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I. FEATURES OF PATHOGENESIS

Respiratory distress syndrome is the most common pathological condition in newborns in the early neonatal period. Its occurrence is the higher, the lower the gestational age and the more often there are pathological conditions associated with the pathology of the respiratory, circulatory and central nervous systems. The disease is polyetiological.

The pathogenesis of ARDS is based on a deficiency or immaturity of the surfactant, which leads to diffuse atelectasis. This, in turn, contributes to a decrease in pulmonary compliance, an increase in the work of breathing, an increase in pulmonary hypertension, resulting in hypoxia that increases pulmonary hypertension, resulting in a decrease in surfactant synthesis, i.e. a vicious circle occurs.

Surfactant deficiency and immaturity are present in the fetus at a gestational age of less than 35 weeks. Chronic intrauterine hypoxia enhances and prolongs this process. Premature babies (especially very premature babies) constitute the first variant of the course of RDSN. Even after going through the birth process without deviations, they can expand the RDS clinic in the future, because their type II pneumocytes synthesize immature surfactant and are very sensitive to any hypoxia.

Another, much more common variant of RDS, characteristic of newborns, is the reduced ability of pneumocytes to “avalanche-like” synthesize surfactant immediately after birth. Etiotropic here are factors that disrupt the physiological course of childbirth. In normal childbirth through the natural birth canal, dosed stimulation of the sympathetic-adrenal system occurs. Straightening the lungs with an effective first breath helps to reduce pressure in the pulmonary circulation, improve the perfusion of pneumocytes and enhance their synthetic functions. Any deviation from the normal course of labor, even planned operative delivery, can cause a process of insufficient surfactant synthesis with the subsequent development of RDS.

The most common cause of this variant of RDS is acute neonatal asphyxia. RDS accompanies this pathology, probably in all cases. RDS also occurs with aspiration syndromes, severe birth trauma, diaphragmatic hernia, often with delivery by caesarean section.

The third variant of the development of RDS, characteristic of newborns, is a combination of previous types of RDS, which occurs quite often in preterm infants.

One can think of acute respiratory distress syndrome (ARDS) in those cases when the child underwent the process of childbirth without deviations, and subsequently he developed a picture of any disease that contributed to the development of hypoxia of any genesis, centralization of blood circulation, endotoxicosis.

It should also be borne in mind that the period of acute adaptation in newborns born prematurely or sick increases. It is believed that the period of maximum risk of manifestations of respiratory disorders in such children is: in those born from healthy mothers - 24 hours, and from sick mothers it lasts, on average, until the end of 2 days. With persistent high pulmonary hypertension in newborns, fatal shunts persist for a long time, which contribute to the development of acute heart failure and pulmonary hypertension, which are an important component in the formation of RDS in newborns.

Thus, in the first variant of the development of RDSN, the starting point is the deficiency and immaturity of the surfactant, in the second - the continuing high pulmonary hypertension and the unrealized process of surfactant synthesis caused by it. In the third option ("mixed"), these two points are combined. The variant of ARDS formation is due to the development of a "shock" lung.

All these variants of RDS are aggravated in the early neonatal period by the limited possibilities of the hemodynamics of the newborn.

This contributes to the existence of the term "cardiorespiratory distress syndrome" (CRDS).

For a more efficient and rational therapy critical conditions in newborns, it is necessary to distinguish between options for the formation of RDS.

Currently, the main method of intensive care for RDSN is respiratory support. Most often, mechanical ventilation in this pathology has to be started with "hard" parameters, under which, in addition to the danger of barotrauma, hemodynamics is also significantly inhibited. To avoid "hard" parameters of mechanical ventilation with a high average pressure in the respiratory tract, it is necessary to start mechanical ventilation preventively, without waiting for the development of interstitial pulmonary edema and severe hypoxia, i.e., those conditions when ARDS develops.

In the case of the expected development of RDS immediately after birth, one should either “simulate” an effective “first breath”, or prolong effective breathing (in preterm infants) with surfactant replacement therapy. In these cases, IVL will not be so "hard" and long. In a number of children, it will be possible, after short-term mechanical ventilation, to carry out SDPPV through binasal cannulas until the pneumocytes are able to "acquire" a sufficient amount of mature surfactant.

The preventive start of mechanical ventilation with the elimination of hypoxia without the use of "hard" mechanical ventilation will allow more effective use of drugs that reduce pressure in the pulmonary circulation.

With this option of starting mechanical ventilation, conditions are created for earlier closure of fetal shunts, which will help improve central and intrapulmonary hemodynamics.

II. DIAGNOSTICS.

A. Clinical signs

1. Symptoms of respiratory failure, tachypnea, chest distention, flaring of the alae, difficulty exhaling, and cyanosis.
2. Other symptoms, eg hypotension, oliguria, muscle hypotension, temperature instability, intestinal paresis, peripheral edema.
3. Prematurity when assessing gestational age.

During the first hours of life, the child is clinically assessed every hour using the modified Downes scale, on the basis of which a conclusion is made about the presence and dynamics of the course of RDS and the required amount of respiratory care.

RDS Severity Assessment (Modified Downes Scale)

Points Frequency Respiratory cyanosis in 1 min.	retraction	expiratory grunt	The nature of breathing on auscultation
0 < 60 нет при 21%	No	No	puerile
1 60-80 present, disappears at 40% O2	moderate	listens- stethoscope	changed weakened
2 > 80 disappears or apnea at	significant	heard distance	Badly held

Score 2-3 points corresponds to RDS mild degree

A score of 4-6 points corresponds to moderate RDS

A score of more than 6 points corresponds to severe RDS

B. RADIOGRAPH OF THE CHEST. Characteristic nodular or round opacities and air bronchograms are indicative of diffuse atelectasis.

B. LABORATORY SIGNS.

1. Lecithin/Sphiringomyelin ratio in amniotic fluid less than 2.0 and negative results of the shake test in the study of amniotic fluid and gastric aspirate. In newborns from mothers with diabetes mellitus, RDS may develop at L/S greater than 2.0.
2. Absence of phosphatyldiglycerol in amniotic fluid.

In addition, when the first signs of RDS appear, Hb / Ht, glucose and leukocyte levels, if possible, CBS and blood gases should be examined.

III. COURSE OF DISEASE.

A. RESPIRATORY INSUFFICIENCY, increasing within 24-48 hours, and then stabilizing.

B. RESOLUTION is often preceded by an increase in the rate of diuresis between 60 and 90 hours of age.

IV. PREVENTION

In case of premature birth in the period of 28-34 weeks, an attempt should be made to inhibit labor activity by using beta-mimetics, antispasmodics or magnesium sulfate, after which glucocorticoid therapy should be carried out according to one of the following schemes:

• - betamethasone 12 mg / m - after 12 hours - twice;
• - dexamethasone 5 mg / m - every 12 hours - 4 injections;
• - hydrocortisone 500 mg / m - every 6 hours - 4 injections. The effect occurs after 24 hours and lasts for 7 days.

In prolonged pregnancy, beta- or dexamethasone 12 mg intramuscularly should be administered weekly. A contraindication for the use of glucocorticoids is the presence of a viral or bacterial infection in a pregnant woman, as well as peptic ulcer.

When using glucocorticoids, blood sugar monitoring should be carried out.

With the intended delivery by cesarean section, if conditions are present, delivery should begin with an amniotomy performed 5-6 hours before the operation in order to stimulate the sympathetic-adrenal system of the fetus, which stimulates its surfactant system. In a critical condition of the mother and fetus, amniotomy is not performed!

Prevention is facilitated by careful removal of the fetal head during caesarean section, and in very premature babies, removal of the fetal head in the fetal bladder.

V. TREATMENT.

The goal of RDS therapy is to support the newborn until the disease resolves. Oxygen consumption and carbon dioxide production can be reduced by maintaining optimal temperature conditions. Since kidney function may be impaired during this period and respiratory losses increase, it is important to carefully maintain fluid and electrolyte balance.

A. Maintenance of airway patency

1. Lay the newborn down with the head slightly extended. Turn the child. This improves the drainage of the tracheobronchial tree.
2. Suction from the trachea is required to sanitize the tracheobronchial tree from thick sputum that appears in the exudative phase, which begins at about 48 hours of life.

B. Oxygen therapy.

1. The warmed, humidified and oxygenated mixture is delivered to the newborn in a tent or through an endotracheal tube.
2. Oxygenation should be maintained between 50 and 80 mmHg and saturation between 85%-95%.

B. Vascular access

1. A venous umbilical catheter with an end above the diaphragm may be useful for providing venous access and measuring central venous pressure.

D. Correction of hypovolemia and anemia

1. Monitor central hematocrit and blood pressure from birth.
2. During the acute phase, maintain hematocrit between 45-50% with transfusions. In the resolution phase, it is sufficient to maintain a hematocrit greater than 35%.

D. Acidosis

1. Metabolic acidosis (BE<-6 мЭкв/л) требует выявления возможной причины.
2. Base deficits of less than -8 mEq/L usually require correction to maintain a pH greater than 7.25.
3. If the pH falls below 7.25 due to respiratory acidosis, then artificial or assisted ventilation is indicated.

E. Feeding

1. If the hemodynamics of the newborn is stable and you manage to stop respiratory failure, then feeding should begin at 48-72 hours of life.
2. Avoid nipple feeding if dyspnoea exceeds 70 breaths per minute as high risk of aspiration.
3. If it is not possible to start enteral feeding, consider parenteral nutrition.
4. Vitamin A parenterally at 2000 IU every other day, until enteral feeding is started, reduces the incidence of chronic lung obstruction.

G. Chest x-ray

1. For diagnosis and assessment of the course of the disease.
2. To confirm the location of the endotracheal tube, pleural drainage, and umbilical catheter.
3. To diagnose complications such as pneumothorax, pneumopericardium and necrotizing enterocolitis.

Z. Excitation

1. Deviations of PaO2 and PaCO2 can and do cause excitation. Such children should be handled very carefully and touched only when indicated.
2. If the newborn is not synchronized with the ventilator, sedation or muscle relaxation may be required to synchronize with the device and prevent complications.

I. Infection

1. In most newborns with respiratory failure, sepsis and pneumonia should be ruled out, so empiric antibiotic therapy with broad-spectrum bactericidal antibiotics should be considered until cultures are silent.
2. Group B hemolytic streptococcus infection may clinically and radiologically resemble RDS.

K. Treatment of acute respiratory failure

1. The decision to use respiratory support techniques should be justified in the medical history.
2. In newborns weighing less than 1500 g, the use of CPAP techniques can lead to unnecessary energy expenditure.
3. It is necessary to initially try to adjust the ventilation parameters in order to reduce FiO2 to 0.6-0.8. Usually this requires maintaining an average pressure in the range of 12-14 cmH2O.

• a. When PaO2 exceeds 100 mm Hg, or there is no sign of hypoxia, FiO2 should be gradually reduced by no more than 5% to 60%-65%.
• b. The effect of reducing ventilation parameters is assessed after 15-20 minutes by analyzing blood gases or a pulse oximeter.
• v. At low oxygen concentrations (less than 40%), a 2%-3% reduction in FiO2 is sufficient.

