RESPIRATORY DISTRESS

SYNDROME
SYNONYME: Hyaline Membrane Disease.
DEFINITIONS
 It’s a respiratory clinical syndrome, caused by
inadequate levels of surfactant,common among
babies born before a gestation of 35 weeks.
Or
 It’s a breathing disorder in which alveoli in an
infant’s lungs don’t remain open upon exhalation
because of insufficient surfactant.
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CAUSES OF SURFCTANT DEFFICIENCY
 Prematurity , mostly those born before a gestation of 32
weeks , accompanied by utero anoxia.
 Perinatal asphyxia ,preceded by prolonged hypoxic
period hence reduced surfactant synthesis.
 Elective caesarean section birth, because of absence of
labour stimulus ,hence surfactant production is not
increased.
-Also due to inadequate reduction of fluid in fetal lungs.
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 Maternal chronic medical conditions, such as
uncontrolled diabetes mellitus prenatally hence
delay in maturation of surfactant.
 Intra-uterine lungs infection leading to death of
some pneumocytes.
 Genetical problems leading to reduced
production of surfactant associated with R.D.S
in a term baby.
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 PATHOPHYSIOLOGY
 Surfactant (surface factor) is a group of surface active
phospholipids .Among them lecithin, normally present in
the alveolar cells surface is the most important.
 Surfactant is secreted by type II alveolar cells
(pneumocytes) ,in the alveolar epithelium under the
influence of high glucocorticoid levels in the circulation.
 Production starts as from 20 weeks gestation but enough
levels are attained as from a gestation of 36 weeks.

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 The main purpose of surfactant is to maintain alveoli
stability.
-This is done through creating minimal surface tension
within the alveoli , so the terminal air pockets remain open
on exhalation .
-Basically surfactant facilitates reopening of the air-
spaces with a lower amount of force.
 So, due to inadequate levels of surfactant , the epithelial
lining of the bronchioles and alveoli capillary walls
oozes a sticky fluid ,forming hyaline membrane .
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 Thereafter the membrane lines the alveolar ducts
leading to :
Cyanosis because of blockage of diffusion of oxygen
Metabolic and respiratory acidosis because of
retention of carbon dioxide hence acidaemia.
Atelectasis as the terminal air pockets stick to one
another on exhalation.
 Generally hypoperfusion of pulmonary tissues occurs
because of vasoconstriction.
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NB 1.Studies have shown that, those babies subjected to stressful
conditions prenatally have low incidence of developing RDS,
irrespective of being born prematurely. This is because the stressors
increase release of high cortisol levels hence more production of
surfactant. Assignment- Stressors
11.RDS type2
-Occurs to term or almost mature (term) babies, due to failure of
complete evacuation of fluid from the lungs .
-On CXR lungs are already expanded or mostly over expanded,
prognosis is generally good.
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 CLINICAL FEATURES
Specifics: Noted within the first 4-6 hours of birth .
 Recession /retraction/in drawing of the chest walls on inspiration.
-That is ,intercostal , subcostal muscles and sternum retracts when
breathing in .This is because of higher inspiratory pressure.
 Tachypnoea and laboured breathing , characterized by
(asynchrony) see- saw pattern on the chest , in order to achieve
normal gaseous exchange hence normal body functions.
 Grunting on expiration /exhalation due to the hyaline membrane
and partial closure of the glottis in an effort to keep in as much air
as possible in the lungs.
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 NON- SPECIFICS
 Nasal flare (nare dilatation) characterized by “chin tug”as the
infant overworks to re-expand the lungs.
 Limpness because of fatigue of forcing in air into the lungs.
 Restlessness characterized by a “whining cry”.
 Tachycardia initially and later bradycardia accompanied by
some degree of hypothermia because of fatigue and poor
oxygen supply.
 Diminished and moist breathe sounds which are accompanied
by a systolic murmur on auscultation.
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 NB
-As condition worsens, the infant:
 Becomes less distressed.
 Limpness increases .
 Apnoeic periods become prolonged.
 Doesn’t respond to stimuli.
 Death may occur within 2-3 days , if immediate and
accurate measures (interventions) are delayed or
ignored. 10 01/19/2025
 SPECIFIC MANAGEMENT
Main Objective
To offer supportive care till production of
surfactant and metabolism occurs.
 Inform the doctor as soon as the condition is
suspected and admit in the NBU if not done earlier.
 Support breathing through positioning in either
prone or laterally and slightly elevates the head.
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 contd
 Maintain a clear airway and administer warm
humidified oxygen through a mechanical ventilator.
-E.g. intermittent positive pressure ventilator (IPPV)
initially because it prevents lungs collapse upon each
exhalation.
 As condition improves, wean off, using a continuous
positive airway pressure (PAP).
-This allows the infant to breath independently since
the airways are continuously distended.
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 Following great improvement extubate and administer oxygen
through either a hood (head box), tent or nasal catheter or
mask.
 A thermal environment is very important as a supportive
treatment.
-Nurse in the incubator set at a temperature range between 32-
34 degrees Celsius, though the heat regulation depends on the
weight and age of the infant and room temp at least 26 degrees.
 Aim is to maintain normal body temperature since the
metabolic rate and oxygen supply are poor.
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 Position flexed symmetrically to prevent heat loss.
Nutritionally:
 Nil orally initially because of poor digestion process
and slowed peristaltic movement since oxygen supply
is poor.
 Maintain on intravenous infusion .Amount determined
by the baby’s condition and oedema.
-Generally, maximum dose of 110ml/kg in 24hrs and
minimum ranges between 60-70ml/kg in 24hrs.
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 As condition improves, oral feeding every 3hours using
mother’s milk through the appropriate mode of feeding.
Stop intravenous infusion.
General Observations in terms of :
 Vital signs every ½ hourly initially, later 2 hourly.
 Interpret correctly in that as improvement occurs:-
-Respiratory effort ranges between 30-40 A/m.
-Temperature 36.2-37.1 degrees Celsius.
- Apical beats 120-160B/M

