Respiratory distress syndrome

Respiratory distress syndrome (RDS) describes any change to frequency and/or quality of breathing pattern in newborns. Breathing rate < 60/minute (can be up to 70/min during the first hours of life and sets to around 40/min) is considered physiologic and newborn should not display any signs of increased work of breathing (dyspnea).

Transition to extra-uterine life is very fast (within seconds to minutes) as a newborn cries, pinks up and then starts to have regular and calm breathing pattern. Successful postnatal adaptation depends mainly on 2 factors:

  • Spontaneous breathing (water in lungs resorbed into blood/lymphatic vessels = gas exchange = increased pO₂ = pulmonary vasodilation = circulation changes see below)
  • Circulation transformation (pulmonary blood flow increases as pulmonary hypertension subsides = ductal shunting changes to left-right + increased pO₂ causes ductus arteriosus to close)

Pulmonary causes

  • hyaline membrane disease (sometimes used interchangeably with RDS, although RDS constitutes multiple origins of breathing problems)
  • transitory tachypnea
  • amniotic fluid aspiration
  • early-onset pneumonia (adnate pneumonia)
  • air leak syndromes (pulmonary interstitial emphysema, pneumothorax)
  • bronchopulmonary dysplasia (chronic lung disease)

Extra-Pulmonary causes

  • infection/sepsis
  • congenital anomalies (cleft palate, choanal atresia, laryngeal obstruction)
  • cardiology problems (congenital defects, arrhythmia, cardiomyopathy)
  • thorax deformities
  • diaphragm problems (congenital diaphragmatic hernia, diaphragm palsy)
  • neuromuscular problems (neurological trauma, medication – sedatives, myasthenia, myotonia)
  • hematological issue (anemia, hypervolemia, hyperviscosity)
  • metabolic disorders (hypoglycemia, inherited metabolic disorders)
  • homeostasis problems (hypothermia, hyperthermia, acidosis)


Clinical Signs

  • Tachypnea = more than 60 breaths / minute
  • Dyspnea = worsened breathing (intercostal recessions, nasal flaring)
  • Apnea = absence of breathing (central x peripheral x mixed)
  • Grunting = expiration sound phenomenon (breathing against the closed glottis maintains positive pressure in lungs)
  • Cyanosis = central x peripheral
  • Tachycardia

Laboratory Findings

  • Blood gas = hypercapnia + hypoxemia + acidosis (respiratory, mixed)


  • Chest X-ray = depends on the nature of RDS = see individual diagnoses and treatments

Pulmonary causes of Respiratory distress syndrome

Hyaline membrane disease (HMD)

  • Typical for very low birth weight (VLBW) infants (birth weight < 1500 grams)
  • Quickly develops during the first hours of life = requires complex treatment (see Therapy)
  • Uncomplicated HMD lasts usually 3-5 days
  • a hyaline membrane composed of proteins (intra-alveolar leak) and dead cells inside the alveoli (pathologic histology of lungs of premature newborns)
  • anatomical and functional prematurity of lungs (i.e. typical for preterm newborns)
    → anatomical = preterm lungs in saccular developmental stage (abundant interstitial tissue and insufficient inner spacing)
    → functional = inability to maintain residual volume due to surfactant deficiency => focal atelectasis surrounded with areas of hyperinflation => reticular granular pattern on chest X-ray (+ intra-alveolar protein leak from plasma to alveoli causing edema and surfactant dysfunction)


  • surface active agent
  • prevents alveoli from collapse at the end of expiration
  • produced and recycled by pneumocytes II during the second half of pregnancy
  • composed of 90% phospholipids (phosphatidylcholine = lecithin + phosphatidylglycerol) and 10% proteins (SP-A/B/C/D)

Learn More

Transitory Tachypnea

  • wet lung” syndrome = caused by diminished pulmonary fluid resorption
  • preterm and term newborns (cesarean delivery, maternal diabetes, perinatal asphyxia)
  • may require complex therapy, however, usually resolves within 12-24 hours (compared to HMD)

Meconium aspiration syndrome (MAS)

