Neonatal respiratory distress syndrome

Last updated: August 22, 2023

Summarytoggle arrow icon

Neonatal respiratory distress syndrome (NRDS), or surfactant deficiency disorder, is a lung disorder in infants that is caused by a deficiency of pulmonary surfactant. It is most common in preterm infants, with the incidence and severity decreasing with gestational age. Surfactant deficiency causes the alveoli to collapse, resulting in impaired blood gas exchange. Symptoms manifest shortly after birth and include tachypnea, tachycardia, increased breathing effort, and/or cyanosis. Suspected diagnosis is based on clinical features and confirmed by evaluating the extent of atelectasis via an x-ray of the chest. Blood gases show respiratory and metabolic acidosis in addition to hypoxia. Treatment primarily involves emergency resuscitative measures, including nasal continuous positive airway pressure (CPAP) and the stabilization of blood sugar levels and electrolytes. Intratracheal surfactant should be administered if infants require an increased FiO2 to maintain a sufficient oxygen saturation despite receiving noninvasive positive pressure ventilation. Intratracheal surfactant should be administered if ventilation alone is unsuccessful. Most cases resolve within 3–5 days of treatment. However, complications such as hypoxemia, tension pneumothorax, bronchopulmonary dysplasia, or sepsis may still occur. In rare cases, NRDS may lead to neonatal death. NRDS can be prevented by administering antenatal glucocorticoids to the mother if premature delivery is expected.

Etiologytoggle arrow icon

Neonatal respiratory distress syndrome is caused by impaired synthesis and secretion of surfactant. Risk factors include:

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiologytoggle arrow icon

Surfactant [3]

Surfactant deficiency

Clinical featurestoggle arrow icon


Diagnosticstoggle arrow icon


Differential diagnosestoggle arrow icon

Overview of NDRDS and its differential diagnoses

Neonatal respiratory distress syndrome

Apnea of prematurity (AOP) Transient tachypnea of the newborn (wet lung disease) [8] Persistent pulmonary hypertension of the newborn (PPHN) [9] Meconium aspiration syndrome [10][11][12]
  • Preterm
  • Immature respiratory control
  • Delayed resorption and clearance of fetal lung fluid
Risk factors
Onset of symptoms
  • Within the first minutes/hours after birth
  • Within 2–3 days after birth
  • Immediately after birth and within the next 2 hours
  • Within 24 hours after birth
  • Immediately after birth
Clinical features
  • Episodes of breathing pauses (usually > 20 seconds) that are frequently accompanied by hypoxemia and/or bradycardia
  • Supportive care
  • Nasal CPAP
  • Endotracheal administration of artificial surfactant
  • Resolves without complications in the majority of cases at approx. 43 to 44 weeks of postmenstrual age
  • Resolves without complications in the majority of cases

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Physiologic O2 saturation in neonates is around 90%. A saturation of 100% is considered toxic for neonates!

Complicationstoggle arrow icon

Bronchopulmonary dysplasia (BPD) [15]

Further complications

Baby oxen have RIBs: Babys receiving too much oxygen get Retinopathy of prematurity, Intraventricular hemorrhage, and Bronchopulmonary dysplasia.

We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

  • Mortality rate: < 10% [16]
  • Most cases resolve within 3–5 days if treated promptly

Preventiontoggle arrow icon

Referencestoggle arrow icon

  1. Besnard AE, Wirjosoekarto SAM, Broeze KA, Opmeer BC, Mol BWJ. Lecithin/sphingomyelin ratio and lamellar body count for fetal lung maturity: a meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2013; 169 (2): p.177-183.doi: 10.1016/j.ejogrb.2013.02.013 . | Open in Read by QxMD
  2. Jo HS. Genetic risk factors associated with respiratory distress syndrome. Korean J Pediatr .. 2014; 57 (4): p.157.doi: 10.3345/kjp.2014.57.4.157 . | Open in Read by QxMD
  3. Andreeva AV, Kutuzov MA, Voyno-Yasenetskaya TA. Regulation of surfactant secretion in alveolar type II cells. Am J Physiol Lung Cell Mol Physiol. 2007; 293 (2): p.L259-L271.doi: 10.1152/ajplung.00112.2007 . | Open in Read by QxMD
  4. Hermansen CL, Mahajan A. Newborn Respiratory Distress.. Am Fam Physician. 2015; 92 (11): p.994-1002.
  5. Dishop MK. Developmental and Pediatric Lung Disease. Elsevier ; 2018: p. 99-124.e5
  6. Wilmott RW, Kendig EL, Boat TF, Bush A, Chernick V. Kendig and Chernick's Disorders of the Respiratory Tract in Children. Elsevier Health Sciences ; 2012
  7. Sher G, Statland BE, Freer DE. Clinical evaluation of the quantitative foam stability index test. Obstet Gynecol. 1980; 55 (5): p.617-20.
  8. Reuter S, Moser C, Baack M. Respiratory distress in the newborn. Pediatr Rev. 2014; 35 (10): p.417-429.doi: 10.1542/pir.35-10-417 . | Open in Read by QxMD
  9. Abman et al. Guidelines From the American Heart Association and American Thoracic Society: Pediatric Pulmonary Hypertension. Circulation. 2015; 132 (21): p.2037-2099.doi: 10.1161/cir.0000000000000329 . | Open in Read by QxMD
  10. Usta et al.. Risk factors for meconium aspiration syndrome.. Obstet Gynecol. 1995; 86 (2): p.230-4.
  11. Dargaville PA. The Epidemiology of Meconium Aspiration Syndrome: Incidence, Risk Factors, Therapies, and Outcome. Pediatrics. 2006; 117 (5): p.1712-1721.doi: 10.1542/peds.2005-2215 . | Open in Read by QxMD
  12. Committee on Obstetric Practice. Committee Opinion No 689: Delivery of a Newborn With Meconium-Stained Amniotic Fluid. Obstet Gynecol.. 2017; 129 (3): p.e33-e34.doi: 10.1097/aog.0000000000001950 . | Open in Read by QxMD
  13. Townsel CD, Emmer SF, Campbell WA, Hussain N. Gender Differences in Respiratory Morbidity and Mortality of Preterm Neonates. Front Pediatr. 2017; 5.doi: 10.3389/fped.2017.00006 . | Open in Read by QxMD
  14. Lakshminrusimha S, Keszler M. Persistent Pulmonary Hypertension of the Newborn. NeoReviews. 2015; 16 (12): p.e680-e692.doi: 10.1542/neo.16-12-e680 . | Open in Read by QxMD
  15. Kinsella JP, Greenough A, Abman SH. Bronchopulmonary dysplasia. The Lancet. 2006; 367 (9520): p.1421-1431.doi: 10.1016/s0140-6736(06)68615-7 . | Open in Read by QxMD
  16. Dyer J. Neonatal Respiratory Distress Syndrome: Tackling A Worldwide Problem.. J Clin Pharm Ther. 2019; 44 (1): p.12-14.
  17. Romejko-Wolniewicz E, Teliga-Czajkowska J, Czajkowski K. Antenatal steroids: can we optimize the dose?. Curr Opin Obstet Gynecol. 2014; 26 (2): p.77-82.doi: 10.1097/gco.0000000000000047 . | Open in Read by QxMD
  18. Respiratory Distress Syndrome in Neonates (Hyaline Membrane Disease). Updated: January 1, 2015. Accessed: May 11, 2017.
  19. Kaplan. USMLE Step 2 CK Lecture Notes 2017: Pediatrics. Kaplan ; 2016

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