Neonatal respiratory distress syndrome (NRDS) more frequently affects the Caucasian boys, especially born to diabetic mothers by cesarean section, second born twins and children with a positive family history. On the other hand, maternal hypertension, antenatal steroid administration and prolonged membrane rupture seem to act as protective factors. Keeping this in mind, mothers should be counseled upon discharge in case they ever want to have another child.

The more prematurely the baby is born, the higher the chances of suffering from this ailment are. However, late prematurity is also associated with this disease [1]. The problem becomes apparent soon after birth, progressively worsens and its signs consist of tachypnea, increased respiratory effort with intercostal, suprasternal and substernal retractions, flaring of the nasal alae, expiratory grunting and cyanosis. In extreme situations, irregular breathing, apnea, and hypothermia are encountered. The consciousness state may be diminished and severe fatigability may be reported. In advanced cases, the patient requires ventilatory support and intensive care [2] [3].

Clinical examination reveals decreased breath sounds and peripheral pulses. Oliguria and peripheral edema can be encountered.

The surfactant deficiency may be secondary to several pathological processes, such as infectious or meconium aspiration pneumonia or pulmonary hemorrhage, intrapartum asphyxia, pulmonary hypoplasia or oxygen toxicity. Furthermore, the newborn may have other associated diseases, such as congenital diaphragmatic hernia, necrotizing enterocolitis or patent ductus arteriosus.

• Pneumonia

  Pneumonia is an infection of the lungs. It’s usually caused by a bacteria or virus. Some babies get pneumonia while they are still in the womb and must be treated at birth. Babies may also develop pneumonia several weeks after delivery. [healthline.com]

  However, surfactant therapy has been shown to be effective in the treatment of other diseases causing neonatal respiratory diseases such as pulmonary hemorrhage, meconium aspiration syndrome, pneumonia/sepsis, pulmonary edema or acute lung injury resulting [ncbi.nlm.nih.gov]

  Pneumonia Pneumonia (lung infection) is commonly treated in newborn care, particularly in developing countries. Bacterial, viral and fungal agents can all cause pneumonia. [futurelearn.com]

  Pulmonary  1- Transient tachypnea of newborn  2- Hyaline membrane disease  3- Meconium aspiration syndrome (MAS)  4- Pneumonia  5- Air Leak Syndromes 6. [slideshare.net]

• Tachypnea

  Neonates with transient tachypnea are usually at term. [emedicine.com]

  Convert to ICD-10-CM : 770.6 converts directly to: 2015/16 ICD-10-CM P22.1 Transient tachypnea of newborn Approximate Synonyms Neonatal transient tachypnea Transient tachypnea (rapid breathing) of newborn Transient tachypnea of newborn Clinical Information [icd9data.com]

  Transient tachypnea is more likely to occur in babies who were: Born before 38 weeks gestation (early term) Delivered by C-section, especially if labor has not already started Born to a mother with diabetes Male Newborns with transient tachypnea have [medlineplus.gov]

  Symptoms manifest shortly after birth and include tachypnea, tachycardia, increased breathing effort, and/or cyanosis. The diagnosis is suspected based on clinical features and confirmed by evaluating the extent of atelectasis via chest x-ray. [amboss.com]

• Nasal Flaring

  The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts. [orpha.net]

  There are 3 classic symptoms associated with respiratory distress syndrome: Intracostal retractions as the infant uses accessory muscles to support the work of ventilation Grunting as the epiglottis attempts to keep air in the lungs Nasal flaring as the [sharecare.com]

  2016 Topics: - Introduction - Cause & Risk Factors - Role of Maternal Diabetes in RDS - Role of Male Gender in RDS - Role of Prematurity in RDS - Role of Surfactant - Composition of Surfactant - Pathogenesis - Morphology - Clinical Features - Cause of Nasal [youtube.com]

  This infant will also probably have nasal flaring. What is most remarkable about the physical appearance of this baby? No. May increase P(a)O2, but any increase is merely transient. [quizlet.com]

• Rales

  […] within minutes of birth may not be recognized for several hours in larger preterm  Tachypnea (>60 breaths/min), nasal flaring, subcostal and intercostal retractions, cyanosis & expiratory grunting  Breath sounds may be normal or diminished and fine rales [slideshare.net]

  Breath sounds can be clear or reveal rales on auscultation. [aafp.org]

• Pulmonary Disorder

  Respiratory Distress Syndrome of the Newborn Hyaline Membrane Disease General Considerations Acute pulmonary disorder of the newborn characterized by Generalized atelectasis Intrapulmonary shunting Ventilation-perfusion abnormalities Reduced lung compliance [learningradiology.com]

• Cyanosis

  A condition of the newborn marked by dyspnea with cyanosis, heralded by such prodromal signs as dilatation of the alae nasi, expiratory grunt, and retraction of the suprasternal notch or costal margins, most frequently occurring in premature infants, [icd9data.com]

  The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts. [orpha.net]

