Hyaline membrane disease

Hyaline Membrane Disease (RDS type I)

• Definition:
– A preterm neonate showing progressive respiratory
difficulty including tachypnea >60/mt, chest
retractions, grunting and cyanosis within 48-96
hours of life
– Chest radiograph shows uniform reticulogranular
pattern and peripheral air bronchogram
 Incidence

• Inversely proportional to gestational age and

birth weight

• 44% between 500 to 1500 gms weight

• Accounts for 6% neonatal deaths prior to

surfactant era
 Pathophysiology: Surfactant
1. Surfactant synthesis begins at 24 weeks
2. Surfactant is a complex system
of lipids, proteins and glycoproteins produce
d in type II pneumocytes.
3. The surfactant is packaged by the cell in
lamellar bodies, and extruded into the air-
spaces.
 Composition of surfactant
1. Surfactant recovered by alveolar wash from
most mammals contains 70-80% phospholipids,
8-10% protein, and 10% neutral lipids, primarily
cholesterol.
2. Dipalmitoyl phosphatidylcholine (DPPC), or
lecithin, is functionally the principle
phospholipid
 Surfactant function
1. Surfactant synthesis begins at 24 weeks
2. It is a complex substance of lipids, proteins
and glycoproteins produced in type II
pneumocytes.
3. It decreases surface tension and maintains
alveolar expansion;
4. Absence of surfactant:
1. Causes alveolar collapse;
2. Exudation of proteineseous substance and
epithelial debris which form hyaline membrane
 Surfactant level
• Decrease in surfactant by:
• Asphyxia

• Fetal hyperinsulinemia ( maternal diabetes)

• Increase by:
• Antenatal corticosteroids

• Stress induced by PIH, IUGR and twin gestation

 Risk factors for RDS
1. Prematurity

2. Male sex

3. Caesarian without labor pain

4. Perinatal asphyxia

5. Chorioamnionitis

6. Multiple gestation

7. Maternal diabetes: too much insulin delays surfactant production

8. Familial predisposition
 Decreased risk
1. Chronic intrauterine distress
2. PROM
3. Maternal hypertension
4. IUGR/SGA
5. Corticosteroids
6. Thyroid hormone
7. Tocolytic agents (b2 agonist, NSAID etc)
 Clinical presentation
1. Preterm delivary

2. Progressive respiratory distress

3. Increasing oxygen requirement
4. Tachypnea
5. Grunting
6. Nasal flaring
7. Chest retraction
8. Cyanosis
 Diagnosis
1. The lecithin/sphingomyelin ratio was less than 2
2. Phosphatidylglycerol was not present in
amniotic fluid or tracheal fluids at birth;
3. Negative bubble stability test
4. CXR:
1. Uniform reticular pattern or ground glass
appearance
2. Air bronchogram
 Lab
1. Pao2 < 50mm hg; saturation < 85%
2. Pco2 > 45 mm of hg
3. Ph < 7.25
4. Septic work up for gr. B. Strepto and H.Inf
which mimic RDS
5. Serum glucose as hypoglycaemia mimics RDS
6. Serum electrolytes and ca
7. Echo for PDA and PFO
 Management
Prevention
1. Antenatal corticosteroids:
1. Antenatal steroid given to mother reduces
neonatal deaths in first 48 hours due to:
1. RDS
2. Intraventricular hemorrhage
3. Necrotising enterocolitis
2. 12 mg betamethazone IM two doses 24 hour
apart (dexamethazone produces PVL and not
recommended)
 Prevention
2. Antenatal fetal monitoring for asphyxia,
3. LS ratio for lung maturity ultrasonography foe
fetal maturity and appropriate measures to
prevent preterm labour and fetal hypoxia
3. Tocolytic agents to prevent preterm labor
4. Erythromycin 500 mg 6 hourly should be given
to mothers with preterm labor as this reduces
the risk of preterm delivery by preventing
ascending infections
 Treatment
General Recommendation
1. The lowest concentration of oxygen
2. Pulse oximetry
3. CPAP: 5–6 cm water via mask or nasal prongs
to stabilize the airway and establish
functional residual volume.
CPAP
 Surfactant treatment

1. Prophylactic surfactants with in 15 mts of birth

to all preterm < 30 weeks

2. Replacement therapy: preferably within 2

hours after birth
3. Repeat doses are given after 6-12 hours if necessary.
1. The synthetic surfactants are no longer
available

2. Survanta ,a natural bovine surfactant and

Curosurf a natural porcine surfactant

Survanta 100 mg/kg

Curosurf 100-200 mg/kg

1. Surfactant is given as continuos infusion via
side port on the ET or as aliquots via a
catheter placed through ET

2. INSURE: intubate → surfactant →extubate

→CPAP.
3. No benefit in administering surfactant > 24
hours age or using more than 2 doses
 Contraindications

1. congenital anomalies incompatible with life

2. respiratory distress in infants with laboratory

evidence of lung maturity
 Side effects of surfactant therapy
1. Small risk of pulmonary hemorrhage
2. Secondary lung infection
3. Apnea
4. Pulmonary hemorrhage
5. Increased necessity for treatment for PDA
6. Marginal increase in retinopathy of
prematurity
7. Barotrauma - pneumothorax
 Other uses of surfactant therapy

1. Severe pneumonias

2. Meconium aspiration syndrome

3. Persistance of pulmonary hypertension

4. Pulmonary hemorrhage

5. Adult RDS
 Other measures in RDS

• Fluid maintenance and nutritional support

• Antibiotics; Sedation
• Prognosis: depends on birth weight