Neonatal respiratory distress syndrome

2. RESPIRATORY DISTRESS
and Respiratory Distress
Syndrome
Paktia University
Medical faculty
Neonatology
Prepared By Ustad Maail Khan Mangal
2022/may/28

3. RESPIRATRORY DISTRESS
It is defined as presence of
u Tachypnea (RR>60/min)
u chest indrawing
u Grunting
u Flaring of alae nasi
u And cyanosis.
It can be due to respiratory and non-respiratory causes.
early recognition and prompt treatment is essential to improve the outcomes.

4. Clinical signs of peripheral respiratory distress:
u 1- Mild :Tachypnea (>60 Imin) & working alae nasi
u 2- Moderate :As mild plus → Intercostal & subcostal retractions.
u 3-Severe :As moderate plus → Grunting
u 4- Advanced : As severe plus → Central cyanosis, disturbed consciousness

5. Causes of RD
(Pulmonary causes of respiratory distress)
Causes Time of onset Remark
RDS or HMD First six hours of life Common in preterm neonates
MAS First six hours of life Common in term, post-term,
H/X of meconium-stained liquor
Pneumonia Any age Often bacterial
TTN First six hours of life Tachypnea with minimal distress; lasts for 48- 72
hrs.
Pneumothorax Any age Sudden deterioration; usually during assisted
ventilation.
Tracheoesophageal fistula, DH Any age May show associated malformation; polyhydramnios
in esophageal atresia.

6. Causes of RD
(Non Pulmonary causes of respiratory distress)
Cardiac Congestive heart failure; congenital heart disease
Metabolic Hypothermia, Hypoglycemia, metabolic acidosis
CNS Asphyxia, cerebral edema, hemorrhage
Chest wall Asphyxiating thoracic dystrophy

7. Clinical points:
Respiratory causes
u if a preterm baby has respiratory distress within the first few hours of life, the most likely cause is (RDS).
u if a term baby born to a mother with meconium-stained liquor develops respiratory distress within the first 24
hours, the most likely cause is (MAS).
u Presence of suprasternal recessions with or without stridor indicates upper airway obstruction.
u A term baby with C.S developing tachypnea in the first few hours of birth is likely to have TTN.
u If a baby has RD and Unable to pass a nasal tube through nostril after birth, the cause is Choanal atresia.
u If a baby has RD and heart sounds deviated to the right , flat abdomen ,H/X of Poly hydramniosis , the most
likely diagnosis is Diaphragmatic hernia.
u If a baby has RD and mother has history of PROM, mother presenting with fever , the most likely diagnosis is
Infectious pneumonia.

8. Cont…
Non pulmonary causes
u It should be noted that chest retractions are mild or absent in RD due to non
respiratory cause.
u If a neonate with distress has cyanosis or hepatomegaly cardiac etiology
should be suspected.
u A preterm neonate having a systolic murmur with tachypnea and hepatomegaly
is likely to have PDA.
u Neonate with BA, cerebral hemorrhage, meningitis can present with
tachypnea and respiratory distress, usually lethargic with poor neonatal reflex,
apneic attack.

9. Downe Score
O-3 mild RD
4-6 mod RD
7-10 severe
OR 1-6 respiratory distress
>6 impending respiratory failure

10. Respiratory Distress Syndrome (RDS)
(Hyaline Membrane Disease)(HMD)
u A syndrome o f respiratory distress occurs in the newborn due to surfactant
deficiency, RDS is the commonest cause o f neonatal death.
u RDS is common in preterm babies less than 34 weeks of gestation.
u The over all incidence is 10-15% but can be as high as 80% in neonates <28 weeks.

