TREATMENT

Hyaline Membrane Disease Prenatal prevention and prediction –Prevent premature birth with tocolytics, antibiotics to address ongoing infection –Antenatal corticosteroids One course reduces risk of RDS and neonatal death Indicated at recognition of risk pf preterm delivery Betamethasone 48 hours before delivery, weeks AOG Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Prenatal prevention and prediction –Antenatal corticosteroids May consider retreatment if the mother does not deliver within 1 week Exercise clinical judgment regarding risk for preterm delivery before giving repeat dose. –If with progressive cervical dilation or persistent signs of labor, may give repeat dose. –If at lower risk, may defer retreatment. Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Prenatal prevention and prediction –Estimating the lecithin-to-sphingomyelin ratio and/or by the presence of phosphatidylglycerol in the amniotic fluid obtained with amniocentesis Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Delivery and resuscitation –Continuous nasal positive airway pressure (CPAP) often used in spontaneously breathing premature infants immediately after birth as potential alternative to immediate intubation and surfactant replacement –Lung injury may be diminished by avoiding intubation Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Surfactant replacement therapy –Mortality rate decreased by ~ 50% over the last decade with surfactant therapy –Ideal surfactant preparation has not been identified –Synthetic vs. animal-derived preparations: animal-derived surfactants superior immediate benefits in pulmonary air leaks, intraventricular hemorrhage, BPD, and mortality Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Surfactant replacement therapy –Neonates who require assisted ventilation with a FIO2 of >0.40 should receive intratracheal surfactant as soon as possible, preferably within 2 hours after birth –Meta-analysis of early vs. delayed selective treatment for neonatal respiratory distress syndrome suggested a decrease in pulmonary air leaks and chronic lung disease. Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Surfactant replacement therapy –Some recommend prophylactic use after resuscitation in extremely premature neonates (<27 weeks' gestation). –In developing countries, surfactant expensive and unnecessary in most instances because > 60% of premature infants do not have surfactant deficiency. Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Oxygenation and CPAP –CPAP keeps the alveoli open at the end of expiration, decreasing the right-to-left pulmonary shunt. –Short binasal-prongs devices were found to be more effective than single prongs and also reduced the rate of reintubation. –Goals: maintain pH , PaO mm Hg, PCO2 of mm Hg, depending on clinical status Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Vapotherm –Allows delivery of high flows of gas at body temperature with close to 100% relative humidity –Advantages over CPAP: reduction in number of ventilator days reduced nasal trauma Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease High frequency ventilation –Small tidal volumes (less than anatomic dead space) usually delivered at rapid frequencies  eliminating wide pressure swings seen with conventional ventilators –Promotes uniform lung inflation, improves lung mechanics and gas exchange, and reduces exudative alveolar edema, air leak, and lung inflammation –Early use of high-frequency oscillatory ventilation superior to conventional ventilation Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Nitric oxide –Role in premature infants ill-defined –Has selective pulmonary vasodilation In premature infants, may have a role in decreasing inflammation, reducing oxidative stress, and enhancing alveolarization and lung growth. Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Supportive therapy –Thermoregulation: Hypothermia increases oxygen consumption  double-walled incubator or radiant warmer –Circulation and anemia: Support circulation with blood or volume expanders, vasopressors; pRBC transfusion when blood loss reaches 10% of estimated blood volume or if hematocrit < 40-45% Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Supportive therapy –Fluids, metabolic, and nutritional support: Initially administer 5% or 10% dextrose IV at mL/kg/d. Monitor blood glucose, electrolytes (including Ca and P), renal function, and hydration. IV sodium bicarbonate often misused  considered an unproven therapy. Gradually increase fluid intake to mL/kg/d. Extremely premature infants: TFI of mL/kg or more because of insensible water loss Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Supportive therapy –Fluids, metabolic, and nutritional support: IV nutrition with amino acids and lipid within hours of birth. If oral feeding tolerated, start trophic feeding to stimulate gut development. Adequate supply of macronutrients, micronutrients, vitamins, and antioxidants should be provided to maintain optimal lung, brain, eye, and somatic growth. Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Supportive therapy –Antibiotic administration: Start in all infants who present with respiratory distress at birth after blood cultures, CBC, and CRP levels are obtained. Discontinue antibiotics after 2-5 days if blood cultures are negative and if no maternal risk factors are found. Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Supportive therapy –Antibiotic administration: Exceptions: absence of findings suggestive of chorioamnionitis, adequate antenatal care, recent negative maternal cervical culture for group B beta-hemolytic streptococci or a baby delivered with intact amniotic membranes Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Hyaline Membrane Disease Supportive therapy –Parental and family support Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article overview.mht. Accessed November 23, 2009.

Other Problems Hyperbilirubinemia: phototherapy as necessary Sepsis: Culture-guided antibiotic treatment Necrotic Digit: Watchful waiting Prematurity: thermoregulation, upbuilding Patent Ductus Arteriosus: medical closure with IV indomethacin 0.2mg/kg at 12-24h intervals x 3 doses or ibuprofen 10mg/kg then 5mg/kg x 2 doses at 24h intervals