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 -Colour change from bluish (cyanosis) to pinkish or as per the
parents ethnicity.
-Breathing pattern :- The exertion on inspiration , grunting, on
expiration “chin tug “ and whining cry, subsides gradually and
eventually stops as surfactant levels increases.
 So maintain records for future reference.
 Investigations
 Blood Specimen for:
*Gases analysis initially shows hypercapnia i.e. High Carbon
dioxide levels.
*Urea & electrolytes: metabolic acidosis because of hypoxia.
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 Chest X-ray ,diagnostic findings are:-
 *”Ground glass’’ appearance usually develops 6-12 hours
after birth and indicates Atelectasis due to alveoli collapsed.
 “Air Bronchogram’’ or bronchial air shadow in which the
airways stand out as dark areas, since they are filled with air.
-This indicates inadequate diffusion and expiration.
 As condition improves oxygen tension rises metabolic
acidosis clears and the alveoli re-opens hence blood
investigations & CxR findings are normal.

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 Drugs
-Basically on supportive purposes includes:
 Prophylactic broad spectrum antibiotics e.g. crystapen
50,000 IU/kg BD and gentamycin 2.5mg/kg BD I.V x5/7
 Coagulant – Vitamin K 0.5 mg i.m start for preterm.
 Steroid [corticosteroid] e.g.dexamethasone , dose ranges
between 0.5-1.mg BD x 4/7 to hasten lung maturity.
 Haematinics and multi vitamin after the 1st week.
 Available and affordable, synthetic surfactant or animal
lungs extracted surfactant e.g. savanta from cows lungs.
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 Administered into the babys lungs through
endotracheal tube flash hence gives temporary relief.
 Maintain high standards of hygiene for comfort and
to prevent infection.
 Change position [turn infant] every 2 hours and
simultaneously carry out various procedures to avoid
unnecessary disturbances.
 Encourage parents to visit and to have physical
contact with the baby.
- This helps to create parental satisfaction of caring.
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 Allay anxiety through informing on the babys progress,
the condition and management plan briefly.
 As condition stabilizes, wean off the baby from the
incubator to the cot while properly dressed.
 Stop oxygen therapy gradually and encourage
breastfeeding appropriately.
 At the weight ranging between 2- 2.2kg discharges the
baby to the postnatal ward.
-Its nursed for at least 2 days before home discharge,
hence monitor the adjustment to a cool environment.
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 Finally prepare mother/parents for home care through
sharing on:-
-Breastfeeding exclusively.
-Hygiene ->personal and environment.
-Follow up ->MCH/FP, paediatric clinic and home visit.
CONCLUSION
 The prognosis is worse between the 2nd to the 4th day
after birth, because in the 1st day the little level of
surfactant is used up.
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 With adequate supportive care, improvement is
noted as soon as enough surfactant is made.
 However the worst period is determined by the
actual state of the neonate at birth and the
quality of care given.
 Generally the more preterm or sick the baby is
at the onset of this condition, the more
complicated is the recovery.
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 COMPLICATIONS
Grouped into two based on amendability.
Acute- Treatable
 Alveolar rupture leading to :
-Pneumothorax
-Pneumomediasternum- air in the space between the
lungs.
-Pneumopericardium- air in the pericardial cavity
-Interstitial emphysema. 23 01/19/2025
 Clinical Features
 Brandycardia, apnoea and persistent metabolic
acidosis.
Specific Management
 Pneumomediasternum and interstial emphysema
resolves spontaneously.
 Pneumothorax & pneumopericardium insertion
of a tubal drainage.
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 Infection:
-Mostly pneumonia, treat with appropriate antibiotics as per
culture and sensitivity results
 Intracranial hemorrhages;
-Due to inadequate blood supply to the cerebral tissues.
-Generally resolves spontaneously though severe cases can
lead to some degree of cerebral palsy and or epilepsy.
 Patent ductus arteriosus, occurs due to retention of carbon
dioxide and fluid hence congestive heart failure.
-Mgt includes, restriction of fluid intake ,administration of
diuresis and if severe, surgical closure.
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 LONG TERM-Not treatable
 1. Bronchopulmonary dysplasia (BPD)
 It’s a chronic lungs diseases characterized by
abnormal development of the lungs such that
normal respiration takes long to occur .
 In most cases, death occurs during infancy
because of pneumonia and cor-pulmonale .
-This is a heart disease after a lung disease
leading to straining of right ventricles.
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 Retrolental fibroplasia.
–Manifests into blindness, as a fibrous tissue forms
behind the lens due to administration of a high
concentration of oxygen.
-It’s associated with use of a tent or a hood for a long
period(over 3 weeks)with eyes unshielded.
Mgt-ophthalmologist reviews before discharge for
the way forward.
 Mental retardation, which may be accompanied by
some physical dysfunction. 27 01/19/2025
 Familiar psychopathology
-The family either over protects or
mistreats the child as they hide him/her
from strangers /guests.

END
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