11. Risk Factors
u prematurity
u Asphyxia
u Acidosis
u maternal diabetes
u and Cesarean section.

12. Pathophysiology
u ↓Surfactant → ↑ alveolar surface tension → diffuse alveolar collapse
(atelectasis).
u during inpiration → higher pressure is required to initiate lung inflation →
increased work o f breathing with impaired gas exchange →
hypoxemia , hypercapnia and respiratory acidosis.
u Hypoxemia and acidosis→ pulmonary vessels vasoconstriction →alveolar
hypoperfusion → ↓metabolism o f alveolar cells type II →more surfactant
deficiency → progressive atelectasis. and the neonate eventually goes into
respiratory failure.
u And Right to left shunting across the foramen Ovale.
Ischemia damage to the alveoli causes transudation of proteins into the alveoli that form Hyaline membrane

13. Pathophysiology

14. Clinical picture
u Respiratory distress usually occurs within the first 6 hours of life.
u Clinical features include
✓ tachypnea
✓ retractions
✓ grunting
✓ cyanosis
✓ and decreased air entry.
u Auscultation:- In severe cases → diminished air entry
→ bilateral fine basal crepitations

15. Investigations
1- Prenatal diagnosis:
u Done on samples from amniocentesis or maternal vagina after ruptured membranes
u 1- Lecithin/sphingomyelin ratio :
u If> 2.5 → Mature lung → No risk of RDS
u If1.5-2 → Transitional lung → Risk of RDS
u If< 2.5 → Immature lung → Severe RDS
u 2- Saturated phosphatidyle choline:
u * If >500 ℳg/dl → immature lung
u * If <500 ℳg/dl → mature lung

16. 2- Post natal diagnosis:
u 1- Suspected clinically in cases with respiratory distress in presence o f risk factors
Diagnosis can be confirmed by chest X-ray.
✓ reticulogranular pattern
✓ ground glass opacity
✓ low lung volume
✓ air bronchogram
✓ and white out lungs in severe disease

17. CXR

18. Cont…
u 3- Shake test:
u * Done on gastric aspirate before baby is one hour age →
u *Add 0.5 ml gastric aspirate to 4ml saline and 0.5 ml absolute alcoho l → shaking:
-Absence of bubbles → indicate absent surfactant
- Incomplete circle of bubbles → intermediate risk of RDS
-Double rows o f bubbles or more → no risk of RDS (mature lung)

19. Cont…
u 4- Arterial blood gases:
*In severe RDS: hypoxemia+ hypercapnia+ respiratory acidosis
u 3- Sepsis workup: Blood picture & blood culture to rule out
early onset sepsis.

20. Complication
IVH
Pneumothorax
Pneumonia
Pulmonary hemorrhage
Hypoglycemia
DIC
BPD
PDA
Severe metabolic acidosis

21. Prevention of RDS
u 1- Avoid risk factors:
- Control maternal diabetes
- Avoid unnecessary CS
- Avoid prematurity

22. u 2- Antenatal steroid therapy:
-Value: steroid enhance surfactant production and accelerate lung
maturity.
- Indications: must be considered in any pregnant woman of 26 to 34
weeks gestation who are at risk for preterm delivery.
- Dose: Betamethasone 12 mg/IM; two doses 24 hours apart. Or
dexamethasone, 6 mg IM, every 12 hours for 48 hours, with a total
of 4 doses.
u 3- Immediate postnatal surfactant and/ or nasal CPAP for very low
birth weight.
Cont …

23. Treatment of RDS
u 1-Incubator care
u 2· Respiratory support to Keep oxygen saturation above 90%).
u 3- Support circulation ; Iv fluid,
u 4- Support nutrition
u 5· Symptomatic treatment:

24. Cont…
u 6- Antibiotics Give ampicillin and Gentamycin
u 7- Surfactant - Immediate after birth for very low birth
weight (prophylactic treatment).
Dose: - 3 - 5 ml/Kg per dose in endotracheal tube. For 2-4
doses at 6-12 hours intervals.

25. Nasal Continuous Positive Airway Pressure
u keep PaO 2 between 50 and 70 mm Hg (91–95% SaO 2 )
u If there is severe retractions and expiratory grunting or if
SaO 2 cannot be kept >90% applying nCPAP at 5-10 cm H2 O
is indicated.
u Nasal CPAP reduces collapse of surfactant-deficient alveoli
u Early use of nCPAP reduces the need for mechanical
ventilation.

27. Prognosis
u It depends upon the gestation and level of nursing care.
u Surfactant therapy has reduced mortality of RDS.

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