LESSON PLAN IN PEADIATRICS

NAME OF SUBJECT: PEADIATRICS

TOPIC: RESPIRATORY DISTRESS SYNDROME
STUDENT LECTURER: BERTHA GONDO
COMPUTER NUMBER: 19012977
TARGET: FIRST YEAR STUDENTS
TEACHING METHOD: LECTUERING/DISCUSSION
SUPERVISOR: DR.SIAME
DURATION: 2HOURS
INTRODUCTION
Good morning class, my name is Bertha Gondo a fourth year student Chreso university. With me is my supervisor
. Today we are going to discuss respiratory distress syndrome.
Respiratory Distress Syndrome (RDS) is the name for a cluster of symptoms that indicate severe malfunctioning of the
lungs. In infants, RDS is termed Infant Respiratory Distress Syndrome (IRDS). Commonly found in premature infants,
IRDS results when the alveoli fail to fully expand during inhalation. Expansion of the alveoli requires a Lipoprotein
called surfactant, but in many premature infants, the alveoli are not developed enough to produce this vital
substance. IRDS is treated by administering air and surfactant through a breathing tube until the alveoli begin
producing surfactant on their own (Diane .M F,et’al,2003).Surfactant a substance found in a group of Phospholipids
and has a tendency to repel water. By so doing, in the lungs, which are naturally wet, it prevents the alveoli surfaces
from adhering to each other on expiration.
GENRAL OBJECTIVE:

At the end of this lecture, students should be able to demonstrate an understanding of Respiratory Distress
Syndrome.
SPECIFIC OBJECTIVES:
At the end of the lesson, the students should be able to:
1. Define respiratory Distress Syndrome (RDS).
2. State the predisposing factors of RDS.
3. Describe the pathophysiology of RDS
4. State the signs and symptoms of RDS
5. Outline the Silverman-Andersen Score.
6. Outline the diagnosis of RDS.
7. Explain the Medical Management of RDS.
8. Explain the Midwifery Management for RDS.
9. Outline prevention measures for RDS.
TIME SPECIFIC C0NTENT AUDIO TEACHER STUDENT EVALUATI
OBJECTIV VISUAL ACTIVITY ACTIVITY ON
ES AIDS

It is a developmental respiratory condition LCD, Teaching, Listening,

Define related to inadequate/inactive surface Laptop, Clarifying, taking Define
respirator active Phospholipids compound chalk and asking notes, respirator
y Distress (surfactant) in the alveoli of the neonate’s black questions asking y distress
Syndrome lungs resulting in difficulties in breathing, board and questions syndrome
(RDS). lung collapse and inadequate oxygenation. answering and ?
-It is a respiratory disease of newborns, questions answering
especially premature infants, caused by questions
the inability of the lungs to take in Oxygen
and marked by cyanosis and difficult
breathing (Diane.F M, 2003).

Lack of surfactant or failure of surfactant LCD, Teaching, Listening, What are

to be released from the alveoli. Laptop, Clarifying, taking the
State the This situation can be precipitated by a chalk and asking notes, predisposi
predisposi number of factors: black questions asking ng factors
ng factors -Prematurity, especially those of less than board and questions of
of RDS. 34 weeks’ gestation, which results in answering and Respirator
labored breathing as there, is alveolar questions answering y Distress
collapse. questions Syndrome
-Infants of diabetic mothers: Are usually ?
premature despite their sizes, as such they
are born with insufficient surfactant.
-Uncontrolled maternal hyperglycemia
also affects fetal respiration due to the
increased aerobic and anaerobic glucose
metabolism which consumes Oxygen
leading to production of
Lactate, lowered pH and fetal acidosis.
-Insulin is an antagonist to surfactant.
-Babies born by caesarean section:
Because their Chest is not compressed
during birthing process, this over whelms
the surfactant available due to so much
liquor volume in the lung.
The normal initiation of breathing by lung
squeezing to remove fluid as the baby
passes through the birth canal is skipped.
On the other hand, the baro receptors of
the head and neck are not stimulated, as it
is the case in vaginal delivery.
-Babies born following ante-partum
hemorrhage: hemorrhage retards the
developmental process of the fetus and
cause less surfactant production
The lower the gestation, age the higher
the risk of developing RDS (Henderson &
Macdonald, 2005).
-Asphyxia neonatorum: Asphyxiation
 results in low apgar score and this disrupts
the respirations establishment, RDS
ensures.
-Meconium aspiration: This impediment to
the airway disturbs all the events that
occur at birth to the lungs resulting in
RDS.