5. In the acute phase of RDS, carbon dioxide retention may be observed.

• a. Maintain pCO2 less than 60 mmHg by changing the ventilation rate or peak pressure.
• b. If your attempts to stop hypercapnia lead to impaired oxygenation, consult with more experienced colleagues.

K. Causes of deterioration of the patient's condition

1. Rupture of the alveoli and the development of interstitial emphysema, pneumothorax or pneumopericardium.
2. Violation of the tightness of the respiratory circuit.

• a. Check the connection points of the equipment to the source of oxygen and compressed air.
• b. Rule out endotracheal tube obstruction, extubation, or tube advancement into the right main bronchus.
• v. If obstruction of the endotracheal tube or self-extubation is detected, remove the old endotracheal tube and breathe the child with a bag and mask. Re-intubation is best done after stabilization of the patient's condition.

3. In very severe RDS, shunting of blood from right to left through the ductus arteriosus may occur.

4. When the function of external respiration improves, the resistance of the vessels of the small circle can decrease sharply, causing shunting through the ductus arteriosus from left to right.

5. Much less often, deterioration in the condition of newborns is due to intracranial hemorrhage, septic shock, hypoglycemia, nuclear jaundice, transient hyperammonemia, or congenital metabolic defects.

Selection scale for some IVL parameters in newborns with RDS

Body weight, g		< 1500	> 1500
	PEEP, see H2O	PIP, see H2O	PIP, see H2O

Note: This diagram is for guidance only. The parameters of mechanical ventilation can be changed based on the clinic of the disease, blood gases and CBS, and pulse oximetry data.

Criteria for the application of respiratory therapy measures

	FiO2 required to maintain pO2 > 50 mmHg
<24 часов	0,65	Non-invasive methods (O2 therapy, ADAP) Tracheal intubation (IVL, IVL)
>24 hours	0,80	Non-invasive methods Tracheal intubation

M. Surfactant therapy

• a. Human, synthetic and animal surfactants are currently being tested. In Russia, the surfactant EXOSURF NEONATAL, manufactured by Glaxo Wellcome, is approved for clinical use.
• b. It is prescribed prophylactically in the delivery room or later, within a period of 2 to 24 hours. Prophylactic use of a surfactant is indicated for: premature newborns with a birth weight of less than 1350 g with a high risk of developing RDS; newborn weighing more than 1350 g with objectively confirmed immaturity of the lungs. For therapeutic purposes, surfactant is used in a newborn with a clinically and radiographically confirmed diagnosis of RDS, who is on a ventilator through an endotracheal tube.
• v. Introduced into the respiratory tract in the form of a suspension in saline solution. WITH preventive purpose"Exosurf" is administered from 1 to 3 times, with therapeutic - 2 times. A single dose of "Exosurf" in all cases is 5 ml / kg. and is administered as a bolus in two half doses over a period of 5 to 30 minutes, depending on the response of the child. It is safer to inject the solution micro-stream at a rate of 15-16 ml/h. A second dose of Exosurf is administered 12 hours after the initial dose.
• d. Reduces the severity of RDS, but the need for mechanical ventilation persists and the incidence of chronic lung disease does not decrease.

VI. TACTICAL ACTIVITIES

A neonatologist heads the team of specialists in the treatment of RDS. trained in resuscitation and intensive care or a qualified resuscitator.

From LU with URNP 1 - 3 it is obligatory to apply to the RCCN and face-to-face consultation on the 1st day. Rehospitalization to a specialized center for resuscitation and intensive care of newborns after stabilization of the patient's condition after 24-48 hours by the RKBN.

The lecture discusses the main aspects of etiology, pathogenesis, clinic, diagnosis, therapy and prevention respiratory distress syndrome.

Respiratory syndrome distress premature infants: modern tactics therapy and prevention

The lecture considers the main aspects of etiology, pathogenesis, clinical manifestations, diagnosis, therapy and prevention of respiratory distress syndrome.

Respiratory distress syndrome (RDS) of newborns is an independent nosological form (code according to ICD-X - R 22.0), clinically expressed as respiratory failure as a result of the development of primary atelectasis, interstitial pulmonary edema and hyaline membranes, which are based on a deficiency of surfactant, manifested in conditions of imbalance of oxygen and energy homeostasis.

Respiratory distress syndrome (synonyms - hyaline membrane disease, respiratory distress syndrome) is the most common cause of respiratory failure in the early neonatal period. Its occurrence is the higher, the lower the gestational age and body weight at birth. RDS is one of the most frequent and severe diseases of the early neonatal period in premature babies, and it accounts for approximately 25% of all deaths, and in children born at 26-28 weeks of gestation, this figure reaches 80%.

Etiology and pathogenesis. The concept that the basis for the development of RDS in newborns is the structural and functional immaturity of the lungs and the surfactant system currently remains the leading one, and its position has been strengthened after data on the successful use of exogenous surfactant appeared.

Surfactant is a monomolecular layer at the interface between the alveoli and air, the main function of which is to reduce the surface tension of the alveoli. Surfactant is synthesized by type II alveolocytes. Human surfactant is approximately 90% lipid and 5-10% protein. The main function - reducing surface tension and preventing the collapse of the alveoli on exhalation - is performed by surface-active phospholipids. In addition, the surfactant protects the alveolar epithelium from damage and promotes mucociliary clearance, has bactericidal activity against gram-positive microorganisms and stimulates the macrophage reaction in the lungs, participates in the regulation of microcirculation in the lungs and the permeability of the walls of the alveoli, and prevents the development of pulmonary edema.

Type II alveolocytes begin to produce surfactant in the fetus from the 20-24th week of intrauterine development. A particularly intense release of surfactant to the surface of the alveoli occurs at the time of childbirth, which contributes to the primary expansion of the lungs. The surfactant system matures by the 35-36th week of intrauterine development.

The primary deficiency of surfactant may be due to low activity of synthesis enzymes, energy deficiency, or increased degradation of surfactant. The maturation of type II alveolocytes is delayed in the presence of hyperinsulinemia in the fetus and accelerated under the influence of chronic intrauterine hypoxia due to factors such as hypertension in pregnant women, intrauterine growth retardation. Surfactant synthesis is stimulated by glucocorticoids, thyroid hormones, estrogens, adrenaline and norepinephrine.

With a deficiency or reduced activity of the surfactant, the permeability of the alveolar and capillary membranes increases, blood stasis in the capillaries develops, diffuse interstitial edema and overstretching lymphatic vessels; collapse of the alveoli and atelectasis. As a result, the functional residual capacity of the lungs, tidal volume and vital capacity of the lungs decrease. As a result, the work of breathing increases, intrapulmonary shunting of blood occurs, and hypoventilation of the lungs increases. This process leads to the development of hypoxemia, hypercapnia and acidosis.

Against the background of progressive respiratory failure, dysfunction of the cardiovascular system occurs: secondary pulmonary hypertension with a right-to-left shunt through functioning fetal communications, transient myocardial dysfunction of the right and / or left ventricles, systemic hypotension.

On pathoanatomical examination, the lungs are airless, sinking in water. Microscopy reveals diffuse atelectasis and necrosis of alveolar epithelial cells. Many of the dilated terminal bronchioles and alveolar ducts contain fibrinous-based eosinophilic membranes. In newborns who die from RDS in the first hours of life, hyaline membranes are rarely found.

Clinical signs and symptoms. Most often, RDS develops in preterm infants with a gestational age of less than 34 weeks. Risk factors for the development of RDS among newborns born in more late dates and full-term, are diabetes mellitus in the mother, multiple pregnancy, isoserological incompatibility of the blood of the mother and fetus, intrauterine infections, bleeding due to abruption or placenta previa, caesarean section before the onset of labor, asphyxia of the fetus and newborn.

The classic picture of RDS is characterized by the staging of the development of clinical and radiological symptoms, appearing 2-8 hours after birth: a gradual increase in breathing, swelling of the wings of the nose, "trumpeter's breathing", the appearance of a sonorous groaning exhalation, retraction of the sternum, cyanosis, CNS depression. The child groans to lengthen the exhalation, which results in a real improvement in alveolar ventilation. With inadequate treatment, there is a decrease in blood pressure, body temperature, muscle hypotension, cyanosis and pallor of the skin intensify, chest rigidity develops. With the development of irreversible changes in the lungs, general edema and oliguria may appear and increase. On auscultation, weakened breathing and crepitant rales are heard in the lungs. As a rule, signs of cardiovascular insufficiency are observed.

Depending on the morphological and functional maturity of the child and the severity respiratory disorders Clinical signs respiratory disorders can occur in various combinations and have varying degrees of severity. Clinical manifestations of RDS in preterm infants weighing less than 1500 g and gestational age less than 32 weeks have their own characteristics: there is a more prolonged development of symptoms of respiratory failure, a peculiar sequence of symptoms. The earliest signs are diffuse cyanosis against a purple background, then swelling of the chest in the anterior upper sections, later - retraction of the lower intercostal spaces and retraction of the sternum. Violation of the rhythm of breathing is most often manifested in the form of apnea attacks, convulsive and paradoxical breathing is often observed. For children with extremely low body weight, signs such as flaring of the wings of the nose, sonorous exhalation, "trumpeter's breath", severe shortness of breath are uncharacteristic.

Clinical assessment of the severity of respiratory disorders is carried out on the scales Silverman (Silverman) and Downes (Downes). In accordance with the assessment, RDS is subdivided into a mild form of the disease (2-3 points), moderate (4-6 points) and severe (more than 6 points).

An x-ray examination of the chest organs shows a characteristic triad of signs: a diffuse decrease in the transparency of the lung fields, the borders of the heart are not differentiated, an "air" bronchogram.

As complications of RDS, the development of air leakage syndromes from the lungs, such as pneumothorax, pneumomediastinum, pneumopericardium and interstitial pulmonary emphysema, is possible. Chronic diseases, late complications of hyaline membrane disease include bronchopulmonary dysplasia and tracheal stenosis.

Principles of therapy for RDS.A prerequisite The treatment of premature infants with RDS is the creation and maintenance of a protective regimen: reduction of light, sound and tactile effects on the child, local and general anesthesia before performing painful manipulations. Of great importance is the creation of an optimal temperature regime, starting with the provision of primary and resuscitation care in the delivery room. When carrying out resuscitation care for premature babies with a gestational age of less than 28 weeks, it is advisable to additionally use a sterile plastic bag with a slot for the head or a disposable polyethylene-based diaper, which can prevent excessive heat loss. At the end of the complex of primary and resuscitation measures, the child from the delivery room is transferred to the intensive care post, where it is placed in an incubator or under a source of radiant heat.

Antibacterial therapy is prescribed for all children with RDS. Infusion therapy is carried out under the control of diuresis. Children usually have fluid retention in the first 24-48 hours of life, which requires limiting the volume of infusion therapy. Prevention of hypoglycemia is of great importance.

In severe RDS and high oxygen dependence, parenteral nutrition is indicated. As the condition stabilizes on the 2nd-3rd day after the trial introduction of water through the probe, it is necessary to gradually connect enteral nutrition with breast milk or mixtures for premature babies, which reduces the risk of necrotizing enterocolitis.

Respiratory therapy for RDS. Oxygen therapy used in mild forms of RDS with a mask, oxygen tent, nasal catheters.

