A 30 week gestation mother delivered 1.2 mg baby with moderate respiratory distress. RR 70/min with grunting and chest retraction. Most logical next step is aEUR'
CPAP The symptoms suggest neonatal respiratory distress syndrome / hyaline membrane disease. Respiratory distress syndrome / hyaline membrane disease occur because of inadequate production of surfactant. Since surfactant deficiency is the basis of RDS, exogenous surfactant is now recommended as the treatment of choice in neonates with RDS. - It is given to all neonates less than 28 weeks irrespective of presence or absence of RDS (Rescue treatment). -Beyond this age surfactant therapy is given according to the clinical condition of the patient. - If the distress is severe surfactant is required. - In the question the neonate is 32 weeks old and presents with moderate respiratory distress. - Surfactant is not necessary in such patient. Remember "Surfactant is not universally indicated in all cases of respiratory distress syndrome". Management of Respiratory distress syndrome Management of respiratory distress syndrome begins with admi-nistration of warm humidified oxygen. - This should maintain the aerial levels between 50 and 70 mm Hg (85-95% saturation) to maintain normal tissue oxygenation. If Pa02 cannot be maintained above 50 mm Hg at inspired 02 concentration of 60% or greater CPAP should be applied. - If the patient is VLBW (very low bih weight) then CPAP is used early (t/t begins with CPAP instead of oxygen). - Another approach in VLBW infant is to intuhate the infant, administer intracheal surfactant, then extubutate the patient and put him on CPAP. (In the question the infant is 1.5 kg at 32 weeks, his weight, for age is adequate). Infants with severe RDS require mechanical ventilation. According to Indian Journal of pediatrics Early cPAP in respiratory distress syndrome It is impoant to note that cPAP helps mainly by preventing the alveolar collapse in infants with surfactant deficiency. Once atelactasis and collapse have occurred cPAP might not help much. - Therefore all preterm infants < 35 weeks with any sign of respiratory distress should be staed immediately on cPAP. Prophylactic cPAP Extending the above logic some have advocated the use of prophylactic cPAP before the onset of respiratory distress in preterm VLBW infants as majority of them would eventually develop respiratory distress. However there is no evidence for any additional benefits with this approach, indeed there are concerns regarding increased adverse effect such as intraventricular hemorrhage. "Hence prophylactic cPAP is not recommended at present". Beneficial effects of cPAP Increase in functional residual capacity Increased pulmonary compliance Prevents alveolar collapse Increases airway diameter Conserves surfactant Decrease in alveolar aerial 02 pressure gradiant. More on cPAP Continuous positive airway pressure is a modality in which increased pulmonary pressure is provided during the expiratory phase of respiration in spontaneously breathing neonates. The mechanism by which CPAP produces its beneficial effects includes:? - Increased alveolar recruitment and stability - Redistribution of lung vvater This results in improved V/Q matching The administration of CPAP :? - Decreases oxygen requirements - Decreased need for mechanical ventilation and - Reduces moality and duration of respiratory assistance Indications of CPAP Inadequate aerial blood gas values - Inability to maintain a Pa02 greater than 50 mmHg with Fi02 .60. cPAP is initiated in newborns with RDS when Pa02 is approximately less than 50 mmHg on a Fi02 of .40. Abnormalities on physical examination - the presence of increased work of breathing as indicated by an increase in respiratory rate of >30% of normal, substernal and suprasternal retractions grunting and nasal flaring, the presence of pale or cyanotic skin colour and agitation. In treatment of RDS in both term and preterm infants. Prolonged and recurrent apneic attacks of prematurity. The presence of poorly expanded and / or infiltrated lung fields on chest radiograph. The presence of a condition thought to be responsive to CPAP and associated with one or more of the clinical presentation described above. - Respiratory distress syndrome - Pulmonary edema - Atelactasis - Apnea of prematurity - Recent extubation - Tracheal malacia or other similar abnormality of the lower airways - Transient tachyapnea of the newborn
Warm humidified oxygen hood
Nasal CPAP
Surfactant and mechanical ventilation
Mechanical ventilation