Surfactant reduces the surface tension in LCD, Teaching, Listening, What is

the alveoli, facilitating lung expansion and Laptop, Clarifying, taking the
preventing total collapse after expiration. chalk and asking notes, pathophys
Describe Surfactant becomes adequate around 36- black questions asking iology of
the 37 weeks of gestation but its production board and questions RDS?
pathophys starts at about 22 weeks. It opposes the answering and
iology of natural tendency of the alveolar tissue to questions answering
RDS. collapse completely at the end of questions
expiration and thereby keeps the lungs
partially expanded at all times. Its
deficiency leads to more respiratory effort
to inflate the lungs with each breathe and
the neonate quickly becomes exhausted,
the alveoli collapse and Hypoxemia results.
Pulmonary capillary permeability increases
and pulmonary edema sets in. The alveoli
are filled with RBCs leaking from the
capillaries and fibrin coagulates it to form
 a membrane that lines the sacs filled with
fluid and blood. Because of the resistance
in pulmonary circulation, the
prostaglandins production in the walls of
the Ductus arteriosus is stimulated and
prevents its closure (Patent Ductus
arteriosus) causing right-to-left shunting of
blood further reducing blood flow to the
lungs for oxygenation. Hypoxemia causes
further impairment in surfactant
production and a vicious cycle ensues.
Metabolism spirals out of control (Aerobic
to Anaerobic).

Cardinal signs; LCD, Teaching, Listening, What are

-Granting as the epiglottis attempts to Laptop, Clarifying, taking the signs
State the keep air in the lungs. chalk and asking notes, and
signs and - Nasal flaring as infant attempts to take in black questions asking symptoms
symptoms additional air. board and questions of RDS?
of RDS -Sternal retraction (Sternum in drawing) answering and
due to strain on breathing, using accessory questions answering
muscles of respirations to support work of questions
ventilation.
Other Signs
-Chest recessions which follows with
substernal retraction.
-The initial signs of RDS occur within 4
hours of birth. As said, they are rare in
infants over 37weeks’ gestation.
-Crepitations due to the ejection of fluid in
the alveolar.
-Reduced breathe sounds on auscultation
due to diminished air inflow.
-Deteriorating Apgar score as a result of
progressive hypoxia.
-Progressive tachypnoea of 60-100bpm as
a result of hypoxia.
-Tachycardia as the heart tries to
compensate the rise in CO2to offset the
hypoxia.
-Apnoea resulting from immaturity of the
CNS in preterm.
-Hypoxia as there is reduced respirations
-Cyanosis (central/peripheral)
-Fatigue which results from labored
breathing.
-Edema that is due to increased capillary
perfusion that builds in the alveolar vessels
to try to overcome the hypoxia.
 OUTLINE OF SILVERMAN-ANDERSEN What is
SCORE the
A system for evaluation of breathing Silverman-
Outline performance of premature infants. It Andersen
the consists of five items; score?
Silverman- 1. Chest retraction as compared with
Andersen abdominal retraction during inhalation.
score. 2. Retraction of the lower Intercostal
Muscles.
3. Xiphoid Retraction.
4.Flaring of the Naires with inhalation
5. Grunting on exhalation.
- Each of the five factors is graded 0; 1or 2.
-The sum of these factors yield the score
-Adequate Ventilation is indicated by a 0
Score, and Severe RDS indicated by a Score
of 10

