The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

RESPIRATORY DISTRESS

SYNDROME

The single most important cause of mortality and morbidity in preterm infants

Bianca Marie Moses

…a premature baby’s alveolus

Not getting much if any O2 in

…or CO2 out

↓ Gas exchange

↓ Gas exchange ↓ Alveolar

expansion

expansion Alveolar collapse

↓ ↓ ↓ Lung Compliance!

Respiratory Distress Syndrome: RDS

Respiratory failure

Respiratory failure Edema

Respiratory failure Edema Alveolar, endothelial and

epithelial damage

epithelial damage Pulmonary vasoconstriction

epithelial damage Pulmonary vasoconstriction Atelectasis

epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis

epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis

epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis Hypoxia

What a nurse looks for…

Increasing cyanosis or acrocyanosis

Tachypnea >60b/min

Tachypnea >60b/min Grunting respirations

Tachypnea >60b/min Grunting respirations Nasal flaring

Tachypnea >60b/min Grunting respirations Nasal flaring Apnea

Tachypnea >60b/min Grunting respirations Nasal flaring Apnea “Ground Glass” pattern on

x-ray Reticulogranular Pattern

Tachypnea >60b/min Grunting respirations Nasal flaring Apnea Significant retractions

Tachypnea >60b/min Grunting respirations Nasal flaring Bradycardia Significant retractions

Tachypnea >60b/min Grunting respirations Lethargy Bradycardia Significant retractions

Tachypnea >60b/min Weak cry Lethargy Bradycardia Significant retractions

Hypotonia Weak cry Lethargy Bradycardia Significant retractions

Pulse Ox 88%-93%

Increased Urination

Pulse Ox 88%-93%

Increased Urination = ↑ respiratory status

Pulse Ox 88%-93%

Respiratory Distress Syndrome (RDS)

Caucausian

Caucausian > Hispanic

Caucausian > Hispanic or African American babies

Affects males

Affects males 2x more often

Affects males 2x more often than females

Risk Factors include:

Prematurity

Prematurity AGA, SGA, LGA

Born to diabetic mom

Surfactant deficiency disease

Genetics

A little background first

Foggy Bathroom Mirror

Water sticks to the glass surface

Adhesive property of water

Rain Drops

Water drops bead up

Rain Drops

Water drops bead up

Cohesive property of water

Rain Drops

Water drops bead up

Rain Drops

Water drops bead up

Rain Drops

Water drops bead up

Caught in the rain…

Adhesion

Caught in the rain…

CohesionWater

+Adhesion Cohesion

Surface Tension…+

Adhesion Cohesion

Surface Tension…

…the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken

Surface Tension…

Shirt is stuck to his skin

Surface Tension…

Amniotic fluid

Birth canal squeezes amniotic fluid out of alveoli

Amniotic fluid

AirIdeally

We’ll realign the alveolus for better visualization

AirIdeally

Alveolar Wall

Pull In

Alveolar Wall

Collapse

Surfactant

O2 Open

A closer look at surfactant

Surfactant

Two components in human surfactant

Surfactant

Lecithin/Sphingomyelin (L/S) ratio

Surfactant

Lecithin:Sphingomyelin (L/S) ratio

Surfactant

Lecithin:Sphingomyelin (L:S) ratio

Surfactant

Produced by baby

Surfactant

Produced by baby

Surfactant

RDS is unlikely

L:S ratio is < 2:1

50% chance of RDS if < 30 weeks

L:S ratio is < 2:1

Limit of Viability

L:S ratio is < 2:1

Limit of Viability ~23-24w

L:S ratio is < 2:1

Limit of Viability ~23-24w

Are baby’s lungs ready?

