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RESPIRATORY DISTRESS
SYNDROME
The single most important cause of mortality and morbidity in preterm infants
Bianca Marie Moses
…a premature baby’s alveolus
…a premature baby’s alveolus
O2
X
Not getting much if any O2 in
…a premature baby’s alveolus
CO2
X
…or CO2 out
…a premature baby’s alveolus
CO2
X
↓ Gas exchange
…a premature baby’s alveolus
CO2
X
↓ Gas exchange
…a premature baby’s alveolus
X
↓ Gas exchange ↓ Alveolar
expansion
…a premature baby’s alveolus
CO2
XX
↓ Gas exchange ↓ Alveolar
expansion Alveolar collapse
…a premature baby’s alveolus
CO2
↓ Gas exchange ↓ Alveolar
expansion Alveolar collapse
…a premature baby’s alveolus
CO2
XXX
↓ Gas exchange ↓ Alveolar
expansion Alveolar collapse
↓ ↓ ↓ Lung Compliance!
…a premature baby’s alveolus
CO2
XXX
↓ Gas exchange ↓ Alveolar
expansion Alveolar collapse
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage Pulmonary vasoconstriction
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage Pulmonary vasoconstriction Atelectasis
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis Hypoxia
Respiratory Distress Syndrome: RDS
…a premature baby’s alveolus
CO2
XXX
Respiratory failure Edema Alveolar, endothelial and
epithelial damage Pulmonary vasoconstriction Atelectasis Respiratory Acidosis Metabolic Acidosis Hypoxia
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations Nasal flaring
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations Nasal flaring Apnea
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations Nasal flaring Apnea “Ground Glass” pattern on
x-ray Reticulogranular Pattern
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations Nasal flaring Apnea Significant retractions
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations Nasal flaring Bradycardia Significant retractions
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Grunting respirations Lethargy Bradycardia Significant retractions
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Tachypnea >60b/min Weak cry Lethargy Bradycardia Significant retractions
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Increasing cyanosis or acrocyanosis
Hypotonia Weak cry Lethargy Bradycardia Significant retractions
Respiratory Distress Syndrome: RDS
What a nurse looks for…
Pulse Ox 88%-93%
Hypotonia Weak cry Lethargy Bradycardia Significant retractions
Increased Urination
What a nurse looks for…
Pulse Ox 88%-93%
Hypotonia Weak cry Lethargy Bradycardia Significant retractions
Increased Urination = ↑ respiratory status
What a nurse looks for…
Pulse Ox 88%-93%
Hypotonia Weak cry Lethargy Bradycardia Significant retractions
Respiratory Distress Syndrome (RDS)
Caucausian
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Risk Factors include:
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Risk Factors include:
Prematurity
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Risk Factors include:
Prematurity AGA, SGA, LGA
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Risk Factors include:
Prematurity AGA, SGA, LGA
Born to diabetic mom
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Risk Factors include:
Prematurity AGA, SGA, LGA
Born to diabetic mom
Surfactant deficiency disease
Respiratory Distress Syndrome (RDS)
Caucausian > Hispanic or African American babies
Affects males 2x more often than females
Risk Factors include:
Prematurity AGA, SGA, LGA
Born to diabetic mom
Surfactant deficiency disease
Genetics
A little background first
Foggy Bathroom Mirror
Foggy Bathroom Mirror
Water sticks to the glass surface
Foggy Bathroom Mirror
Adhesive property of water
Water sticks to the glass surface
Foggy Bathroom Mirror
Adhesive property of water
Water sticks to the glass surface
Rain Drops
Rain Drops
Water drops bead up
Rain Drops
Water drops bead up
Cohesive property of water
Rain Drops
Water drops bead up
Cohesive property of water
Rain Drops
Water drops bead up
Cohesive property of water
Rain Drops
Water drops bead up
Cohesive property of water
Caught in the rain…
Caught in the rain…
Caught in the rain…
Skin
Shirt
Caught in the rain…
Skin
Shirt
Caught in the rain…
Adhesion
Adhesion
Skin
Shirt
Caught in the rain…
Skin
Shirt
Water
Caught in the rain…
Skin
Shirt
Water
Caught in the rain…
Skin
Shirt
Water
Caught in the rain…
Skin
Shirt
CohesionWater
+Adhesion Cohesion
Surface Tension…+
Adhesion Cohesion
Surface Tension…
…the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken
Surface Tension…
…the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken
Skin
Shirt
Water
Surface Tension…
…the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken
Skin
Shirt
Surface Tension…
…the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken
Shirt is stuck to his skin
Surface Tension…
Surface Tension…
Amniotic fluid
Amniotic fluid
Amniotic fluid
Birth canal squeezes amniotic fluid out of alveoli
Amniotic fluid
Amniotic fluid
Birth canal squeezes amniotic fluid out of alveoli
Amniotic fluid
Amniotic fluid
Birth canal squeezes amniotic fluid out of alveoli
AirIdeally
AirIdeally
We’ll realign the alveolus for better visualization
AirIdeally
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Pull In
Alveolar Wall
Alveolar Wall
Alveolar Wall
Alveolar Wall
Collapse
Surfactant
Surfactant
Open
O2
Open
O2
Open
O2
Open
O2
Open
O2 Open
CO2
Open
CO2
Open
CO2
Open
CO2
Open
CO2
Open
A closer look at surfactant
Surfactant
Surfactant
Two components in human surfactant
Surfactant
Lecithin/Sphingomyelin (L/S) ratio
Two components in human surfactant
Surfactant
Lecithin:Sphingomyelin (L/S) ratio
Two components in human surfactant
Surfactant
Lecithin:Sphingomyelin (L:S) ratio
Two components in human surfactant
Surfactant
Lecithin:Sphingomyelin (L:S) ratio
Produced by baby
Two components in human surfactant
Surfactant
Lecithin:Sphingomyelin (L:S) ratio
Produced by baby
Surfactant
20
Lecithin:Sphingomyelin (L:S) ratio
Surfactant
20
Lecithin:Sphingomyelin (L:S) ratio
0.5:1
Surfactant
30
Lecithin:Sphingomyelin (L:S) ratio
32
Surfactant
30
Lecithin:Sphingomyelin (L:S) ratio
1:1
32
Surfactant
35
Lecithin:Sphingomyelin (L:S) ratio
Surfactant
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
RDS is unlikely
35
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
RDS is unlikely
35
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
X XX
XX
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
X XX
XX
L:S ratio is < 2:1
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
X XX
XX
L:S ratio is < 2:1
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
L:S ratio is < 2:1
X XX
XX
50% chance of RDS if < 30 weeks
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
L:S ratio is < 2:1
X XX
XX
Limit of Viability
50% chance of RDS if < 30 weeks
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
L:S ratio is < 2:1
X XX
XX
Limit of Viability ~23-24w
50% chance of RDS if < 30 weeks
35
Lecithin:Sphingomyelin (L:S) ratio
2:1
35
L:S ratio is < 2:1
XX
X
XX
XXX
XX
XX
50% chance of RDS if < 30 weeks
Limit of Viability ~23-24w
Are baby’s lungs ready?
Are baby’s lungs ready?
L:S Ratio
Are baby’s lungs ready?
L:S Ratio Ratio closer to 2 is better
Are baby’s lungs ready?
L:S Ratio Ratio closer to 2 is betterMay require ratio of 3:1 or
3.5:1
Are baby’s lungs ready?
L:S Ratio Ratio closer to 2 is betterMay require ratio of 3:1 or
3.5:1
Are baby’s lungs ready?Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS
L:S Ratio Ratio closer to 2 is betterMay require ratio of 3:1 or
3.5:1Meconium and blood
invalidate results
Are baby’s lungs ready?Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS
L:S Ratio Ratio closer to 2 is betterMay require ratio of 3:1 or
3.5:1Meconium and blood
invalidate resultsSome conditions
accelerate lung maturity
Are baby’s lungs ready?Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS
L:S Ratio PG (phosphatidylglycerol)
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol)
Appears at 36 weeks or sooner if distressed
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol)
Appears at 36 weeks or sooner if distressed
Present or Absent
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol)
Appears at 36 weeks or sooner if distressed
Present or AbsentResults are not invalid if
contaminated by blood
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol)
Appears at 36 weeks or sooner if distressed
Present or AbsentResults are not invalid if
contaminated by bloodPG + L:S >2 is good
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization
Uncentrifuged AF
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization
Uncentrifuged AFMeasures ratio of
Surfactant:Albumin
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization
Uncentrifuged AFMeasures ratio of
Surfactant:Albumin○ Non diabetic >50mg/g○ Diabetic >70mg/g
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization
Uncentrifuged AFMeasures ratio of
Surfactant:Albumin○ Non diabetic >50mg/g○ Diabetic >70mg/g
Blood and meconium will not yield a false positive
Are baby’s lungs ready?
L:S Ratio PG (phosphatidylglycerol) Flourescence Polarization
Uncentrifuged AFMeasures ratio of
Surfactant:Albumin○ Non diabetic >50mg/g○ Diabetic >70mg/g
Blood and meconium will not yield a false positive
Vaginally collected AF is ok
Are baby’s lungs ready?
