TREATMENT. Hyaline Membrane Disease Prenatal prevention and prediction –Prevent premature birth...

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-976034-overview.mht. Accessed November 23, 2009.


• 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.



• Prenatal prevention and prediction– Estimating the lecithin-to-sphingomyelin ratio

and/or by the presence of phosphatidylglycerol in the amniotic fluid obtained with amniocentesis



• 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



• 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



• 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.



• 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.



• 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



• 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



• 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



• 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.



• 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%



• 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



• 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.



• 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.



• 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



• Supportive therapy– Parental and family support


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

TREATMENT. Hyaline Membrane Disease Prenatal prevention and prediction –Prevent premature birth...

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