Respiratory Distress Syndrome

Also known as Hyaline Membrane Disease, Neonatal Respiratory Distress Syndrome, Infant Respiratory Distress Syndrome, Surfactant Deficiency
Respiratory distress syndrome (RDS) is a common breathing disorder that affects newborns. RDS occurs most often in babies born preterm, affecting nearly all newborns who are born before 28 weeks of pregnancy. Less often, RDS can affect full term newborns.

RDS is more common in premature newborns because their lungs are not able to make enough surfactant. Surfactant is a foamy substance that keeps the lungs fully expanded so that newborns can breathe in air once they are born.

Without enough surfactant, the lungs collapse and the newborn has to work hard to breathe. He or she might not be able to breathe in enough oxygen to support the body's organs. Most babies who develop RDS show signs of breathing problems and a lack of oxygen at birth or within the first few hours that follow. The lack of oxygen can damage the baby's brain and other organs if not treated promptly.

RDS may change over time to become bronchopulmonary dysplasia, or BPD. This is another breathing disorder that may affect babies, especially premature babies.

RDS usually develops in the first 24 hours after birth. If premature newborns still have breathing problems by the time they reach 36 weeks gestation, they may be diagnosed with BPD. Some of the life-saving treatments used for RDS may contribute to BPD. Some newborns who have RDS recover and never get BPD.

Due to better treatments and medical advances, most newborns who have RDS survive. However, these babies may need extra medical care after going home. Some babies have complications from RDS or its treatments. Serious complications may include chronic breathing problems, such as asthma and BPD; impaired vision; and movement, learning, or behavior problems.

Explore this Health Topic to learn more about respiratory distress syndrome, our role in research and clinical trials to improve health, and where to find more information.

Causes - Respiratory Distress Syndrome

RDS is a type of neonatal respiratory disease that is caused most often by a lack of surfactant in the lungs. A fetus's lungs start making surfactant during the third trimester of pregnancy, or weeks 26 through labor and delivery. Surfactant coats the insides of the air sacs, or alveoli, in the lungs. This helps keep the lungs open so breathing can occur after birth. To understand respiratory distress syndrome, it helps to learn about how the lungs work.

Without enough surfactant, the lungs may collapse when the newborn exhales. The newborn then has to work harder to breathe. He or she might not be able to get enough oxygen to support the body's organs.

Some full-term newborns develop RDS because they have faulty gene that affect how their bodies make surfactant.

ewborn in respiratory distress following a premature delivery.
Newborn in respiratory distress following a premature delivery. The top image shows a healthy newborn with healthy levels of surfactant in the lungs and oxygen in the blood. The bottom image shows a baby born prematurely. The lack of surfactant causes the alveoli, or air sacs, to thicken and become inflamed, making it hard to breathe. This reduces the amount of oxygen-rich blood that reaches the brain and other tissues in the body. Medical Illustration Copyright © 2019 Nucleus Medical Media, All rights reserved.


Risk Factors - Respiratory Distress Syndrome

Certain factors may increase the risk that your newborn will have RDS. These factors include:

  • Infection
  • Premature delivery. The earlier your baby is born, the greater his or her risk for RDS. Most cases of RDS occur in babies born before 28 weeks of pregnancy.
  • Problems with your baby’s lung development
  • Stress during your baby's delivery, especially if you lose a lot of blood
  • You having diabetes

Your baby also is at greater risk for RDS if you require an emergency cesarean delivery before your baby is full term. You may need an emergency cesarean delivery because of a condition, such as a detached placenta, that puts you or your newborn at risk.

Planned cesarean deliveries that occur before a baby's lungs have fully matured can also increase your baby’s risk for RDS. Your doctor can do tests before delivery that show whether it is likely that your baby's lungs are fully developed. These tests determine the age of the fetus or lung maturity.

Screening and Prevention - Respiratory Distress Syndrome

Taking steps to ensure a healthy pregnancy might prevent your newborn from being born before his or her lungs have fully developed. These steps include:

  • Following a healthy eating plan
  • Managing any medical conditions you have
  • Not smoking and avoiding tobacco smoke, alcohol, and illegal drugs
  • Preventing infections
  • Seeing your doctor regularly during your pregnancy

Your doctor may give you injections of a corticosteroid medicine if he or she thinks you may give birth too early. This medicine can speed up development of the lungs, brain, and kidneys in your baby and surfactant production. Usually, within about 24 hours of your taking this medicine, the baby's lungs start making enough surfactant.