  […] neonatal respiratory distress syndrome a condition of the newborn marked by dyspnea with cyanosis, preceded by symptoms such as dilatation of the nostrils, grunting on exhalation, and retraction of the suprasternal notch or costal margins. [web.archive.org]

  Tachypnea (>60 breaths/min), nasal flaring, subcostal and intercostal retractions, cyanosis & expiratory grunting. Breath sounds may be normal or diminished and fine rales may be heard. Progressive worsening of cyanosis & dyspnea. [slideshare.net]

  Definition (NCI_FDA) A condition of the newborn marked by dyspnea with cyanosis, most frequently occurring in premature infants, children of diabetic mothers and infants delivered by cesarean section, and sometimes with no predisposing cause. [fpnotebook.com]

• Tachycardia

  The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts. [orpha.net]

  Symptoms manifest shortly after birth and include tachypnea, tachycardia, increased breathing effort, and/or cyanosis. The diagnosis is suspected based on clinical features and confirmed by evaluating the extent of atelectasis via chest x-ray. [amboss.com]

• Oliguria

  Oliguria and peripheral edema can be encountered. [symptoma.com]

  These manifestations progress to apnea, flaccidity, unresponsiveness, mottling, peripheral edema, oliguria, hypotension, and bradycardia. [medical-dictionary.thefreedictionary.com]

   Pneumothorax and/or pneumomediastinum  PPHN in severe cases  Hypoxia to other organs (e.g., seizures, oliguria) 36. Pathophysiology 37. Chest x-ray: Areas of hyperexpansion mixed with patchy densities and atelectasis 38. [slideshare.net]

An amniocentesis is able to predict if NRDS will occur after birth, based on the lecithin-to-sphingomyelin ratio the presence of phosphatidylglycerol in the amniotic fluid. If these tests are not available, birth is in progress at the time the mother comes to the hospital or fetal distress is seen and childbirth is required, the diagnosis is made after the delivery is done.

Once respiratory distress is noticed, the physician should determine its severity and arterial blood gases offer a good measurement tool. Central (umbilical) or peripheral arterial blood should be analyzed [4] and may show hypoxemia, hypercapnia and respiratory (caused by alveolar atelectasis) and metabolic (due to lactic acid accumulation) acidosis. If a congenital right to left shunt heart malformation coexists, hypoxia will be severe and the child is likely to be cyanotic. A patent ductus arteriosus can have the same results. Blood workup should include a blood glucose level, that is often low, a complete cell count, bilirubin level, renal and liver function and electrolytes.

Oxygenation may also be monitored using a less invasive method, pulse oximetry. Probes should be placed on the right wrist or palm in order to establish the preductal saturation and on either foot for postductal saturation. Saturation should be kept at 91-95% [5]. This is a good screening technique for congenital heart disease, but the diagnosis should finally be evaluated by echocardiography in selected cases.

A thoracic radiography is done in order to observe the pulmonary aspect. Pleural effusion, atelectasis or air bronchograms, interstitial emphysema, pneumothorax, bronchogenic cyst or pulmonary sequestration may be described by this exam. Cardiomegaly is often found and further characterization by echocardiography is required. Doppler echocardiography is reliable in determining if pulmonary hypertension is present. Hyperinflation (in a non-ventilated patient) or a normal aspect at 6 hours of age exclude the NRDS.

Pulmonary ultrasonography may be a reliable method [6] [7] that visualizes the existing pleural effusions [8]. However, pneumothorax is harder to find by lung ultrasonography [9].

If infection signs are detected, tracheal aspirate, cerebrospinal fluid and blood cultures should be obtained.

In situations where the outcome is unfavorable, a histology evaluation will describe the presence of hyaline membranes - an amorphous material, lining the alveolar spaces, collapsed alveoli alternating with hyper aerated ones and vascular congestion.

• Bilateral Atelectasis

  atelectasis (grade IV); (5) Arterial blood gas analysis showing hypoxia, hypercapnia and oxygen tension/fraction of inspired oxygen ratio (PaO 2 /FiO 2 ) ≤ 26.7 kPa. [omicsgroup.org]

  atelectasis (grade IV); (4) arterial blood gas analysis showing hypoxia, hypercapnia, and oxygen tension/fraction of inspired oxygen ratio (PaO2/FiO2) ≤ 26.7 kPa. [hindawi.com]

• Hypercapnia

  Central (umbilical) or peripheral arterial blood should be analyzed and may show hypoxemia, hypercapnia and respiratory (caused by alveolar atelectasis) and metabolic (due to lactic acid accumulation) acidosis. [symptoma.com]

  Clinical evaluation ABG (hypoxemia and hypercapnia) Chest x-ray Blood, 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. [msdmanuals.com]

  Surfactant deficiency → little or no reduction of alveolar surface tension → reduced pulmonary unfolding → atelectasis → decreased lung compliance and functional residual capacity → hypoxemia and hypercapnia References:[1][3] Clinical features History [amboss.com]

  […] and hypercapnia; and chest x-ray. [merckmanuals.com]

Sixty babies were recruited, with 29 in the bLES and 31 in the Survanta treatment group. [ncbi.nlm.nih.gov]

