Op RDS

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Submitted byMr. Om Prakash Choudhary

M.Sc. Nursing(pediatric )PGIMER CHD.

INTRODUCTION

Infant respiratory distress syndrome (IRDS), also called

‘NRDS’ or hyaline membrane disease, is a syndrome caused in

premature infants by developmental insufficiency of

‘surfactant’ production and structural immaturity in the lungs.

It can also result from a genetic problem with the production

of surfactant associated proteins.

Respiratory distress is the highest risk in long term respiratory

& neurologic complications.

Respiratory Distress Syndrome.It is also called HMD. It is condition of surfactant deficiency and physiologic

immaturity of thorax.

Presence of at least 2 of the 3 feature is essential. Tachypnea Retraction Expiratory grunt

It may be associated with multifetal pregnancies,

infants of diabetic mothers ,caesarian section,

pre-term delivery , asphyxia etc.

Phases of Lung Development

Surfactant

Complex lipoprotein

Composed of 6 phospholipids and 4 apoproteins

70-80% phospholipids, 8-10% protein, and 10% neutral lipids

Surfactant Metabolism

Normal Lung Hyaline Membranes

Causes:-

Sepsis

Exposure to cold

Airway obstruction (atresia)

Intra-ventricular hemorrhage

Hypoglycemia

Metabolic acidosis

Acute blood loss

Drugs

. Risk factors

deficient surfactant production

Unequal inflation of alveoli

Increased efforts to keep unstable alveoli open

Pulmonary vascular resistance increases

Hypo perfusion of lungs

Etiopathogenesis

Cont. Hypo perfusion of lungs

Right to left shunt

Hypoxemia , hypercapnia ,acidosis

Hyaline membrane formed

Inhibition of gas exchange

Decreased lung compliance

Respiratory distress syndrome

Clinical manifestations Tachypnea

Tachycardia

Chest wall Retractions

Fine crackles

Expiratory grunting

Nasal flaring

Central cyanosis

Ventilator failure (rising CO2 in the blood)

Extremities puffy or swollen

apnea

Chest wall Retractions

Complications

Metabolic disorders (acidosis, low blood sugar)

Patent ductus arteriosus

Low blood pressure

chronic lung changes

Intracranial hemorrhage

Diagnostic evaluation Laboratory findings include an arterial pco2 above 65mmof Hg

and a pH of 7.15 .

The foam stability or shake test is done .

Radiographic examination of chest shows areas of atelectasis .

Prenatal Diagnosis

History of premature delivery

Concentration of lecithin in amniotic fluids.

Ratio of lecithin/sphingomyelin

Lecithin indicate lung maturity

Sphingomyelin remains constant during

pregnancy

L/S ratio 2:1 indicate lung maturity

low lung volume and the classic diffuse reticulogranular

ground-glass appearance

L/S ratio 2:1 indicate lung maturity

Cont. Assessment of severity of the respiratory Distress in

two methods

Paramet

er

0 1 2

RR(per

min)

<60 60-80 >80

Cynosis Absent In room

air

In

40%O2

Grunt Absent Audible

with a

Stethosc

ope

Audible

with a

nacked

ear

Retracti

on

Absent Mild Moderat

e –sever

Air

entry

Good Diminis

hed

Barely

Audible

Signs

0 1 2

Upper Chest Synchronized

Lags on inspiration

See saw respiration

Lower Chest No retraction

Just visible

Marked

Xiphoid Retraction

None Just visible

Marked

Nares dilatation

None Minimal

Marked

Expiratory Grunt

None Stethoscope only

Naked ear

A. Downe’score B. Silverman –Anderson score

•A score of >6 indicates impending respiratory failure and warrants mechanical

ventilation

B. Silverman –Anderson score

THERAPEUTIC MANAGEMENT

OXYGEN THERAPY

Indications

1. Clinical central cyanosis

2. Hypoxemia (O2 saturation<87% and

PaO2<50mmHg in room air )

1. Neonates suspected RDS.

Commonly used O2 delivery system in neonates:-

Low flow system are commonly used in neonate. These

system provide a variable FiO2 depending upon the inspiratory

flow rate generate by the neonate.

Cont.

Precaution while administering O2 :-

i. humidify

ii. O2 saturation should never cross 93% in preterm infant as –

hyperoxia leads

iii. Use O2 analyzer to check FiO2

following way of oxygen therapy-

i. CPAP(continuous positive airway pressure)

ii. PEEP(positive end-expiratory pressure)

iii. SIMV(synchronized intermittent mandatory ventilation)

iv. HFV (high frequency ventilation)

Cont.SURFACTANT THERAPY

Indications:-

Prophylactic:-preterm infants of <28wks gestation.

Administered within the initial 15-20min of life.

Early rescue:-Administration is typical within the initial 2 hr

of life.

Late rescue:- Administration is typical within the beyond24

hr of life.