L:S Ratio

L:S Ratio Ratio closer to 2 is better

L:S Ratio Ratio closer to 2 is betterMay require ratio of 3:1 or

Are baby’s lungs ready?Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS

3.5:1Meconium and blood

invalidate results

3.5:1Meconium and blood

invalidate resultsSome conditions

accelerate lung maturity

L:S Ratio PG (phosphatidylglycerol)

Appears at 36 weeks or sooner if distressed

Present or Absent

Present or AbsentResults are not invalid if

contaminated by blood

Present or AbsentResults are not invalid if

contaminated by bloodPG + L:S >2 is good

L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization

Uncentrifuged AF

Uncentrifuged AFMeasures ratio of

Surfactant:Albumin

Surfactant:Albumin○ Non diabetic >50mg/g○ Diabetic >70mg/g

Blood and meconium will not yield a false positive

Vaginally collected AF is ok

Medications to “make” lungs ready

Medications to “make” lungs ready Surfactants

Medications to “make” lungs ready Surfactants Steroids

Surfactant

Within 2 hrs after birth

Surfactant

AdministerIntratracheally

Surfactant

Survanta (bovine) Infasurf (bovine) Beractant (bovine) Calfactant (bovine) Poractant (porcine) Curosurf (porcine)

Surfactant

Survanta (bovine) Infasurf (bovine) Beractant (bovine) Calfactant (bovine) Poractant (porcine) Curosurf (porcine) Exosurf Surfaxin Colfosceril Lucinactant Pumactant

Steroids

Steroids Given antenatally

X XX X X

L:S ratio is < 2:1

X XX X X

Improve survivability of the 24-34 week gestation and babies <1250g

Speed up lung development

L:S ratio is < 2:1

X XX X X

L:S ratio is < 2:1

X XX X X

Initiate surfactant production

L:S ratio is < 2:1

X XX X X

L:S ratio is < 2:1

X XX X X

2 doses

L:S ratio is < 2:1

X XX X X

Bethamethasone (IM)

2 doses

L:S ratio is < 2:1

X XX X X

Bethamethasone (IM)12mgq24 hrs2-3 days before delivery

2 doses

L:S ratio is < 2:1

X XX X X

Dexamethasone (IM)

2 doses

L:S ratio is < 2:1

X XX X X

Dexamethasone (IM)6mgq12 hrs2 days before delivery

2 doses

Nursing Diagnoses for RDS

ND#1 Risk for ineffective breathing pattern r/t immature lung development

Review records Initiate cardiac and respiratory

monitoring and calibrate q8 hrs Monitor infants

Respiratory rate and rhythmPulseBlood pressureActivity

ND#1 Risk for ineffective breathing pattern r/t immature lung development

Assess skin colorCyanosis, duskiness and/or pallor

Administer warmed humidified O2 by oxygen hoodMonitor O2 concentration q30 minutesMaintain stable O2 by ↑ or ↓ 5%-10%

increments

ND#2 Ineffective thermoregulation r/t increased respiratory effort

Review Records Assess temperature frequently

Place servo probe on skin or over organ Observe for signs of ↑ O2 consumption

and metabolic acidosis Warm and humidify all inspired gases

Record temps for all administered gases

ND#2 Ineffective thermoregulation r/t increased respiratory effort

Use radiant warmers or incubators with servo controls and open cribs with appropriate clothing

Note s/sx of respiratory distress

TachypneaApneaCyanosisAcrocyanosis

BradycardiaLethargyWeak cryHypotonia

ND#3 Imbalanced Nutrition: Less than body requirements r/t increased metabolic needs of infant Assess suck, swallow, gag and cough

reflexes Assess respiratory status of infant Monitor IV rates per infusion pump

Start at 80 mL/kg/day Record hourly I/O and daily weights Provide TPN when indicated

ND#3 Imbalanced Nutrition: Less than body requirements r/t increased metabolic needs of infant Advance from IV to GI tube feedings

Based on toleranceGavage or nipple feedings are usedIV is used as supplement

○ Discontinue when oral intake is sufficient

Provide adequate caloric intake Assesss infusion site for s/sx of infection

Erythema, edema, drainage w/ foul odor

ND#4 Risk for deficient fluid volume r/t increased insensible water loss Observe for weight fluctuations Document cumulative I/O Obtain urinalysis

Closely monitor nitrates and specific gravity Monitors vitals

BP, pulse, temp, MAP Assess for s/sx dehydration

Poor skin turgor, pale mucous membranes, sunken fontanels

Assess IV site for s/sx of infection

Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard

Operational definition of RDS to distinguish babies who would get treatment from those who would not

Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed:• Chest x-rays readings• Diagnosis of another respiratory disorder (ie.

pneumothorax or diaphragmatic hernia)• Distress w/o identifiable mechanical stressors

• …surfactant use would be assessed at 2h and 4h

Clinical judgment superseded the standards agreed upon for treating ARDS children

“We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all”

”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found”

“Our findings of racial/ethnic disparities in this potentially life-saving treatment highlight the critical need to understand, improve, and deliver high-quality care to all. The inadequate delivery of surfactant to 63% of infants within 2h of delivery and the failure to deliver surfactant at all to infants within 4h emphasizes why we need to re-design health care such that delivery of treatment, such as surfactant, is a function of clinical characteristics and of the health care delivery system and less dependent on the individuals who are functioning within it.”

