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

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O2

X

Not getting much if any O2 in

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CO2

X

…or CO2 out

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CO2

X

↓ Gas exchange

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CO2

X

↓ Gas exchange

X

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↓ Gas exchange ↓ Alveolar

expansion

CO2

XX

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expansion Alveolar collapse

CO2

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CO2

XXX

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↓ ↓ ↓ Lung Compliance!

CO2

XXX

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Respiratory Distress Syndrome: RDS

CO2

XXX

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Respiratory failure

CO2

XXX

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Respiratory failure Edema

CO2

XXX

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Respiratory failure Edema Alveolar, endothelial and

epithelial damage

CO2

XXX

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epithelial damage Pulmonary vasoconstriction

CO2

XXX

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epithelial damage Pulmonary vasoconstriction Atelectasis

CO2

XXX

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epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis

CO2

XXX

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epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis

CO2

XXX

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epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis Hypoxia

CO2

XXX

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epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis Hypoxia

What a nurse looks for…

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Increasing cyanosis or acrocyanosis

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Tachypnea >60b/min

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Tachypnea >60b/min Grunting respirations

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Tachypnea >60b/min Grunting respirations Nasal flaring

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Tachypnea >60b/min Grunting respirations Nasal flaring Apnea

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

x-ray Reticulogranular Pattern

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

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

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

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

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Hypotonia Weak cry Lethargy Bradycardia Significant retractions

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Pulse Ox 88%-93%

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Increased Urination

Pulse Ox 88%-93%

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Increased Urination = ↑ respiratory status

Pulse Ox 88%-93%

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Respiratory Distress Syndrome (RDS)

Caucausian

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Caucausian > Hispanic

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Caucausian > Hispanic or African American babies

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Affects males

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Affects males 2x more often

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Affects males 2x more often than females

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Risk Factors include:

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Prematurity

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Prematurity AGA, SGA, LGA

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Born to diabetic mom

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Surfactant deficiency disease

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Surfactant deficiency disease

Genetics

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A little background first

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Foggy Bathroom Mirror

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Water sticks to the glass surface

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Adhesive property of water

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Adhesive property of water

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Rain Drops

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Rain Drops

Water drops bead up

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Rain Drops

Water drops bead up

Cohesive property of water

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Rain Drops

Water drops bead up

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Rain Drops

Water drops bead up

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Rain Drops

Water drops bead up

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Caught in the rain…

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Skin

Shirt

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Skin

Shirt

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Adhesion

Skin

Shirt

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Skin

Shirt

Water

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Skin

Shirt

Water

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Skin

Shirt

Water

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Skin

Shirt

CohesionWater

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+Adhesion Cohesion

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Surface Tension…+

Adhesion Cohesion

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Surface Tension…

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

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Surface Tension…

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Skin

Shirt

Water

Surface Tension…

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Skin

Shirt

Surface Tension…

Shirt is stuck to his skin

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Surface Tension…

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Surface Tension…

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Amniotic fluid

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Amniotic fluid

Birth canal squeezes amniotic fluid out of alveoli

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Amniotic fluid

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Amniotic fluid

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AirIdeally

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AirIdeally

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We’ll realign the alveolus for better visualization

AirIdeally

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Alveolar Wall

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Alveolar Wall

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Alveolar Wall

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Alveolar Wall

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Alveolar Wall

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Alveolar Wall

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Alveolar Wall

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Alveolar Wall

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Pull In

Alveolar Wall

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Alveolar Wall

Collapse

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Surfactant

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Surfactant

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Open

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O2

Open

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O2

Open

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O2

Open

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O2

Open

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O2 Open

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CO2

Open

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CO2

Open

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CO2

Open

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CO2

Open

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CO2

Open

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A closer look at surfactant

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Surfactant

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Surfactant

Two components in human surfactant

Page 119: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Surfactant

Lecithin/Sphingomyelin (L/S) ratio

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Surfactant

Lecithin:Sphingomyelin (L/S) ratio

Page 121: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Surfactant

Lecithin:Sphingomyelin (L:S) ratio

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Surfactant

Produced by baby

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Surfactant

Produced by baby

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Surfactant

20

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Surfactant

20

0.5:1

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Surfactant

30

32

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Surfactant

30

1:1

32

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Surfactant

35

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Surfactant

35

2:1

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35

2:1

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35

2:1

35

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35

2:1

RDS is unlikely

35

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35

2:1

RDS is unlikely

35

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35

2:1

35

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35

2:1

35

X XX

XX

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35

2:1

35

X XX

XX

L:S ratio is < 2:1

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35

2:1

35

X XX

XX

L:S ratio is < 2:1

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35

2:1

35

L:S ratio is < 2:1

X XX

XX

50% chance of RDS if < 30 weeks

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35

2:1

35

L:S ratio is < 2:1

X XX

XX

Limit of Viability

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35

2:1

35

L:S ratio is < 2:1

X XX

XX

Limit of Viability ~23-24w

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35

2:1

35

L:S ratio is < 2:1

XX

X

XX

XXX

XX

Limit of Viability ~23-24w

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Are baby’s lungs ready?

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L:S Ratio

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L:S Ratio Ratio closer to 2 is better

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

3.5:1

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3.5:1

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

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3.5:1Meconium and blood

invalidate results

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3.5:1Meconium and blood

invalidate resultsSome conditions

accelerate lung maturity

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L:S Ratio PG (phosphatidylglycerol)

Page 151: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Appears at 36 weeks or sooner if distressed

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Present or Absent

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Present or AbsentResults are not invalid if

contaminated by blood

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Present or AbsentResults are not invalid if

contaminated by bloodPG + L:S >2 is good

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L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization

Page 156: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Uncentrifuged AF

Page 157: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Uncentrifuged AFMeasures ratio of

Surfactant:Albumin

Page 158: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

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Blood and meconium will not yield a false positive

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Blood and meconium will not yield a false positive

Vaginally collected AF is ok

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Medications to “make” lungs ready

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Medications to “make” lungs ready Surfactants

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Medications to “make” lungs ready Surfactants Steroids

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Surfactant

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Surfactant

Within 2 hrs after birth

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Surfactant

AdministerIntratracheally

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Surfactant

Page 168: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Surfactant

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

Page 169: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Surfactant

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

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Steroids

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Steroids Given antenatally

X XX X X

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L:S ratio is < 2:1

X XX X X

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

Page 173: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Speed up lung development

L:S ratio is < 2:1

X XX X X

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L:S ratio is < 2:1

X XX X X

Initiate surfactant production

Page 175: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

L:S ratio is < 2:1

X XX X X

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L:S ratio is < 2:1

X XX X X

2 doses

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L:S ratio is < 2:1

X XX X X

Bethamethasone (IM)

2 doses

Page 178: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

L:S ratio is < 2:1

X XX X X

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

2 doses

Page 179: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

L:S ratio is < 2:1

X XX X X

Dexamethasone (IM)

2 doses

Page 180: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

L:S ratio is < 2:1

X XX X X

Dexamethasone (IM)6mgq12 hrs2 days before delivery

2 doses

Page 181: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Nursing Diagnoses for RDS

Page 182: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 183: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 184: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 185: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 186: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 187: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 188: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 189: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

Study to: Standardize practices for RDS intervention

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

Page 191: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

Page 192: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

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Page 195: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

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

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n=773

Clinical judgment superseded the standards agreed upon for treating ARDS children

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n=773

Page 203: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

n=773

“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”

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n=773

Page 205: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

n=773

Page 206: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

n=773

Page 207: The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

n=773

“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.”

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n=773

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n=773

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n=773

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n=773

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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

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