Syndrome of respiratory disorders. Prevention of respiratory distress syndrome (RDS) in preterm birth. Corticosteroid (glucocorticoid) therapy for threatened preterm birth. Contraindications to hormone therapy

Respiratory distress syndrome of newborns is a pathological condition that occurs in the early neonatal period and is clinically manifested by signs of acute respiratory failure. In the medical literature, to refer to this syndrome, there are also alternative terms "respiratory distress syndrome", "hyaline membrane disease".

The disease is usually detected in preterm infants and is one of the most severe and common pathologies of the neonatal period. Moreover, the lower the gestational age of the fetus and its birth weight, the higher the likelihood of developing respiratory disorders in the child.

Predisposing factors

The basis of the RDS syndrome of newborns is the lack of a substance covering the alveoli from the inside - a surfactant.

The basis for the development of this pathology is the immaturity of the lung tissue and the surfactant system, which explains the occurrence of such disorders mainly in preterm infants. But babies born at term can also develop RDS. The following factors contribute to this:

intrauterine infections;
fetal asphyxia;
general cooling (at temperatures below 35 degrees, the synthesis of surfactant is disrupted);
multiple pregnancy;
incompatibility by blood group or Rh factor in mother and child;
(increases the likelihood of detecting RDS in a newborn by 4-6 times);
bleeding due to premature detachment of the placenta or its presentation;
delivery by planned caesarean section (before the onset of labor).

Why develops

The occurrence of RDS in newborns is due to:

violation of the synthesis of surfactant and its excretion on the surface of the alveoli due to insufficient maturation of lung tissue;
birth defects of the surfactant system;
its increased destruction during various pathological processes (for example, severe hypoxia).

Surfactant begins to be produced in the fetus during fetal development at the 20-24th week. However, during this period, it does not have all the properties of a mature surfactant, it is less stable (it quickly collapses under the influence of hypoxemia and acidosis) and has a short half-life. This system fully matures at the 35-36th week of pregnancy. A massive release of surfactant occurs during childbirth, which helps to expand the lungs during the first breath.

Surfactant is synthesized by type II alveolocytes and is a monomolecular layer on the surface of the alveoli, consisting of lipids and proteins. Its role in the body is very large. Its main functions are:

an obstacle to the collapse of the alveoli on inspiration (due to a decrease in surface tension);
protection of the epithelium of the alveoli from damage;
improvement of mucociliary clearance;
regulation of microcirculation and permeability of the alveolar wall;
immunomodulatory and bactericidal action.

In a child born prematurely, surfactant reserves are only enough to carry out the first breath and ensure respiratory function in the first hours of life, and then its reserves are depleted. Due to the lagging of the processes of surfactant synthesis from the rate of its decay, the subsequent increase in the permeability of the alveolo-capillary membrane and the leakage of fluid into the interalveolar spaces, a significant change in the functioning of the respiratory system occurs:

in different parts of the lungs are formed;
stagnation is observed;
interstitial develops;
increasing hypoventilation;
intrapulmonary shunting occurs.

All this leads to insufficient oxygenation of tissues, the accumulation of carbon dioxide in them, and a change in the acid-base state towards acidosis. The resulting respiratory failure disrupts the functioning of the cardiovascular system. These children develop:

increased pressure in the pulmonary artery system;
systemic;
transient myocardial dysfunction.

It should be noted that the surfactant synthesis is stimulated by:

corticosteroids;
estrogens;
thyroid hormones;
epinephrine and norepinephrine.

Its maturation is accelerated under the influence of chronic hypoxia (with intrauterine growth retardation, late preeclampsia).

How it manifests itself and what is dangerous

Depending on the time of appearance of the symptoms of this pathology and the general condition of the child's body at this moment, three main variants of its clinical course can be distinguished.

In some premature babies born in a satisfactory condition, the first clinical manifestations are recorded 1-4 hours after birth. This variant of the disease is considered a classic. The so-called "light gap" is associated with the functioning of an immature and rapidly decaying surfactant.
The second variant of the syndrome is typical for premature babies who have undergone severe hypoxia during childbirth. Their alveolocytes are not able to quickly accelerate the production of surfactant after the expansion of the lungs. The most common cause of this condition is acute asphyxia. Initially, the severity of the condition of newborns is due to cardio-respiratory depression. However, after stabilization, they quickly develop RDS.
The third variant of the syndrome is observed in very premature babies. They have a combination of immaturity of the mechanisms of synthesis of surfactant with a limited ability of alveolocytes to increase the rate of its production after the first breath. Signs of respiratory disorders in such newborns are noticeable from the first minutes of life.

In the classic course of the respiratory syndrome, some time after birth, the child develops the following symptoms:

gradual increase in respiratory rate (against the background of the skin of normal color, cyanosis appears later);
swelling of the wings of the nose and cheeks;
sonorous groaning exhalation;
retraction of the most pliable places of the chest on inspiration - supraclavicular fossae, intercostal spaces, lower part of the sternum.

