European Consensus Guidelines on the Management of Respiratory Distress Syndrome (RDS)- 2019 Update

RDS remains significant problem in premature newborn. It is most common cause for morbidity and mortality in premature newborn. today we will discuss summary of updated European guidelines of management of RDS.

I will cover this topic under following headlines-

• Definition

• Risk factors

• Pathophysiology

• Prenatal care

• Use of antenatal steroids

• Post delivery room stabilisation

• Surfactant therapy

• Oxygen use and non- invasive ventilation

• mechanical ventilation

• supportive care

1. Definition- Mainly disease of Preterm

Respiratory distress-

—Respiratory rate> 60/min

— subcostal retraction

—Grunting present

These days diagnosis based on typical xray picture ( ground glass appearance), blood gas analysis is no more valid because of prompt use of antenatal steroids and surfactant.

The incidence of RDS is inversely proportion to gestational age.

2. Risk Factors-

Increased risk

1.Prematurity

2.Male babies

3.Caucasian race

4.Caesarian section without labour

5.Infant of diabetic mother

6. Familial predisposition

Decreased risk

1.Prolonged rupture of membrane

2.IUGR/ SGA

3.Maternal stress

4.Antenatal steroids

5.Maternal drugs

6.Maternal hypertension

3. Pathophysiology- It is multifactorial but mainly because of surfactant deficiency or insufficiency.

Surfactant produced by alveolar type II cells . Surfactant Lowers surface tension.

Figure: Pathophysiology of RDS

4. Clinical Features- Tachypnea, Nasal flaring Intercostal, sternal recession ,Grunting

Investigations- Xray, CBC, VBG, SE, KFT, LFT, USG Skull, ECHO, Amniotic fluid L/S ratio, Shake Test.

Severity based on Xray findings-

I  -   Fine reticulogranular mottling

II -  Mottling with air bronchograms, low volume

III-  Diffuse mottling,  Prominent discernible air bronchograms

IV -  Bilateral confluent opacification of lung (White out lung)

5. Prenatal Care-

• Identify High risk pregnancy ( Previous preterm delivery, Short cervix, Previous child has chromosomal defect, congenital infections)

• Progesterone supplementation helps to prevent premature delivery

• encirclage in case short cervix

• Transfer high risk patient to tertiary centre.

• Use of tocolytics in very premature delivery to give time for antenatal steroid course completion

• Use of MgSO4 in women in imminent labour before 32 weeks gestation

• Antibiotics in PTPROM

• Use of antenatal steroids -

• Current recommendations according for the administration of antenatal corticosteroids in pregnancy.

• In India ACOG guidelines are usually used.

  

  

  6. Delivery room stabilization-

• prepare pre-delivery setup as per guidelines ( Set a room temperature at 26 degree warm sterile cloths, start warmer, ready intubation tray, resuscitation tray, Blended oxygen, suction catheter etc.)

• Delayed cord clamping (>60sec) is advised so that left ventricular filling does not decrease and this will time to lung aeration and smooth transition.

• Use supportive transition approach rather than resuscitation approach.

• Use CPAP for initial support not mechanical ventilation. Start CPAP at 6 cm of pressure by nasal prongs or mask.

• Use gentle positive pressure ventilation (PIP up to 20-25cm) in apneic or weak respiratory efforts.

• Oxygen for resuscitation should be controlled using a blender. Use an initial FiO2 of 0.30 for babies <28 weeks’ gestation and 0.21–0.30 for those 28–31 weeks, 0.21 for 32 weeks’ gestation and above. FiO2 adjustments up or down should be guided by pulse oximetry.

• Prevent heat loss by using polybag, plastic wrapping around coat.

7. Surfactant therapy-

• When to give- if child needs intubation ,give surfactant in delivery room itself. In general early rescue is preferred over prophylactic and late surfactant.

• If child is showing signs of RDS, xray and USG finding suggestive of RDS, increase Fio2 requirement, give early surfactant.

• What surfactant- Natural synthetic ,animal derived is preferred over synthetic surfactant.

• Poractant alfa at an initial dose of 200 mg/kg is better than 100 mg/kg of poractant alfa or 100 mg/kg of beractant for rescue therapy

  

How to give ( Technique)- INSURE is preferred if child needs intubation but in spontaneous breathing child on CPAP, LISA ( less invasive surfactant administration) is preferred.

LISA is a less invasive technique than INSURE. A special catheter is used under direct laryngoscope or video fluoroscopy for surfactant administration. Study showed less requirements of mechanical ventilation with use of LISA technique.

How many dosage-

• If extubated or on FiO2 <0.4, no more doses

• Improved after 1st dose but worsened again, give repeat dose irrespective of time gap

• Generally no more than 2 doses required

• Rarely 3, never 4

8. OXygen supplementation

• In preterm babies receiving oxygen, the saturation target should be between 90 and 94% .

• Alarm limits should be set to 89 and 95%

• Low saturation cause high mortality and high morbidity, while saturation >95% will cause retinopathy of prematurity.

9. Non-Invasive ventilation-

• CPAP is preferred mode at present.

• CPAP should be started in all babies <30 weeks, who are at risk of RDS.

• Start CPAP at 6-8cm H2O. PEEP is determined as per patients condition.

• Some study compared HHFNC with CPAP in >28 weeks, HHFNC was effective as CPAP with less nasal injury but sometimes newborn needed CPAP rescue, so at present CPAP is preferred method for non invasive ventilation. but for weaning HHFNC can be used in place of CPAP.

• In CPAP , Bubble CPAP is preferred .

• If child need synchronised NIPPV, use ventilator rather than BiPAP.

Mechanical ventilation-

• If child need MV, try to minimise its duration.

• Conventional mode of MV is used but still not clear whether which mode( pressure, volume, combined mode ) should be preferred. mostly volume targeted mode is used. Starting target of volume is 5ml/

• Some protective mechanism which decreases duration of MV are- permissive hypercarbia ( 8-10kPa with target pH of 7.22 ), caffeine, low dose postnatal steroid.

• Early caffein should be considered in patients who are at risk of RDS. Loading dose is 20mg/kg with maintenance of 5-10mg/kg

• Very low dose dexamethasone (.05mg/kg) for 1-2 weeks helps to reduce MV duration. Inhaled budesonide can be used, it helps both in decreasing duration of MV as well as reduce risk of BPD.

• Sedation and analgesic should be used on case to case basis.

Monitor and supportive care-

• Maintain body temperature at 36.5–37.5°C at all times.

• Most babies should be started on intravenous fluids of 70–80 mL/kg/day in a humidified incubator, although some very immature babies may need more

• Start parenteral nutrition immediately after birth. Amino acids 1–2 g/kg/day should be started from day one and quickly built up to 2.5–3.5 g/kg/day . Lipids should be started from day one and built up to a maximum of 4.0 g/kg/day if tolerated

• Enteral feeding with mothers’ milk should also be started on day one if the baby is stable.

• Antibiotics should be used judiciously and stopped early when sepsis is ruled out. Blood pressure should be monitored regularly aiming to maintain normal tissue perfusion, if necessary using inotropes.

• Haemoglobin should be maintained at acceptable levels.

• If a decision is made to attempt therapeutic closure of the PDA then indomethacin, ibuprofen or paracetamol can be used

• Protocols should be in place for monitoring pain and discomfort and consideration given for non-pharmacologic methods of minimising procedural pain and judicious use of opiates for more invasive

I hope this summary will help you. let me know in comment section.

The link of article : European Consensus Guidelines on the Management of

https://pubmed.ncbi.nlm.nih.gov

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