Respiratory Distress Syndrome,

Transient Tachypnea of the Newborn

and Meconium Aspiration Syndrome

Reporter:
YUQUE, Marian Joyce Princess G.
Senior Clerk
Group 6, subgroup 2

November 10, 2021

Topics for discussion

Respiratory Distress Syndrome

Meconium Aspiration Syndrome

Transient Tachypnea of Newborn

Respiratory
Distress
Syndrome
 TABLE OF CONTENTS

Incidence & Risk Factors Diagnosis & Prevention

Etiology & Pathophysiology Treatment

Clinical Manifestation Complications

1 Incidence
AKA Hyaline Membrane Disease ( HMD )
occurs primarily in premature infants
inversely related to gestational age and
birthweight
 Risk Factors
1
Pregnancy with chronic or
Maternal diabetes
pregnancy-associated
Multiple births
hypertension
Cesarean delivery
Maternal heroine use
Precipitous delivery
Prolonged rupture of
Asphyxia
membranes
Cold stress
Antenatal corticosteroid
Maternal history of
prophylaxis
previous affected infants
 Etiology & Pathophysiology
1 SURFACTANT
mixture of phospholipids and proteins produced by type
2 alveolar cells.
Major constituents:
Dipalmitoyl phosphatidylcholine ( lecithin )
Major component
Phosphatidylglycerol
Apoproteins ( surfactant proteins SP- A, -B, -C, -D )
Cholesterol
1 Etiology & Pathophysiology
SURFACTANT
Phospholipids --> reduces alveolar surface tension -->
prevents the alveoli from collapsing
Production = 20 weeks' gestation --> distribution
throughout the lungs begins around weeks 28–32 &
does not reach sufficient concentration until week 35 --
> thus any infant born preterm is vulnerable to
surfactant deficiency
 Etiology & Pathophysiology
1 SURFACTANT
Synthesis depends on:
normal pH, temperature,and perfusion.

Synthesis is suppressed in the ff:

Asphyxia, hypoxemia, and pulmonary
ischemia, particularly in association w/
hypovolemia, hypotension, and cold stress
1 Etiology & Pathophysiology
SURFACTANT DEFICIENCY
primary cause of RDS
→
little/ no reduction of alveolar surface tension inc.
alveolar collapse→ →
atelectasis dec. lung compliance
& FRC → hypoxemia and hypercapnia → hypoxic
vasoconstriction & respiratory acidosis → intrapulmonary
right-to-left shunt→ inc. permeability d/t alveolar
epithelial damage → fibrinous exudation w/in the alveoli
→ development of hyaline membranes in the lungs →
further impairs oxygenation → vicious cycle
1 Clinical Presentation
Signs of RDS usually appear within minutes of birth; even
hours until rapid, shallow breathing occurs for larger premature
; peak within 3 days, after w/c improvement is gradual
tachypnea ( RR > 60/min )
prominent (often audible) expiratory grunting
IC and SC retractions
nasal flaring
cyanosis
Normal / dec. breath sounds ( w/ harsh tubular quality )
fine crackles ( deep inspiration )
 Clinical Presentation
1 If untreated
progressive worsening of cyanosis and dyspnea
If inadequately treated
BP may fall
cyanosis and pallor increase
grunting decreases or disappears
Apnea and irregular respirations
ominous signs requiring immediate intervention.
Death - from severe impairment of gas exchange, alveolar air
leaks (pulmonary interstitial emphysema, pneumothorax),
pulmonary hemorrhage, or IVH
1 Diagnosis
Clinical course, x - ray findings and blood gas -->
help establish the clinical diagnosis
Chest x-ray
low lung volumes
Diffuse, fine reticular granularity of the
parenchyma (ground-glass appearance)
Air bronchograms
Blood gas
hypoxemia ( initially ) --> progressive hypoxemia,
hypercapnia and variable metabolic acidosis
1 Prevention
1.) Avoidance of unnecessary or poorly timed early (<39 wk
GA) CS delivery or induction of labor