As the pathological process progresses, the child's condition worsens:

the skin becomes cyanotic;
there is a decrease in blood pressure and body temperature;
increased muscle hypotension and hyporeflexia;
chest rigidity develops;
moist rales are heard above the lungs against the background of weakened breathing.

In very preterm infants, RDS has its own characteristics:

an early sign of the pathological process is diffuse cyanosis;
immediately after birth, they experience swelling of the anterior upper chest, which is later replaced by its retraction;
respiratory failure is manifested by apnea attacks;
symptoms such as swelling of the wings of the nose may be absent;
symptoms of respiratory failure persist for a longer period of time.

In severe RDS, due to severe circulatory disorders (both systemic and local), its course is complicated by damage to the nervous system, gastrointestinal tract, and kidneys.

Diagnostic principles

Women who are at risk undergo amniocentesis and examine the lipid content in the resulting sample of amniotic fluid.

Early diagnosis of RDS is extremely important. In women at risk, prenatal diagnosis is recommended. To do this, examine the lipid spectrum of amniotic fluid. According to its composition, the degree of maturity of the lungs of the fetus is judged. Given the results of such a study, it is possible to timely prevent RDS in an unborn child.

In the delivery room, especially in the case of preterm birth, the compliance of the maturity of the main systems of the child's body with his gestational age is assessed, and risk factors are identified. At the same time, the “foam test” is considered quite informative (ethyl alcohol is added to the amniotic fluid or aspirate of gastric contents and the reaction is observed).

In the future, the diagnosis of respiratory distress syndrome is based on an assessment of clinical data and the results of an X-ray examination. The radiological signs of the syndrome include the following:

reduced pneumatization of the lungs;
air bronchogram;
blurred borders of the heart.

For a full assessment of the severity of respiratory disorders in such children, special scales are used (Silverman, Downs).

Medical tactics

Treatment of RDS begins with proper care of the newborn. He should be provided with a protective mode with minimization of light, sound and tactile irritations, optimal ambient temperature. Usually the child is placed under a heat source or in an incubator. His body temperature should not be less than 36 degrees. The first time until the condition stabilizes, the child is provided with parenteral nutrition.

Therapeutic measures for RDS begin immediately, usually they include:

ensuring normal airway patency (suction of mucus, the appropriate position of the child);
the introduction of surfactant preparations (carried out as early as possible);
adequate ventilation of the lungs and normalization of the gas composition of the blood (oxygen therapy, CPAP therapy, mechanical ventilation);
fight against hypovolemia (infusion therapy);
correction of the acid-base state.

Considering the severity of RDS in newborns, the high risk of complications and the numerous difficulties of the therapy Special attention should be given to the prevention of this condition. It is possible to accelerate the maturation of the lungs of the fetus by administering glucocorticoid hormones (dexamethasone, betamethasone) to a pregnant woman. The indications for this are:

high risk of preterm birth and their initial signs;
complicated course of pregnancy, in which early delivery is planned;
outflow of amniotic fluid ahead of time;
bleeding during pregnancy.

A promising direction in the prevention of RDS is the introduction of thyroid hormones into the amniotic fluid.

The time required for the full development of all organs of the child in the prenatal period is 40 weeks. If the baby is born before this time, his lungs will not be formed enough for full breathing. This will cause a violation of all body functions.

With insufficient development of the lungs, respiratory distress syndrome of the newborn occurs. It usually develops in premature babies. Such babies cannot fully breathe, and their organs lack oxygen.

This disease is also called hyaline membrane disease.

Why does pathology occur?

The causes of the disease are a lack or change in the properties of the surfactant. It is a surfactant that provides elasticity and firmness to the lungs. It lines the surface of the alveoli from the inside - respiratory "sacs", through the walls of which the exchange of oxygen and carbon dioxide takes place. With a lack of surfactant, the alveoli collapse and the respiratory surface of the lungs decreases.

Fetal distress syndrome can also be caused by genetic diseases and congenital malformations of the lungs. These are very rare conditions.

The lungs begin to fully develop after the 28th week of pregnancy. The sooner they happen, the higher the risk of pathology. Boys are particularly affected. If a baby is born before 28 weeks, the disease is almost inevitable.

Other risk factors for pathology:

the appearance of a distress syndrome during a previous pregnancy;
(twins, triplets);
due to Rhesus conflict;
diabetes mellitus (or type 1) in the mother;
asphyxia (suffocation) of the newborn.

Mechanism of development (pathogenesis)

The disease is the most common pathology in newborns. It is associated with a lack of surfactant, which leads to the subsidence of lung areas. Breathing becomes inefficient. A decrease in the concentration of oxygen in the blood leads to an increase in pressure in the pulmonary vessels, and pulmonary hypertension increases the violation of the formation of surfactant. There is a "vicious circle" of pathogenesis.