Treatment with corticosteroids can reduce your baby's risk for RDS. If the baby does develop RDS, it may not be as serious.

Signs, Symptoms, and Complications - Respiratory Distress Syndrome

signs and symptoms of RDS usually happen at birth or within the first few hours that follow. Depending on the severity of a newborn's RDS, he or she may develop other medical problems.

Signs and symptoms
- Respiratory Distress Syndrome

Signs and symptoms of RDS include:

  • Grunting sounds
  • Rapid, shallow breathing
  • Sharp pulling inward of the muscles between the ribs when breathing
  • Widening of the nostrils, or flaring, with each breath

The newborn also may have pauses in breathing that last for a few seconds. This condition is called apnea.

- Respiratory Distress Syndrome

Many babies who are born with RDS develop bronchopulmonary dysplasia (BPD). If babies born with RDS still require oxygen therapy by the time they reach their original due dates, they are diagnosed with BPD.

Depending on the severity of a newborn's RDS, he or she may develop other medical problems.

  • Bleeding in the brain, which can delay cognitive development or cause intellectual disabilities or cerebral palsy
  • Blood and blood vessel complications. Newborns who have RDS may develop Sepsis. This infection can be life threatening.
  • Bowel disease called necrotizing enterocolitis
  • Impaired vision, including blindness
  • Kidney failure
  • Lung complications. These may include atelectasis; leakage of air from the lung into the chest cavity, called pneumothorax, a type of pleural disorder; and bleeding in the lung, or hemorrhage. Some of the life-saving treatments used for RDS may cause bronchopulmonary dysplasia.
  • Patent ductus arteriosus, a type of congenital heart defect. The ductus arteriosus connects pulmonary arteries to the aorta. If it remains open, it can strain the heart and increase blood pressure in the lung arteries.

Diagnosis - Respiratory Distress Syndrome

RDS is common in premature newborns. Thus, doctors usually recognize and begin treating the disorder as soon as babies are born.

Doctors also do several tests to rule out other conditions that could be causing a newborn's breathing problems. The tests also can confirm that the doctors have diagnosed the condition correctly.

The tests include:

  • Chest X-ray to show whether a newborn has signs of RDS. A chest X-ray also can detect problems, such as a collapsed lung, that may require urgent treatment.
  • Blood tests to see whether a newborn has enough oxygen in the blood. Blood tests also can help find out whether an infection is causing the newborn's breathing problems.
  • Echocardiography (echo) to rule out heart defects as the cause of the newborn's breathing problems.

Treatment - Respiratory Distress Syndrome

Treatment for RDS usually begins as soon as a newborn is born, sometimes in the delivery room. Treatments for RDS include surfactant replacement therapy, breathing support from a ventilator or nasal continuous positive airway pressure (NCPAP) machine, or other supportive treatments.

Most newborns who show signs of RDS are quickly moved to a neonatal intensive care unit (NICU). There they receive around-the-clock treatment from healthcare professionals who specialize in treating premature newborns.

Surfactant replacement therapy
- Respiratory Distress Syndrome

Surfactant helps keep the lungs open so that a newborn can breathe in air once he or she is born. Babies who have RDS get surfactant until their lungs are able to start making the substance on their own. Surfactant is usually given through a breathing tube. The tube allows the surfactant to go directly into the baby's lungs.

Once the surfactant is given, the breathing tube is connected to a ventilator, or the baby may get breathing support from NCPAP.

Surfactant often is given right after birth in the delivery room to try to prevent or treat RDS. It also may be given several times in the days that follow, until the baby is able to breathe better.

Some women are given medicines called corticosteroids during pregnancy. These medicines can speed up surfactant production and lung development in a fetus. Even if you had these medicines, your newborn may still need surfactant replacement therapy after birth.