Cont.surfactant - commercially available

Medicine Dosage Max.dose Interval b/w dose

Survanta(Abbot)

100mg /kg=4ml/kg

2 6h

Curosurf(Nicholas/Abbot)

200mg/kg (first)=2.5ml/kg100mg/kg(repeat)=1.25ml/kg

2 12h

Neosurf(Cipla)

135mg/kg(5ml/kg)

2 12h

Cont. Medical therapy

• Maintenance of I/V line for hydration & nutrition

• Systemic antibiotics if sepsis

• Morphine, Lorazepam for pain & sedation

• Methylxanthines (Theophylline) for apnea

• VLBW & LBW needs mechanical ventilation

• Inotropes (dopamine & dobutamine) to support BP

• Blood transfusion / Erythropoitin therapy

.Nitric oxide therapy

For relieving, persistent pulmonary hypertension, pulmonary

vasoconstriction, subsequent acidosis, severe hypoxia. NO

reduces pulmonary vasoconstriction & subsequent pulmonary

hypertension when inhaled into lungs (6-20ppm)

Prevention

prevention of premature delivery especially in elective early

delivery (ELSCS)

Improved amniocentesis methods for assessing the maturity of

fetal lung,

administration of corticosteroid to induce surfactant production

(24 hours to 7 days before delivery).

Cont.

Prophylactic surfactant therapy is not recommended in infant greater than 30 weeks gestation

Delaying premature birth. Tocolytics may delay delivery by 48 hours and therefore enable time for antenatal corticosteroids to be given.

Good control of maternal diabetes

Avoid hypothermia in the neonate

NURSING MANAGEMENT Nursing diagnosis

1 Impaired Gas Exchange related to decreased volumes and

lung compliance, pulmonary perfusion and alveolar ventilation.

2. Potential risk for hypothermia development related to

prematurity

3. Potential risk for infection due to prematurity, low immunity

& invasive procedure

4. Imbalance Nutrition Less Than Body Requirements related

to the inability to suck decreased intestinal motility.

NURSING CARE PLAN RDS.docx

Diagnosis

1.Impaired Gas Exchange related to decreased volumes

and lung compliance, pulmonary perfusion and alveolar

ventilation.

Intervention:-

Monitor dyspnea, tachypnea, breath sounds, increased respiratory effort, lung expansion, and weakness.

Oxygen delivery in accordance with the additional requirements.

Monitor vital signs. (T,P,R,B/P)

See that the prongs are placed properly in the nostril of the baby

See whether the prongs are of the size of the baby

Do not ignore any alarm of the ventilator attached to the baby

2. Potential risk for hypothermia

development related to prematurity

Intervention:-

Care of the baby under radiant warmer

Set the temperature of warmer accurately

Fix the temperature probe to the baby’s abdomen properly

Check the baby’s temperature 2hrly with thermometer.

Prepare injections under the laminar air flow (UV light) using proper aseptic technique

Clean the I/V site & change plaster when soiled

3. Potential risk for infection due to prematurity,

low immunity & invasive procedure

Intervention:-

Wear sterile gown & chapels & wash hands before entering NICU

Wash hands thoroughly with soap & water & apply sterlium before & after touching the Baby

Ensure the baby is getting adequate feed

Do place a thin plastic wrap on the cot of baby

Maintain documentation

4. Imbalance Nutrition Less Than Body

Requirements related to the inability to suck decreased

intestinal motility.

Implementation

Facilitate rooming in.

Allow mother to have good access to the baby

Allow mother to touch & hold the baby

Wash hands before preparing feeds

Prepare feeds as suggested

Teach the mother the manual expression of breast milk

Give feeds with katori & spoon

Weigh the baby daily

Maintain intake output

NURSING CARE

Nursing management with surfactant administration are-

1. Assistance in delivery of product.

2. Monitoring ABG and infants tolerance of procedure.

3. Monitoring oxygenation.

4. Delaying suctioning.

Providing effective ventilation.

Providing optimal enviromental temperature.

Cont.

Adequate nutrition .

Effective ventilation and oxygen therapy .

Acid base balance.

Normal hematocrit and blood pressure.

Additional nursing management includes –

1. head elevation and hyperextension.

2. skin irritation from oxygen tubings.

3. Minimal handing.

summarization Introduction

Definition

Etiopathogenesis

Clinical manifestation

Diagnostic evaluation

Assessment of severity of the respiratory Distress in two

methods

Therapeutic management

References. Whaley & Wong’s, Nursing care of infant & children, fifth edition,

page 396-405

Hockenberry, Wong’s Nursing Care of Infant & Children, eighth edition, page;379-

Dutta D C, textbook of Obstetric, Page: 194-98

www.google//https://respiratory.distress.syndrome.in.com

national neonatology forum of india. National neonal perinataldatabse-report for 2002-03,

international organization for standardization. Respiratory tract humidifier for medical use ,particular requirement for humidification system.ISO 8185-07

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