Respiratory Distress Syndrome

Risma Kerina Kaban - Idham Amir

Division of Neonatology Dept. of Child Health -
Faculty of Medicine University of Indonesia
 Introduction
• Respiratory distress syndrome (RDS) is a condition of
pulmonary insufficiency that in its natural course commences at
or shortly after birth and increases in severity over the first 2
days of life.

• RDS, also known as hyaline membrane disease, is the

commonest respiratory disorder in preterm infants.

• If left untreated, death can occur from progressive hypoxia and

respiratory failure, In survivors, resolution begins between 2 and
4 days

• Antenatal Steroid, Surfactant replacement therapy is crucial in

the management of RDS

European consesus guidelines. Neonatology 2010;97:402-417

 Epidemiology
Tabel 1. Incidence of RDS by Birth Weight.

Birth Weight (g) Incidence of RDS

501-750 86%

751-1,000 79%

1,001-1,250 48%

1,251-1,500 27%

UCSF Medical Center, 2004

 Predisposing Factors

• Prematurity
• Male sex
• Neonate of diabetic mother
• Asphyxia
• Cesarean section
• Maternal hypertension

Aly H. Pediatrics in Review 2004, 25:201-208

 Protective Factors

• Chronic intrauterine stress

- Premature Rupture Of Membran (PROM)
- Maternal hypertension
- Narcotic use
- IUGR
• Corticosteroids - prenatal

Aly H. Pediatrics in Review 2004, 25:201-208

 Pathophysiology
Surfactant deficiency

Alveolar collapse

Reduced lung volume  low FRC
↓Lung compliance  ↑work of breathing
Right to left shunting (intrapulmonary)

Hypoxemia

Edberg KE, et al, Pediatr Res 1991;30:496-500

 …pathophysiology

Persistent hypoxemia & metabolic acidosis


↓cardiac output
hypotension
poor renal function
peripheral edema

Neonatal Respiratory Disorders 2nd ed, 2003, 247-71

 …pathophysiology
• Some infants normal surfactant at birth
normal respiration at birth after a few hours
surfactant is used up if no replacement therapy
 respiratory function deteriorate

• Endogenous surfactant production

- 2-3 days of age  clinical recovery
-Exogenous surfactant  might ↑ endogenous
surfactant production
Ikegami M, Jacobs H, Jobe A, J Pediatr1983;102:443-7
Jobe AH, New Engl J Med 1993;328:861-8
 Clinical Signs
• Tachypnea
• Grunting expiration
• Indrawing of sternum, intercostal spaces
and lower ribs during inspiration
• Cyanosis without oxygen supplementation

Rudolph AJ, Smith CA, J Pediatr 1960;57:905-21

 Cardiorespiratory Findings
• Tachycardia
• Hypotension
• PDA

Jenkins JG, et al, Paediatr Scand 1989;69:393-6

 CNS Findings
Hypoxia, acidosis and hypercapnia

Loss cerebral autoregulation

IVH and /or PVL

Lou HC, Lassen NA, Hansen FB, J Pediatr 1992;94:118-21

 Renal Function Changes
Reduced GFR :
• Oliguria (< 1 ml/kg/h)
• Poor sodium excretion  hypernatremia,
• Raised blood urea
• Hyperkalemia with generalized edema

Engle WD, J Pediatr 1983;102:912-7

 Gastrointestinal Signs
• Ileus
• Bowel sounds are absent
• Do not pass meconium
• Delayed gastric emptying

Dunn PM, Arch Dis Child 1963;38:459-67

 Natural History of Illness
• Symptoms  within 4 hours after birth

• Next 24-36 hours  worsening dyspnea and edema  die

due to respiratory failure
•
• After 48-72 hours  recovery due to production of
endogenous surfactant  spontaneous diuresis occurs.