Surfactant pathology is present in all fetuses up to 35 weeks of intrauterine development. If there is chronic hypoxia, this process is more pronounced, and even after birth, lung cells cannot produce enough of this substance. In such babies, as well as with deep prematurity, type 1 neonatal distress syndrome develops.

A more common variant is the inability of the lungs to produce enough surfactant immediately after birth. The reason for this is the pathology of childbirth and caesarean section. In this case, the expansion of the lungs during the first breath is disturbed, which interferes with the launch of the normal mechanism for the formation of surfactant. Type 2 RDS occurs with asphyxia during childbirth, birth trauma, and operative delivery.

In premature babies, both of the above types are often combined.

Violation of the lungs and increased pressure in their vessels cause an intense load on the heart of the newborn. Therefore, there may be manifestations of acute heart failure with the formation of cardiorespiratory distress syndrome.

Sometimes children of the first hours of life develop or manifest other diseases. Even if the lungs functioned normally after birth, comorbidity leads to a lack of oxygen. This starts the process of increasing pressure in the pulmonary vessels and circulatory disorders. This phenomenon is called acute respiratory distress syndrome.

The adaptation period, during which the lungs of a newborn adapt to breathing air and begin to produce surfactant, is prolonged in preterm infants. If the mother of the child is healthy, it is 24 hours. If a woman is ill (for example, diabetes), the adaptation period is 48 hours. During this time, the child may develop respiratory problems.

Manifestations of pathology

The disease manifests itself immediately after the birth of a child or during the first days of his life.

Symptoms of distress syndrome:

cyanosis of the skin;
flaring nostrils when breathing, fluttering of the wings of the nose;
retraction of the pliable sections of the chest (xiphoid process and the area under it, intercostal spaces, zones above the collarbones) on inspiration;
fast shallow breathing;
decrease in the amount of urine excreted;
"groaning" during breathing, resulting from spasm of the vocal cords, or "expiratory grunts".

Additionally, the doctor fixes such signs as low muscle tone, lowering blood pressure, lack of stool, changes in body temperature, swelling of the face and extremities.

Diagnostics

To confirm the diagnosis, the neonatologist prescribes the following studies:

a blood test with the determination of leukocytes and C-reactive protein;
continuous pulse oximetry to determine the oxygen content in the blood;
the content of gases in the blood;
blood culture "for sterility" for differential diagnosis with sepsis;
lung radiography.

X-ray changes are not specific for this disease. They include darkening of the lungs with areas of enlightenment in the root area and a mesh pattern. Such signs occur with early sepsis and pneumonia, but an x-ray is done for all newborns with respiratory disorders.

Fetal distress syndrome in childbirth is differentiated with such diseases:

temporary tachypnea (rapid breathing): usually occurs in full-term babies after caesarean section, quickly disappears, does not require the introduction of a surfactant;
early sepsis or congenital pneumonia: the symptoms are very similar to RDS, but there are signs of inflammation in the blood and focal shadows on the x-ray of the lungs;
meconium aspiration: appears in full-term babies when meconium is inhaled, has specific radiological signs;
pneumothorax: diagnosed radiologically;
pulmonary hypertension: an increase in pressure in the pulmonary artery, does not have signs characteristic of RDS on x-rays, is diagnosed using an ultrasound of the heart;
aplasia (absence), hypoplasia (underdevelopment) of the lungs: it is diagnosed even before childbirth, in the postpartum period it is easily recognized by radiography;
diaphragmatic hernia: on x-ray, the displacement of organs from abdominal cavity into the chest.

Treatment

Emergency care for fetal distress syndrome is to warm the newly born baby and constantly monitor its temperature. If the birth occurred before 28 weeks, the baby is immediately placed in a special plastic bag or wrapped in plastic wrap. It is recommended that the umbilical cord be cut as late as possible so that the baby receives blood from the mother before starting intensive treatment.

Support for the baby's breathing begins immediately: in the absence of breathing or its inferiority, prolonged inflation of the lungs is carried out, and then a constant supply of air is carried out. If necessary, begin artificial ventilation with a mask, and if it is ineffective - a special device.

The management of newborns with respiratory distress syndrome is carried out in the intensive care unit by the joint efforts of a neonatologist and an intensive care specialist.

There are 3 main methods of treatment:

Replacement therapy with surfactant preparations.
Artificial ventilation of the lungs.
Oxygen therapy.

The introduction of a surfactant is carried out from 1 to 3 times, depending on the severity of the infant's condition. It can be administered through an endotracheal tube placed in the trachea. If the child breathes on his own, the medicine is injected into the trachea through a thin catheter.

In Russia, 3 surfactant preparations are registered:

Curosurf;
Surfactant BL;
Alveofakt.

These drugs are obtained from animals (pigs, cows). Curosurf has the best effect.

After the introduction of the surfactant, ventilation of the lungs is started through a mask or nasal cannula. The child is then transferred to CPAP therapy. What it is? This is a method of maintaining a constant pressure in the airways, which prevents the lungs from collapsing. With insufficient efficiency, artificial ventilation of the lungs is carried out.