  • fetal hypoxia = gasping = amniotic fluid aspiration => meconium in the fluid = meconium aspiration syndrome
  • requires support right after delivery (chest X-ray with focal atelectasis or decreased transparency)
  • meconium in lungs = inflammation, surfactant dysfunction, PPHN = respiratory failure = mechanical ventilation, surfactant, inhaled nitric oxide


  • intrauterine / perinatal aspiration of infectious amniotic fluid (chorioamnionitis)
  • Streptococcus agalactiae (Group B Streptococcus = GBS), Gram negative bacteria, Ureaplasma spp.
  • lung inflammation = surfactant dysfunction, PPHN + sepsis (BSI = blood-stream infection) = respiratory-circulatory failure = mechanical ventilation, surfactant, inhaled nitric oxide, antibiotics

Air leak syndromes

  • air leak to interstitial tissue (PIE = pulmonary interstitial emphysema) or pleural cavity (PNO = pneumothorax)
  • asymmetrical auscultation + typical chest X-ray findings
  • Spontaneous = vigorous breathing following amniotic fluid aspiration; can resolve spontaneously
  • Iatrogenic = artificial ventilation / mechanical ventilation; can cause tension PNO
  • tension pneumothorax is an emergency presenting with sudden bradycardia and/or desaturations and requires chest drainage (unilateral x bilateral with FR 8/10 tube inserted in the 3rd intercostal space) !

Bronchopulmonary dysplasia

  • chronic lung disease (CLD/BPD) caused by various factors (infection, degree of prematurity, nutrition, aspiration, oxygen, mechanical ventilation, fetal growth restriction) on immature and developing lung tissue (preterm newborns!) = anatomical and functional changes
  • alveolar space restriction + interstitial tissue increase + disruption of alveolarization and vascular bed formation
  • mild BPD = oxygen dependency at day of life (DOL) 28
  • moderate BPD = oxygen dependency at 36 weeks of gestation (36+0)
  • severe BPD = mechanical ventilation at 36 weeks of gestation (36+0)
  • Chest X-ray : lung fibrosis, heterogenous involvement, focal emphysema and atelectasis, diffusely decreased transparency
  • Treatment (see Therapy)
  • Eventual resolution – oxygen and functional rejuvenation within 1 year (usually)
  • Pulmonary hypertension (cor pulmonale) – worse prognosis



  • Transfer in utero (to Perinatal centre)
  • Corticosteroids


  • Oxygen (to reduce hypoxic injury, esp. brain; careful with overdosing = hyperoxia = retinal damage); pulse oximetry used to monitor hemoglobin oxygen saturation; oxygen (gas) needs to be warmed and humidified; FiO₂ 0.21 = 21% oxygen concentration = air; FiO₂ 1.0 = 100% oxygen concentration; vital signs monitoring – temperature, blood pressure, saturation, heart rate)
  • Ventilation support (CPAP = non-invasive; mechanical ventilation = invasive)
  • Surfactant (causal therapy; animal surfactant from pig lungs; synthetic surfactant; needs to be warmed up before bolus administration; immediate effect = increased lung compliance)
  • Circulation support (severe RDS, sepsis, PPHN = inhaled nitric oxide)
  • Parenteral nutrition (energy requirements, antioxidants)
  • Caffein, Antibiotics, Analgesia/Sedation (during mechanical ventilation = blocks interference)
  • Surgery if necessary (cleft palate, diaphragmatic hernia, congenital airway malformations, oesophageal atresia, congenital heart defects)
  • Nursing care (secretions, handling, vitals signs monitoring, comfort and pain scoring, invasive lines check-up – endotracheal tube, cannulas, skin care, enteral feeding, eye care)
  • Home oxygen therapy (BPD)
  • Prevention of RSV infection (Synagis = Palivizumab = passive immunisation)


① Sweet DG, Carnielli V, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology. 2019;115(4):432-450. doi:10.1159/000499361

② Wang C, Guo L, Chi C, et al. Mechanical ventilation modes for respiratory distress syndrome in infants: a systematic review and network meta-analysis. Crit Care. 2015;19(1):108. Published 2015 Mar 20. doi:10.1186/s13054-015-0843-7

③ Dargaville PA, Gerber A, Johansson S, et al. Incidence and Outcome of CPAP Failure in Preterm Infants. Pediatrics. 2016;138(1):e20153985. doi:10.1542/peds.2015-3985

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