1. Maria Victoria B. Pertubal M.D. PGY1
Case Conference
Maria Victoria B. Pertubal M.D.
PGY1

2. Case 33 weeker preterm male NSVD APGAR 9/9 BW 1990g
Admitted to NICU for prematurity and LBW
labored breathing

3. What are your considerations?
Respiratory causes:
Respiratory Distress Syndrome (RDS) aka Hyaline Membrane Disease (HMD)
Transient tachypnea of the Newborn (TTN)
Pneumonia
Air leak / pneumothorax
Persistent pulmonary hypertension
aspiration syndromes (meconium, amniotic fluid),
congenital anomalies such as cystic adenomatoid malformation, pulmonary lymphangiectasia, diaphragmatic hernia, and lobar emphysema

4. Other differential diagnoses?
Cardiac causes:
Cyanotic congenital heart disease
5T’s
Other Systemic disorders:
Hypothermia
Hypoglycemia
Anemia ; polycythemia
Metabolic acidosis
Cardiac causes are usually have milder respiratory distress. On CXR, you don’t see the typical findings seen in rds (reticulo-granular ground glass appearance and airbronchogram. Hyperoxia and surfactant administration don’t help

5. Initial Work-up
Chest X-ray
ABG
CBC, Blood culture
BMP, glucose

6. CXR C

8. Hospital course: 1st hospital day : NCPAP, FiO2 25-35%
O2 sats 93-95%
2nd hospital day: NCPAP, FiO %
SC/IC retractions, O2 sats 88-92%
Repeat CXR, ABG

11. Respiratory Distress Syndrome aka. Hyaline Membrane disease (HMD)

12. Incidence male > females primarily in premature infants
white infants
inversely related to gestational age and birthweight.
60-80% of <28 wk of gestational age
15-30% of  weekers,
rarely in those >37 wk.

13. Other Risk factors maternal diabetes multiple births cesarean delivery
precipitous delivery
asphyxia,
cold stress
maternal history of previously affected infants.
Synthesis of surfactant depends in part on normal pH, temperature, and perfusion

14. Reduced risk in..
pregnancies with chronic or pregnancy-associated hypertension
maternal heroin use
prolonged rupture of membranes
antenatal corticosteroid prophylaxis.

15. Etiology and Pathophysiology of RDS:
Surfactant deficiency
(decreased production and secretion)

18. SurFactant Facts 90% Lipids (Phospholipids)
10% Proteins (4 Surfactant specific)
-A,-B,-C,-D
produced by type alveolar cells
Nelson Pediatrics Figure 95-2  (From Jobe AH: Fetal lung development, tests for maturation, induction of maturation, and treatment. In Creasy RK, Resnick R, editors: Maternal-fetal medicine: principles and practice, ed 3, Philadelphia, 1994, WB Saunders.)

19. The Premature Lung
Both decreased in quantity and quality of surfactant
LESS QUALITY due to:
Less protein content
PhosphatidylINOsitol > PhosphatidylGLYcerol
PG is used as a marker for fetal lung maturity at 35 weeks AOG

20. Figure 95-4 Nelson pediatrics

21. Clinical Manifestations
Tachypnea
Nasal flaring,
Expiratory grunting
Intercostal, subxiphoid, and subcostal retractions,
Cyanosis or pallor
breath sounds are decreased
diminished peripheral pulses.
urine output often low in the first 24 to 48 hours and peripheral edema
Grunting - results from exhalation through a partially closed glottis
Retractions – because chest wall is highly compliant
Cyanosis – due to R to L shunting

22. CXR: diffuse reticulogranular ground-glass appearance with airbronchogram
A. Severe RDS B. Moderate RDS

24. Other Laboratory findings
Arterial blood gas
hypoxemia that responds to supplemental oxygen.
PCO2 initially is normal or slightly elevated, but may increases as the disease worsens.
hyponatremia
Hyponatremia develops from water retention, treat with fluid restriction

25. Management
DELIVERY ROOM: Provide warmth, position head, clear air, stimulate baby.
2. Assisted ventilation (MV, CPAP, NIPPV)
3. Surfactant therapy
4. Inhaled NO
5. Glucocorticoid (post-natal)
6. Other supportive care
Fluid status monitoring
Early nutrition
Fluid status must be carefully monitored as excessive fluid increases the risk of patent ductus arteriosus, necrotizing enterocolitis (NEC), and BPD
Nutrition to support growth and development. Prevent protein breakdown

26. Surfactant therapy
Types available- Survanta (Bovine); Curosurf(porcine); Infrasurf (Calf); Exosurf(synth)
Indications:
Prophylactic therapy – immediately after birth
Early-rescue therapy – during the 1st few hours after birth.
AAP recommends to give when the diagnosis of RDS is established;
Continued therapy - clinical evidence of persistent disease

27. Ventilatory support
to improve oxygenation and elimination of CO2 w/o causing pulmonary injury/toxicity
Criteria for mechanical ventilation 
Respiratory acidosis- pH <7.20, PaCO2 >60 mm Hg
Hypoxia- PaO2 <60 mm Hg oxygen, O2sats <85% despite supplementation of 70 % on nasal CPAP
Severe apnea
CPAP, HFV, NIPPV- alternative to mechanical ventilation

28. Other treatment options: (controversial)
Inhaled Nitric oxide
Mosty benefits or late preterm infants with persistent pulmonary hypertension through:
reduced lung inflammation,
improved surfactant function,
Slows down hyperoxic lung injury,
promotes lung growth
Not commonly used due to cost

29. Other treatment options: (controversial)
Postnatal glucocorticoids
given in the first day of life
improves pulmonary and circulatory function and decreases the incidence of BPD
Limitations of use:
short-term complications: intestinal perforation, metabolic instability;
long-term abnormal neurodevelopmental outcomes

31. Prevention Avoidance of unnecessary or poorly timed cesarean section,
appropriate management of high-risk pregnancy and labor
 Antenatal corticosteroids for all women in preterm labor (24-34 wk of gestation) who are likely to deliver a fetus within 1 wk

34. Complications of RDS: Endotracheal tube complications
Bronchopulmonary dysplasia (BPD)
Pulmonary air leak 
Pneumothorax
Pneumomediastinum
Pulmonary interstitial emphysema (PIE)

35. pneumothorax

37. Pneumothorax, Left

38. case

39. pneumomediastinum

40. pneumomediastinum

42. Pulmonary interstitial emphysema

43. Pulm Interstitial empysema Pneumomediastinum pneumopericardium
Subcutaneous emphysema
Courtesy of Gerardo Cabrera-Meza, MD

44. References:
Carlo, W.  Respiratory Distress Syndrome (Hyaline Membrane Disease) Nelson Textbook of Pediatrics. 2011
Welty, Stephen. Treatment and complications of respiratory distress syndrome in preterm infants. Uptodate may2011
Fernandes, Caraciolo. Pulmonary Air Leak in the Newborn. Uptodate. May 2011
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