Updated: 6/4/2018

Neonatal Respiratory Distress Syndrome

Topic
Review Topic
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Questions
8
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Evidence
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Introduction
  • CXRPathophysiology
    • aka hyaline membrane disease
    • immature fetal lungs have a deficiency in surfactant
    • reduced surfactant results in low lung compliance and subsequent atelectasis, intrapulmonary shunting, and acute lung injury
  • Causes
    • prematurity (most important)
      • type II pneumocytes not developed
        • normal source of surfactant production
    • Cesarean section
      • lack of vaginal compression stress on the infant during delivery results in reduced fetal cortisol production and resultant reduction in surfactant production
    • maternal diabetes
      • high insulin levels decrease surfactant production
        • increased fetal blood glucose results in increased fetal insulin production
Presentation
  • Symptoms
    • dyspnea, tachypnea during first hours of life
    • nasal flaring
    • expiratory grunting,
    • intercostal, subxiphoid retractions
  • Physical exam
    • severe hypoxemia 
      • not responsive to 100% O2
        • atelectasis results in intrapulmonary (right-to-left) shunting
          • perfusion without ventilation
Evaluation
  • ABG
    • Hypoxemia
    • respiratory acidosis (elevated PCO2) from poor ventilation 
  • Histology 
    • hyaline membrane surrounds collapsed alveoli
  • CXR
    • "ground-glass" appearance 
  • Amniotic Fluid  
    • lecithin:sphingomyelin ratio < 1.5 
Treatment
  • Prevention 
    • corticosteroids given to mother between 23 and 34 weeks gestation at increased risk for preterm delivery within 7 days  
      • results in increased surfactant production
  • Treatment
    • nasal CPAP
    • surfactant replacement (endotracheal, so intubation is needed) 
Complications
  • Bronchopulmonary dysplasia
    • still very common
  • Patent ductus arteriosus
    • normally closed by increased Otension at birth
      • hypoxia keeps shunt open
  • 100% O2 therapy damage
    • free radical damage of eyes and lungs
      • may result in blindness and pulmonary dysplasia 
    • damage also when the neonate is taken off oxygen therapy
      • upregulation of VEGF due to relative hypoxia results in neovascularization in the retina (retinopathy of prematurity)
 
 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.PL.25) An infant male born premature at 30 weeks to a 24-year-old woman is found to be dyspneic during the first few hours of life. The newborn appears hypoxemic, and his SpO2 is not increased by 100% O2 given via facemask. A chest radiograph is shown in Figure A. Which of the following substances, if administered to the mother in the prenatal period, could have prevented this patient's symptoms? Review Topic

QID: 101919
FIGURES:
1

Oxygen

1%

(1/105)

2

Lecithin

5%

(5/105)

3

Sphingomyelin

4%

(4/105)

4

Insulin

2%

(2/105)

5

Dexamethasone

86%

(90/105)

M1

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PREFERRED RESPONSE 5
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(M1.PL.70) An infant born prematurely at 28 weeks gestation is immediately noticed to be tachypneic and cyanotic following birth. A chest CT scan is obtained, which is shown in Figure A. A presumptive diagnosis is made based on the clinical picture and chest CT, and treatment is initiated. Which of the following organelles and cell types are involved in this clinical picture? Review Topic

QID: 106490
FIGURES:
1

Lamellar bodies - type I pneumocytes

0%

(0/16)

2

Mitochondria - type II pneumocytes

12%

(2/16)

3

Lamellar bodies - type II pneumocytes

81%

(13/16)

4

Endoplasmic reticulum - type I pneumocytes

0%

(0/16)

5

Plasma membrane - type II pneumocytes

0%

(0/16)

M1

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PREFERRED RESPONSE 3

(M1.PL.70) A P2G1 diabetic woman is at risk of delivering at 29 weeks gestation. Her obstetrician counsels her that there is a risk the baby could have significant pulmonary distress after it is born. However, she states she will give the mother corticosteroids, which will help prevent this from occurring. Additionally, the obstetrician states she will perform a test on the amniotic fluid which will indicate the likelihood of the infant being affected by this syndrome. Which of the following ratios would be most predictive of the infant having pulmonary distress? Review Topic

QID: 106471
1

lecithin:sphingomyelin > 1.5

13%

(2/15)

2

lecithin:phosphatidylserine > 3.0

0%

(0/15)

3

lecithin:sphingomyelin > 3.0

0%

(0/15)

4

lecithin:sphingomyelin < 1.5

80%

(12/15)

5

lecithin:phosphatidylserine < 1.5

7%

(1/15)

M1

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PREFERRED RESPONSE 4
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(M1.PL.71) A pathologist examines the section of tissue shown in Figure A. A defect in the structure marked with the letter "X" is associated with which of the following diseases? Review Topic

QID: 100874
FIGURES:
1

Asthma

0%

(0/7)

2

Neonatal Respiratory Distress Syndrome

71%

(5/7)

3

Silicosis

0%

(0/7)

4

Asbestosis

14%

(1/7)

5

Bronchiolitis Obliterans

0%

(0/7)

M1

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PREFERRED RESPONSE 2

(M1.PL.33) A male is born at 30-weeks gestation. His first few days of life are complicated by multiple issues. On delivery he is profoundly dyspneic and lacks normal coloration. Oxygen saturation reveals severe hypoxemia. When the patient still does not improve with supplemental oxygen, he is intubated and transferred to the ICU. He is treated with artificial surfactant, and his status improves though he requires multiples days on mechanical ventilation with high levels of supplemental oxygen. His hospital course is also complicated by intraventricular hemorrhage. Regarding this patient's pulmonary issues, what would be the diagnostic finding on chest x-ray consistent with this disease, and which of the following fundoscopic images depicts a complication of the treatment for this pulmonary disease? Review Topic

QID: 105431
FIGURES:
1

The chest x-ray would reveal ground glass opacities and the fundoscopic image depicting a complication of the treatment is Figure C

9%

(1/11)

2

The chest x-ray would reveal tracheal deviation and the fundoscopic image depicting a complication of the treatment is Figure A

0%

(0/11)

3

The chest x-ray would reveal an interstitial infiltrate and the fundoscopic image depicting a complication of the treatment is Figure A

9%

(1/11)

4

The chest x-ray would reveal tracheal deviation and the fundoscopic image depicting a complication of the treatment is Figure C

9%

(1/11)

5

The chest x-ray would reveal ground glass opacities and the fundoscopic image depicting a complication of the treatment is Figure B

73%

(8/11)

M1

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PREFERRED RESPONSE 5

(M1.PL.75) A neonate suffering from neonatal respiratory distress syndrome is given supplemental oxygen. Which of the following is a possible consequence of oxygen therapy in this patient? Review Topic

QID: 100878
1

Atelectasis

25%

(6/24)

2

Anosmia

0%

(0/24)

3

Atopy

0%

(0/24)

4

Blindness

75%

(18/24)

5

Cardiac anomalies

0%

(0/24)

M1

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PREFERRED RESPONSE 4
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