Describe -Antenatal, intra-natal and postnatal LCD, Teaching, Listening, What is

the history. Laptop, Clarifying, taking the
diagnosis -Neonatal signs and symptoms chalk and asking notes, diagnosis
of RDS. -Auscultation of the chest will depict black questions asking of RDS?
reduced breathe sounds. board and questions
-Chest X-ray shows a fine ground-glass answering and
mottling display. questions answering
-A clear line of membrane along the questions
bronchial tree (hyaline membrane
 disease).
-Blood gas studies (↓PO2 and ↑PCO2)
-↓blood pH (acidosis).

AIMS: LCD, Teaching, Listening, What is

o To avoid Hypoxemia. Laptop, Clarifying, taking the
Explain o To provide supportive care with chalk and asking notes, medical
the appropriate interventions. black questions asking managem
Medical -Give oxygen to alleviate hypoxemia and board and questions ent of
Managem respiratory failure. answering and RDS?
ent of -Put the neonate on artificial ventilation questions answering
RDS. for assisted breathing. Continuous Positive questions
Airway Pressure or Intermittent Positive-
Pressure Ventilation (CPAP or IPPV).
-Administration of surfactant where
available.
-Sodium bicarbonate to buffer acidosis.
- Correct hypoglycemia
-Dextrose 10%, given by i.v infusion in the
first 24 hours to stabilize the newborn
-Site an arterial line for blood gas
monitoring.

Aims LCD, Teaching, Listening, What is

-Prevent complications such as secondary Laptop, Clarifying, taking the
Explain asphyxiation. chalk and asking notes, nursing
the -Continue assessing the baby and scoring. black questions asking managem
nursing Airway board and questions ent of
managem -Clear the air way by suctioning answering and RDS?
ent of In addition, ventilation. This will help clear questions answering
RDS. the lung fluid and activate questions
Surfactant or its productivity.
-Resuscitative procedure should be
followed. Mouth first then nostrils to avoid
aspirations.
-Do artificial ventilation with ambubag and
musk to facilitate initial expansion of lungs
and stimulate respiration.
-If need be intubation may be done and if
that be the case, IPPV may be the best
option of
Oxygen administration. In this case give
Alcuronium Bromide to paralyze the
respiratory muscles in order prevent
counteraction of pressures. The oxygen
tubing is introduced to the bronchiole tree
through the Endotracheal tube.
If there is no need of intubation and
actually the best way to manage apnea,
give oxygen by CPAP using a musk or hood.
CPAP works by pumping in air/O2 at a high
pressure to keep the airway open at all
times while CO2 is pushed out through the
side holes of the musk.
-Oxygen administration is vital to relieve
hypoxia and prevent brain damage.
Use electronic oxygen analyzer to
Measure inspired O2 concentration, blood
gas studies. Be careful not cause burns in
the neonatal unit.
-If it is given by continuous positive
pressure, air of about 5-10cm³ is pushed in
to effectively splint the airway.
The stomach may be distended by fluids or
meconium and impair the respiratory
efforts. This is managed by inserting a
nasal gastric tube and
Leaving it in situ with neonate’s head tilted
to one side to help in the continuous
drainage of the gastric fluids.
-If IPPV is used, i.e. the neonate is
intubated in cases of very low O2 levels
˂5kpa (40mmhg) or a PCO2 ˃12kpa. This is
a state of acidosis and NaH2CO3 2mEq/kg
is administered to buffer the acidosis.
Warmth: it is very cardinal to keep the
neonate warm in RDS management.
Radiant heaters may be used with water
points to humidify the environment.
-The neonate is admitted in NICU in the
incubator to help in maintaining the
environment and ease observations. All
the precautions of incubator care must be
employed to avoid cold stress, prevent
infection, prevent burns etc.
Check temperatures every 4 hourly, make
sure the body temperature falls within
36.5˚-37˚c. If a skin probe is available and
working, use it for continuous checking.
The incubator temperature should be
maintained between 34˚c and 37˚c.
Other observations should be checked
continuously to assess the well-being of
the newborn. Heart rate, respiratory rate,
trans-cuteneous oxygen monitoring, urine
output, edema, stools for colour and
consistency and the general behavior of
the newborn should be monitored closely.
Feeding: in the early stages of the
Disease, Entero feeds should not be given
to prevent aspiration and abdominal
distention due to the likelihood of paralytic
illeus. Apart from that, Entero feeds
introduce microbes into the GIT but in this
case the neonate is so weak that even the
supposedly normal flora
may result into Necrotizing Entero Colitis.
Para-Entero feeds are therefore
administered for the first few days. Fluids
like 10% dextrose may be prescribed.
Depending on the condition, gradual
introduction of expressed breast milk and
weaning from iv line may start.
-Do 4 hourly glucose checkups to manually
monitor blood sugar levels where there is
no automated monitoring gadget.
Infection prevention: At all stages of care
and handling, observe aseptic techniques.
Use sterile instruments for all invasive
procedures like suctioning, intravenous
insertions and intubation. Wash hands
before and after handling the neonate.
Restrict visitors to the NICU but give
psychological care to parents who may be
allowed to enter the NICU sometimes to
facilitate bonding. Teach parents the basic
precautions of the NICU.
Turn the neonate 2 hourly to promote
blood circulation and prevent bed sores.
Remove dirty linen through the back
windows of the incubator and the clean
should enter through the clean front
window. All dirty procedure should be
done through the back windows and the
 clean/sterile procedures should be done
via the front window.
Give antibiotics as prescribed to prevent
infections. Example, Gentamycin or X-pen

