Respiratory

Distress
Syndrome
Prepared by:
Lina Lontoc De Ramos
 Infant Respiratory
Distress Syndrome
 Infant respiratory distress
syndrome (IRDS)
• neonatal respiratory distress
syndrome
• respiratory distress syndrome of
newborn
• previously called hyaline membrane
disease
It is a syndrome
in premature infants 

Developmental caused by
insufficiency of surfactant production
and structural immaturity in
the lungs
• result from a genetic problem with
the production of surfactant
associated proteins.
• is the leading cause of death
in preterm infants
 frequent in infants of diabetic
mothers and in the second born of
premature twins
Decreased blood perfusion of the
lungs
Meconium aspirations
 Risk factors:
– Low gestational age
– Male
– Born to diabetic mothers
– Born after an asphyxial insult before
birth
– Born after maternal-fetal hemorrhage
– Multiple gestation
Pathologic features of RDS

• Hyaline like (fibrous) membrane

formed from an exudate of an
infant’s blood that begins to line the
terminal bronchioles, alveolar ducts
and alveoli
Pathologic…
• This membrane prevents exchange
of O2 and CO2 at the alveolar-
capillary membrane
 Causes:
1. Low level or absence of surfactant
2. Phospholipid that normally lines the
alveoli
3. Reduce surface tension to keep the
alveoli fromcollapsing on expiration
 Pathophysiology

• The lungs of infants with

respiratory distress syndrome are
developmentally deficient in a
material called surfactant,
 Patho…
• which helps prevent collapse of
the terminal air-spaces
throughout the normal cycle of
inhalation and exhalation.
 Patho…

• High pressure is required to fill

the lungs with air for the first
time and overcome the pressure
of the lung fluid
 Patho…

• Alveoli collapse with each

expiration- as happens when
surfactant is deficient
• With the deficient surfactant, areas
of hypoinflation begin to occur
 Patho…
• Pulmonary resistance increases
• Lungs are poorly perfused, affecting
gas exchange
• As a result of decrease production
of surfactant
Patho…
• Poor oxygen exchange that results to
tissue hypoxia
• Tissue hypoxia- causes the release of
lactic acid
• Lactic acid combined with increasing
CO2 resulting formation of hyaline
membrane
 Patho…
• formation of hyaline membrane leads
to severe acidosis
• Acidosis causes:
[Link]
[Link] tissue perfusion
• Resulting limit surfactant production
 Macrosomia
• Birth Weight > 4000 g or > 90th %-ile
• Incidence 15 to 45% among IODM
• Increased rate of C-section
• Birth Trauma
shoulder and body dystocia
brachial plexus injury
facial nerve injury
asphyxia
abdominal trauma
 Intrauterine Growth Restriction

• Incidence reported as high as 20 %

• Contributing factors:
– Maternal vascular disease
– Hypertension
– Intrauterine infection
– Chromosomal abnormalities
Intrauterine Growth Restriction
• Oligohydramnios
• Hypoxia
• Fetal distress
• Asphyxia
• Intrauterine and neonatal death
Normal Arterial Blood Gas Values
for the Newborn

• pH : 7.31 - 7.45
• Arterial oxygen pressure (Pao2) :
50–70 mm Hg
• Carbon dioxide pressure (Paco2) :
33-48 mm Hg
• Bicarbonate : 16-24 mEq/L
• Oxygen saturation : > 90%
Signs and Symptoms
 tachypnea
Tachycardia
chest wall retractions
(sternal and subcostal)
expiratory grunting
nasal flaring
Cyanosis
S/S

As the disease progresses, the

baby may develop
ventilatory failure (rising carbon
dioxide concentrations in the
blood)
Apnea
 S/S
• Seesaw respirations (on
inspiration, the anterior chest wall
retracts and the abdomen
protrudes; on expiration, the
sternum rises)
• Heart failure
 S/S