2. ) Appropriate management of high-risk pregnancy and

labor (i.e. adm. of antenatal corticosteroids)
before 37 wk gestation - reduce mortality, admission
to NICU and duration for ventilatory support , and
incidence of RDS, IVH, and necrotizing enterocolitis
Betamethasone > Dexamethasone
1 Prevention
ACOG recommends for all women between 24 and 36 wk
gestation who present in preterm labor and are likely to deliver a
fetus within 1 wk --> antenatal corticosteroid administration

3.) Prediction of pulmonary immaturity w/ possible in utero

acceleration of maturation

4.) Antenatal and intrapartum fetal monitoring may dec. the risk of
fetal asphyxia
 Treatment
1 Most are self-limited; best carried out at NICU
Goal : minimize abnormal physiologic variations and
superimposed iatrogenic problems

Major Types of Treatment:

Supportive
Nasal Continuous Positive Airway Pressure ( nCPAP )
Mechanical Ventilation
Surfactant Replacement Therapy
1 Treatment
1. Supportive care ( thermoregulatory, circulatory, fluid,
electrolytes, and respiratory ) is essential while FRC is
maintained and established
Hypothermia -> inc O2 consumption -> incubator or
radiant warmer
Circulation -> blood or volume expanders, vasopressors;
RBC transfusion when blood loss reaches 10% of
estimated BV or Hct < 40%
1 Treatment
Fluids, metabolic and nutritional support --> initially
5%-10% dextrose IV at 60-80mL/kg/day --> gradually
inc. to 120-140mL/kg/d.
Monitor blood glucose, electrolytes ( i.e. Ca and P ), renal
function and hydration
IV nutrition; AA and lipids within 24-48 hrs of birth
If oral feeding tolerated, start small feeding
Antibiotics given only if sepsis is suspected
1 Treatment
2. Nasal Continuous Positive Airway Pressure ( nCPAP )
warm, humidified O2 provided at a concentration sufficient
to keep PaO2 between 50 and 70mmHg ( 91-95% SaO2 )
- to maintain normal tissue oxygenation while minimizing
the risk of O2 toxicity
nCPAP ( 5-10cmH2O ) is indicated in:
respiratory distress (severe retractions & expiratory
grunting )
SaO2 cannot be kept at >90% at FiO2 >=40-70
1 Treatment
2. Nasal Continuous Positive Airway Pressure nCPAP
nasal CPAP reduces collapse of surfactant - deficient alveoli
and improves both FRC and ventilation-perfusion matching
Early use - for at risk preterm infants reduces need for
mechanical ventilation; allow lung inflation to be maintained
while preventing lung injury
amount of nCPAP required decreases after 72 hours of age ,
most infants can be weaned shortly thereafter
1 Treatment
3. Mechanical Ventilation
Goal: improve oxygenation and ventilation w/o causing pulmonary
injury or oxygen toxicity
improve by increasing FiO2 and mean airway pressure
MAP is increased by increasing peak inspiratory pressure (
PIP ), inspiratory time , ventilator rate, positive end-
expiratory pressure ( PEEP )
PEEP levels - 4-6cmH2O - safe and effective
if excessive - impede venous return -thereby
reducing CO and O2 delivery
1 Treatment
3. Mechanical Ventilation
high rate ( > 60 breaths/ min ) - fewer air leaks and increased survivals ;
sufficient expiratory time : allowed to avoid trapping and inadvertent PEEP
Indication:
infants with respiratory failure or persistent apnea
Respiratory failure are :
A. Arterial blood pH < 7.20 ( pH 7.20-7.35 )
B. PaCO2 >= 60mmHg ( 45-65mmHg )
C. SaO2 < 90% at O2 concentration of 40-70% and nCPAP of 5-10 cmH2O
D. persistent and severe apnea
1 Treatment
4. Surfactant Replacement Therapy
Immediate effects:
improve alveolar-arterial oxygen gradients
reduced ventilatory support
increased pulmonary compliance
improved chest radiograph appearance
CPAP at birth is as effective as prophylactic or early
surfactant ; Prophylactic nCPAP- still approach of choice
 Treatment
1 4. Surfactant Replacement Therapy
Indication:
neonates with RDS who fail nCPAP and require intubation
and mechanical intubation
initiated immediately to avoid lung injury
repeat dose every 6-12 hr ; total 2-4 doses
Complications:
transient hypoxia, hypercapnia, bradycardia , and
hypotension , blockage of ETT, and pulmonary hemorrhage
1 Complications
Most serious complications from ET intubation:
Pulmonary air leaks
asphyxia from obstruction or dislodgement of tube
bradycardia during intubation or suctioning
subglottic stenosis
Others:
bleeding from trauma
posterior pharyngeal pseudodiverticula
need for tracheostomy
1 Complications
ulceration of the nares
permanent narrowing of the nostrils - tissue damage and
scarring from irritation or infection around the tube
erosion of the palate
avulsion and papilloma of a vocal cord
laryngeal ulcer
persistent hoarseness, stridor ,or edema of the larynx
extrapulmonary air leaks ( pneumothorax , pneumomediastinum
, pulmonary interstitial emphysema - 3-9% extremely preterm
1 Complications
Umbilical arterial catheterization
vascular embolization, thrombosis, spasm and vascular
perforation
ischemic or chemical necrosis of abdominal viscera
infection , accidental hemorrhage
impairment circulation to a leg with subsequent
gangrene
Renovascular hypertension
occurs days to weeks after
1 Complications
Umbilical vein catheterization - same risks
Additional risk: cardiac perforation and
pericardial tamponade ; portal vein
thrombosis
 1. A neonate boy born at 27 weeks of gestation is transferred
to the newborn intensive care unit due to difficulty breathing
shortly after delivery. PE reveals tachypnea, intercostal
retractions, nasal flaring, and cyanosis. On chest x-ray, the
lungs have a diffuse ground glass appearance. He is
intubated, and oxygen therapy is started.