-Prenatal assessment of fetal lung maturity LCD, Teaching, Listening, How can
by amniocentesis Laptop, Clarifying, taking RDS be
Outline -Delaying of elective caesarian sections chalk and asking notes, prevented
the allows for further maturity of the lungs black questions asking ?
preventio and the surfactant production cycle board and questions
n of RDS -Administration of surfactant to the answering and
newborn at risk of RDS. It can be synthetic questions answering
or natural. questions
-Give corticosteroids to mothers who are
likely to go into premature labor in order
to stimulate the lungs.

Complicati - Atelectasis, when small air pockets in the LCD, Teaching, Listening, What are
ons of RDS lung collapse Laptop, Clarifying, taking the
-Complications of treatment in a hospital chalk and asking notes, complicati
-Failure of multiple organs black questions asking ons of
-Pulmonary hypertension, or an increase in board and questions RDS?
blood pressure in the major artery leading answering and
from the heart to the lungs. questions answering
questions
 SUMMARY

RDS is a common condition, which is usually mismanaged in our NICUs partly because of lack of equipment and partly
because of the midwives/obstetricians incompetence. It should be born mind that any condition in the newborn that
because the metabolism to spiral out of control i.e. from aerobic to anaerobic also disturbs the surfactant production
cycle and breathing becomes more labourous with consequential development of RDS. Apart from prematurity, such
other conditions may include Asphyxia, Cold stress, Starvation (hypoglycemia) etc.
 REFERENCES

Fraser, D. & Cooper, M. (2003): Myles Textbook For Midwives. 14th ed. Livingstone Churchill: Elsevier.
Henderson, S. & Macdonald, S. (2004). Maye’s Midwifery: A textbook for Midwives. 13th ed. China: Bailliere Tindall.
Hull, D. & Johnson,(1993)D.I: Essential Paediatrics. 4th ed. ChMurchill Livingstone: Elsevier.
Miller- Keane (2003) Encyclopedia and Dictionary of Medicine and Allied Health, Third edition, Saunders Incorporation.
Sellers, P.C. (2013). Seller’s Midwifery, second edition,Juta and company Ltd, Cape Town.