• Pale grey skin

• Bradycardia
• Pneumothorax
Treatment
Therapeutic Management

Oxygen
intravenous fluids are
administered to stabilize the
blood sugar, blood salts, and
blood pressure
 Therapeutic
If the baby's condition worsens
endotracheal tube
continuous positive airway pressure
(CPAP) that delivers slightly
pressurized air through the nose can
help keep the airways open
 Therapeutic
Extracorporeal membrane
oxygenation (ECMO)
to directly put oxygen in the blood if
a breathing machine can't be used
 Therapeutic

• ECMO - providing oxygenation

through an apparatus that
imitates the gas
exchange process of the lungs.
 Therapeutic
• Administration of surfactant
• Surfactant replacement-
[Link]
replacement- as a
preventive measure
2. extracted from animal lungs
Medical management

• Oxygenation: oxyhood, Nasal cannula

• Ventilatory support: ventilator, ECMO,
nitrous oxide
• Transcutaneous O2 and CO2
monitoring, pulse oximetry
 Therapeutic

• Blood gas monitoring

• Correction of acid-base imbalance
• Environmental temperature regulation
• Adequate nutrition: oral, gavage, and TPN
• Protection from infection
Nursing Assessment and
Diagnosis
 Assessment
• Increasing cyanosis
• Tachypnea (60 or > breaths per minute)
• Grunting respirations
• Nasal flaring
• Significant retractions, labored
respirations
• Apnea (episode of nonbreathing for
more than 20 seconds)
• Flaccid, hypotonic, unresponsive to
stimuli
• Seizures (indicative of deterioration
and possible CNS damage.
 Diagnosis

• Impaired Gas exchange

• Altered Nutrition: Less than Body
Requirements
• Risk for infection
 Nursing care plan
• Admit directly to the special care
nursery
• Lab as ordered: blood type, Rh,
Coombs, CBC
• Administer antibiotics as ordered.
• IV access for meds, hydration and
nutritional support.
• Assist MD/NP with placement of arterial
catheter lines.
• Attach servo probe to infant’s skin,
radiant warmer on servo control.
• Attach 3 lead EKG for continuous
cardiac and respiratory monitoring.
• Attach pulse ox to infant extremity.
• Monitor oxygen administration
 Complications
• Air or gas may build up in:
• The space surrounding the lungs
(pneumothorax)
• The space in the chest between two
lungs (pneumomediastinum)
 Complication

• The area between the heart and

the thin sac that surrounds the
heart (pneumopericardium)
 Complication

• Bleeding into the brain

(intraventricular hemorrhage)
• Bleeding into the lung
• Blood clots due to an umbilical
arterial cathete
 Complication
• Bronchopulmonary dysplasia
• Delayed mental development and
mental retardation associated with
brain damage or bleeding
• Retinopathy of prematurity and
blindness
 Evaluation

• Prompt identification and early intervention

occurred.
• Newborn is free of respiratory distress and
metabolic alterations.
• Parents verbalize concerns, survival
factors and understanding of treatment
rationales.
Meconium Aspiration
Syndrome
Meconium aspiration syndrome
• is a serious condition in which a
newborn breathes a mixture of
meconium and amniotic fluid into
the lungs around the time of
delivery.
 Meconium
present in the fetal bowel as early
as 10 weeks’ gestation
first intestinal discharge from
newborns
a viscous, dark green substance
composed of intestinal epithelial
cells
babies born breech
the appearance of the fluid at
birth is green to greenish black
from the staining
Meconium Aspiration Syndrome
an infant may aspirate
meconium either in utero or with
the first breath after birth.
Once the meconium has passed
into the surrounding amniotic
fluid, the baby may breathe
meconium into the lungs
meconium can block the infant's
airways right after birth
 cause breathing difficulties due
to swelling (inflammation) in the
baby's lungs after birth.
 CRITERIA