Compared with a baby boy at term, this neonate most likely has
decreased levels of which of the following?

A. Phosphatidylcholine
B. Phospatidylethanolamines
C. Phosphatidylinositol
D. Sphingomyelin
2. A neonate boy born at 27 weeks of gestation is transferred to
the newborn intensive care unit due to difficulty breathing
shortly after delivery. PE reveals tachypnea, intercostal
retractions, nasal flaring, and cyanosis. On chest x-ray, the lungs
have a diffuse ground glass appearance. He is intubated, and
oxygen therapy is started.

Compared with a baby boy at term, this neonate most likely has
decreased levels of which of the following?

A. Phosphatidylcholine
B. Phospatidylethanolamines
C. Phosphatidylinositol
D. Sphingomyelin
Which of the following statements about the risk
factors for respiratory distress syndrome in
infants is FALSE?

A. Maternal diabetes increases risk

B. Maternal heroine use decreases risk
C. prolonged rupture of membrane increases risk
D. Antenatal corticosteroid prophylaxis decreases risk
Which of the following statements about the risk
factors for respiratory distress syndrome in
infants is FALSE?

A. Maternal diabetes increases risk

B. Maternal heroine use decreases risk
C. prolonged rupture of membrane increases risk
D. Antenatal corticosteroid prophylaxis decreases risk
Meconium
Aspiration
Syndrome
 TABLE OF CONTENTS

Definition & Incidence Complications

Risk Factors & Pathophysiology Treatment & Prevention

Clinical Manifestation Prognosis

2 Definition

A respiratory distress of an infant born

through meconium stained amniotic fluid
 Incidence
2 10-15%
Meconium stained amniotic fluid
present in term and postterm infant