RDS Citations

(n.d.). Retrieved from 25.media.tumblr.com/tumblr_ls8z2bC8dv1r0l4eno1_400.jpg

(n.d.). Retrieved from cardiophile.org/2010/01/sinus-bradycardia-with-first-degree-av-block/

(n.d.). Retrieved from en.wikipedia.org/wiki/Hydrogen_bond

(n.d.). Retrieved from ga.water.usgs.gov/edu/adhesion.html

(n.d.). Retrieved from hankandwillie.wordpress.com/2007/06/22/part-2-the-first-forty-hours/

(n.d.). Retrieved from http://archive.nrc-cnrc.gc.ca/obj/ibd/images/spectroscopy/spec_fetal_3.jpg

(n.d.). Retrieved from http://www.irvinesci.com/techinfo/docs/PB_91030_AmnioStat_FLM_PGRev2.pdf

(n.d.). Retrieved from newborns.stanford.edu/PhotoGallery/Retractions1.html

(n.d.). Retrieved from perfectlypink-randomthoughts.blogspot.com/2011_05_01_archive.html

(n.d.). Retrieved from pregnancy.about.com/od/physicalattributes/ss/What-A-Newborn-Baby-Looks-Like_5.htm

(n.d.). Retrieved from www.fetalfacts.net/

(n.d.). Retrieved from www.gentiva.kramesonline.com/3,S,88187

(n.d.). Retrieved from www.ghanavisions.com/world/25054-presi-drenched-obama-the-heavens-opened-on-the-president.html

(n.d.). Retrieved from www.guardian.co.uk/technology/2008/feb/28/research.energyefficiency

(n.d.). Retrieved from www.ndsu.edu/pubweb/~tcolvill/gas_xchng.htm

(n.d.). Retrieved from www.wikiradiography.com/page/Neonatal+Chest+Pathology

Carnielli, V. P., Zimmermann, L. I., Hamvas, A. A., & Cogo, P. E. (2009). Pulmonary surfactant kinetics of the newborn infant: novel insights from studies with stable isotopes. Journal Of Perinatology, 29S29-S37. doi:10.1038/jp.2009.32

Davidson, M., London, M., & Ladewig, P. (2012). Olds' maternal newborn nursing & women's health across the lifespan. (9th ed.). Upper Saddle River: Pearson

Going "foreword": the new CLSI guidelines. (2012). MLO: Medical Laboratory Observer, 44(2), 10.

Haitsma, J. J. (2010). Surfactant therapy. Canadian Journal Of Respiratory Therapy, 46(3), 38.

Howell, E., Holzman, I., Kleinman , L., Wang, J., & Chassin, M. (2010). Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: discordance of practice from a community clinician consensus standard.Journal of Perinatology, 30, 590-595.

Howell, E., Holzman, I., Kleinman, L., Wang, J., & Chassin, M. (n.d.). Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard. (2010). Journal of Perinatology, 30, 590-595.

Hussain, N., Noce, T., Jagivan, B., Hedge, P., Pappagallo, M., Bhandari, A., & Sharma, P. (2010). Pneumatoceles in preterm infantsfincidence and outcome in the post-surfactant era. Journal of Perinatology, 30, 330-336.

Moya, F. F. (2009). Synthetic surfactants: where are we? Evidence from randomized, controlled clinical trials. Journal Of Perinatology, 29S23-S28. doi:10.1038/jp.2009.26

Verder, H., Bohlin, K., Kamper, J., Lindwall, R., & Jonsson, B. (2009). Nasal CPAP and surfactant for treatment of respiratory distress syndrome and prevention of bronchopulmonary dysplasia. Acta Paediatrica, 98(9), 1400-1408. doi:10.1111/j.1651-2227.2009.01413.x

The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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