Respiratory Distress Syndrome

Respiratory distress syndrome is caused by pulmonary surfactant deficiency in the lungs of

neonates, most commonly in those born at < 37 weeks gestation. Risk increases with degree of
prematurity. Symptoms and signs include grunting respirations, use of accessory muscles, and nasal
flaring appearing soon after birth. Diagnosis is clinical; prenatal risk can be assessed with tests of
fetal lung maturity. Treatment is surfactant therapy and supportive care.

Signs and Symptoms

Signs and symptoms of RDS include:

 rapid, labored, grunting respirations

appearing immediately or within a
few hours after delivery

 With suprasternal and substernal

retractions and nasal flaring.

 As atelectasis and respiratory failure

progress, symptoms worsen, with:

 Cyanosis, lethargy, irregular

breathing, and apnea, and may lead
to cardiac failure if adequate lung
expansion, ventilation, and
oxygenation are not established.
ultimately

Neonates weighing < 1000 g may have lungs

so stiff that they are unable to initiate or sustain respirations in the delivery room.

On examination, breath sounds are decreased, and crackles may be heard.

EPIDEMIOLOGY
As the most common cause of respiratory distress in premature infants, RDS occurs in about 24,000
infants born in the United States annually. It is also the most common complication of prematurity
leading to significant morbidity in late preterm neonates and even mortality in very low birth weight
infants. The exact definition of RDS is imprecise, thus requiring a careful analysis of statistical data. The
most important risk factors are prematurity and low birth weight. Other risk factors include white race,
male gender, late preterm delivery, maternal diabetes, perinatal hypoxia and ischemia, and delivery in
the absence of labor. The incidence of RDS increases with decreasing gestational age at birth. In one
study of babies born between 2003 and 2007 at various National Institute of Child Health and Human
Development (NICHD) Neonatal Research Network centers, 98% of babies born at 24 weeks had RDS,
while at 34 weeks, the incidence was 5%, and at 37 weeks was less than 1%.

Diagnosis:

 Clinical evaluation

 Arterial blood gases (ABGs; hypoxemia and hypercapnia)

 Chest x-ray

 Blood, cerebrospinal fluid (CSF), and tracheal aspirate cultures

Diagnosis of RDS is by clinical presentation, including recognition of risk factors; ABGs showing
hypoxemia and hypercapnia; and chest x-ray. Chest x-ray shows diffuse atelectasis classically
described as having a ground-glass appearance with visible air bronchograms and low lung expansion;
appearance correlates loosely with clinical severity.

Air bronchogram refers to the phenomenon of air-filled bronchi

(dark) being made visible by the opacification of surrounding
alveoli (grey/white).

Air bronchograms will not be visible if the bronchi themselves are

opacified (e.g. by fluid) and thus indicate patent proximal airways.

Differential diagnosis includes:
 Group B streptococcal pneumonia  and sepsis
 Transient tachypnea of the newborn
 Persistent pulmonary hypertension
 Aspiration
 Pulmonary edema
 Congenital cardiopulmonary anomalies

Neonates typically require cultures of blood. CSF cultures are not routinely done after birth because
there is low incidence of meningitis associated with early-onset sepsis, but they may be done in
certain cases (eg, blood cultures are positive for gram-negative bacilli, concern of late-onset sepsis) .

Clinically, group B streptococcal pneumonia is extremely difficult to differentiate from RDS; thus,
antibiotics should be started pending culture results.
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY

Pulmonary surfactant is a mixture of phospholipids and lipoproteins secreted by type II pneumocytes

(see Neonatal pulmonary function ). It diminishes the surface tension of the water film that lines
alveoli, thereby decreasing the tendency of alveoli to collapse and the work required to inflate them.
With surfactant deficiency, a greater pressure is needed to open the alveoli. Without adequate airway
pressure, the lungs become diffusely atelectatic, triggering inflammation and pulmonary edema.
Because blood passing through the atelectatic portions of lung is not oxygenated (forming a right-to-
left intrapulmonary shunt), the infant
becomes hypoxemic. Lung
compliance is decreased, thereby
increasing the work of breathing. In
severe cases, the diaphragm and
intercostal muscles fatigue, and CO2
retention and respiratory
acidosis develop.