CPAP- continuous positive airway pressure - constant (i.e. continuously maintained) positive pressure in the airways prevents the alveoli from collapsing and the development of atelectasis. Continuous positive pressure increases functional residual capacity (FRC), reduces airway resistance, improves lung tissue extensibility, promotes stabilization and synthesis of endogenous surfactant. The use of binasal cannulas and variable flow devices (NCPAPs) is preferred.

Prophylactic or early (within the first 30 minutes of life) administration of CPAP is given to all neonates 27–32 weeks gestational age who are spontaneously breathing. In the absence of spontaneous breathing in preterm infants, mask ventilation is recommended; after spontaneous breathing is restored, CPAP is started.

The use of CPAP in the delivery room is contraindicated, despite the presence of spontaneous breathing in children: with choanal atresia or other malformations of the maxillofacial region, diagnosed with pneumothorax, with congenital diaphragmatic hernia, with congenital malformations incompatible with life, with bleeding (pulmonary, gastric, bleeding of the skin), with signs of shock.

Therapeutic use of CPAP. It is indicated in all cases when the child develops the first signs of respiratory disorders and the dependence on oxygen increases. In addition, CPAP is used as a method of respiratory support after extubation of newborns of any gestational age.

mechanical ventilation is the main treatment for severe respiratory failure in newborns with RDS. It should be remembered that mechanical ventilation, even with the most advanced devices, inevitably leads to lung damage. Therefore, the main efforts should be aimed at preventing the development of severe respiratory failure. The introduction of surfactant replacement therapy and the early use of CPAP contribute to a decrease in the proportion of mechanical ventilation in the intensive care of newborns with RDS.

In modern neonatology, a fairly large number of methods and modes of mechanical ventilation are used. In all cases where a child with RDS is not in critical condition, it is best to start with synchronized assisted (triggered) ventilation modes. This will allow the child to actively participate in maintaining the required volume of minute ventilation of the lungs and will help to reduce the duration and frequency of complications of mechanical ventilation. With the inefficiency of traditional IVL, the method of high-frequency IVL is used. The choice of a specific mode depends on the severity of the patient's respiratory efforts, the experience of the doctor and the capabilities of the ventilator used.

A necessary condition for the effective and safe conduct of mechanical ventilation is monitoring of the vital functions of the child's body, blood gas composition and respiratory parameters.

Surfactant replacement therapy. Surfactant replacement therapy is a pathogenetic treatment for RDS. This therapy is aimed at replenishing the deficiency of surfactant, and its effectiveness has been proven in numerous randomized controlled trials. It makes it possible to avoid high pressures and oxygen concentrations during mechanical ventilation, which contributes to a significant reduction in the risk of barotrauma and the toxic effect of oxygen on the lungs, reduces the incidence of bronchopulmonary dysplasia, and increases the survival rate of preterm infants.

Of the surfactants registered in our country, curosurf, a natural surfactant of pig origin, is the drug of choice. Produced as a suspension in vials of 1.5 ml with a concentration of phospholipids 80 mg/ml. The drug is injected in a stream or slowly in a stream into the endotracheal tube (the latter is possible only if special double-lumen endotracheal tubes are used). Curosurf must be warmed to 35-37ºC before use. Jet administration of the drug promotes a homogeneous distribution of surfactant in the lungs and provides an optimal clinical effect. Exogenous surfactants are prescribed for both prevention and treatment of neonatal respiratory distress syndrome.

Preventive the use of a surfactant is considered before the development of clinical symptoms of respiratory distress syndrome in newborns with the highest risk of developing RDS: gestational age less than 27 weeks, no course of antenatal steroid therapy in premature infants born at 27-29 weeks of gestation. The recommended dose of curosurf for prophylactic administration is 100-200 mg/kg.

Early therapeutic use called the use of surfactant in children at risk for RDS due to an increase in respiratory failure.

In premature infants with regular spontaneous breathing against the background of early application It is advisable to administer CPAP surfactant only with an increase in clinical signs of RDS. For children born at a gestational age of less than 32 weeks and requiring tracheal intubation for mechanical ventilation in the delivery room due to the inefficiency of spontaneous breathing, the introduction of a surfactant is indicated within the next 15-20 minutes after birth. The recommended dose of Curosurf for early therapeutic administration is at least 180 mg/kg (optimally 200 mg/kg).

Delayed therapeutic use of surfactants. If a newborn has not been given surfactant for prophylactic or early therapeutic purposes, then after transferring a child with RDS to a ventilator, surfactant replacement therapy should be carried out as soon as possible. The effectiveness of late therapeutic use of surfactant is significantly lower than preventive and early therapeutic use. In the absence or insufficient effect of the introduction of the first dose, the surfactant is re-administered. Usually, the surfactant is re-administered 6-12 hours after the previous dose.

The appointment of a surfactant for therapeutic treatment is contraindicated in pulmonary hemorrhage, pulmonary edema, hypothermia, decompensated acidosis, arterial hypotension and shock. Before administering a surfactant, the patient must be stabilized. In case of complications of RDS with pulmonary bleeding, surfactant can be used no earlier than 6-8 hours after bleeding has stopped.

Prevention of RDS. The use of the following measures can improve survival among newborns at risk of developing RDS:

1. Antenatal ultrasound diagnostics for more accurate determination of gestational age and assessment of the condition of the fetus.

2. Continuous fetal monitoring for confirmation satisfactory condition fetus during childbirth or detection of fetal distress, followed by a change in the tactics of childbirth.

3. Assessment of the maturity of the lungs of the fetus before delivery - the ratio of lecithin / sphingomyelin, the content of phosphatidylglycerol in the amniotic fluid.

4. Prevention of preterm labor using tocolytics.

5. Antenatal corticosteroid therapy (ACT).

Corticosteroids stimulate the processes of cellular differentiation of numerous cells, including type II alveolocytes, increase the production of surfactant and the elasticity of the lung tissue, and reduce the release of proteins from the pulmonary vessels into the air space. Antenatal administration of corticosteroids to women at risk of preterm birth at 28–34 weeks significantly reduces the incidence of RDS, neonatal death, and intraventricular hemorrhage (IVH).

The appointment of corticosteroid therapy is indicated for the following conditions:

- premature rupture of amniotic fluid;

- clinical signs of the onset of preterm labor (regular labor activity, a sharp shortening / smoothing of the cervix, opening up to 3-4 cm);

- bleeding during pregnancy;

- complications during pregnancy (including preeclampsia, intrauterine growth retardation, placenta previa), in which early termination of pregnancy is performed on a planned or emergency basis.

Maternal diabetes mellitus, preeclampsia, prophylactically treated chorioamnionitis, treated tuberculosis are not contraindications to ACT. In these cases, a correspondingly tight control of glycemia is carried out, monitoring blood pressure. Corticosteroid therapy is prescribed under the guise of antidiabetic drugs, antihypertensive or antibiotic therapy.

Corticosteroid therapy is contraindicated in systemic infectious diseases (tuberculosis). Precautions should be taken if chorioamnionitis is suspected (therapy is carried out under the cover of antibiotics).

The optimal interval between corticosteroid therapy and delivery is 24 hours to 7 days from the start of therapy.

Drugs used to prevent RDS:

Betamethasone- 2 doses of 12 mg intramuscularly after 24 hours.

Dexamethasone- 6 mg intramuscularly every 12 hours for 2 days. Since in our country the drug dexamethasone is distributed in ampoules of 4 mg, it is recommended to administer it intramuscularly at 4 mg 3 times a day for 2 days.

With the threat of preterm birth, antenatal administration of betamethasone is preferable. Studies have shown that it stimulates lung maturation faster, helps to reduce the incidence of IVH and periventricular leukomalacia in premature babies with a gestational age of more than 28 weeks, leading to a significant decrease in perinatal morbidity and mortality.

Doses of corticosteroids in multiple pregnancies do not increase.

A second course of ACT is carried out no earlier than 7 days after the decision of the council.

Respiratory distress syndrome (RDS) continues to be one of the most frequent and severe diseases of the early neonatal period in preterm infants. Antenatal prophylaxis and adequate therapy for RDS can reduce mortality and reduce the incidence of complications in this disease.

O.A. Stepanova

Kazan State Medical Academy

Stepanova Olga Alexandrovna — Candidate of Medical Sciences, Associate Professor of the Department of Pediatrics and Neonatology

Literature:

1. Grebennikov V.A., Milenin O.B., Ryumina I.I. Respiratory distress syndrome in newborns. - M., 1995. - 136 p.

2. Prematurity: Per. from English. / ed. V.Kh.Yu. Victor, E.K. Wood - M.: Medicine, 1995. - 368 p.

3. Neonatology: National Guide / ed. N.N. Volodin. — M.: GEOTAR-Media, 2007. — 848 p.

4. Neonatology: Per. from English. / ed. T.L. Gomella, M.D. Cunnigam. - M., 1995. - 640 p.

5. Perinatal audit in preterm birth / V.I. Kulakov, E.M. Vikhlyaeva, E.N. Baibarina, Z.S. Khodzhaeva and others // Moscow, 2005. - 224 p.

6. Principles of management of newborns with respiratory distress syndrome / Guidelines, ed. N.N. Volodin. - M., 2009. - 32 p.

7. Shabalov N.P. Neonatology. - In 2 volumes - M .: MEDpress-inform, 2006.

8. Emmanuilidis G.K., Bailen B.G. Cardiopulmonary distress in newborns / Per. from English. - M., Medicine, 1994. - 400 p.

9. Crowley P., Chalmers I., Keirse M. The effects of corticosteroid administration before preterm delivery: an overview of the evidence from controlled trials // BJOG. - 1990. - Vol. 97. - P. 11-25.

10. Yost C.C., Soll R.F. Early versus delate selective surfactant treatment for neonatal respiratory distress syndrome // Cochrane Library issue 4, 2004.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014

Neonatal respiratory distress syndrome (P22.0)

Neonatology, Pediatrics

general information

Short description

Approved by the Expert Commission

For Health Development

Ministry of Health of the Republic of Kazakhstan

Respiratory Distress Syndrome (RDS)- this is a state of respiratory failure that develops immediately or after a short period of time after birth and the severity of its manifestations increases during the first two days of life. The development of RDS is due to surfactant deficiency and structural immaturity of the lungs, which are observed mainly, but not only, in preterm infants.

INTRODUCTION

Protocol name: Respiratory distress syndrome in the newborn.

Protocol code

ICD-10 code:

P22.0 Neonatal respiratory distress syndrome

Abbreviations used in the protocol:

BPD - bronchopulmonary dysplasia

congenital heart disease

IVH - intraventricular hemorrhage

FiO2 - concentration of supplied oxygen

MV - mechanical ventilation

NIPPV - nasal intermittent positive pressure ventilation

KLA - complete blood count

PDA - open ductus arteriosus

RDS − Respiratory Distress Syndrome

ROP - retinopathy of prematurity

See H2O - centimeters of water column

CRP - C-reactive protein

CPAP - continuous positive airway pressure

SUV - Air Leak Syndrome

TTN - transient tachypnea of ​​the newborn

TBI is a severe bacterial infection

RR - respiratory rate

HR - heart rate

EchoCG - echocardiography

Protocol development date: year 2013

Protocol Users: neonatologists of obstetric organizations.