The goal of treatment is to stabilize breathing, which usually occurs after 2-3 days. After that, breastfeeding is allowed. If shortness of breath persists with a respiratory rate of more than 70 per minute, it is impossible to feed the baby from the nipple. If normal feeding is delayed, the infant is fed with intravenous infusions of special solutions.

All these measures are carried out in accordance with international standards, which clearly define the indications and sequence of procedures. In order for the treatment of neonatal respiratory distress syndrome to be effective, it must be carried out in specially equipped institutions with well-trained personnel (perinatal centers).

Prevention

Women who are at risk of preterm birth should be admitted to the perinatal center on time. If this is not possible, conditions should be created in advance for nursing the newborn in the maternity hospital where the birth will be taken.

Timely delivery is the best prevention of fetal distress syndrome. To reduce the risk of preterm birth, qualified obstetric monitoring of the course of pregnancy is necessary. A woman should not smoke, use alcohol or drugs. Preparing for pregnancy should not be neglected. In particular, it is necessary to correct the course of chronic diseases such as diabetes in a timely manner.

Prevention of fetal respiratory distress syndrome at high risk of preterm birth is the use of corticosteroids. These drugs promote faster lung development and surfactant production. They are administered for a period of 23-34 weeks intramuscularly 2-4 times. If after 2-3 weeks the threat of preterm labor persists, and the gestational age has not yet reached 33 weeks, the administration of corticosteroids is repeated. The drugs are contraindicated in case of peptic ulcer in the mother, as well as any viral or bacterial infection in her.

Before the completion of the course of hormones and for the transportation of the pregnant woman to the perinatal center, the introduction of tocolytics, drugs that reduce uterine contractility, is indicated. With premature outflow of water, antibiotics are prescribed. With a short cervix or already undergone preterm birth, progesterone is used to lengthen the pregnancy.

Corticosteroids are also given at 35-36 weeks for planned caesarean section. This reduces the risk of breathing problems in the infant after surgery.

5-6 hours before cesarean, the fetal bladder is opened. This stimulates the fetal nervous system, which triggers the synthesis of surfactant. During the operation, it is important to remove the baby's head as carefully as possible. With deep prematurity, the head is removed directly in the bubble. This protects against injury and subsequent respiratory disorders.

Possible Complications

Respiratory distress syndrome can quickly worsen a newborn's condition during the first days of his life and even cause death. The likely consequences of the pathology are associated with a lack of oxygen or with incorrect treatment tactics, these include:

accumulation of air in the mediastinum;
mental retardation;
blindness;
vascular thrombosis;
bleeding in the brain or lungs;
bronchopulmonary dysplasia (improper development of the lungs);
pneumothorax (air entering the pleural cavity with compression of the lung);
blood poisoning;
kidney failure.

Complications depend on the severity of the disease. They may be pronounced or not appear at all. Each case is individual. It is necessary to obtain detailed information from the attending physician on further tactics of examination and treatment of the baby. The mother of the child will need the support of loved ones. A psychological consultation would also be helpful.

Respiratory function is vital, so at birth it is assessed on the Apgar scale along with other important indicators. Breathing problems sometimes lead to serious complications, as a result of which, in certain situations, you have to fully fight for life.

One of these serious pathologies is neonatal respiratory distress syndrome - a condition in which respiratory failure develops in the first hours or even minutes after birth. In most cases, breathing problems occur in premature babies.

There is such a pattern: the shorter the gestational age (the number of complete weeks from conception to birth) and the weight of the newborn, the greater the likelihood of developing respiratory distress syndrome (RDS). But why is this happening?

Causes and mechanism of development

Modern medicine today believes that the main cause of the development of respiratory failure is the immaturity of the lungs and the still imperfect work of the surfactant.

It may be that there is enough surfactant, but there is a defect in its structure (normally it is 90% fat, and the rest is protein), which is why it does not cope with its purpose.

The following factors may increase the risk of developing RDS:

Deep prematurity, especially for children born before the 28th week.
If the pregnancy is multiple. The risk exists for the second baby of twins and for the second and third of triplets.
Delivery by caesarean section.
Large blood loss during childbirth.
Severe illnesses in the mother, such as diabetes.
Intrauterine hypoxia, asphyxia during childbirth, infections (intrauterine and not only), such as streptococcal, contributing to the development of pneumonia, sepsis, etc.
Aspiration of meconium masses (a condition when a child swallows amniotic fluid with meconium).

The important role of surfactant

The surfactant is a mixture of surfactants that lays down evenly on the lung alveoli. It plays an indispensable role in the breathing process by reducing surface tension. In order for the alveoli to work smoothly and not fall off during exhalation, they need lubrication. Otherwise, the child will have to expend a lot of effort on straightening the lungs with each breath.