How is RDS treated?

Treatments depend on how severe and persistent RDS is. They can include:

Artificial surfactant. Each dose is given through an endotracheal tube (ETT). This is a tube that goes
through the baby’s mouth or nose into the windpipe. Using this tube, 1 to 4 doses of surfactant may
be given several hours apart. If the baby responds well and breathes better without help, the tube
may then be removed.

Oxygen without ventilation. This is often given with a nasal cannula (soft tubes fixed under the baby’s
nostrils). Or it can be given with an oxygen hood (clear plastic box that fits around the baby’s head).
These devices give your baby oxygen without inserting tubes into the baby’s airway.
CPAP (continuous positive airway pressure). A CPAP machine provides continuous air flow into the
baby’s airways. This helps keep alveoli from collapsing. CPAP may be used with or without
supplemental oxygen.

Ventilator. This machine takes over some or all of the work of breathing. First, an ETT is inserted. The
ventilator is then attached and used to send air into the lungs to help the baby breathe. To avoid
damage to the lungs, the machine uses the lowest amount of pressure that works to fill the baby's
lungs with air. The ventilator is used until the baby’s lungs are making surfactant and the baby is
strong enough to breathe without help.

THERAPUETIC ACTIONS

Treatments for RDS include surfactant replacement therapy, breathing support from a ventilator or
nasal continuous positive airway pressure (NCPAP) machine, or other supportive treatments. Most new-
borns who show signs of RDS are quickly moved to a neonatal intensive care unit (NICU).

Management/ Treatment

 Maintaining the airway

 Providing adequate oxygenation
 Supporting hemodynamic function ( ECG monitoring, Central venous pressure monitoring, ABG
monitoring, Pulse oximetry, kidney function )
 Ensure Perfusion
 Positioning
 Protective Lung ventilation
 Protocol weaning ( from ventilator, CPAP)
 Preventing Complications ( Corticosteroid Therapy, Surfactant Replacement Therapy, Antibiotic
Prophylaxis)

NURSING CARE PLAN

Impaired Gas Exchange related to decreased volumes and lung compliance, pulmonary perfusion and
alveolar ventilation.

Goal: Signs and symptoms of respiratory distress, deviation of the function and the risk of infant
respiratory distress syndrome can be identified.

Outcomes:
Demonstrate improved ventilation and adequate tissue oxygenation with blood gas analysis in the
normal range.

Free of symptoms of respiratory distress. Outcomes: Breathing does not use nasal flaring, intercostal
retractions No, normal respiration, cyanosis (-), warm extremities.

Clients showed improvement of ventilation and tissue oxygen levels with a blood gas analyzer in the
normal range.

Intervention

1. Monitor dyspnea, tachypnea, breath sounds, increased respiratory effort, lung expansion, and
weakness.

R: / pulmonary tuberculosis resulted in far-reaching effects on the lungs of a small part of

bronchopneumonia to inflammatory wide diffusion, necrosis, Pleural effusion and extensive fibrosis. The
effect on respiratory symptoms varies from mild, severe dyspnea, until respiratory distress.

2. Evaluation of changes in the level of consciousness, cyanosis noted, and skin color changes, including
mucous membranes and nails.

R: / accumulation of secretions and less healthy lung tissue oxygenation can disrupt the body's vital
organs and tissues.

3. Support the lip breathing during expiration, especially for clients with fibrosis and lung parenchymal
damage.

R: / creating custody fight outside air to prevent collapse / narrowing of the airway that helps spread the
air through the lungs and reduces shortness of breath.

4. Assessing mental status.

R: / weakness, irritability, confusion can merefleksikana presence of hypoxemia / decrease in cerebral

oxygenation.

5. Oxygen delivery in accordance with the additional requirements.

R: / Oxygen therapy can correct the hypoxemia that occurs due to decreased ventilation / decrease in
pulmonary alveolar surface.