Classification

Clinical classification: absent, since with modern tactics of early therapy, clinical symptoms do not reach the classical definition of RDS.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic diagnostic measures

A. Risk factors: gestational age less than 34 weeks, maternal diabetes or gestational mellitus, caesarean section, maternal bleeding during pregnancy, perinatal asphyxia, male, second (or each subsequent) in multiple pregnancies.

B. Clinical manifestations:

RDS is clinically manifested by early respiratory disorders in the form of cyanosis, groaning breathing, retraction of compliant chest areas and tachypnea. In the absence of therapy, death may occur due to progressive hypoxia and respiratory failure. In the presence of adequate therapy, regression of symptoms begins after 2-4 days. .

Additional diagnostic measures

Radiological signs:

The classic picture of reduced pneumatization of the lungs in the form of "frosted glass" and the presence of air bronchograms.

Diagnostic criteria

A. Laboratory indicators:

Blood gases: PaO2 level less than 50 mm Hg (less than 6.6 kPa).

Blood culture, CRP, KLA to exclude TBI (pneumonia, sepsis).

B. EchoCG: to exclude congenital heart disease, detect PDA, pulmonary hypertension and clarify the direction of blood bypass.

Differential Diagnosis

Differential Diagnosis: TTN, SUV, pneumonia, sepsis.

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Treatment

Purpose of treatment: providing interventions that maximize the number of surviving preterm infants while minimizing potential side effects.

Treatment tactics

1. Stabilization of the condition of the newborn after birth

A. Necessary conditions for adequate stabilization of the newborn:

At the birth of a child at risk for the development of RDS, the most trained employees who have modern knowledge and skills in resuscitation in newborns with extremely low and very low birth weight are called for delivery.

To maintain the optimal air temperature in the delivery room (25-26ºС), additional heaters, sources of radiant heat, open resuscitation systems can be used. To avoid overheating, it is necessary to carry out servo control within 10 minutes (B).

Warming and humidifying the gases used to stabilize the condition can also help maintain normothermia.

To prevent hypothermia in neonates less than 28 weeks' gestational age, place immediately after birth in a plastic bag or use an occlusive wrap with a parallel heater (A).

It has been proven that uncontrolled inspiratory volumes, both too high and too low, can be dangerous for immature lungs of preterm infants. Therefore, the traditional use of a self-expanding bag is recommended to be replaced by a resuscitation system with a T-connector, which provides control of a set constant positive airway pressure (CPAP) with a measured peak inspiratory pressure (PIP) when the tee is closed.

B. Stabilization of the condition of the newborn after birth

Immediately after birth, attach a pulse oximeter to the newborn's right wrist to obtain information on heart rate and saturation targets (B).

Clamping of the umbilical cord in a preterm infant, if condition permits, is recommended to be delayed for 60 seconds, with the infant lower than the mother, to facilitate placento-fetal transfusion (A).

CPAP should be started at birth in all newborns at risk of developing RDS, as well as in all those with gestational

Up to 30 weeks of age, providing an airway pressure of at least 6 cm H2O, through a mask or nasal prongs (A). Short binasal cannulas are preferred because they reduce the need for intubation (A).

Oxygen should only be supplied through an oxygen-air mixer. To start stabilization, an oxygen concentration of 21-30% is appropriate, and an increase or decrease in its concentration is made on the basis of pulse oximeter readings of heart rate and saturation (B).

Normal saturation immediately after birth for a premature baby is 40-60%, rises to 80% by the 5th minute and should reach 85% or more by the 10th minute after birth. Hyperoxia should be avoided during stabilization (B).

Intubation should be performed in neonates who have not responded to non-invasive ventilation (CPAP) (A). All intubated newborns are shown replacement therapy surfactant (A).

Following surfactant administration, a decision should be made to extubate immediately (or early) (INSURE technique: IN-intubation-SUR-surfactant-E-extubation) to non-invasive ventilation (CPAP or nasal intermittent positive pressure ventilation ─ NIPPV), but under the condition stability in relation to other systems of the newborn (B). Nasal intermittent positive pressure ventilation (NIPPV) can be considered as a means to reduce the risk of failed extubation in infants who are not helped by CPAP, but this approach does not provide significant long-term benefits (A).

B. Surfactant Therapy

All neonates with or at high risk of RDS should be given natural surfactant preparations (A).

Early administration of surfactant for life-saving therapeutic purposes should be the standard and is recommended for all neonates with RDS at an early stage of the disease.

Surfactant should be administered directly in the delivery room in cases where the mother has not received antenatal steroids or when intubation is necessary to stabilize the newborn (A), and in preterm infants less than 26 weeks' gestational age when FiO2 is > 0.30, and for newborns with a gestational age of more than 26 weeks, with FiO2 > 0.40 (B).

For the treatment of RDS, poractant alfa at an initial dose of 200 mg/kg is better than 100 mg/kg of the same drug or beractant (A).

A second and sometimes a third dose of surfactant should be given if signs of RDS persist, such as a constant need for oxygen and the need for mechanical ventilation (A).

2. Additional oxygen therapy after stabilization of the newborn

When oxygen therapy is given to preterm infants after initial stabilization, oxygen saturation levels should be maintained between 90-95% (B).

After the introduction of the surfactant, it is necessary to quickly reduce the concentration of the supplied oxygen (FiO2) to prevent a hyperoxic peak (C).

It is extremely important to avoid fluctuations in saturation in the postnatal period (C).

3. Mechanical ventilation (MV) strategy

MV should be used to support newborns with respiratory failure who have failed with nasal CPAP (B).

MV can be delivered through conventional intermittent positive pressure ventilation (IPPV) or high frequency oscillatory ventilation (HFOV). HFOV and traditional IPPV have similar efficiencies, so the ventilation method that is most effective in each department should be used.

The goal of MV is to maintain optimal lung volume after expansion by applying adequate positive end expiratory pressure (PEEP), or constant expansion pressure (CDP), to the HFOV throughout the respiratory cycle.

To determine the optimal PEEP for conventional ventilation, it is necessary to change the PEEP step by step with the assessment of FiO2, CO2 levels and observation of respiratory mechanics.

Target inspiratory volume ventilation should be used as this shortens the duration of ventilation and reduces BPD (A).

Hypocapnia should be avoided as it is associated with an increased risk of bronchopulmonary dysplasia and periventricular leukomalacia.

MV settings should be adjusted more frequently to ensure optimal lung volume.

Termination of CF with extubation and transition to CPAP should be done as early as possible, if it is clinically safe and blood gas concentrations are acceptable (B)

Extubation can be successful with an average air pressure of 6-7 cmH2O on traditional modes and with 8-9 cmH2O of TSPV, even in the most immature children.

4. Exclusion or reduction of the duration of mechanical ventilation of the lungs.

CPAP or NIPPV should be preferred to avoid or shorten the duration of invasive mechanical ventilation (B).

A moderate degree of hypercapnia is tolerated on CF weaning, provided the pH is maintained above 7.22 (B).

To reduce the duration of MV, it is necessary to use conventional ventilation modes with synchronized and set respiratory volume using aggressive weaning from the device (B).

Caffeine should be included in the treatment regimen for neonatal apnea and to facilitate extubation (A), and caffeine may be used for infants with birth weight less than 1250 g who are on CPAP or NIPPV and are likely to require invasive ventilation (B). Caffeine citrate is administered at a saturation dose of 20 mg/kg, then 5-10 mg/kg/day is a maintenance dose.

5. Infection prevention

All newborns with RDS should be started on antibiotic treatment until the possibility of a severe bacterial infection (sepsis, pneumonia) is completely ruled out. The usual regimen includes a combination of penicillin/ampicillin with an aminoglycoside. Each neonatal unit should develop its own protocols for the use of antibiotics based on the analysis of the spectrum of pathogens that cause early sepsis (D).

Antibiotic treatment should be discontinued as soon as possible, once a TBI has been ruled out (C).

In departments with high frequency For invasive fungal infections, fluconazole prophylaxis is recommended in infants with birth weight less than 1000 g or gestational age ≤ 27 weeks starting on day 1 of life at a dose of 3 mg/kg twice a week for 6 weeks (A).

6. Supportive care

In newborns with RDS, the best outcome is provided by optimal maintenance normal temperature body at the level of 36.5-37.5ºС, treatment of open ductus arteriosus(PDA), support for adequate blood pressure and tissue perfusion.

A. Infusion therapy and nutrition

Most preterm infants should be started

Intravenous fluids at 70-80 ml/kg per day, while maintaining high humidity in the incubator (D).

In preterm infants, the volume of infusion and electrolytes should be calculated individually, allowing for 2.4-4% weight loss per day (15% overall) in the first 5 days (D).

Sodium intake should be limited in the first few days of postnatal life and initiated after the onset of diuresis, with close monitoring of fluid balance and electrolyte levels (B).

Parenteral nutrition should be started on day 1 to avoid growth retardation and provide for early administration of proteins starting at 3.5 g/kg/day and lipids at 3.0 g/kg/day to maintain proper caloric intake. This approach improves the survival of preterm infants with RDS (A)

Minimal enteral nutrition should also be started from the first day (B).

B. Maintenance of tissue perfusion

Hemoglobin concentrations must be maintained within the normal range. The estimated cut-off value for hemoglobin concentration in assisted-ventilated neonates is 120 g/l at week 1, 110 g/l at week 2, and 90 g/l after 2 weeks of postnatal life.

If blood pressure cannot be satisfactorily increased by circulating blood volume, dopamine (2–20 µg/kg/min) should be given (B).

If it remains low systemic circulation, or there is a need to treat myocardial dysfunction, dobutamine (5-20 mcg / kg / min) should be used as a first-line drug and epinephrine (adrenaline) as a second-line drug (0.01-1.0 mg / kg / min) .

In cases of refractory hypotension where conventional therapy fails, hydrocortisone (1 mg/kg every 8 hours) should be used.

Echocardiography can help guide decisions about when to start treatment for hypotension and the choice of treatment (B).

B. Treatment of patent ductus arteriosus

If a decision is made about drug treatment PDA, the use of indomethacin and ibuprofen has the same effect (B), however, ibuprofen is associated with a lower rate of side effects from the kidneys.

Neonatal respiratory distress syndrome (RDS)

ICD 10: P22.0

Year of approval (revision frequency): 2016 (review every 3 years)

ID: KR340

Professional associations:

• Russian Association of Perinatal Medicine Specialists
• Russian Society of Neonatologists

Approved

Russian Association of Perinatal Medicine Specialists __ __________201_

Agreed

Russian Society of Neonatologists __ __________201_ Scientific Council of the Ministry of Health of the Russian Federation __ __________201_

Keywords

• respiratory distress syndrome
• respiratory distress syndrome
• prematurity
• surfactant
• artificial lung ventilation (ALV)
• non-invasive artificial lung ventilation
• extended breath

List of abbreviations

BPD - bronchopulmonary dysplasia

IVH - intraventricular hemorrhage

IVL - artificial lung ventilation

Ministry of Health of the Russian Federation - Ministry of Health of the Russian Federation

mg / kg - the amount of the drug in milligrams per kilogram of body weight of the newborn

VLBW - very low body weight

NICU - neonatal intensive care unit

RDS - respiratory distress syndrome

RCT - randomized controlled trial

SDR - respiratory distress syndrome

beats / min - the number of beats per minute

HR - heart rate

ELBW - extremely low body weight

EET - endotracheal tube

CO 2 - partial tension of carbon dioxide

Fi fraction of oxygen in the inhaled gas mixture

Peep - peak pressure at the end of expiration

Pip - peak inspiratory pressure

SpO 2 - saturation, blood oxygen saturation, measured by pulse oximetry

CPAP - continuous positive airway pressure / respiratory therapy method - continuous positive airway pressure

Terms and Definitions

Respiratory distress syndrome or "respiratory distress syndrome" (RDS) newborn - respiratory distress in children in the first days of life, due to primary surfactant deficiency and immaturity of the lungs.