Surfactant is vital for maintaining normal breathing

While in the mother's womb, the baby "breathes" through the umbilical cord, but already at the 22-23rd week, the lungs begin to prepare for full-fledged work: the process of producing surfactant starts, and they talk about the so-called maturation of the lungs. However, enough of it is produced only by the 35-36th week of pregnancy. Babies born before this period are at risk for the development of RDS.

Types and prevalence

Approximately 6% of children struggle with respiratory distress. RDS is observed in approximately 30-33% in premature babies, in 20-23% in those born after the term, and only in 4% of cases in full-term babies.

Distinguish:

Primary RDS - occurs in preterm infants due to surfactant deficiency.
Secondary RDS - develops due to the presence of other pathologies or the addition of infections.

Symptoms

The clinical picture unfolds immediately after childbirth, in a few minutes or hours. All symptoms point to acute respiratory failure:

Takhiapnea - breathing with a frequency above 60 breaths per minute, with periodic stops.
Swelling of the wings of the nose (due to reduced aerodynamic resistance), as well as retraction of the intercostal spaces and the whole chest during inspiration.
Cyanosis of the skin, blue nasolabial triangle.
Breathing is heavy, "grunting" noises are heard on exhalation.

To assess the severity of symptoms, tables are used, for example, the Downs scale:

When assessing up to 3 points, they speak of a mild respiratory disorder; if the score is > 6, then we are talking about a serious condition that requires immediate resuscitation measures

Diagnostics

Respiratory distress syndrome in newborns is, one might say, a symptom. In order for the treatment to be effective, it is necessary to establish the true cause of this condition. First, they check the "version" about the possible immaturity of the lungs, the lack of surfactant, and also look for congenital infections. If these diagnoses are not confirmed, they are examined for the presence of other diseases.

To make a correct diagnosis, consider the following information:

History of pregnancy and general condition of the mother. They pay attention to the age of the woman in labor, whether she has chronic diseases (in particular, diabetes), infectious diseases, how the pregnancy proceeded, its duration, the results of ultrasound and tests during gestation, what medications the mother took. Is there polyhydramnios (or oligohydramnios), what kind of pregnancy is in a row, how did the previous ones proceed and end.
Labor activity was independent or by caesarean section, fetal presentation, characteristics of amniotic fluid, anhydrous time, heart rate in the child, whether the mother had a fever, bleeding, whether she was given anesthesia.
Newborn condition. The degree of prematurity, the condition of the large fontanelle are assessed, the lungs and heart are auscultated, an assessment is made on the Apgar scale.

The following indicators are also used for diagnostics:

X-ray of the lungs, very informative. There are blackouts in the picture, they are usually symmetrical. Lungs are reduced in volume.
Determination of the coefficient of lecithin and sphingomyelin in amniotic fluid. It is believed that if it is less than 1, then the probability of developing RDS is very high.
Measurement of the level of saturated phosphatidylcholine and phosphatidylglycerol. If their number is sharply reduced or there are no substances at all, there is a high risk of developing RDS.

Treatment

The choice of therapeutic measures will depend on the situation. Respiratory distress syndrome in newborns is a condition that requires resuscitation, including securing the airway and restoring normal breathing.

Surfactant therapy

One of effective methods treatment is the introduction of a surfactant into the trachea of a premature baby in the first so-called golden hour of life. For example, the drug Curosurf is used, which is a natural surfactant obtained from the lungs of a pig.

The essence of manipulation is as follows. Before administration, the vial with the substance is heated to 37 degrees and turned upside down, trying not to shake. This suspension is collected using a syringe with a needle and injected into the lower trachea through an endotracheal tube. After the procedure, manual ventilation is performed for 1-2 minutes. With insufficient effect or its absence, a second dose is administered after 6-12 hours.

Such therapy has good results. It improves neonatal survival. However, the procedure has contraindications:

arterial hypotension;
shock state;
pulmonary edema;
pulmonary bleeding;
low temperature;
decompensated acidosis.

One of the surfactant preparations

In such critical situations, first of all, it is necessary to stabilize the condition of the baby, and then proceed to treatment. It should be noted that surfactant therapy gives the most effective results in the first hours of life. Another disadvantage is the high cost of the drug.

CPAP therapy

This is a method of creating continuous positive airway pressure. It is used for mild forms of RDS, when the first signs of respiratory failure (RD) are just developing.

IVL

If CPAP therapy is ineffective, the child is transferred to a ventilator (artificial ventilation of the lungs). Some indications for IVL:

increasing bouts of apnea;
convulsive syndrome;
a score of more than 5 points according to Silverman.

It must be taken into account that the use of mechanical ventilation in the treatment of children inevitably leads to lung damage and complications such as pneumonia. When carrying out mechanical ventilation, it is necessary to monitor the vital signs and functioning of the baby's body.