Medications to “make” lungs ready
Medications to “make” lungs ready Surfactants
Medications to “make” lungs ready Surfactants Steroids
Surfactant
Surfactant
Within 2 hrs after birth
Surfactant
AdministerIntratracheally
Within 2 hrs after birth
Surfactant
AdministerIntratracheally
Within 2 hrs after birth
Surfactant
AdministerIntratracheally
Within 2 hrs after birth
Survanta (bovine) Infasurf (bovine) Beractant (bovine) Calfactant (bovine) Poractant (porcine) Curosurf (porcine)
Surfactant
AdministerIntratracheally
Within 2 hrs after birth
Survanta (bovine) Infasurf (bovine) Beractant (bovine) Calfactant (bovine) Poractant (porcine) Curosurf (porcine) Exosurf Surfaxin Colfosceril Lucinactant Pumactant
Steroids
Steroids Given antenatally
X XX X X
Steroids Given antenatally
L:S ratio is < 2:1
X XX X X
Improve survivability of the 24-34 week gestation and babies <1250g
Steroids Given antenatally
Speed up lung development
L:S ratio is < 2:1
X XX X X
Improve survivability of the 24-34 week gestation and babies <1250g
L:S ratio is < 2:1
X XX X X
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
Improve survivability of the 24-34 week gestation and babies <1250g
Improve survivability of the 24-34 week gestation and babies <1250g
L:S ratio is < 2:1
X XX X X
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
Improve survivability of the 24-34 week gestation and babies <1250g
L:S ratio is < 2:1
X XX X X
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
2 doses
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
L:S ratio is < 2:1
X XX X X
Bethamethasone (IM)
2 doses
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
L:S ratio is < 2:1
X XX X X
Bethamethasone (IM)12mgq24 hrs2-3 days before delivery
2 doses
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
L:S ratio is < 2:1
X XX X X
Bethamethasone (IM)12mgq24 hrs2-3 days before delivery
Dexamethasone (IM)
2 doses
Steroids Given antenatally
Speed up lung development
Initiate surfactant production
L:S ratio is < 2:1
X XX X X
Bethamethasone (IM)12mgq24 hrs2-3 days before delivery
Dexamethasone (IM)6mgq12 hrs2 days before delivery
2 doses
Nursing Diagnoses for RDS
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
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
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
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
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
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
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
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
Study to: Standardize practices for RDS intervention
Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010…
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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.”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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.”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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.”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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.”
Study to: Standardize practices for RDS intervention
Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard
Operational definition of RDS to distinguish babies who would get treatment from those who would not
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
n=773
Clinical judgment superseded the standards agreed upon for treating ARDS children
“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.”
Study to: Standardize practices for RDS intervention
RDS Citations
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Carnielli, V. P., Zimmermann, L. I., Hamvas, A. A., & Cogo, P. E. (2009). Pulmonary surfactant kinetics of the newborn infant: novel insights from studies with stable isotopes. Journal Of Perinatology, 29S29-S37. doi:10.1038/jp.2009.32
Davidson, M., London, M., & Ladewig, P. (2012). Olds' maternal newborn nursing & women's health across the lifespan. (9th ed.). Upper Saddle River: Pearson
Going "foreword": the new CLSI guidelines. (2012). MLO: Medical Laboratory Observer, 44(2), 10.
Haitsma, J. J. (2010). Surfactant therapy. Canadian Journal Of Respiratory Therapy, 46(3), 38.
Howell, E., Holzman, I., Kleinman , L., Wang, J., & Chassin, M. (2010). Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: discordance of practice from a community clinician consensus standard.Journal of Perinatology, 30, 590-595.
Howell, E., Holzman, I., Kleinman, L., Wang, J., & Chassin, M. (n.d.). Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard. (2010). Journal of Perinatology, 30, 590-595.
Hussain, N., Noce, T., Jagivan, B., Hedge, P., Pappagallo, M., Bhandari, A., & Sharma, P. (2010). Pneumatoceles in preterm infantsfincidence and outcome in the post-surfactant era. Journal of Perinatology, 30, 330-336.
Moya, F. F. (2009). Synthetic surfactants: where are we? Evidence from randomized, controlled clinical trials. Journal Of Perinatology, 29S23-S28. doi:10.1038/jp.2009.26
Verder, H., Bohlin, K., Kamper, J., Lindwall, R., & Jonsson, B. (2009). Nasal CPAP and surfactant for treatment of respiratory distress syndrome and prevention of bronchopulmonary dysplasia. Acta Paediatrica, 98(9), 1400-1408. doi:10.1111/j.1651-2227.2009.01413.x