• Mild: requires <40%O2 for <48hrs

• Moderate: >40%O2 for >48hrs, no air
leak.
• Severe: assisted ventilation for >48hrs
 Effect of meconiumaspiration
• causes inflammation of the
bronchioles
• can block small bronchioles by
mechanical plugging
• can cause a decrease in surfactant
production
 Etiology
Placental insufficiency
Maternal HPN
Preeclampsia
oligohydramnios
maternal drug abuse, especially of
tobacco and cocaine.
Diabetes in the pregnant mother
CLINICAL FEATURES
Physical examination  
• Evidence of postmaturity:
[Link] skin
[Link] fingernails
[Link] vernix
.
• The vernix, umbilical cord, and
nails may be meconium-stained,
depending upon how long the
infant has been exposed in utero.
• nails will become stained after 6 hours
• vernix after 12 to 14 hours of exposure
 Manifestations
• respiratory distress with marked
tachypnea and cyanosis.
• Reduced pulmonary compliance
• use of accessory muscles of respiration
are evidenced by:
[Link] and subcostal retractions
[Link] (paradoxical) breathing
[Link]
4. nasal flaring.
• chest typically appears barrel-
shaped, with an increased anterior-
posterior diameter caused by
overinflation.
• Auscultation reveals rales and rhonchi
-immediately after birth.
• Some patients are asymptomatic at
birth
• develop worsening signs of respiratory
distress as the meconium moves from
the large airways into the lower
tracheobronchial tree.
S/S
- enlargement of the
anteroposterior diameter of the
chest( barrel chest)
-
 S/S

• bilateral coarse infiltrates in the

lungs with spaces of hyper
aeration as shown in the x-ray
 S/S

• Hypoxemia
• carbon dioxide retention
• an intrapulmonary and extra
pulmonary shunting
• secondary infection
 Diagnosis

MAS must be considered in any

infant born through MSAF who
develops symptoms of RD.
• chest radiograph.
• The initial CXR may show streaky,
linear densities similar in appearance
to transient tachypnea of the newborn
(TTN).
• As the disease progresses, the lungs
typically appear hyperinflated with
flattening of the diaphragms.
• Diffuse patchy densities may alternate
with areas of expansion.
 Coarse focal consolidation with
emphysema.
Hyperinflation and patchy asymmetric
airspace disease that is typical of MAS.
Coarse interstitial infiltrates +L side
pneumothorax
 Nursing Diagnosis

• Ineffective Gas Exchange

• Altered Nutrition: Less than Body
Requirements
• Ineffective Family Coping:
Compromised
 Nursing Care Plan

• Prevention of meconium aspiration

• Maintaining adequate oxygenation and

ventilation

• Regulating temperature
• Observing intravenous fluids

• Providing caloric requirements

• Monitoring antibiotic treatment

nt

Amniotransfusion- used to
dilute the amount of amniotic
fluid and reduce risk of
aspiration
oxygen administration and
assisted ventilation after birth
tracheal suction
 Antibiotic therapy
• Radiant warmer -neutral
environment
• observed closely for signs of
trapping air in the alveoli
• chest physiotherapy with
clapping and vibration
 Complications

• Aspiration pneumonia
• Brain damage
• Breathing difficulty
• Collapsed lung (pneumothorax)
• Persistent pulmonary hypertension
 Prevention

Risk factors should be identified

as early as possible
Assess rupture of BOW
fluid was clear
stained with a greenish or brown
substance.
 Evaluation

• The newborn is free of respiratory

distress and metabolic complications

• Parents can verbalize concern,

understanding of treatment.
Neonatal
Sepsis
What is Neonatal Sepsis?

- a term used for a severe infection in

newly born infants.
Neonatal Sepsis affects approximately
2 infants per 1000 births with a
higher incidence in premature & low
birth weight infants.