General principles of therapy

Temperature regime. It is extremely important to prevent heat loss in a child with RDS, as cooling reduces the production of surfactant and increases the frequency of sleep apnea. After birth, the baby is wrapped in a warm sterile diaper, the remains of amniotic fluid on the skin are blotted and placed under a radiant heat source, after which it is transported to the incubator. Be sure to put on a hat on your head, as there is a large loss of heat and water from this part of the body. When examining a child in an incubator, sudden changes in temperature should be avoided, so the examination should be as short as possible, with minimal touching.
Sufficient humidity in the room. The baby loses moisture through the lungs and skin, and if he was born with a small weight (
Normalization of blood gas parameters. For this purpose, oxygen masks, a ventilator and other options for maintaining breathing are used.
Proper feeding. In a severe form of RDS, a newborn is "fed" on the first day by administering infusion solutions parenterally (for example, glucose solution). The volume is introduced in very small portions, since fluid retention is observed at birth. Breast milk or adapted milk formulas are included in the diet, focusing on the condition of the baby: how developed is his sucking reflex, whether there is prolonged apnea, regurgitation.
Hormone therapy. Glucocorticoid preparations are used to accelerate the maturation of the lungs and the production of their own surfactant. However, today such therapy is being abandoned due to many side effects.
Antibiotic therapy. All children with RDS are prescribed a course of antibiotic therapy. This is due to the fact that the clinical picture of RDS is very similar to the symptoms of streptococcal pneumonia, as well as the use of a ventilator in the treatment, the use of which is often accompanied by infection.
The use of vitamins. Vitamin E is prescribed to reduce the risk of developing retinopathy (vascular disorders in the retina of the eye). The introduction of vitamin A helps to avoid the development of necrotizing enterocolitis. Riboxin and inositol help reduce the risk of bronchopulmonary dysplasia.

Placing a baby in an incubator and taking care of him is one of the basic principles of nursing premature babies.

Prevention

Women who have a threat of termination of pregnancy at 28-34 weeks are prescribed hormone therapy (usually dexamethasone or betamethasone is used according to the scheme). Timely treatment of existing chronic and infectious diseases in a pregnant woman is also necessary.

If doctors offer to lie down for preservation, you should not refuse. After all, increasing the gestational age and preventing preterm birth allows you to buy time and reduce the risk of respiratory distress syndrome at birth.

Forecast

In most cases, the prognosis is favorable, and a gradual recovery is observed by the 2-4th day of life. However, childbirth at short gestational ages, the birth of infants weighing less than 1000 g, complications due to comorbidities (encephalopathy, sepsis) make the prognosis less rosy. In the absence of timely medical care or the presence of these factors, the child may die. Lethal outcome is approximately 1%.

In view of this, a pregnant woman should be responsible for the bearing and birth of a child, not neglect examination, observation in the antenatal clinic and be treated for infectious diseases in a timely manner.

The newborn develops due to a lack of surfactant in the immature lungs. Prevention of RDS is carried out by prescribing pregnant therapy, under the influence of which there is a faster maturation of the lungs and accelerated surfactant synthesis.

Indications for the prevention of RDS:

- Threatening premature birth with the risk of developing labor activity (3 courses from the 28th week of pregnancy);
- Premature rupture of membranes during premature pregnancy (up to 35 weeks) in the absence of labor;
- From the beginning of the first stage of labor, when it was possible to stop labor;
- Placenta previa or low attachment of the placenta with the risk of rebleeding (3 courses from the 28th week of pregnancy);
- Pregnancy is complicated by Rh-sensitization, which requires early delivery (3 courses from the 28th week of pregnancy).

With active labor, the prevention of RDS is carried out through a set of measures for the intranatal protection of the fetus.

Acceleration of the maturation of the lung tissue of the fetus contributes to the appointment of corticosteroids.

Dexamethasone is prescribed intramuscularly at 8-12 mg (4 mg 2-3 times a day for 2-3 days). In tablets (0.5 mg) 2 mg on the first day, 2 mg 3 times on the second day, 2 mg 3 times on the third day. The appointment of dexamethasone, in order to accelerate the maturation of the lungs of the fetus, is advisable in cases where saving therapy does not have a sufficient effect and there is a high risk of preterm birth. Due to the fact that it is not always possible to predict the success of maintenance therapy for threatened preterm labor, corticosteroids should be prescribed to all pregnant women undergoing tocolysis. In addition to dexamethasone, for the prevention of distress syndrome, prednisolone at a dose of 60 mg per day for 2 days, dexazone at a dose of 4 mg intramuscularly twice a day for 2 days can be used.

In addition to corticosteroids, other drugs may be used to stimulate surfactant maturation. If a pregnant woman has a hypertensive syndrome, for this purpose, a 2.4% solution of aminophylline is prescribed at a dose of 10 ml in 10 ml of a 20% glucose solution for 3 days. Despite the fact that the effectiveness of this method is low, with a combination of hypertension and the threat of preterm labor, this drug is almost the only one.

