Transcript MANAGEMENT

TREATMENT
Hyaline Membrane Disease
• Prenatal prevention and prediction
– Prevent premature birth with tocolytics,
antibiotics to address ongoing infection
– Antenatal corticosteroids
• One course reduces risk of RDS and neonatal
death
• Indicated at recognition of risk pf preterm delivery
• Betamethasone 48 hours before delivery, 24-34
weeks AOG
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Prenatal prevention and prediction
– Antenatal corticosteroids
• May consider retreatment if the mother does not
deliver within 1 week
• Exercise clinical judgment regarding risk for
preterm delivery before giving repeat dose.
– If with progressive cervical dilation or persistent signs of
labor, may give repeat dose.
– If at lower risk, may defer retreatment.
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Prenatal prevention and prediction
– Estimating the lecithin-to-sphingomyelin ratio
and/or by the presence of
phosphatidylglycerol in the amniotic fluid
obtained with amniocentesis
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Delivery and resuscitation
– Continuous nasal positive airway pressure
(CPAP) often used in spontaneously breathing
premature infants immediately after birth as
potential alternative to immediate intubation
and surfactant replacement
– Lung injury may be diminished by avoiding
intubation
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Surfactant replacement therapy
– Mortality rate decreased by ~ 50% over the
last decade with surfactant therapy
– Ideal surfactant preparation has not been
identified
– Synthetic vs. animal-derived preparations:
animal-derived surfactants superior
• immediate benefits in pulmonary air leaks,
intraventricular hemorrhage, BPD, and mortality
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Surfactant replacement therapy
– Neonates who require assisted ventilation
with a FIO2 of >0.40 should receive
intratracheal surfactant as soon as possible,
preferably within 2 hours after birth
– Meta-analysis of early vs. delayed selective
treatment for neonatal respiratory distress
syndrome suggested a decrease in
pulmonary air leaks and chronic lung disease.
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Surfactant replacement therapy
– Some recommend prophylactic use after
resuscitation in extremely premature
neonates (<27 weeks' gestation).
– In developing countries, surfactant expensive
and unnecessary in most instances because
> 60% of premature infants do not have
surfactant deficiency.
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Oxygenation and CPAP
– CPAP keeps the alveoli open at the end of
expiration, decreasing the right-to-left
pulmonary shunt.
– Short binasal-prongs devices were found to
be more effective than single prongs and also
reduced the rate of reintubation.
– Goals: maintain pH 7.25-7.4, PaO2 50-70 mm
Hg, PCO2 of 40-65 mm Hg, depending on
clinical status
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Vapotherm
– Allows delivery of high flows of gas at body
temperature with close to 100% relative
humidity
– Advantages over CPAP:
• reduction in number of ventilator days
• reduced nasal trauma
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• High frequency ventilation
– Small tidal volumes (less than anatomic dead space)
usually delivered at rapid frequencies  eliminating
wide pressure swings seen with conventional
ventilators
– Promotes uniform lung inflation, improves lung
mechanics and gas exchange, and reduces exudative
alveolar edema, air leak, and lung inflammation
– Early use of high-frequency oscillatory ventilation
superior to conventional ventilation
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Nitric oxide
– Role in premature infants ill-defined
– Has selective pulmonary vasodilation
• In premature infants, may have a role in
decreasing inflammation, reducing oxidative
stress, and enhancing alveolarization and lung
growth.
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Supportive therapy
– Thermoregulation: Hypothermia increases
oxygen consumption  double-walled
incubator or radiant warmer
– Circulation and anemia: Support circulation
with blood or volume expanders,
vasopressors; pRBC transfusion when blood
loss reaches 10% of estimated blood volume
or if hematocrit < 40-45%
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Supportive therapy
– Fluids, metabolic, and nutritional support:
• Initially administer 5% or 10% dextrose IV at 60-80
mL/kg/d.
• Monitor blood glucose, electrolytes (including Ca
and P), renal function, and hydration.
• IV sodium bicarbonate often misused 
considered an unproven therapy.
• Gradually increase fluid intake to 120-140 mL/kg/d.
• Extremely premature infants: TFI of 200-300 mL/kg
or more because of insensible water loss
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Supportive therapy
– Fluids, metabolic, and nutritional support:
• IV nutrition with amino acids and lipid within 24-48
hours of birth.
• If oral feeding tolerated, start trophic feeding to
stimulate gut development.
• Adequate supply of macronutrients, micronutrients,
vitamins, and antioxidants should be provided to
maintain optimal lung, brain, eye, and somatic
growth.
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Supportive therapy
– Antibiotic administration:
• Start in all infants who present with respiratory
distress at birth after blood cultures, CBC, and
CRP levels are obtained.
• Discontinue antibiotics after 2-5 days if blood
cultures are negative and if no maternal risk
factors are found.
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Supportive therapy
– Antibiotic administration:
• Exceptions: absence of findings suggestive of
chorioamnionitis, adequate antenatal care, recent
negative maternal cervical culture for group B
beta-hemolytic streptococci or a baby delivered
with intact amniotic membranes
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Hyaline Membrane Disease
• Supportive therapy
– Parental and family support
Pramanik, AK. Respiratory Distress Syndrome: Treatment & Medication in http--emedicine_medscape_com-article-976034overview.mht. Accessed November 23, 2009.
Other Problems
• Hyperbilirubinemia: phototherapy as
necessary
• Sepsis: Culture-guided antibiotic treatment
• Necrotic Digit: Watchful waiting
• Prematurity: thermoregulation, upbuilding
• Patent Ductus Arteriosus: medical closure
with IV indomethacin 0.2mg/kg at 12-24h
intervals x 3 doses or ibuprofen 10mg/kg
then 5mg/kg x 2 doses at 24h intervals