Early Onset
Late Onset
 Neonatal sepsis

• Clinical syndrome of systemic illness

accompanied by bacteremia occurring
in the first month of life
 Early Onset

• First 5-7 days of life

• Usually multisystem fulminant illness
with prominent respiratory symptoms
(probably due to aspiration of infected
amniotic fluid)
• High mortality rate
– 5-20%
• acquired during intrapartum period
from maternal genital tract
– Associated with maternal
chorioamnionitis
 Late Onset

• May occur as early as 5 days but is

most common after the first week of life
• Less association with obstetric
complications
• Usually have an identifiable focus
– Most often meningitis or sepsis
• Acquired from maternal genital tract or
human contact
 Nosocomial sepsis

• Occurs in high-risk newborns

Pathogenesis is related to
– the underlying illness of the infant
– the flora in the NICU environment
– invasive monitoring
• Breaks in the barrier function of the
skin and intestine allow for
opportunistic infection
Causative organisms

• Primary sepsis
– Group B streptococcus
– Gram-negative enterics (esp. E. coli)
– Listeria monocytogenes,
Staphylococcus, other streptococci
(entercocci), anaerobes, H. flu
• Nosocomial sepsis
– Varies by nursery
– Staphylococcus epidermidis,
Pseudomonas, Klebsiella, Serratia,
Proteus, and yeast are most common
 Causes:

The primary causes of sepsis -

pathogens, such
As:
• Staphylococcus
• Group Beta Streptoccocus
These pathogens can enter a
neonate’s
body during the:
[Link]
[Link]
[Link] period
 Major Risk Factors

• Ruptured membranes > 24 hrs.

• Maternal Fever (100.4 o F(38 o C)
• Chorionamnionitis
• Sustained fetal heart rate
>160/min
 Minor Risk Factors

• Ruptured membranes > 12 hrs.

• Foul smelling amniotic fluid
• Maternal Fever > 99.5 o F (37.5 o
C)
• Low APGAR < 5 at 1 min, < 7 at 5
min
• Prematurity
• Multiple gestation
• Presence of 1 major or 2 minor
risk factors -> High Risk of
Sepsis
Factors:
• immaturity of the neonate’s
immune system
• genetic predisposition that is
caused by polymorphisms
 Risk factors

• Maternal peripartum fever

• Amniotic fluid problems (i.e. mec,
chorio)
• Resuscitation at birth, fetal distress
• Multiple gestation
• Invasive procedures
• Galactosemia
• Other factors: sex, race, variations in
immune function, hand washing in the
NICU
Clinical signs and
symptoms
– RDS
– Metabolic disease
– Hematologic disease
– CNS disease
– Cardiac disease
– Other infectious processes (i.e.
TORCH)
Clinical presentation
• Temperature irregularity (high or low)

• Change in behavior
• Lethargy, irritability, changes in
tone
• Skin changes
• Poor perfusion, mottling, cyanosis,
pallor, petechiae, rashes, jaundice

• Feeding problems
• Intolerance, vomiting, diarrhea,
abdominal distension
 Diagnosis
• Cultures
– Blood
• Confirms sepsis
• 94% grow by 48 hours of age
– Urine
• Don’t need in infants <24 hours old
because UTIs are exceedingly rare in
this age group
– CSF
• Controversial
• May be useful in clinically ill newborns
or those with positive blood cultures
 Radiology
• CXR
– Obtain in infants with respiratory
symptoms
– Difficult to distinguish GBS or
Listeria pneumonia from
uncomplicated RDS
• Renal ultrasound and/or VCUG in
infants with accompanying UTI
 Maternal studies

• Examination of the placenta and fetal

membranes for evidence of
chorioamnionitis
 Management

• Antibiotics
– Primary sepsis: ampicillin and
gentamicin
– Nosocomial sepsis: vancomycin and
gentamicin or cefotaxime
– Change based on culture sensitivities
– Don’t forget to check levels
 Supportive therapy
• Respiratory
• Oxygen and ventilation as
necessary
• Cardiovascular
• Support blood pressure with
volume expanders and/or pressors
• Hematologic
• Treat DIC with FFP and/or cryo
• CNS
• Treat seizures with phenobarbital
• Watch for signs of SIADH (decreased
UOP, hyponatremia) and treat with
fluid restriction
• Metabolic
• Treat hypoglycemia/hyperglycemia
and metabolic acidosis
Prevention is better than
cure
Thank you
God bless!
THANK YOU
&
GOD BLESS!