml=10,680
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S Ashwini et al.2009

56. Administration
 Dosage:
 Precautions:
 Check ETT position
 Close monitoring
 Do not shake vial
 Opened vials can be kept in refrigerator for up to 12 hours
[Do not freeze! Keep at 2-8oC]
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57. Administration
 Techniques: Rapid bolus administration
i) Through 5 Fr feeding catheter inserted into ETT:
A. Give as 4 equal aliquots, remove catheter and ventilate
0.5-2 min between doses
B. 2-4 postural changes recommended
a. Head up 10o, head to right, then left; followed by Head
down 10o, head to right then left
b. Right or left side dependent (Earlier Preferred)
European J. Perinat..2007 1/6/2021
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58. Administration
 Immediately after administration, watch for:
o Acute airway obstruction (ETT may get occluded):
bradycardia, cyanosis, hypotension
o Rapid improvement in oxygenation and ventilation
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59. Surfactant therapy in preterm infants with respiratory distress
syndrome and in near-term or term newborn with acute RDS
Conclusion :-Comparative trials with poractant alfa at a higher
initial dose of 200 mg/kg appear to decreased mortality in infants
<32 weeks gestation when compared with beractant. Early rescue
(<30 min of age) surfactant therapy is an effective method to
minimize over treatment of some preterm infants who may not
develop RDS.
surfactant therapy has been shown to be 70% effective in
improving
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Ramanathan R Journal of Perinatology.2006

60. Nursing management
.
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61. Nursing management
1. Assessment
 The most essential nursing function is to observe and assess the
infants response to therapy.
 Continuous close monitoring of the infant is mandatory as the
infants condition can change rapidly.
 Continuous pulse oximetry readings are required to determine
the FiO2 required. ABG monitoring is also necessary to decide
ventilator settings.
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62. Nursing diagnosis Expected outcome interventions
Risk of Ineffective
breathing pattern
related to
pulmonary
immaturity
Child will maintain
Normal breathing
pattern
- Assess the general condition of the
child
- Monitor the vital signs and oxygen
saturation every hourly
- Monitor the breathing pattern every
hourly.
- Provide a neutral thermal
environment.
- Instill normal saline nasal drops
every two hourly and keep nose
patent
- Make sure that there is proper
delivery of oxygen through oxygen
hood
Cont….
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63. Nursing diagnosis Expected outcome interventions
Ineffective
thermoregulation
related to immature
temperature control
and decreased
subcutaneous fat
Child maintains
normal body
temperature
-Assess the general condition of
child
-Monitor the temperature of the
child every hourly
-Maintain the temperature of the
incubator
-Provide additional dress like
sweaters, cap, nappy and soaks.
-Do not open the incubator door
frequently or for a long time.
Cont…
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64. Nursing diagnosis Expected outcome Interventions
Risk for Infection
related to deficient
immunological
defences, exposure to
environmental
pathogens and invasive
procedures
Child remains
protected from the
risk of infection
-Monitor the vital signs every hourly
-Maintain strict aseptic precautions for
every invasive procedure.
-Provide a neutral thermal environment.
-Administer antibiotics as per order.
-Maintain hygiene of the baby
-Inspect the umbilicus for any signs of
infection
-Maintain the cleanliness of the
incubator
-Advise the mother to maintain hand
hygiene before touching the infant
Cont…
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65. Nursing diagnosis Expected
outcome
Interventions
Risk for Imbalanced
nutrition less than
body requirement
related to inability
to ingest nutrients
Child
maintains
normal
nutritional
status
-Assess the nutritional status and hydration
status of the child.
-Assess the abdomen for any abdominal
distension and monitor the abdominal girth
every 6 hourly.
-Check the stools for colour, consistency,
and presence of any streaks of blood.
-Encourage breast feeding on demand and
every 2 hrs
-Nurse the baby in prone position or side
lying position after giving feeds.
Cont…
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66. References
1. Farrell P, Zachman R: In Quilligan EJ, Kretchmer N. Fetal and Maternal Medicine. New
York, John Wiley; 1980.
2. Fanaroff , Martin’s Neonatal-Perinatal medicine, Diseases of the fetus and Infant, 8th
edition,1097-1107, 2006.
3. Polin, Yoder, Burg Practical Neonatology, 3rd edition, 155-180, 2001
4. www.UpToDate.com. Overview of neonatal respiratory distress Disorder of transition.
2015.
5. Steinberg KP, Hudson LD, Goodman RB, et al, an efficacy and safety of corticosteroids
for persistent acute respiratory distress syndrome. N Engl J Med 2006, 354:1671-1684
6. Michael A. kahn, DDS/Lynn W.Solomon DDS.
7. Bernard GR, Luce JM, Sprung CL,et al. a high-dose corticosteroids in patients with the
adult respiratory distress syndrome. N Engl J Med 1987, 317:1565-1570.
8. Anne Greenough and et al; Neonatal Respiratory Disorders: 2nd Edition; 247-64
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67. Cont…
9. Kliengman and et al; Nelson Textbook of Pediatrics; 18th edition; vol.2; 731-41
10. Kumar and et al; Robbins Basic Pathology; 8th edition; 257-59.
11. Donna L Wong; Essentials of Pediatric Nursing; 5th edition;:259-63
12. Hockenberry and et al. Wong’sNursing Care of Infants and Children.7th edition.Mosby.2003;
379-88
13. Accessed from www.google.com (respiratory distress syndrome, hyaline membrane disease).
14. MV murali, Ray D, Paul VK, et al. continuous positive airway pressure with a face mask in infants
with hyaline membrane disease. Indian Pediatric 1988, 25: 627-31.
15. MT stahlman, Young WC, Payne G. Studies of ventilatory aids in hyaline membrane disease. Am J
Dis Child 1962,104: 526-32.
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68. Cont…
16. Crowley PA. Antenatal corticosteroid therapy: a meta-analysis of the randomized trials.
Am J Obstet Gynecol 1995; 173: 322–335.
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69. .
• .
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