eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Respiratory Distress Syndrome: Follow-up

Author: Arun K Pramanik, MD, MBBS, Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center
Contributor Information and Disclosures

Updated: Sep 23, 2009

Follow-up

Further Inpatient Care

Further Outpatient Care

Inpatient & Outpatient Medications

Transfer

  • Transfer the following patients to a tertiary care center:
    • Mothers with high-risk pregnancy
    • Mothers in premature labor
    • Newborn infants with respiratory failure

Deterrence/Prevention

Complications

  • Acute complications
    • Alveolar rupture: Suspect an air leak (eg, pneumomediastinum, pneumopericardium, interstitial emphysema, pneumothorax [see Treatment]) when an infant with respiratory distress syndrome suddenly deteriorates with hypotension, apnea, or bradycardia or when metabolic acidosis is persistent.
    • Infection: Infections may complicate the management of respiratory distress syndrome and may manifest in various ways, including failure to improve, sudden deterioration, or a change in WBC count or thrombocytopenia. Also, invasive procedures (eg, venipuncture, catheter insertion, use of respiratory equipment) and use of postnatal steroids provide access for organisms that may invade the immunologically compromised host. With the advent of surfactant therapy, small and ill infants are surviving, with increased incidence of septicemia secondary to staphylococcal epidermidis and/or candidal infection. When septicemia is suspected, obtain blood cultures from 2 sites and start appropriate antibiotics until culture results are obtained.
    • Intracranial hemorrhage and periventricular leukomalacia: Intraventricular hemorrhage is observed in 20-40% of premature infants with greater frequency in infants with respiratory distress syndrome who require mechanical ventilation. Cranial ultrasonography is performed in the first week and thereafter as indicated in premature neonates younger than 32 weeks' gestation. Prophylactic indomethacin therapy and antenatal steroids have decreased the frequency of intracranial hemorrhage in these patients with respiratory distress syndrome. Hypocarbia and chorioamnionitis are associated with an increase in periventricular leukomalacia.
    • Patent ductus arteriosus (PDA) with increasing left-to-right shunt: This shunt may complicate the course of respiratory distress syndrome, especially in infants weaned rapidly after surfactant therapy. Suspect PDA in any infant who deteriorates after initial improvement or who has bloody tracheal secretions. Although helpful in the diagnosis of PDA, cardiac murmur and wide pulse pressure are not always apparent in critically ill infants. An echocardiogram enables the clinician to confirm the diagnosis. Treat PDA with ibuprofen or indomethacin, which can be repeated during the first 2 weeks if the PDA reopens. In refractory incidents of respiratory distress syndrome or in infants in whom medical therapy is contraindicated, surgically close the PDA.
    • Pulmonary hemorrhage: The occurrence of pulmonary hemorrhage increases in tiny premature infants, especially after surfactant therapy. Increase positive end-expiratory pressure (PEEP) on the ventilator and administer intratracheal epinephrine to manage pulmonary hemorrhage. In some patients, pulmonary hemorrhage may be associated with PDA; promptly treat pulmonary hemorrhage in such individuals. In a retrospective study, intratracheal surfactant therapy was used successfully, with the rationale that blood inhibits pulmonary surfactant.
    • Necrotizing enterocolitis (NEC) and/or GI perforation: Suspect NEC and/or GI perforation in any infant with abnormal abdominal findings on physical examination. Radiography of the abdomen assists in confirming their presence. Spontaneous perforation (not necessarily as part of NEC) occasionally occurs in critically ill premature infants and has been associated with the use of steroids and/or indomethacin.
    • Apnea of prematurity: Apnea of prematurity is common in immature infants, and its incidence has increased with surfactant therapy, possibly because of early extubation. Manage apnea of prematurity with methylxanthines (caffeine) and/or bubble or continuous flow nasal continuous positive airway pressure (CPAP), or with assisted ventilation in refractory incidents. Exclude septicemia, seizures, gastroesophageal reflux, and metabolic and other causes in infants with apnea of prematurity.
  • Chronic complications
    • Bronchopulmonary dysplasia (BPD)
      • BPD is a chronic lung disease defined as a requirement for oxygen at a corrected gestational age of 36 weeks. BPD is related directly to the high volume and/or pressures used for mechanical ventilation or to manage infections, inflammation, and vitamin A deficiency. BPD increases with decreasing gestational age.
      • Postnatal use of surfactant therapy, gentler ventilation, vitamin A, low dose steroids and inhaled nitric oxide may reduce the severity of BPD.
      • Clinical studies have demonstrated various incidences of BPD, which has been attributed to increased survival of small and ill infants with respiratory distress syndrome after the introduction of the therapies discussed above (see Treatment). BPD may also be associated with Gastroesophageal Reflux or Sudden Infant Death Syndrome. Hence, consider these entities in infants with unexplained apnea before discharging them from the hospital.
    • Retinopathy of prematurity (ROP): Infants with respiratory distress syndrome and a PaO2 >100 mm Hg are at increased risk for ROP. Hence, closely monitor PaO2 and maintain it at 50-70 mm Hg. Although pulse oximetry is used in all premature infants, it is not helpful in preventing ROP in tiny infants because of the flat portion of the oxygen-hemoglobin dissociation curve. An ophthalmologist examines the eyes of all premature infants at 34 weeks' gestation and thereafter as indicated. If ROP progresses, laser therapy or cryotherapy is used to prevent retinal detachment and blindness. Closely monitor infants with ROP for refractive errors.
    • Neurologic impairment: Neurologic impairment occurs in approximately 10-70% of infants and is related to the infant's gestational age, the extent and type of intracranial pathology, and the presence of hypoxia and infections. Hearing and visual handicaps may further compromise development in affected infants. They may develop a specific learning disability and aberrant behavior. Therefore, periodically follow up these infants to detect those with neurologic impairment, and undertake appropriate interventions.
    • Familial psychopathology
      • Infants with respiratory distress syndrome are at increased risk for child abuse and failure to thrive; therefore, obtain home clearance in conjunction with a nurse and social worker before discharging the patient from the hospital. Encourage and document parental visits and the parent's interaction with the infant.
      • Advise parents to spend time with their infants with respiratory distress syndrome in a separate room before discharge, especially if the parents are at high social risk (eg, teenagers) who also have extremely premature infants.
      • Advise parents of infants who are discharged with oxygen and/or an apnea monitor, with a gastrostomy or a requirement for tube feeding, or with a tracheostomy or other special needs to spend time with their infants with respiratory distress syndrome in a separate room before discharge.
      • Physicians who are skilled in recognizing the problems encountered in these infants should be involved with their ongoing care because of the high risk of morbidity and mortality in infancy.