Breathing support
- Respiratory Distress Syndrome

Newborns who have RDS often need breathing support, or oxygen therapy, until their lungs start making enough surfactant. Until recently, a mechanical ventilator usually was used. The ventilator was connected to a breathing tube that ran through the newborn's mouth or nose into the windpipe.

Today, more and more newborns are receiving breathing support from NCPAP. NCPAP gently pushes air into the baby's lungs through prongs placed in the newborn's nostrils.

Other supportive treatments
- Respiratory Distress Syndrome

Treatment in the NICU helps limit stress on babies and meet their basic needs of warmth, nutrition, and protection. Such treatment may include:

  • Checking liquid intake to make sure that fluid does not build up in the baby’s lungs.
  • Checking the amount of oxygen in the blood using sensors on fingers or toes.
  • Giving fluids and nutrients through needles or tubes inserted into the newborns' veins. This helps prevent malnutrition and promotes growth. Nutrition is critical to the growth and development of the lungs. Later, babies may be given breast milk or newborn formula through feeding tubes that are passed through their noses or mouths and into their throats.
  • Measuring blood pressure, heart rate, breathing, and temperature through sensors taped to the baby’s body.
  • Using a radiant warmer or incubator to keep newborns warm and reduce the risk of hypothermia.

Living With - Respiratory Distress Syndrome

After your baby leaves the hospital, he or she will likely need follow-up care. It is important to follow your child’s treatment plan and get regular care. It is also important to take care of your mental health as you care for your baby at home.

Receive routine follow-up care
- Respiratory Distress Syndrome

Your baby may need special care after leaving the NICU, including:

  • Special hearing and eye exams
  • Speech or physical therapy
  • Specialty care for other medical problems caused by premature birth

Talk to your child's doctor about ongoing care for your newborn and any other medical concerns you have.

Ongoing health issues and developmental delays
- Respiratory Distress Syndrome

Newborns who have RDS may have health problems even after they leave the hospital. These include:

  • Delayed growth during their first two years. Children who survive RDS usually are smaller than other children of the same age.
  • Increased risk for infections, such as colds and the flu. If these children develop respiratory infections, they may need to be treated in a hospital.
  • Lung problems throughout childhood and even into adulthood. These problems can include underdeveloped lungs and asthma.
  • Need for ongoing oxygen therapy or breathing support from NCPAP or a ventilator. A pulmonary specialist may help with your child's long-term care and make treatment recommendations.
  • Trouble swallowing. This may put them at risk for getting food stuck in their airways. This condition is called aspiration, and it can cause infection. Children who have RDS may need help from a specialist to learn how to swallow correctly.
  • Apnea, a condition in which breathing stops for short periods.
  • Poor coordination and muscle tone.
  • Delayed speech and problems with vision and hearing.
  • Learning problems.
  • Gastroesophageal reflux disease (GERD), a condition in which the stomach contents back up into the esophagus during or after a feeding. The esophagus is the passage leading from the mouth to the stomach. GERD may lead to aspiration.

The risk of these complications increases in newborns who are very small at birth.

Prevent and treat complications over your child’s lifetime
- Respiratory Distress Syndrome

You can take steps to help manage your child's RDS and help him or her recover.

  • Try to prevent infection. Wash your hands often, and discourage visits from family and friends who are sick. Keep your baby away from large daycare centers and crowds to avoid colds, the flu, and other infections.
  • Do not smoke in your home. Keep your baby away from substances that could irritate the lungs, such as cigarette smoke.
  • Get recommended childhood vaccines.
  • Treat complications of RDS. Your doctor may give your child antibiotics for infections. Treatment for patent ductus arteriosus, a possible complication of RDS, includes medicines, catheter procedures, or surgery.
  • Call your child's doctor if you see any signs of respiratory infection. These may include irritability, fever, stuffy nose, cough, changes in breathing patterns, and wheezing.

Take care of your mental health
- Respiratory Distress Syndrome

Caring for a premature newborn can be challenging. You may experience:

  • Emotional distress, including feelings of guilt, anger, and depression
  • Anxiety about your baby's future
  • A feeling of a lack of control over the situation
  • Financial stress
  • Problems relating to your baby while he or she is in the neonatal intensive care unit (NICU)
  • Fatigue
  • Frustration that you cannot breastfeed your newborn right away. You can pump and store your breast milk for later use.