Surfact?nt(translated from English - surfactant) - a mixture of surfactants lining the pulmonary alveoli from the inside (that is, located at the air-liquid border).

SRAP - therapy from the English Continuous Positive Airways Pressure (CPAP) is a method of creating a constant positive pressure in the airways.

The extended breath maneuver- an extended artificial breath, carried out at the end primary activities, in the absence of spontaneous breathing, with irregular breathing or with "gasping" type breathing with a pressure of 20 cm H 2 O for 15-20 seconds, for the effective formation of residual lung capacity in premature babies.

INSURE – Ying tubation- sur factant- uh Cstubation - a method of rapid administration of surfactant on non-invasive respiratory support with short-term tracheal intubation, which reduces the need for invasive ventilation

Minimally invasive administration of surfactant - a method of administering a surfactant to a patient on non-invasive respiratory support without tracheal intubation with an endotracheal tube. The surfactant is administered through a thin catheter inserted into the trachea while the patient is spontaneously breathing under constant positive pressure. It can significantly reduce the need for invasive ventilation.

1. Brief information

1.1 Definition

Respiratory distress syndrome or "respiratory distress syndrome" (RDS) of the newborn is a respiratory disorder in children in the first days of life, due to primary surfactant deficiency and lung immaturity.

RDS is the most common cause of respiratory failure in the early neonatal period in newborns. Its occurrence is higher, the lower the gestational age and body weight of the child at birth.

1.2 Etiology and pathogenesis

The main causes of RDS in newborns are:

• violation of the synthesis and excretion of surfactant by alveolocytes of the 2nd type, associated with functional and structural immaturity of the lung tissue;
• a congenital qualitative defect in the structure of the surfactant, which is an extremely rare cause.

1.3 Epidemiology

1.4 ICD code - 10

P22.0 - Syndrome of respiratory distress in a newborn.

1.5 Classification

1.6 Clinical picture

• Shortness of breath that occurs in the first minutes - the first hours of life;
• Expiratory noises ("groaning breath"), due to the development of compensatory spasm of the glottis on exhalation;
• Retraction of the chest on inspiration (retraction of the xiphoid process of the sternum, epigastric region, intercostal spaces, supraclavicular fossae) with the simultaneous occurrence of tension of the wings of the nose, swelling of the cheeks (breathing "trumpeter");
• Cyanosis when breathing air;
• Weakening of breathing in the lungs, crepitant wheezing on auscultation.
• Increasing need for supplemental oxygenation after birth.

2. Diagnostics

2.1 Complaints and medical history

Risk factors

Predisposing factors for the development of RDS, which can be identified before the birth of a child or in the first minutes of life, are:

• Development of RDS in siblings;
• Gestational diabetes and type 1 diabetes in the mother;
• Hemolytic disease of the fetus;
• Premature placental abruption;
• premature birth;
• Male fetus in preterm birth;
• Caesarean section before the onset of labor;
• Asphyxia of the newborn.

2.2 Physical examination

• It is recommended to evaluate respiratory failure on scales.

Comments:Clinical assessment of the severity of respiratory disorders on the Silverman scale (Silverman) (Appendix G1) is carried out not so much with diagnostic purpose how much to evaluate the effectiveness of ongoing respiratory therapy or as an indication for its initiation. Along with assessing the neonate's need for supplemental oxygenation, it can be a criterion for moving from one level of respiratory support to another.

2.3 Laboratory diagnostics

• It is recommended for all newborns with respiratory disorders in the first hours of life, along with routine blood tests for acid-base status, gas composition and glucose levels, it is also recommended to conduct tests for markers of the infectious process in order to exclude infectious genesis respiratory disorders.
• clinical analysis blood with the calculation of the neutrophil index;
• determination of the level of C-reactive protein in the blood;
• microbiological blood culture (the result is evaluated no earlier than 48 hours later).

Comments : When making a differential diagnosis with severe course early neonatal sepsis in patients requiring strict regimens of invasive mechanical ventilation, with a short-term effect from repeated injections of exogenous surfactant, it is recommended to determine the level of procalcitonin in the blood. Determining the level of C-reactive protein and conducting a clinical blood test should be repeated after 48 hours, if it is difficult to make a diagnosis of RDS on the first day of a child's life. RDS is characterized by negative markers of inflammation and a negative result of a microbiological blood test.

2.4 Instrumental diagnostics

• X-ray examination is recommended for all newborns with respiratory disorders in the first day of life.

Comments : The radiological picture of RDS depends on the severity of the disease - from a slight decrease in pneumatization to "white lungs". Characteristic features are: a diffuse decrease in the transparency of the lung fields, a reticulogranular pattern and stripes of enlightenment in the region of the lung root (air bronchogram). However, these changes are nonspecific and can be detected in early neonatal sepsis, congenital pneumonia.

2.5 Other diagnostics

Differential Diagnosis

• Transient tachypnea of ​​newborns;
• Early neonatal sepsis, congenital pneumonia;
• Meconium aspiration syndrome;
• Air leak syndrome, pneumothorax;
• Persistent pulmonary hypertension of the newborn;
• Aplasia / hypoplasia of the lungs;
• Congenital diaphragmatic hernia.

3. Treatment

3.1 Conservative treatment

3.1.1 Prevention of hypothermia in the delivery room in preterm infants

• Prevention of hypothermia in the delivery room in preterm infants is recommended.

Comments: The main measures to ensure thermal protection are carried out in the first 30 seconds of life as part of the initial activities primary care newborn. The volume of measures to prevent hypothermia differs in premature babies weighing more than 1000 g (gestation period 28 weeks or more) and in children weighing less than 1000 g (gestation period less than 28 weeks).

3.1.2 Delayed clamping and cutting of the umbilical cord and pumping of the umbilical cord

• Delayed clamping and cutting of the umbilical cord is recommended.

Comments: Clamping and cutting the umbilical cord 60 seconds after birth in preterm infants with VLBW and ELBW leads to a significant reduction in the incidence of necrotizing enterocolitis, IVH, sepsis, and a decrease in the need for blood transfusions. The decision to carry out this manipulation is made collectively by obstetrician-gynecologists and neonatologists. In vaginal delivery, the newborn is laid out on the mother's stomach or on a warm diaper next to the mother. With the continued pulsation of the umbilical cord, there is no need for urgent assistance to the mother (decided by obstetricians), it is carried out. delayed clamping of the umbilical cord while maintaining the thermal chain. When delivering by Caesarean section, the first decision is made by obstetrician-gynecologists who assess the condition of the woman, the situation in the surgical wound, the presence or absence of bleeding. In the absence of a need to provide emergency assistance mother, the remaining pulsation of the umbilical cord, the child is placed in a specially heated sterile diaper at the woman's legs and covered with it to prevent excessive heat loss. The time of birth in this situation is the complete separation of the child from the mother, regardless of the time of crossing the umbilical cord, therefore, the Apgar timer is turned on immediately after the child is removed from the uterine cavity during caesarean section or from the birth canal during vaginal delivery. An alternative to delayed cord clamping and cutting may be cord pumping when delayed clamping is not possible for the mother or baby.

3.1.3 Non-invasive respiratory therapy in the delivery room

• It is recommended to start non-invasive respiratory therapy in the delivery room.

Comments: Premature, born at a gestational age of 32 weeks or less with spontaneous breathing, including in the presence of respiratory disorders, is considered preferable starting therapy with the CPAP method with a pressure of 6-8 cm H2O. Preterm infants born more than 32 weeks' gestation should be given CPAP if respiratory problems are present.

Extended breaths can only be used when there is no breathing or "gasping" breathing or when breathing is irregular. If a child cries from birth or breathes regularly, then even if there are respiratory disorders, an extended breath should not be carried out. A prerequisite for performing the “extended inspiration” maneuver is the registration of heart rate (HR) and SpO2 by pulse oximetry, which allows you to evaluate the effectiveness of the maneuver and predict further actions.

Further traditional tactics, described in the methodological letter of the Russian Ministry of Health, provide for the start of artificial lung ventilation (ALV) with a mask if the child does not breathe spontaneously and / or with persistent bradycardia, followed by a transition to CPAP when breathing / heart rate is restored or to intubation in the absence of breathing and / or persistent bradycardia. At the same time, at the end of the prolonged inspiration, a sequence of actions other than in the methodical letter may be recommended, presented in Appendix B. (patient management algorithm)

CPAP in the delivery room can be performed by a ventilator with the CPAP function, a manual ventilator with a T-connector, various CPAP systems. The CPAP technique can be performed using a face mask, nasopharyngeal tube, endotracheal tube (used as a nasopharyngeal), binasal cannulas. At the stage of the delivery room, the CPAP method is not essential.

The use of CPAP in the delivery room is contraindicated in children with: choanal atresia or other congenital malformations of the maxillofacial region that prevent the correct application of nasal cannulas, masks, nasopharyngeal tubes; diagnosed with pneumothorax; with congenital diaphragmatic hernia; with congenital malformations incompatible with life (anencephaly, etc.); with bleeding (pulmonary, gastric, bleeding of the skin).

3.1.4 Invasive respiratory therapy in the delivery room.

• Tracheal intubation and mechanical ventilation are recommended if CPAP and mechanical ventilation with a mask are ineffective.

Comments: Artificial ventilation of the lungs in preterm infants is carried out with bradycardia persisting against the background of CPAP and / or with a prolonged (more than 5 minutes) absence of spontaneous breathing. The necessary conditions for effective mechanical ventilation in very preterm infants are: control of airway pressure; mandatory maintenance Reer + 5-6 cm H 2 O; possibility of smooth adjustment of oxygen concentration from 21 to 100%; continuous monitoring of heart rate and SpO 2 .

Starting parameters of IVL: Pip - 20-22 cm H 2 O, Peep - 5 cm H 2 O, frequency 40-60 breaths per minute. The main indicator of the effectiveness of mechanical ventilation is the increase in heart rate>100 beats/min.

Conducting invasive mechanical ventilation in the delivery room under tidal volume control in very preterm patients is a promising technology to minimize mechanical ventilation - associated lung damage. Verification of the position of the endotracheal tube by auscultation in children with extremely low body weight may present certain difficulties due to the low intensity of respiratory sounds and their significant irradiation. The use of devices for indicating CO2 in exhaled air allows faster and more reliable than other methods to confirm the correct position of the endotracheal tube.

