Respiratory Distress Syndrome

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Chapter 66 Respiratory Distress Syndrome

PATHOPHYSIOLOGY

Respiratory distress syndrome (RDS) results from the absence, deficiency, or alteration of the components of pulmonary surfactant. Surfactant, a lipoprotein complex, is an ingredient of the filmlike surface of each alveolus that prevents alveolar collapse. It is secreted from type II respiratory cells in the alveoli. When surfactant is inadequate, alveolar collapse occurs and hypoxia results. Pulmonary vascular constriction and decreased pulmonary perfusion then occur, which lead to progressive respiratory failure.

INCIDENCE

1. The incidence of RDS shows an inverse relationship to gestational age: the younger the infant, the greater the risk of RDS. However, the occurrence of RDS appears to be more dependent on lung maturity than on actual gestational age.

a. Diagnosed in 60% of infants at less than 28 weeks’ gestation, in 30% of infants born between 28 weeks and 34 weeks gestation; and 5% of infants born after 34 weeks’ gestation

2. The severity of RDS is decreased in infants whose mothers received corticosteroids 24 to 48 hours before delivery. There appears to be an additive effect in improved lung function when antenatal steroid therapy is combined with postnatal surfactant administration.

3. RDS occurs twice as often in males as in females.

4. Incidence increases in full-term infants in the presence of certain factors:

a. Diabetic mother who delivers at less than 38 weeks’ gestation
b. Cesarean delivery without labor
c. Perinatal hypoxia

CLINICAL MANIFESTATIONS

The following symptoms are observed in the first 2 to 8 hours of life. Symptoms are progressive as atelectasis increases:

1. Tachypnea (more than 60 breaths/min)

2. Intercostal and sternal retractions

3. Audible expiratory grunting

4. Nasal flaring

5. Cyanosis as hypoxemia increases

6. Decreasing lung compliance (paradoxic seesaw respirations)

7. Systemic hypotension (peripheral pallor, edema, capillary filling delayed by more than 3 to 4 seconds)

8. Decreased urinary output

9. Decreased breath sounds with rales

10. Tachycardia as acidosis and hypoxemia progress

RDS is a self-limiting disease. Improvement is typically seen 48 to 72 hours after birth, when type II alveolar cell regeneration occurs and surfactant is produced. Presentation and duration of symptoms can be altered with surfactant replacement therapy.

COMPLICATIONS

1. Metabolic: acid-base imbalance

2. Pulmonary: air leaks (pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, subcutaneous emphysema, pulmonary interstitial emphysema), pulmonary hemorrhage, chronic lung disease of infancy (in 5% to 10% of infants, see Chapter 13), apnea

3. Cardiovascular: systemic hypotension

4. Hematologic: anemia

5. Infection: pneumonia, septicemia—transplacental or nosocomial

6. Developmental: altered infant development and parenting behaviors

Complications Associated with Intubation

1. Endotracheal tube complications (displacement, dislodgement, occlusion, atelectasis after extubation, palatal grooves)

2. Tracheal lesions (erosion, granuloma, subglottic stenosis, necrotizing tracheobronchitis)

Complications Associated with Prematurity

1. Cardiovascular: patent ductus arteriosus, often associated with pulmonary hypertension, intraventricular hemorrhage, retinopathy of prematurity

2. Neurologic impairment

LABORATORY AND DIAGNOSTIC TESTS

1. Chest radiographic studies—to visualize lung and cardiac involvement

a. Diffuse reticulogranular pattern in superimposed air bronchograms
b. Central lung markings and heart border that are difficult to see; hypoinflated lungs
c. Possible presence of cardiomegaly when other systems are also involved (infants of diabetic mothers, infants with hypoxia or congestive heart failure)
d. Large thymic silhouette
e. Whiteout (uniform granularity) in air bronchograms, indicating severe disease if present in first few hours

2. Arterial blood gas values—to determine the level of oxygen and carbon dioxide in the blood; hypoxemia with respiratory and/or metabolic acidosis

3. Complete blood count—to determine the cellular profile of the blood such as red blood cells, white blood cells, hemoglobin, hematocrit, and platelet count

4. Serum electrolytes, calcium, sodium (Na+), potassium (K+), glucose levels

5. Lecithin/sphingomyelin ratio and phosphatidylglycerol levels are beneficial in determining timing for labor induction or elective cesarean deliveries as a means of preventing RDS

MEDICAL MANAGEMENT

The goal of medical management is to improve oxygenation and maintain optimal lung volume. Stabilization of the infant’s condition is indicated by laboratory values of arterial partial pressure of oxygen (PaO2) of 50 to 80 mm Hg, arterial partial pressure of carbon dioxide (PaCO2) of 40 to 50, and pH of at least 7.25. This aim is achieved by the following: (1) treat the infant with warm, humidified oxygen; (2) replace surfactant via endotracheal tube (ET); and (3) provide continuous positive airway pressure via nasal prongs or ET tube to prevent volume loss during expiration or mechanical ventilation for severe hypoxemia (PaO2 lower than 50 mm Hg) and/or hypercapnia (PaCO2 higher than 60 mm Hg). Transcutaneous monitoring and pulse oximetry are done to monitor the infant’s response to oxygen supplementation and adjusted as necessary. Aerosol administration of bronchodilators is administered as needed, as is chest physiotherapy. Additional cardiorespiratory measures include high-frequency ventilation and nitric oxide.