5%
MAS among infants

30% ; 3-5 %
require mechanical ventilation ; die
2 Risk Factors
Preeclampsia
Maternal Hypertension/ DM
Oligohydramnios
Chorioamnionitis
Maternal Infections
Maternal Drug use
Placental insufficiency
Intrauterine growth restriction
Heavy cigarette smoking
Maternal chronic
respiratory /
cardiovascular disease
Postterm pregnancy
Abnormal Fetal Heart
Pattern
 2
Pathophysiology
2 Pathophysiology
1. Mechanical obstruction of Airways
thick and viscous meconium lead to complete (
atelectasis ) or partial airway obstruction ( ball-
valve --> air trapping --> air leak ( risk of
pneumothorax 33% )
2 Pathophysiology
2. Chemical Pneumonitis
Distal progressing meconium --> chemical pneumonitis
--> bronchiolar edema and narrowing of small airway

3.Surfactant Inactivation
Bilirubin, FA, TG, cholesterol content of meconium inhibit
surfactant function and inactivation
2 Pathophysiology
4. Pulmonary Hypertension
Meconium in lung stimulate proinflammatory
cytokines and vasoactive substances -->
pulmonary vasoconstriction --> hypoxia , acidosis,
hyperinflation --> pulmonary hypertension
 Clinical Manifestations
2 Signs and symptoms:
Meconium stained skin, nails and umbilical cord
Signs of respiratory distress ( develop within 1st hour of
birth )
Tachypnea
retractions
coarse bronchial sounds
expiratory grunting
cyanosis
 Clinical Manifestations
2 Chest : overinflated/ barrel - shaped; Hamman's signs
( pneumomediastinum ) ; unequal breath sounds or decreased
wall movement on affected side ( pneumothorax )

condition improves w/in 72hrs; but when in ventilation -

may be severe w/ high risk of mortality
2 Diagnosis
Chest x-ray
1. patchy infiltrates ( bilateral )
2. coarse streaking of both lung fields
3. increased anteroposterior diameter
4. flattening of the diaphragm.
ABG in 1st hour ( often reveals perinatal asphyxia )
1.hypoxemia
2.Some degree of metabolic acidosis
 Complications
2 Pneumothorax
Persistent pulmonary hypertension of the
newborn
Secondary bacterial infection of the lungs
subglottic stenosis ( secondary to
extended presence of ET tube in patients
on mechanical ventilation )
 Treatment
2 Supportive care and standard management of
respiratory distress

In infants w/ signs of respiratory failure, O2 saturation

by pulse oximetry, ABG and chest
x-ray should be obtained ASAP

often require high peak inspiratory pressures to

maintain adequate ventilation and oxygenation
2 Treatment
In infants who develop complications
( pneumothorax) --> mechanical ventilation

Refractory to conventional mechanical

ventilation --> Benefit from HFV or ECMO
2 Treatment
Administration of exogenous surfactant/ iNO to
infants w/ MAS and hypoxemic respiratory failure /
pulmonary hypertension requiring mechanical
ventilation --> decreases need for ECMO

Routine antiobiotic has no role for MAS with no signs

of sepsis
2 Prevention
MAS is decreased by rapid identification of fetal
distress and initiation of prompt delivery in the
presence of late fetal heart rate deceleration or poor
beat-to-beat FHR variability.
Amnioinfusion, intrapartum nasopharyngeal
suctioning, routine intubation and aspiration of
depressed infants- does not decrease risk thus not
recommended in neonatal resuscitation
2 Prognosis
mortality rate of meconium-stained infants is
considerably higher than that of nonstained infants.
The decline in neonatal death due to MAS during
the last decades is related to improvement in
obstetric and neonatal care
depends on the extent of CNS injury from asphyxia
and the presence of associated problems such as
pulmonary hypertension.
1. The following are risk factors
for development of Meconium
aspiration syndrome, EXCEPT?
A. Advance gestational age ( > 40 weeks )
B. Gestational DM/ Hypertension
C. Preterm pregnancy
D. All answers are correct
1. The following are risk factors
for development of Meconium
aspiration syndrome, EXCEPT?
A. Advance gestational age ( > 40 weeks )
B. Gestational DM/ Hypertension
C. Preterm pregnancy
D. All answers are correct
Risk Factors for MAS:
Preeclampsia
Maternal Hypertension/ DM
Oligohydramnios
Chorioamnionitis
Maternal Infections
Maternal Drug use
Placental insufficiency
Intrauterine growth restriction
Heavy cigarette smoking
Maternal chronic respiratory / cardiovascular disease
Postterm pregnancy
Abnormal Fetal Heart Pattern
Transient
Tachypnea of
the Newborn
TABLE OF CONTENTS