3.1.5 Oxygen therapy and pulse oximetry

• It is recommended to monitor heart rate and SpO2 in the delivery room when providing primary and resuscitation care to premature newborns using pulse oximetry.

Comments: Registration of heart rate and SpO2 by pulse oximetry begins from the first minute of life. The pulse oximetry sensor is installed in the area of ​​the wrist or forearm of the child's right hand (“preductally”) during initial activities. Pulse oximetry in the delivery room has 3 main application points: continuous monitoring of heart rate, starting from the first minutes of life; prevention of hyperoxia (SpO2 not more than 95% at any stage of resuscitation, if the child receives additional oxygen) prevention of hypoxia (SpO2 not less than 80% by 5 minutes of life and not less than 85% by 10 minutes of life). Starting respiratory therapy in children born at a gestational age of 28 weeks or less should be carried out with FiO2 = 0.3. Respiratory therapy in children of greater gestational age is carried out with air.

Starting from the end of the 1st minute of life, one should be guided by the indicators of the pulse oximeter (see Appendix D2) and follow the algorithm for changing the oxygen concentration described below. If the indicators determined in the child are outside the specified values, it is necessary to change (increase/decrease) the concentration of additional O2 in steps of 10-20% every subsequent minute until the target indicators are reached. The exception is children who require indirect heart massage against the background of mechanical ventilation. In these cases, simultaneously with the beginning of chest compressions, the concentration of O2 should be increased to 100%.

In the course of further treatment of preterm infants receiving additional oxygenation, the SpO2 level should be maintained within the range of 90-94%.

3.1.6 Surfactant therapy.

• It is recommended to administer a surfactant according to indications, regardless of birth weight, to preterm infants with RDS.

Comments: Prophylactically, in the first 20 minutes of life, to all children born at a gestational age of 26 weeks or less in the absence of a full course of antenatal prophylaxis with steroids for their mothers. All children of gestational age? 30 weeks who required tracheal intubation in the delivery room. The most effective time of administration is the first 20 minutes of life.

Premature infants > 30 weeks of gestational age who require tracheal intubation in the delivery room and remain dependent on FiO2 > 0.3-04. The most effective time of administration is the first two hours of life.

Premature babies on initial respiratory therapy using the CPAP method in the delivery room with a need for FiO2? 0.5 or more to achieve SpO2 = 85% by 10 minutes of life and the absence of regression of respiratory disorders, as well as improved oxygenation in the next 10-15 minutes.

By 20-25 minutes of life, a decision should be made on the introduction of a surfactant or on preparation for transporting the child to the NICU for CPAP.

Babies born at ≥28 weeks' gestation on initial CPAP therapy, if indicated in the delivery room, may be given a minimally invasive surfactant. For children of older gestational age on initial CPAP therapy, if indicated in the delivery room, surfactant may be administered. be introduced by the traditional method.

In the intensive care unit for children born at term? 35 weeks, on respiratory therapy using CPAP / non-invasive ventilation with a score on the Silverman scale > 3 points on the first day of life and / or FiO2 requirement up to 0.35 in patients<1000 г и до 0,4 у детей >1000 g of surfactant can be administered either by the minimally invasive method or by the INSURE method.

Re-introduction of surfactant is recommended: for children ≥35 weeks of gestational age on CPAP who have already received the first dose of surfactant, when they are transferred to mechanical ventilation due to an increase in respiratory disorders (FiO2 up to 0.3 in patients<1000г и до 0,4 у детей >1000g) on ​​the first day of life; ventilated children ≥35 weeks of gestational age who have already received the first dose of surfactant, with tightening of ventilation parameters: MAP up to 7 cm H 2 O and FiO2 up to 0.3 in patients<1000 г и до 0,4 у детей >1000g in the first day of life. Re-introduction is recommended only after a chest x-ray. A third administration may be indicated for mechanically ventilated children with severe RDS. The intervals between injections are 6 hours. However, the interval may be reduced with an increase in children's need for FiO2 up to 0.4. The surfactant can be reintroduced either by the minimally invasive method or by the INSURE method.

Currently, the Pharmaceutical Committee of the Russian Federation is approved for use on the territory of our country the following drugs natural surfactants: Poractant alfa, Bovaktant, Beraktant, Surfactant BL. According to the literature, surfactant preparations are not uniform in their effectiveness. The most effective is alfa poractant at a starting dosage of 200 mg/kg. This dosage of poractant alfa is more effective than 100 mg/kg and results in best results treatment of preterm infants with RDS compared with beractant and bovaktant. There are no large randomized comparative studies in the literature on the effectiveness of Surfactant-BL. Surfactant may be used in the treatment of congenital pneumonia in preterm infants

3.1.7 Non-invasive respiratory therapy in the NICU

• Non-invasive respiratory therapy in combination with surfactant therapy, as indicated, is recommended in preterm infants with respiratory problems.

Comments: Non-invasive respiratory therapy includes CPAP, various types of non-invasive ventilation through nasal cannulas or a mask, high-flow cannulas. Non-invasive ventilation via nasal cannulas or nasal mask is currently used as the optimal initial method of non-invasive respiratory support, especially after the introduction of a surfactant and / or after extubation. The use of non-invasive mechanical ventilation after extubation in comparison with CPAP, as well as after the introduction of a surfactant, leads to a lower need for reintubation, a lower incidence of apnea.

Indications: As a starting respiratory therapy after prophylactic minimally invasive administration of surfactant without intubation; as respiratory therapy in preterm infants after extubation (including after using the INSURE method); the occurrence of apnea resistant to CPAP therapy and caffeine; an increase in respiratory disorders up to 3 or more points on the Silverman scale and / or an increase in the need for Fio2 > 0.4 in preterm infants on CPAP.

Contraindications: Shock, convulsions, pulmonary hemorrhage, air leak syndrome, Starting parameters for open circuit devices (variable flow systems): Pip 8-10 cmH2O; Peep 5-6 cm H2O; Frequency 20-30 per minute; Inspiratory time 0.7-1.0 second;

Starting parameters for devices with a semi-closed circuit (constant flow systems): Pip 12-18 cmH2O; Peep 5 cm H2O; Frequency 40-60 per minute; Inspiratory time 0.3-0.5 seconds;

Decrease in parameters: When using non-invasive ventilation for the treatment of apnea, the frequency of artificial breaths is reduced. When using non-invasive ventilation to correct respiratory disorders, Pip is reduced.

In both cases, a transfer from non-invasive ventilation to CPAP is carried out with a further transfer to breathing without respiratory support.

Indications for transferring from non-invasive ventilation to conventional ventilation:

PaCO2 > 60 mmHg

FiO2 ? 0.4

Silverman score 3 or more points.

Apnea recurring more than 4 times within an hour.

Air leak syndrome, convulsions, shock, pulmonary hemorrhage.

In the absence of a non-invasive ventilator in the hospital as a starting method of non-invasive respiratory? support, the method of spontaneous breathing under constant positive airway pressure through nasal cannulas is preferred. In very preterm infants, the use of variable-flow CPAP devices has some advantage over constant-flow systems in providing the least work of breathing in these patients. CPAP cannulas should be as wide and short as possible.

Indications in neonates with RDS for spontaneous breathing support with nasal CPAP:

Prophylactically in the delivery room for premature babies with a gestational age of 32 weeks or less.

A Silverman score greater than 3 in children of gestational age over 32 weeks with spontaneous breathing.

Contraindications include:

Shock, convulsions, pulmonary hemorrhage, air leak syndrome.

Starting parameters СРАР: 5-6 cm. H2O, FiO2 0.21-0.3. An increase in the need for FiO2 over 0.3 in children less than 1000 g and more than 0.35-0.4 in children over 1000 g on the first day of life is an indication for the introduction of surfactant by the INSURE method or a minimally invasive method. Cancellation of CPAP is carried out with a decrease in airway pressure to 2 cmH2O or less and there is no need for additional oxygenation.

The use of high-flow cannulas may be recommended as an alternative to CPAP in some children who are weaned from respiratory therapy A flow of 4-8L/minute is used.

3.1.8 Mechanical ventilation in preterm infants with RDS

• It is recommended to perform mechanical ventilation through an endotracheal tube in those patients in whom other methods of respiratory support have been ineffective.

Comments: Indications for transfer to artificial ventilation in children with RDS are the ineffectiveness of non-invasive methods of respiratory support, as well as severe concomitant conditions: shock, convulsive status, pulmonary hemorrhage. The duration of mechanical ventilation in children with RDS should be minimal. If possible, ventilation should be performed with tidal volume control, which reduces its duration and minimizes the incidence of complications such as BPD and IVH.

Hypocarbia and severe hypercarbia should be avoided as factors contributing to brain damage. When weaning from the respirator, moderate hypercarbia is acceptable while maintaining the pH level of the arterial blood above 7.22. Caffeine should be used when weaning from ventilators. Caffeine should be given from birth to all children weighing less than 1500 g requiring respiratory therapy as a proven means of reducing the incidence of BPD

A short course of low-dose dexamethasone may be given for faster weaning from ventilators if the patient continues to need ventilators after 1–2 weeks of age

The technique of IVL in newborns is described in the relevant medical manuals. A prerequisite for the successful use of this type of respiratory therapy in newborns is the ability to regularly monitor the gas composition of the blood. Routine sedation and analgesia is not recommended for all ventilated children

The need for additional oxygenation up to 45-50%, as well as high pressure by the end of inspiration up to 25 cm H2O and higher in premature newborns is an indication for transferring to high-frequency oscillatory (HFO) mechanical ventilation.

With VFO IVL, due to the stabilization of the volume of the alveoli, there is a decrease in atelectasis, an increase in the area of ​​gas exchange and an improvement in pulmonary blood flow. As a result of properly conducted therapy, a decrease in the ventilation-perfusion ratio, a decrease in intrapulmonary shunting, a reduction in exposure high concentration oxygen. At the same time, the respiratory volume decreases, the overdistension of the lungs decreases, and the risk of baro- and volutrauma decreases.

3.1.9 Antibacterial therapy

• Antibacterial therapy is not recommended for newborns with RDS.

Comments: During the differential diagnosis RDS with congenital pneumonia or with early neonatal sepsis, carried out in the first 48-72 hours of life, it is advisable to prescribe antibiotic therapy with its subsequent rapid withdrawal in case of negative markers of inflammation and a negative result of microbiological blood tests. The appointment of antibiotic therapy for the period of differential diagnosis can be indicated for children weighing less than 1500 g, children on invasive mechanical ventilation, as well as children in whom the results of inflammation markers obtained in the first hours of life are doubtful. The drugs of choice may be a combination of penicillin antibiotics and aminoglycosides, or a single broad-spectrum antibiotic from the group of protected penicillins.

• It is not recommended to prescribe amoxicillin + clavulonic acid due to the possible adverse effects of clavulonic acid on the intestinal wall in preterm infants.

3.2 Surgical treatment

Surgical treatment does not exist.

4. Rehabilitation

5. Prevention and follow-up

• If there is a threat of preterm birth, it is recommended that pregnant women be transported to obstetric hospitals of II-III levels, where there are intensive care units for newborns. If there is a threat of premature birth at 32 weeks of gestation or less, transportation of pregnant women to a level III hospital (perinatal center) is recommended.