Prognosis

Patient Education

  • Because the risk of prematurity and respiratory distress syndrome is increased for subsequent pregnancies, counsel the parents.
  • Promptly manage high-risk factors, such as diabetes, hypertension, incompetent cervix, and chorioamnionitis.
  • Educating and counseling of the parents, caregivers, and families of premature infants must be undertaken as part of discharge planning. They should be advised of the potential problems infants with respiratory distress syndrome may encounter during and after their nursery stay. Audiovisual aids and handouts supplement such education.

Miscellaneous

Medicolegal Pitfalls

  • Trained and experienced professionals at a tertiary care facility should treat infants with respiratory distress (RDS) whenever possible, because complications of premature births, respiratory distress, and the procedures performed on infants with respiratory distress are associated with an increase in medicolegal action against health care professionals and institutions.
  • To minimize such actions, adequately document the infant's clinical progress, including discussions with the families and/or caregivers.
  • Obtain written informed consent before transport, elective procedures, or administration of blood products.
 


More on Respiratory Distress Syndrome

Overview: Respiratory Distress Syndrome
Differential Diagnoses & Workup: Respiratory Distress Syndrome
Treatment & Medication: Respiratory Distress Syndrome
Follow-up: Respiratory Distress Syndrome
Multimedia: Respiratory Distress Syndrome
References
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Further Reading

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Keywords

respiratory distress syndrome, RDS, HMD, hyaline membrane disease, premature infant, surfactant therapy, mechanical ventilation, continuous positive airway pressure, CPAP, inhaled nitric oxide, patent ductus arteriosus, prematurity, septicemia, bronchopulmonary dysplasia, BPD, necrotizing enterocolitis, NEC, retinopathy of prematurity, ROP, hypertension, failure to thrive, intraventricular hemorrhage, periventricular leukomalacia, group B streptococcus, , influenza virus, adenovirus, respiratory syncytial virus, RSV, metabolic acidosis, chronic lung disease, congenital diaphragmatic hernia, pulmonary hypoplasia, meconium aspiration pneumonia, hypothermia, hypoglycemia, anemia, polycythemia, jaundice, transient tachypnea of newborn, aspiration syndrome, pneumothorax, interstitial emphysema, pneumomediastinum, pneumopericardium, chylothorax, treatment, diagnosis

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Contributor Information and Disclosures

Author

Arun K Pramanik, MD, MBBS, Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center
Arun K Pramanik, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, National Perinatal Association, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Steven M Donn, MD, Professor of Pediatrics, University of Michigan Medical School; Director, Division of Neonatal-Perinatal Medicine, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan Health System
Steven M Donn, MD is a member of the following medical societies: American Pediatric Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

David A Clark, MD, Chairman, Professor, Department of Pediatrics, Albany Medical College
David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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