Curosurf for “early treatment” (the new treatment) was donated by Serono Nordic, Copenhagen, Denmark. [doi.org]

Also, gestational age has an important role in determining the prognosis, where late preterm infants usually have a better prognosis in comparison with early preterm infants. 5. [intechopen.com]

Prognosis Prevention Prevent premature birth if possible. See tocolysis in the Preterm labor and birth learning card. [amboss.com]

Monitoring the changes of serum BMP-7 and TGF-β1 is very important for treatment and prognosis assessment of the NRDS. [ncbi.nlm.nih.gov]

[…] ground-glass” opacification of both lungs with air bronchograms and hypoaeration Hypoaeration from loss of lung volume (may be counteracted by respiratory therapy) Fine granular pattern Prominent air bronchograms Bilateral and symmetrical distribution Prognosis [learningradiology.com]

Etiology Impaired synthesis and secretion of surfactant Risk factors Premature birth Genetic predisposition Scheduled cesarean section Maternal diabetes mellitus Hydrops fetalis Multifetal pregnancies Rarely, hereditary References:[1] Pathophysiology [amboss.com]

The etiologies of NRD in the 334 newborns were dominated by neonatal infections (Figure 1). [panafrican-med-journal.com]

Pathogenesis Etiology Infection EHV1 Equine herpesvirus or EVA Equine viral arteritis virus (less common). Prematurity/dysmaturity Reproduction: prematurity / dysmaturity. Stress at parturition. [vetstream.com]

Epidemiology References:[1][2] Epidemiological data refers to the US, unless otherwise specified. [amboss.com]

Knowledge of the epidemiology and clinical characteristics of maternal and fetal infection can be used to select a diagnostic approach. Etiologic diagnosis will guide prognosis and the selection of specific chemotherapy. [ncbi.nlm.nih.gov]

Published on May 25, 2018 In this video, the viewer will learn the differential diagnosis for newborn respiratory distress, and the epidemiology, pathophysiology, presentation, diagnosis, and management of its most common etiologies. [youtube.com]

In this chapter, we are going to have a rapid review on epidemiology, diagnosis and treatments of RDS. [intechopen.com]

[…] groups, the GT genotype and A allele were less frequent among the RDS groups in 26-32.9 weeks of gestational age and in a birth weight subgroup of CONCLUSION: Our study raises the possibility that a genetic variation of NOS3 could be implicated in the pathophysiology [ncbi.nlm.nih.gov]

Etiology Impaired synthesis and secretion of surfactant Risk factors Premature birth Genetic predisposition Scheduled cesarean section Maternal diabetes mellitus Hydrops fetalis Multifetal pregnancies Rarely, hereditary References:[1] Pathophysiology [amboss.com]

Historical Perspective: Failure of Oxygen Treatment Before discussing the pathophysiology of RDS and the current modalities of treatment, it is useful first to consider why the historical mode of treatment, administration of oxygen, was ... [accessmedicine.mhmedical.com]

Calfactant (Infasurt) is a natural bovine surfactant which has been evaluated for intratracheal use in the prevention and rescue treatment of respiratory distress syndrome (RDS) in preterm infants. [ncbi.nlm.nih.gov]

[…] between 4-5 mL/kg to prevent volutrauma. [rtmagazine.com]

Prognosis Prevention Prevent premature birth if possible. See tocolysis in the Preterm labor and birth learning card. [amboss.com]

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2. Escobar GJ, Clark RH, Greene JD. Short-term outcomes of infants born at 35 and 36 weeks’ gestation: we need to ask more questions. Semin Perinatol. 2006;30:28-33.
3. Jain L, Eaton DC. Physiology of fetal lung fluid clearance and the effect of labor. Semin Perinatol. 2006;30:34-43
4. Billman GF, Hughes AB, Dudell GG, et al. Clinical performance of an in-line, ex vivo point-of-care monitor: a multicenter study. Clin Chem. 2002;48(11):2030-43.
5. Tarnow-Mordi W, Stenson B, Kirby A, et al. Outcomes of Two Trials of Oxygen-Saturation Targets in Preterm Infants. N Engl J Med. 2016; 374(8):749-60.
6. Liu J, Cao HY, Liu Y. Lung ultrasonography for the diagnosis of neonatal respiratory distress syndrome: a pilot study. Zhonghua Er Ke Za Zhi. 2013; 51(3):205-10.
7. Vergine M, Copetti R, Brusa G, et al. Lung ultrasound accuracy in respiratory distress syndrome and transient tachypnea of the newborn. Neonatology. 2014;106(2):87-93.
8. Ahuja CK, Saxena AK, Sodhi KS, et al. Role of transabdominal ultrasound of lung bases and follow-up in premature neonates with respiratory distress soon after birth. Indian J Radiol Imaging. 2012;22(4):279-83.
9. Sawires HK, Abdel Ghany EA, Hussein NF, et al. Use of lung ultrasound in detection of complications of respiratory distress syndrome. Ultrasound Med Biol. 2015;41 (9):2319-25.