Comments:In areas where perinatal centers are located at a remote distance, and the transportation of women to level III institutions is difficult, it is recommended to organize in a timely manner the conditions for nursing premature newborns in those medical institutions where preterm births occur.

• Pregnant women at 23-34 weeks' gestation with threatened preterm labor are advised to take a course of corticosteroids to prevent RDS prematurity and reduce the risk of possible adverse complications such as IVH and NEC.

• Two alternative regimens for prenatal prevention of RDS are recommended:
• Betamethasone - 12 mg intramuscularly every 24 hours, only 2 doses per course;
• Dexamethasone - 6 mg intramuscularly every 12 hours, a total of 4 doses per course.

Comments:The maximum effect of therapy develops 24 hours after the start of therapy and lasts a week. By the end of the second week, the effect of steroid therapy is significantly reduced.

• A second course of prevention of RDS is recommended only 2-3 weeks after the first in case of recurrence of the threat of preterm birth at a gestational age of less than 33 weeks.

• It is recommended that corticosteroid therapy be prescribed to women with a gestational age of 35-36 weeks in the event of a planned caesarean section in the absence of labor in the woman.

Comments: Prescribing a course of corticosteroid hormones (betamethasone, dexamethasone) to women in this category does not affect outcomes in newborns, however, it reduces the risk of developing respiratory disorders in children and, as a result, admission to the neonatal intensive care unit.

• With the threat of preterm labor in the early stages, a short course of tocolytics is recommended to delay the onset of labor in order to transport pregnant women to a perinatal center, as well as to complete the full course of antenatal prevention of RDS with corticosteroids and the onset of a full therapeutic effect.

• Antibacterial therapy is recommended for women with premature rupture of the membranes (premature rupture of amniotic fluid), as it reduces the risk of preterm birth.

Criteria for assessing the quality of medical care

Group name: RDS

ICD codes: R 22.0

Type of medical care: specialized, including high-tech

Age group: children

Conditions for the provision of medical care: stationary

Form of medical assistance: emergency

Quality Criteria

Level of Evidence

The severity of respiratory disorders was assessed according to the Silverman scale

Pulse oximetry was performed with monitoring of heart rate no later than 1 minute from the moment of detection of respiratory disorders

Subsidized air-oxygen mixture and/or non-invasive artificial ventilation of the lungs and/or mechanical ventilation of the lungs (depending on medical indications)

Monitored vital functions (respiration, blood oxygen saturation, pulse, blood pressure)

Poractant alfa was administered (if there are indications and there are no medical contraindications)

A study of the acid-base state of the blood (pH, PaCO 2 , PaO 2 , BE, lactate) was performed no later than 3 hours from the moment of detection of respiratory disorders

A general (clinical) blood test, CRP and microbiological blood tests were performed no later than 24 hours from the moment respiratory disorders were detected

A chest X-ray was taken no later than 24 hours after the detection of respiratory disorders

Bibliography

1. McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S: Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Syst Rev 2010:CD004210.

2. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists: Committee Opinion No. 543. Timing of umbilical cord clamping after birth. Obstet Gynecol 2012; 120: 1522–1526.

3. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T: Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 2012:CD003248.

4. Lista G, Castoldi F, Cavigioli F, Bianchi S, Fontana P: Alveolar recruitment in the delivery room. J Matern Fetal Neonatal Med 2012; (suppl 1): 39–40.

5. Methodological letter of the Ministry of Health of Russia “Primary and resuscitation care newborn children” dated April 21, 2010 N 15-4/10/2-3204.

6. Soll R, Ozek E: Prophylactic protein free synthetic surfactant for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2010:CD001079.

7. Verlato G, Cogo PE, Benetti E, Gomirato S, Gucciardi A, Carnielli VP: Kinetics of surface-tant in respiratory diseases of the newborn infant. J Matern Fetal Neonatal Med 2004; 16(suppl 2):21–24.

8. Cogo PE, Facco M, Simonato M, Verlato G, Rondina C, Baritussio A, Toffolo GM, Carnielli VP: Dosing of porcine surfactant: effect on kinetics and gas exchange in respiratory distress syndrome. Pediatrics 2009; 124: e950–957.

9. Singh N, Halliday HL, Stevens TP, Suresh G, Soll R, Rojas-Reyes MX Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants Cochrane Database Syst Rev. 2015 Dec 21;(12):CD010249 .

10. Speer CP, Gefeller O, Groneck P, Laufkötter E, Roll C, Hanssler L, Harms K, Herting E, Boenisch H, Windeler J, et al: Randomised clinical trial of two treatment regimens of natural surfactant preparations in neonatal distress respiratory syndrome. Arch Dis Child Fetal Neonatal Ed 1995; 72:F8-F13.

11. Sandri F, Plavka R, Ancora G, Simeoni U, Stranak Z, Martinelli S, Mosca F, Nona J, Thomson M, Verder H, Fabbri L, Halliday HL, CURPAP Study Group: Prophylactic or early selective surfactant combined with nCPAP in very preterm infants. Pediatrics 2010;125:e1402-e1409.

12. Rojas-Reyes MX, Morley CJ, Soll R: Prophylactic versus selective use of surfactant in pre-venting morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2012:CD000510.

13. Rich W, Finer NN, Gantz MG, Newman NS, Hensman AM, Hale EC, Auten KJ, Schibler K, Faix RG, Laptook AR, Yoder BA, Das A, Shankaran S, SUPPORT and Generic Database Subcommittees of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network: Enrollment of extremely low birth weight infants in a clinical research study may not be representative. Pediatrics 2012;129: 480–484.

14. Prof Wolfgang Göpel, Angela Kribs, Andreas Ziegler Reinhard Laux, Thomas Hoehn Christian Wieg, Jens Siegel, Stefan Avenarius, Axel von der Wense, Matthias Vochem, MDb MDa, Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomized, controlled trial. THE LANCET Volume 378, Issue 9803, 5–11 November 2011, Pages 1627–1634.

15. Egbert Herting Less Invasive Surfactant Administration (LISA) - Ways to deliver surfactant in spontaneously breathing infants. Early Human Development Volume 89, Issue 11, November 2013, Pages 875–880.

16. Stevens TP, Harrington EW, Blennow M, Soll RF: Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2007:CD003063.

17. Rautava L, Eskelinen J, Häkkinen U, Lehtonen L, PERFECT Preterm Infant Study Group: 5-year morbidity among very preterm infants in relation to level of hospital care. Arch Pediatr Adolesc Med 2013; 167:40–46.

18. Roberts D, Dalziel S: Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2006:CD004454.

19 Sotiriadis A, Makrydimas G, PapatheodorouS, Ioannidis JP: Corticosteroids for preventing neonatal respiratory morbidity after elective caesarean section at term. Cochrane Database Syst Rev 2009:CD006614.

20. Kenyon S, Boulvain M, Neilson JP: Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev 2010:CD001058.

21 Neetu Singh, Kristy L. Hawley and Kristin Viswanathan Efficacy of Porcine Versus Bovine Surfactants for Preterm Newborns With Respiratory Distress Syndrome: Systematic Review and Meta-analysis Pediatrics 2011;128;e1588

22 Tan K, Lai NM, Sharma A: Surfactant for bacterial pneumonia in late preterm and term infants. Cochrane Database Syst Rev 2012; 2:CD008155

23 Bancalari E, Claure N: The evidence for noninvasive ventilation in the preterm infant. Arch Dis Child Fetal Neonatal Ed 2013; 98:F98-F102.

24. De Paoli AG, Davis PG, Faber B, Morley CJ: Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev 2002; 3:CD002977.

25. Reynolds P, Leontiadi S, Lawson T, Otunla T, Ejiwumi O, Holland N: Stabilization of premature infants in the delivery room with nasal high flow. Arch Dis Child Fetal Neonatal Ed 2016; 101:F284-F287.

26. Wilkinson D, Andersen C, O'Donnell CP, de Paoli AG, Manley BJ: High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 2016; 2: CD006405.

27. Erickson SJ, Grauaug A, Gurrin L, Swaminathan M: Hypocarbia in the ventilated preterm infant and its effect on intraventricular haemorrhage and bronchopulmonary dysplasia. J Paediatr Child Health 2002; 38:560–562.

28. Ambalavanan N, Carlo WA, Wrage LA, Das A, Laughon M, Cotten CM, et al; SUPPORT Study Group of the NICHD Neonatal Research Network: Pa CO 2 in surfactant, positive pressure, and oxygenation randomized trial (SUPPORT). Arch Dis Child Fetal Neonatal Ed 2015; 100:F145–F149

29. Woodgate PG, Davies MW: Permissive hypercapnia for the prevention of morbidity and mortality in mechanically ventilated newborn infants. Cochrane Database Syst Rev 2001; 2:CD002061

30. Dobson NR, Patel RM, Smith PB, KuehnDR, Clark J, Vyas-Read S, et al: Trends incaffeine use and association between clinical outcomes and timing of therapy in very low birth weight infants. J Pediatr 2014; 164:992–998.

31. Taha D, Kirkby S, Nawab U, Dysart KC, Genen L, Greenspan JS, Aghai ZH: Early caffeine therapy for prevention of bronchopulmonary dysplasia in preterm infants. J Matern Fetal Neonatal Med 2014; 27:1698–1702.

32. Lodha A, Seshia M, McMillan DD, Barrington K, Yang J, Lee SK, Shah PS; Canadian Neonatal Network: Association of early caffeine administration and neonatal outcomes in very preterm neonates. JAMA Pediatr 2015; 169:33–38.

33. Jefferies AL: Postnatal corticosteroids to treat or prevent chronic lung disease in preterm infants. Pediatric Child Health 2012; 17:573–574

34. Bell? R, de Waal K, Zanini R: Opioids for neonates receiving mechanical ventilation: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2010; 95:F241-F251.