The acceleration of the maturation of the lungs of the fetus occurs under the influence of the appointment of small doses (2.5-5 thousand OD) folliculin daily for 5-7 days, methionine (1 tab. 3 times a day), Essentiale (2 capsules 3 times a day) introduction of an ethanol solution , partusist. Lazolvan (ambraxol) is not inferior to cortecosteroids in terms of the effectiveness of the effect on the lungs of the fetus and has almost no contraindications. It is administered intravenously in a dose of 800-1000 mg per day for 5 days.

Lactin (the mechanism of action of the drug is based on the stimulation of prolactin, which stimulates the production of lung surfactant) is administered at 100 IU intramuscularly 2 times a day for 3 days.
Nicotinic acid is prescribed at a dose of 0.1 g for 10 days no more than a month before a possible premature delivery. Contraindications for this method of prevention of fetal SDR have not been clarified. Perhaps the combined appointment of nicotinic acid with corticosteroids, which contributes to the mutual potentiation of the action of drugs.

Prevention of fetal RDS makes sense at a gestational age of 28-34 weeks. The treatment is repeated after 7 days 2-3 times. In cases where prolongation of pregnancy is possible, after the birth of a child, alveofact is used as a replacement therapy. Alveofact is a purified natural surfactant from the lungs of livestock. The drug improves gas exchange and motor activity of the lungs, reduces the period of intensive care with mechanical ventilation, reduces the incidence of bronchopulmonary dysplasia. Alveofactoma treatment is carried out immediately after birth by intratracheal instillation. During the first hour after birth, the drug is administered at the rate of 1.2 ml per 1 kg of body weight. The total amount of the drug administered should not exceed 4 doses for 5 days. There are no contraindications for the use of Alfeofakt.

With water up to 35 weeks, conservative-expectant tactics are permissible only in the absence of infection, late toxicosis, polyhydramnios, fetal hypoxia, suspicion of fetal malformations, severe somatic diseases of the mother. In this case, antibiotics are used, means for the prevention of SDR and fetal hypoxia and a decrease in the contractive activity of the uterus. Diapers for women must be sterile. Every day, it is necessary to conduct a study of a blood test and vaginal discharge from a woman to timely detect possible infection of the amniotic fluid, as well as monitor the heartbeat and condition of the fetus. In order to prevent intrauterine infection of the fetus, we have developed a method of intra-amniotic drip administration of ampicillin (0.5 g in 400 ml of saline), which contributed to the reduction of infectious complications in the early neonatal period. If there is a history of chronic diseases of the genitals, an increase in leukocytosis in the blood or in a vaginal smear, a deterioration in the condition of the fetus or mother, they switch to active tactics (incitation of labor).

With the discharge of amniotic fluid during pregnancy more than 35 weeks after the creation of an estrogen-vitamin-glucose-calcium background, labor induction is indicated by intravenous drip of enzaprost 5 mg per 500 ml of 5% glucose solution. Sometimes it is possible to simultaneously introduce enzaprost 2.5 mg and oxytocin 0.5 ml in a glucose solution 5%-400 ml intravenously.
Premature birth is carried out carefully, following the dynamics of cervical dilatation, labor activity, advancement of the presenting part of the fetus, the condition of the mother and fetus. In case of weakness of labor activity, a mixture of enzaprost 2.5 mg and oxytocin 0.5 ml and glucose solution 5% -500 ml is carefully injected intravenously at a rate of 8-10-15 drops per minute, monitoring the contractile activity of the uterus. In case of rapid or rapid preterm labor, drugs that inhibit the contractile activity of the uterus - b-agonists, magnesium sulfate should be prescribed.

Mandatory in the first period of preterm labor is the prevention or treatment of fetal hypoxia: glucose solution 40% 20 ml with 5 ml of 5% ascorbic acid solution, sigetin 1% solution - 2-4 ml every 4-5 hours, the introduction of curantyl 10-20 mg in 200 ml of 10% glucose solution or 200 ml of reopoliglyukin.

Premature birth in the II period is carried out without protection of the perineum and without "reins", with pudendal anesthesia 120-160 ml of 0.5% novocaine solution. In women who give birth for the first time and with a rigid perineum, an episio-or perineotomy is performed (dissection of the perineum towards the ischial tuberosity or anus). A neonatologist must be present at the birth. The newborn is taken in warm diapers. The prematurity of the child is evidenced by: body weight less than 2500 g, height does not exceed 45 cm, insufficient development of subcutaneous tissue, soft ear and nasal cartilage, the boy’s testicles are not lowered into the scrotum, in girls the large labia do not cover small, wide sutures and the volume of the “cells, a large amount of cheese-like lubricant, etc.

The pathological condition of newborns that occurs in the first hours and days after birth due to the morphofunctional immaturity of the lung tissue and surfactant deficiency. The syndrome of respiratory disorders is characterized by respiratory failure of varying severity (tachypnea, cyanosis, retraction of compliant chest areas, participation of accessory muscles in the act of breathing), signs of CNS depression and circulatory disorders. Respiratory distress syndrome is diagnosed on the basis of clinical and radiological data, assessment of surfactant maturity indicators. Treatment of respiratory distress syndrome includes oxygen therapy, infusion therapy, antibiotic therapy, endotracheal instillation of surfactant.