Imbalanced Nutrition: Less Than Body Requirements related to the inability to suck, decreased
intestinal motility.
Goal: Maintain and support the nutritional intake

Outcomes:

The client demonstrates adequate food intake and metabolismetubuh.

Increased food intake, there is no further weight loss, expressed feelings of well-being.

Interventions:

1. Give IV fluids containing glucose as needed neonates.

R: / a Food portion is a little but often requires less energy.

2. Identifying the factors which cause difficulty in swallowing.

R: / to be able to select interventions according to the cause.

3. Refer to dietitian for help choosing a liquid that can meet the nutritional needs.

R: / Dieticians are specialized in nutritional science that can help clients mimilih foods that meet the
needs of calories and nutritional needs according to the state of illness, age, height, weight.

Ineffective family coping related to anxiety, guilt, and parting with the baby as a result of a crisis
situation

Goal: Minimizing anxiety and guilt, and support bounding between parent and infant.

Outcomes:

Family clients reveal knowledge about the disease suffered by the patient.

Can be report immediately to the medical team if something suddenly happens to the patient.

Families of patients can stabilize emotions.

Interventions:

1. Assess verbal and non-verbal responses of parents of anxiety and the use of coping mechanisms.

R: / this will help identify and build effective coping strategies.

2. Help parents verbally express his feelings about the condition of sick children, old care intensive unit,
procedure and treatment of infants.
R: / creating parents to express their feelings freely so that helps establish mutual trust, as well as
reduce the level of anxiety.

3. Provide accurate and consistent information on the condition of infant development.

R: / information can reduce anxiety.

4. Whenever possible, encourage parents to visit and get involved in their care.

R: / facilitate the bounding process.

HEALTH TEACHING

 If your baby is sent home with oxygen, follow your doctor's directions for giving the oxygen.
 Learn how to do rescue breathing. It is important to know this in case your baby stops
breathing. Talk to your doctor or take a class to learn how to do rescue breathing and infant
CPR.
 Follow instructions on using a breathing monitor at home if your doctor tells you to use one.
 Do not smoke or allow anyone else to smoke in your house. Smoking increases the chance of
sudden infant death syndrome (SIDS), ear infections, asthma, colds, and pneumonia.
 Wash your hands well before holding your baby. Keep him or her away from crowds and people
who are sick.
 Make sure your baby gets all of his or her immunizations. Also, make sure anyone who comes
near your baby has had all of the recommended shots.

DISCHARGE INSTRUCTIONS:

Medicines:

Bronchodilators: This medicine may be given to open up your baby's airways so that he can breathe
easier.

Diuretics: This medicine may be given to help your baby's body get rid of extra fluid or water. This may
help your baby breathe easier.

Give your child's medicine as directed. Contact your child's healthcare provider if you think the
medicine is not working as expected. Tell him or her if your child is allergic to any medicine. Keep a
current list of the medicines, vitamins, and herbs your child takes. Include the amounts, and when, how,
and why they are taken. Bring the list or the medicines in their containers to follow-up visits. Carry your
child's medicine list with you in case of an emergency.
Oxygen:

Your child may need extra oxygen to help him breathe easier. It may be given through a plastic mask
over his mouth and nose. It may be given through a pair of short, thin tubes that rest just inside his
nose. Tell your child's pediatrician if his nose gets dry or if he has redness or sores on his skin.

Follow up with your child's pediatrician as directed:

Your child will need close follow up. Ask when you should bring your child in for his next visit. Write
down your questions so you remember to ask them during your child's visits.

Do not expose your child to smoke:

This includes cigarette and other tobacco smoke. Never smoke around or allow others to smoke around
your child because it can irritate your child's lungs.

Contact your child's pediatrician if:

 Your child has a fever.

 Your child is not eating as much as he should be.
 You think your child is losing weight or not gaining weight.
 You have questions or concerns about your child's condition or care.

Seek care immediately or call 911 if:

 Your child has hard time breathing, or has pauses in his breathing.
 Your child's lips or nails are blue.
 Your child's symptoms do not get better or get worse.