Annex A1. Composition of the working group

Averin Andrey Petrovich- senior resident of the intensive care unit for newborns and premature babies, MBUZ "City Clinical Hospital No. 8", Chelyabinsk

Antonov Albert Grigorievich– Doctor of Medical Sciences, Professor, Honored Scientist, Chief Researcher of the Department of Resuscitation and Intensive Care of the Department of Neonatology and Pediatrics of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Professor of the Department Neonatology M.I. Sechenov of the Ministry of Health of the Russian Federation, Moscow

Baibarina Elena Nikolaevna- Doctor of Medical Sciences, Professor, Chief Researcher of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Moscow

Grebennikov Vladimir Alekseevich- Doctor of Medical Sciences, Professor, Professor of the Department of Pediatric Anesthesiology and Intensive Care of the State Educational Institution of Higher Education N.I. Pirogov, Moscow

Degtyarev Dmitry Nikolaevich- Doctor of Medical Sciences, Professor, Deputy Director of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Head of the Department of Neonatology of the Federal State Budgetary Educational Institution of Higher Education PMSMU named after V.I. M.I. Sechenov of the Ministry of Health of the Russian Federation, Moscow

Degtyareva Marina Vasilievna- Doctor of Medical Sciences, Professor, Head of the Department of Neonatology, FDPO Russian National Research Medical University. N.I. Pirogov of the Ministry of Health of the Russian Federation, Moscow

Ivanov Dmitry Olegovich- Doctor of Medical Sciences, Chief Neonatologist of the Ministry of Health of the Russian Federation, Acting Rector of St. Petersburg State Pediatric Medical University, St. Petersburg

Ionov Oleg Vadimovich- Candidate of Medical Sciences, Head of the Department of Resuscitation and Intensive Care of the Department of Neonatology and Pediatrics of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Associate Professor of the Department of Neonatology of the FSBEI HE PMSMU named after. THEM. Sechenov of the Ministry of Health of the Russian Federation, Moscow

Kirtbaya Anna Revazievna- Candidate of Medical Sciences, Head of Clinical Work of the Department of Resuscitation and Intensive Care of the Department of Neonatology and Pediatrics of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Associate Professor of the Department of Neonatology of the Federal State Budgetary Educational Institution of Higher Education . THEM. Sechenov of the Ministry of Health of the Russian Federation, Moscow

Lenyushkina Anna Alekseevna- Candidate of Medical Sciences, Head of Clinical Work of the Department of Resuscitation and Intensive Care of the Department of Neonatology and Pediatrics of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Moscow

Mostovoy Alexey Valerievich- Candidate of Medical Sciences, Head of the NICU of the Kaluga Regional Clinical Hospital, Chief Neonatologist of the Ministry of Health of the Russian Federation in the North Caucasus Federal District, Kaluga

Mukhametshin Farid Galimovich- Candidate of Medical Sciences, Head of OARITN and ND No. 2 GBUZ SO ODKB No. 1, Assistant of the Department of Anesthesiology and Resuscitation of the FPC and PP USMU, Roszdravnadzor expert in the specialty "Neonatology", Yekaterinburg

Pankratov Leonid Gennadievich– Candidate of Medical Sciences, resuscitator-neonatologist of the Center for Resuscitation and Intensive Care of Children's City Hospital No. 1, assistant of the Department of Neonatology and Neonatal Resuscitation of the FPC and PP SPbGPMA, St. Petersburg

Petrenko Yury Valentinovich- c.m.s., acting Vice-Rector for Medical Work, St. Petersburg State Pediatric Medical University, St. Petersburg

Prutkin Mark Evgenievich- Head of the OAR and ITN and ND No. 1 GBUZ SO ODKB No. 1, Yekaterinburg

Romanenko Konstantin Vladislavovich- Candidate of Medical Sciences, Head of the NICU and ND of the Children's City Clinical Hospital No. 8, Chief Neonatologist Chelyabinsk region, Chelyabinsk

Ryndin Andrey Yurievich– Candidate of Medical Sciences, Senior Researcher of the Department of Resuscitation and Intensive Care of the Department of Neonatology and Pediatrics of the FGBU "Scientific Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov" of the Ministry of Health of the Russian Federation, Moscow, Associate Professor of the Department of Neonatology FGBOU AT PMGMU them. THEM. Sechenov of the Ministry of Health of the Russian Federation, Moscow

Soldatova Irina Gennadievna- Doctor of Medical Sciences, Professor, Deputy Minister of Health of the Moscow Region, Moscow

Starring:

Babak Olga Alekseevna- Candidate of Medical Sciences, Head of ICU 2 GKB No. 24 "Perinatal Center", Moscow

Vereshchinsky Andrey Mironovich- Head of the Department of Resuscitation and Intensive Care of the Khanty-Mansiysk Autonomous Okrug-Yugra "Nizhnevartovsk District Clinical Perinatal Center", Nizhnevartovsk

Vorontsova Yulia Nikolaevna- Candidate of Medical Sciences, Anesthesiologist-Resuscitator of the Department of Resuscitation and Intensive Care for Newborns and Premature Babies, Center for Psychological and Rehabilitation, Moscow

Gorelik Konstantin Davidovich- doctor anesthesiologist-resuscitator of the NICU GBUZ Pediatric city ​​Hospital No. 1, St. Petersburg

Efimov Mikhail Sergeevich– Doctor of Medical Sciences, Professor, Head of the Department of Neonatology FGBOU DPO RMPO of the Ministry of Health of the Russian Federation, Moscow

Ivanov Sergey Lvovich- anesthesiologist-resuscitator of the department of resuscitation and intensive care of newborns of Children's hospital No. 1 of St. Petersburg, assistant of the department of anesthesiology, resuscitation and emergency pediatrics of the FPC and PP SPbGPMA, St. Petersburg

Karpova Anna Lvovna- Candidate of Medical Sciences, Deputy Chief Physician for Childhood, Kaluga Regional Clinical Hospital Perinatal Center, Chief Neonatologist of the Kaluga Region

Lyubimenko Vyacheslav Andreevich- Candidate of Medical Sciences, Associate Professor, Honored Doctor of the Russian Federation, Deputy. ch. doctor in resuscitation and anesthesiology, Children's City Hospital No. 1, St. Petersburg

Obelchak Elena Vadimovna- Head of the Department of Resuscitation and Intensive Care of Newborns Branch No. 1 Maternity Hospital No. 64, Moscow

Pankratyeva Ludmila Leonidovna- candidate of medical sciences, neonatologist Dmitry Rogachev, Moscow

Romanenko Vladislav Alexandrovich- Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Head of the Department of Emergency Pediatrics and Neonatology, PhD and DPO, SBEE HPE "South Ural State Medical University" of the Ministry of Health of Russia, Chelyabinsk

Rusanov Sergey Yurievich- Candidate of Medical Sciences, Head of the Department of Resuscitation and Intensive Care of Newborns, Federal State Budgetary Institution "Ural Research Institute of Maternal and Infant Health" of the Ministry of Health of Russia, Yekaterinburg

Shvedov Konstantin Stanislavovich- Head of the department of resuscitation and intensive care of newborns No. 1, State Budgetary Institution of Health of the Tyumen Region "Perinatal Center", Tyumen

Everstova Tatyana Nikolaevna- Candidate of Medical Sciences, Head of the Department of Resuscitation and Intensive Care of Children's City Clinical Hospital No. 13 named after. N.F. Filatov, Moscow

Conflict of interest: All members of the Working Group confirmed that there was no financial support/conflict of interest to report.

Methods used to collect/select evidence:

search in electronic databases, library resources.

Description of the methods used to collect/select evidence: the evidence base for recommendations are publications included in the Cochrane Library, the EMBASE and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on this topic. The search depth was 10 years.

Methods used to assess the quality and strength of evidence: expert consensus, significance assessment according to a rating scheme.

1. Neonatology;
2. Pediatrics;
3. Obstetrics and gynecology.

Table A.1

Levels of certainty of evidence according to international criteria

	Proof
	Meta-analysis of randomized controlled trials
	At least 1 randomized controlled trial
	At least 1 controlled study without randomization
	At least 1 quasi-experimental study
	Descriptive studies such as comparison studies, correlation studies, or case-control studies
	Report of an expert committee or opinion and/or clinical experience of respected authorities

Table A.2 - Levels of persuasiveness of recommendations

The mechanism for updating clinical guidelines provides for their systematic updating - at least once every three years or when new information on the management of patients with this disease. The decision to update is made by the Ministry of Health of the Russian Federation on the basis of proposals submitted by medical non-profit professional organizations. Formed proposals should take into account the results of a comprehensive assessment of drugs, medical devices, as well as the results of clinical testing.

Annex A3. Related Documents

1. Methodical letter of the Ministry of Health and Social Development of the Russian Federation dated April 21, 2010 N 15-4 / 10 / 2-3204 “Primary and resuscitation care for newborn children”.
2. The procedure for providing medical care in the profile "Obstetrics and gynecology (with the exception of the use of assisted reproductive technologies)" (Order of the Ministry of Health of the Russian Federation dated November 1, 2012 No. 572n).
3. The procedure for providing medical care in the neonatology profile (Order of the Ministry of Health of the Russian Federation of November 15, 2012 N 921n).

1. International Classification of Diseases, Injuries and Conditions Affecting Health, 10th Revision (ICD-10) (World Health Organization) 1994.
2. Federal Law "On the fundamentals of protecting the health of citizens in the Russian Federation" dated November 21, 2011 No. 323 F3.
3. The list of vital and essential medicines for 2016 (Decree of the Government of the Russian Federation of December 26, 2015 No. 2724-r.
4. nomenclature of medical services (Ministry of Health and Social Development of the Russian Federation) 2011.

Appendix B. Patient Management Algorithms

Appendix B. Information for Patients

An insufficient amount of surfactant in the lungs of a premature baby leads to the fact that on exhalation the lungs seem to collapse (collapse) and the child has to re-inflate them with each breath. This requires a lot of energy, as a result, the strength of the newborn is depleted and severe respiratory failure develops. In 1959, American scientists M.E. Avery and J. Mead found a lack of pulmonary surfactant in preterm infants suffering from respiratory distress syndrome, thus establishing the main cause of RDS. The frequency of development of RDS is higher, the shorter the period at which the child was born. Thus, on average, 60 percent of children born at a gestational age of less than 28 weeks suffer from it, 15-20 percent - at a period of 32-36 weeks, and only 5 percent - at a period of 37 weeks or more. It is difficult to predict whether a given child will develop RDS or not, but scientists have been able to identify a certain risk group. Predispose to the development of the syndrome diabetes mellitus, infections and smoking of the mother during pregnancy in the mother, childbirth by caesarean section, birth as the second of twins, birth asphyxia. In addition, it was found that boys suffer from RDS more often than girls. Prevention of the development of RDS is reduced to the prevention of preterm birth.

Appendix D

Clinical	Score in points
signs
Chest movements	chest and abdomen evenly participate in the act of breathing	irregular, irregular breathing	retraction of the upper chest during inhalation
Retraction of the intercostal spaces on inspiration	Missing	slight retraction	noticeable retraction
Retraction of the xiphoid process of the sternum on inspiration	missing	slight retraction	noticeable retraction
Position of the lower jaw	the mouth is closed, the lower jaw does not sink	mouth closed, chin down on inhalation	mouth open, chin down on inhalation
The sonority of exhalation	breathing is calm, even	expiratory noises heard on auscultation	Expiratory noises heard at a distance

Note:

• A score of 0 indicates the absence of respiratory distress syndrome (RDS);
• Score from 1 to 3 points - initial signs of SDR;
• Score 4-5 points - moderate severity of SDR (indication for transition to the next level of respiratory support)
• With a total score of 6 points or more, severe RDS is diagnosed in newborns.

Currently, in connection with the change in the concept of managing children with respiratory distress, the assessment of the severity of respiratory disorders in newborns according to the Silverman scales is carried out not so much for a diagnostic purpose, but to determine the indications for early initiation of respiratory therapy, as well as to evaluate its effectiveness.

A score of 1-3 balavas indicates a compensated state of the child against the background of ongoing therapeutic measures. A score of 4 or more points indicates the ineffectiveness of respiratory support and requires an increase in the intensity of respiratory therapy (switching from high-flow cannulas to CPAP, from CPAP to non-invasive mechanical ventilation, and if non-invasive mechanical ventilation is insufficient, switching to traditional mechanical ventilation). In addition, the increase in severity respiratory distress, assessed on the Silverman scale, along with an increase in the child's need for additional oxygen, may serve as an indication for surfactant replacement therapy.