III (severe)- usually occurs in immature and very premature babies. Signs of the syndrome of respiratory disorders (hypoxia, apnea, areflexia, cyanosis, severe depression of the central nervous system, impaired thermoregulation) occur from the moment of birth. From the side of the cardiovascular system, tachycardia or bradycardia, arterial hypotension, signs of myocardial hypoxia on the ECG are noted. High probability of death.

Symptoms of respiratory distress syndrome

Clinical manifestations of the syndrome of respiratory disorders usually develop on the 1-2 day of a newborn's life. Shortness of breath appears and intensively increases (respiratory rate up to 60–80 per minute) with the participation of auxiliary muscles in the respiratory act, retraction of the xiphoid process of the sternum and intercostal spaces, swelling of the wings of the nose. Characterized by expiratory noises (“grunting exhalation”) caused by spasm of the glottis, apnea attacks, cyanosis of the skin (first perioral and acrocyanosis, then general cyanosis), foamy discharge from the mouth often mixed with blood.

In newborns with respiratory distress syndrome, there are signs of CNS depression due to hypoxia, an increase in cerebral edema, and a tendency to intraventricular hemorrhages. DIC can be manifested by bleeding from injection sites, pulmonary bleeding, etc. In a severe form of respiratory distress syndrome, acute heart failure rapidly develops with hepatomegaly, peripheral edema.

Other complications of the respiratory distress syndrome can be pneumonia, pneumothorax, pulmonary emphysema, pulmonary edema, retinopathy of prematurity, necrotizing enterocolitis, renal failure, sepsis, etc. As a result of the respiratory distress syndrome, the child may experience recovery, bronchial hyperreactivity, perinatal encephalopathy, impaired immunity, COPD (bullous disease, pneumosclerosis, etc.).

Diagnosis of respiratory distress syndrome

In clinical practice, to assess the severity of the syndrome of respiratory disorders, the I. Silverman scale is used, where the following criteria are evaluated in points (from 0 to 2): chest excursion, retraction of the intercostal spaces on inspiration, retraction of the sternum, nostrils flaring, lowering the chin on inspiration , expiratory noises. A total score below 5 points indicates a mild degree of respiratory distress syndrome; above 5 - medium, 6-9 points - about severe and from 10 points - about extremely severe degree of SDR.

In the diagnosis of respiratory distress syndrome, lung radiography is of decisive importance. The X-ray picture changes in various pathogenetic phases. With disseminated atelectasis, a mosaic pattern is revealed, due to the alternation of areas of reduced pneumatization and swelling of the lung tissue. The disease of hyaline membranes is characterized by "air bronchogram", reticular-nadose grid. In the stage of edematous-hemorrhagic syndrome, fuzziness, blurring of the lung pattern, massive atelectasis are determined, which determine the picture of the "white lung".

To assess the degree of maturity of the lung tissue and the surfactant system in respiratory distress syndrome, a test is used that determines the ratio of lecithin to sphingomyelin in amniotic fluid, tracheal or gastric aspirate; "foam" test with the addition of ethanol to the analyzed biological fluid, etc. It is possible to use the same tests when conducting invasive prenatal diagnostics - amniocentesis, carried out after 32 weeks of gestation, a pediatric pulmonologist, a pediatric cardiologist, etc.

A child with a syndrome of respiratory disorders needs continuous monitoring of emergency situations, respiratory rate, blood gases, CBS; monitoring of indicators of general and biochemical blood tests, coagulograms, ECG. To maintain optimal body temperature, the child is placed in an incubator, where he is provided with maximum rest, mechanical ventilation or inhalation of humidified oxygen through a nasal catheter, parenteral nutrition. The child is periodically performed tracheal aspiration, vibration and percussion massage of the chest.

With the syndrome of respiratory disorders, infusion therapy is carried out with a solution of glucose, sodium bicarbonate; transfusion of albumin and fresh frozen plasma; antibiotic therapy, vitamin therapy, diuretic therapy. An important component of the prevention and treatment of respiratory distress syndrome is endotracheal instillation of surfactant preparations.

Forecast and prevention of respiratory distress syndrome

The consequences of the syndrome of respiratory disorders are determined by the term of delivery, the severity of respiratory failure, the associated complications, the adequacy of resuscitation and therapeutic measures.

In terms of prevention of respiratory distress syndrome, the most important is the prevention of preterm birth. In the event of a threat of premature birth, it is necessary to conduct therapy aimed at stimulating the maturation of the lung tissue in the fetus (dexamethasone, betamethasone, thyroxine, aminophylline). Premature babies should be given early (in the first hours after birth) surfactant replacement therapy.

In the future, children who have had a syndrome of respiratory disorders, in addition to the district pediatrician, should be observed by a pediatric neurologist, pediatric pulmonologist, and pediatric ophthalmologist.