• The infants is in room air by 7-10 days

Kavvadia V, et al, J Perinat Med 1998;26:469-74

 Investigations
• Chest radiograph
• Full Blood Examination (Complete blood
cell, CRP, IT)
• Biochemical (Blood Gas Analysis +
electrolyte, glucose)
• Microbiological (culture)

Neonatal Respiratory Disorders 2nd ed, 2003, 247-71

Radiologic Appearance of RDS
(Giedion A, et al, Pediatr Rad 1973;1:145-52)

Grade I Grade II

Grade III Grade IV

 Management
• General supportive care
 Delivery room management
 Transportation to NICU
 Stabilization on the NICU
• Specific treatment
 Surfactant treatment
 Ventilatory support

Neonatal Respiratory Disorders 2nd ed, 2003, 247-71

 Delivery Room Management
Resuscitation by experienced medical staff
• Prompt gentle stimulation and inflation to
produce and maintain the Functional Residual
capacity (FRC) by Continuous positive air
pressure (CPAP) and Positive Pressure
Ventilation (PPV)
• Give surfactant as soon as possible
• Minimize heat loss

Jobe AH, New Engl J Med 1993;328:861-8

 CPAP
Early CPAP :
Soon after birth:
Birth weight < 1000 g (Hany Aly et al; 2004) Prophylactic
CPAP
Gestational age < 32 minggu (Peter Dijk et al)
Respiratory distress ( tachypnoe, expiratory grunting,
nasal flaring, chest recession) (Gittermann M.K. et al;
1997) – Rescue CPAP

Started at delivery room

Downe’s score ?  leading for further respiratory
support
 Respiratory Distress Evaluation
Downe Score
 0  1  2
 Cyanosis  None  In room air  In 40% FIO2
 Retractions None  Mild  Severe
 Audible with  Audible without
 Grunting  None
stethoscope stethoscope
 Decreased or
 Air entry Clear  Barely audible
delayed
 Respiratory rate  Under 60  60-80  Over 80 or apnea
Respiratory Distress Evaluation
Downe Score

Mild Respiratory Distress (nasal

<4
canule/ head box)
Moderate Respiratory Distress
4-5
(CPAP)
Severe Respiratory Distress
>6 (monitoring arterial blood gases,
use ventilator)
 Transportation to NICU
• After resuscitation  transferred to NICU
without any deterioration
• Keep warm
• Avoid hypoxemia  O2, CPAP or IPPV
• Use pulse oximetre for adequacy of O2

Neonatal Respiratory Disorders 2nd ed, 2003, 247-71

 Stabilization on the NICU
In the first hour organize :
• A thermoneutral environment
• Clear airway
• Oxygen saturation 88-92%
• Adequate breathing or ventilation

The Royal Women’s Hospital, Clinician’s Handbook, 2005

 …stabilization on the NICU
• Blood tests: full blood examination, arterial
blood gases, cultures, glucose, cross match
• Chest X-ray
• IV line
• Minimal handling

The Royal Women’s Hospital, Clinician’s Handbook, 2005

 …stabilization on the NICU
Fluid and calories :
• Peripheral IV or UVC
• 10% dextrose  60 mL/kg/day
• Keep fluid intake low  asses sodium level
• Keep blood glucose level above 36 mg/dl
• Total Parenteral Nutrition (TPN)
• No oral feeds
 …stabilization on the NICU
Low blood pressure :
• 10-20 mL/kg of normal saline
• If doesn’t work  dopamine or
dobutamine
• Blood loss is corrected by a similar
volume blood transfusion

The Royal Women’s Hospital, Clinician’s Handbook, 2005

 Surfactant Therapy

Prophylactic surfactant:
• Surfactant within 10-15 min of birth
• For infants of < 27-28 weeks of gestation
Rescue surfactant:
• Surfactant given based on severity of RDS
assessed by clinical signs, blood gas result
and Chest X-Ray
Egberts J, et al, Pediatrics 1983;102:912-7
 Recommendation for Surfactant
Treatment
• Type of surfactant:
– Natural preferred
– Synthetic may still be used for mild disease
• Timing is early rather than late (e.g FiO2 > 0.40
• Initial dose is 100-200 mg phospholipids/kg
• Retreatment: Flexible (6-12 hourly) when FiO2
> 0.30 and still on ventilator
Radiologic Appearance Before and After
Surfactant Therapy
 Ventilatory Support
• CPAP and PPV reduce mortality in neonates
with RDS
• CPAP  for baby with vigorous
spontaneous respiration .
Initial pressure 5-6 cm H2O, sometimes
higher pressure of 7-8 cm H2O needed
 …ventilatory support
• Intermittent Positive Pressure Ventilation
(IPPV) :
– rates 60-80/min,
– peak pressure 20 cm H2O or less,
– inspiration time 0,3-0,4 seconds,
– Positive End-Expiratory Pressure (PEEP) levels
5 cm H2O (increased if RDS is severe).

Halliday HL, Croatian Medical Journal 1998;39:165-70

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