Definition Clinical Presentation

Incidence & RiskFactors Diagnosis

Pathophysiology Treatment
3 Definition
Clinical syndrome of self-limited
tachypnea associated with delayed
clearance of fetal lung fluid
3 Incidence

3-6 per 1000

Term infant births

Most common etiology of tachypnea in newborn

 Risk Factors
3 Twin Gestation
Maternal Asthma
Late Prematurity
Precipitous Delivery
Gestation Diabetes
Cesarean Delivery without labor
3 Pathophysiology
ineffective expression of activity of
ENaC and Na+,K+,ATPase -->
slows absorption of lung fluid -->
decreased pulmonary compliance &
impeded gas exchange
3 Clinical Presentation
Early onset tachypnea (>60 breaths/min )
may occur w/ retractions or respiratory
grunting
cyanosis ( ocassional ) - relieved by minimal
O2 supplementation ( < 40% )
clear breath sounds
Hypercapnia and acidosis ( uncommon )
 Diagnosis
3
Diagnosis of exclusion

Chest x-ray
Prominent Perihilar
Pulmonary Vascular
Marking, fluid in
intralobular fissures ,
and rarely small
pleural effusions
3 Treatment
Supportive
Respiratory failure requiring positive pressure
support (either with nCPAP or mechanical
ventilation) is uncommon - if it occurs usually it
resolves rapidly (<12-24 hr).
Most infants recover with supportive care alone,
and over the first 24-72 hours the tachypnea
and O2 requirements slowly resolve.
 Treatment
3
Albuterol ( Salbutamol )
improve oxygenation, shorten
duration of O2 therapy, & expedite
recovery
NOT USEFUL - Oral furosemide or
nebulized racemic epinephrine
References:
Nelson Textbook of Pediatrics, 21th Edition
Manual of Neonatal Care, 7th Edition, John P. Cloherty.
MD, Eric C. Eichenwald, MD, Anne R. Hansen, MD, MPH,
Ann R. Stark , MD
Pramanik, AK. Respiratory Distress Syndrome: Treatment
& Medication in http--emedicine_ medscape_com-article-
976034-overview.mht. Accessed November 23, 2009
Thank you!
God bless and stay safe
always!
1. What should be the
approximate pressure used
in CPAP?
A. 2-10 cmH2O
B. 2-8cmH2O
C. 2-6 cmH2O
D. 5-10 cmH2O
1. What should be the
approximate pressure used
in CPAP?
A. 2-10 cmH2O
B. 2-8cmH2O
C. 2-6 cmH2O
D. 5-10 cmH2O
2. Which of the following cannot be
regarded as an advantage of CPAP?
A. It increases oxygenation by relieving
respiratory function
B. It decreases the need for surfactant treatment
C. It increases incidence of chronic lung disease (
CLD ) or BPD
D. It decreases the need for oxygen treatment at
home after discharge from the hospital
2. Which of the following cannot be
regarded as an advantage of CPAP?
A. It increases oxygenation by relieving
respiratory function
B. It decreases the need for surfactant treatment
C. It increases incidence of chronic lung disease
( CLD ) or BPD
D. It decreases the need for oxygen treatment at
home after discharge from the hospital