Efforts are directed to maintaining temperature stabilization, and appropriate fluid, electrolyte, and nutritional intake are provided. Arterial blood gas levels, hemoglobin level and hematocrit, and bilirubin level are monitored closely to determine the infant’s status. An arterial line is inserted for monitoring PaO2 and blood sampling. Blood is transfused as needed to maintain hematocrit, for optimal oxygenation. Medications are administered as indicated. These medications include the following:

1. Diuretics to minimize interstitial edema

2. Sodium bicarbonate (NaHCO3) or sodium acetate for metabolic acidosis

3. Antibiotics for associated infection

4. Analgesics for pain and irritability

5. Theophylline as a respiratory stimulant

6. Vasopressors (dopamine, dobutamine)

7. Corticosteroids to enhance lung maturity

8. Bronchodilators

Refer to Chapter 13 for management of ongoing problems.

NURSING ASSESSMENT

1. See the Respiratory Assessment section in Appendix A.

2. Assess child’s cardiorespiratory status.

3. Assess child’s oxygenation.

4. Assess child’s hydration status.

5. Assess child’s nutritional status.

6. Assess child’s developmental level (see Appendix B).

7. Assess infant-family interaction.

8. Assess family’s ability to cope with home care needs.

NURSING DIAGNOSES

• Gas exchange, Impaired

• Airway clearance, Ineffective

• Breathing pattern, Ineffective

• Nutrition: less than body requirements, Imbalanced

• Hypothermia

• Tissue perfusion, Ineffective

• Fluid volume, Excess

• Growth and development, Delayed

• Parenting, Impaired

• Therapeutic regimen management, Ineffective

NURSING INTERVENTIONS

1. Maintain cardiorespiratory stability.

a. Monitor depth, symmetry, and rhythm of respirations.
b. Monitor rate, quality, and murmurs of heart sounds.
c. Assess responsiveness to medical interventions: mechanical ventilation, aerosol administration, and surfactant replacement therapy.
d. Monitor PaO2 through pulse oximetry and/or transcutaneous monitoring.
e. Monitor arterial blood gases and laboratory data.
f. Monitor blood pressure and fluctuations with activity and treatments.
g. Administer medications as indicated.

2. Optimize oxygenation.

a. Monitor correlation between environment, positioning, and transcutaneous monitoring readings.
b. Coordinate delivery of routine care and procedures and cluster care as appropriate.
c. Maintain ET or nasal prong position and patency.
d. Suction as needed. Insert suction catheter only as far as end of ET tube.
e. Administer sedatives and analgesics as needed.
f. Maintain temperature stability through thermoregulation strategies.

3. Maintain appropriate fluid, nutrient, and caloric intake.

a. Maintain intravenous access as needed.
b. Administer feedings via most appropriate route for medical and developmental status.
c. Record weight daily and length and head circumference weekly.
d. Monitor and record intake and output (including blood products, urine, and stool); check pH and specific gravity.

4. Promote normal growth and development (see Appendix B).

a. Maintain therapeutic environment with controlled handling and appropriate stimulation.
b. Identify individual stress and interaction cues.
c. Coordinate nursing care and procedures with tolerance level of infant.
d. Facilitate parent-infant interaction by teaching parents infant cues and encouraging parents to hold infant, to participate in kangaroo care, and to provide some routine care for infant (e.g., feeding and bathing).

5. Incorporate other immediate family members (siblings) into infant’s care as soon as appropriate.

Discharge Planning and Home Care

1. Monitor readiness for discharge (see Chapter 13).

2. Provide appropriate discharge instructions for parents (see Chapter 13).

CLIENT OUTCOMES

1. Infant will have optimal lung functioning, with gas exchange and oxygenation sufficient for tissue perfusion and growth.

2. Infant will meet growth and development parameters appropriate for corrected age.

3. Parents will be competent in care of their infant.

REFERENCES

American Lung Association:. Respiratory distress syndrome of the newborn fact sheet, American Lung Association (serial online). www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=3052585. Accessed February 25, 2007

Guillory C, Cabrera-Meza G. Approaches to the patient with respiratory disease. Weisman LE, Hansen TN. Contemporary diagnosis and management of neonatal respiratory diseases, ed 3, Newtown, PA: Handbooks in Health Care, 2003.

Kenner C, Lott J. Comprehensive neonatal nursing: a physiologic perspective, ed 3, Philadelphia: WB Saunders, 2003.

Merenstein G, Gardner S. Handbook of neonatal intensive care, ed 6, St. Louis: Mosby, 2006.

U.S. National Library of Medicine, National Institutes of Health:. Respiratory distress syndrome (RDS) in infants, MedlinePlus (serial online). www.nlm.nih.gov/medlineplus/ency/article/001563.htm. Accessed February 24, 2007

Zukowsky K. Respiratory distress. Verklan MT, Walden M. Core curriculum for neonatal intensive care nursing, ed 3, St. Louis: Elsevier, 2004.

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