You can take steps to help yourself during this difficult time.

  • Ask questions about your newborn's condition and what is involved in daily care. This will help you feel more confident about your ability to care for your baby at home.
  • Learn as much as you can about what happens in the NICU. You can help your baby during his or her stay there and begin to bond with the baby before he or she comes home.
  • Seek out support from family, friends, and hospital staff. Ask the case manager or social worker at the hospital what you will need after your baby leaves the hospital. The doctors and nurses can assist with questions about your newborn's care. Also, you may want to ask whether your community has a support group for parents of premature newborns.
  • Visit your baby in the NICU as much as possible. Spend time talking to your baby and holding and touching him or her.

Research for Your Health

The NHLBI is part of the U.S. Department of Health and Human Services’ National Institutes of Health (NIH)—the Nation’s biomedical research agency that makes important scientific discovery to improve health and save lives. We are committed to advancing science and translating discoveries into clinical practice to promote the prevention and treatment of heart, lung, blood, and sleep disorders including respiratory distress syndrome. Learn about current and future NHLBI efforts to improve health through research and scientific discovery.

Improving health with current research
- Respiratory Distress Syndrome

Learn about the following ways the NHLBI continues to translate current research into improved health for newborns who have respiratory distress syndrome. Research on this topic is part of the NHLBI’s broader commitment to advancing lung disease scientific discovery.

  • Pioneering Advances in Critical Care for Newborns Who Have Respiratory Diseases. Ground-breaking research funded by the NHLBI has helped establish the standard of care for newborns who have respiratory distress syndrome. Our research helped develop the use of corticosteroids to accelerate lung development in babies at risk for premature birth. We also funded studies to develop the use of surfactant replacement therapy to improve breathing in premature newborns and the use of nitric oxide to help prevent chronic lung disease. These treatment methods continue to significantly improve the survival and long-term quality of life for premature newborns.
  • Preventing the Long-Term Complications of Respiratory Diseases in Newborns. The NHLBI has organized several workshops to help direct future research into respiratory diseases in newborns. These workshops have focused on research to improve our understanding of the development of chronic lung disease and eliminate health disparities in the survival and long-term quality of life for newborns who have respiratory diseases. View NHLBI Workshop on Prenatal and Perinatal Determinants of Lung Health and Disease in Early Life and NHLBI and NICHD Workshop on Adults Born Preterm: The Epidemiology and Biological Basis for Outcomes for more information.
  • Using Vitamin D to Help Reduce Wheezing in Premature Newborns. Wheezing is a common long-term complication of respiratory diseases in newborns. Research funded by the NHLBI has shown that premature newborns who received regular vitamin D supplements had a lower risk of wheezing than those who did not receive supplements. This finding helps improve clinical care to prevent the complications of respiratory distress syndrome in newborns.
  • Identifying the Complications of Oxygen Therapy. NHLBI-funded research helped determine that forceful and prolonged oxygen therapy in newborns can cause chronic lung disease. These findings led to guideline changes for the use of oxygen therapy to treat newborns who have respiratory distress syndrome.
  • Fostering Research on New Treatments for Lung Diseases. We continue to support the Centers for Advanced Diagnostics and Experimental Therapeutics in Lung Diseases (CADET) program, which stimulates the development of new treatments for lung diseases and sleep disorders. The first stage, CADET I, supported research on how lung diseases develop. The second stage, CADET II, is funding research on new drugs to treat lung diseases.
  • Providing Resources to Catalyze Lung Research. The NHLBI-funded Lung Tissue Research Consortium (LTRC) provides human lung tissues to qualified investigators to fuel cutting-edge research on lung diseases. The program enrolls patients who are planning to have lung surgery, collects blood and other clinical data from these donors, and stores donated tissue that otherwise would be discarded after the lung surgery. LTRC resources have been used in numerous research projects, leading to the publication of more than 60 scientific articles.
  • Advancing the Understanding of Lung Development. The NHLBI-funded Molecular Atlas of Lung Development Program (LungMAP) is integrating many datasets to build a molecular map of the developing lung in both humans and mice. The program is helping advance lung research, in part through its web-based data resource, called BREATH, that allows users to access LungMAP data and findings.

Advancing research for improved health
- Respiratory Distress Syndrome

In support of our mission, we are committed to advancing respiratory distress syndrome research, in part through the following ways.

  • We fund research. The research we fund today will help improve our future health. Our Division of Lung Diseases, which includes the Lung Biology and Disease Branch, oversees much of the research on respiratory distress syndrome we fund, helping us to understand, prevent, and manage respiratory distress syndrome. Search the NIH RePORTer to learn about research the NHLBI is funding on respiratory distress syndrome.
  • We stimulate high-impact research. The NHLBI Strategic Vision highlights ways we may support research over the next decade.

Learn about exciting research areas the NHLBI is exploring about respiratory distress syndrome.

Participate in NHLBI Clinical Trials

We lead or sponsor many studies related to respiratory distress syndrome. See if you or someone you know is eligible to participate in our clinical trials.

Has your newborn been diagnosed with patent ductus arteriosus?

Patent ductus arteriosus (PDA) is a condition in which a connection between two major blood vessels close to the heart does not close properly after birth. This affects blood flow to the lungs and may cause neonatal respiratory diseases. PDA may correct itself, but sometimes treatment may be necessary. This study aims to identify ways by which doctors can predict which cases of PDA need to be treated. To participate in this study, your newborn must have been born between 23 and 29 weeks’ gestation and have been diagnosed with PDA. This study is located in Columbus, Ohio.

Is your premature newborn in a neonatal intensive care unit in Chicago, Illinois?

This study is investigating how brain development affects breathing in premature newborns. To participate in this study, your newborn must have been born prematurely between 24 and 29 weeks’ gestation and admitted to the neonatal intensive care unit within a week of birth. This study is located in Chicago, Illinois.

Is your newborn in the NICU at Holtz Children’s Hospital in Miami?

Newborns born very prematurely often need oxygen therapy or ventilation to help them breathe and survive. This study will help doctors understand how changes in oxygen and carbon dioxide levels while newborns are getting treatment affect how their lungs develop. While your newborn is in the newborn neonatal intensive care unit (NICU), researchers will record his or her oxygen and carbon dioxide levels, heart rate, and other measures. To participate in this study, your newborn must have been born prematurely between 23 and 28 weeks’ gestation, be less than 28 days old, and be receiving oxygen therapy. This study is located in Miami, Florida.

Was your newborn born prematurely?

This study aims to better understand the effects of premature delivery on a baby’s lungs during his or her first year of life. To participate in this study, your newborn must have been born prematurely between 24 and 36 weeks’ gestation and not have any congenital heart or lung defects. This study is located in Indianapolis, Indiana.

Is your newborn receiving care at the University of Alabama at Birmingham Women and Infants Center?

This study is testing new ways to help control breathing and oxygen and carbon dioxide levels in premature newborns. To participate in this study, your premature newborn must be in the neonatal intensive care unit or the critical care nursery at the Birmingham Women and Infants Center at the University of Alabama. This study is located in Birmingham, Alabama.

Is your newborn in the neonatal intensive care unit at St. Louis Children’s Hospital?

This study aims to better understand breathing problems and blood flow through the heart in premature newborns to better detect conditions such as pulmonary hypertension. To participate in this study, your newborn must have been born prematurely between 24 and 29 weeks’ gestation and be a patient in the Neonatal Intensive Care Unit at St. Louis Children’s Hospital. This study is located in St. Louis, Missouri.

Have you been diagnosed with high blood pressure while pregnant?

This study is investigating whether a mother’s blood pressure during pregnancy affects her newborn’s lung development. To participate in this study, your newborn must have been born either prematurely at more than 25 weeks’ gestation or at full term to a healthy mother or a mother who was diagnosed with high blood pressure during pregnancy. This study is located in Indianapolis, Indiana.

More Information

After reading our Respiratory Distress Syndrome Health Topic, you may be interested in additional information found in the following resources.

NHLBI resources
- Respiratory Distress Syndrome

Non-NHLBI resources
- Respiratory Distress Syndrome