172 Respiratory Physiology

CLINICAL CORRELATE
Respiratory Distress Syndrome of the Newborn
Immediately after delivery, a newborn takes its rst breath. Nega-
tive pressure of 40 to 100 cm H
2
O is required to draw air into the
collapsed airways and inate the alveoli. During this rst breath,
in a healthy, normal, term infant, surfactant stored in type II
alveolar epithelial cells is released and forms a mononuclear layer
at the air-uid interface of the small airways and alveoli. By the
third breath, only a small negative pressure is required to inate
the lung. Respiratory distress syndrome (previously known as
hyaline membrane disease) is the most common cause of death in
premature infants, and is caused by a lack of surfactant produc-
tion. Without surfactant, the negative pressure required to inate
the lungs remains high (CL is low) and portions of the lung col-
lapse, leading to respiratory distress and potentially respiratory
failure and death. Treatment consists of ventilatory support and
surfactant therapy through the breathing tube.
Negative pressure of 40 to 100
cm H
2
O needed to inflate sac
(alveolus) with air.
Monomolecular layer of surfactant
lining fluid layer on surface of
terminal sac (alveolus)
The initial inflation of the collapsed lungs of a neonate requires large negative pressure (40 to 100 cm H
2
0), but surface tension is reduced in
subsequent breaths as surfactant lines the alveoli and small airways, reducing the work required to inflate the lungs. Premature birth is often
associated with surfactant deficiency and respiratory distress.
Drop of water with surface tension
of 72 dynes/cm forms a globule
Drop of water mixed with household
detergent; surface tension reduced to 20
dynes/cm and thus water spreads out
Glass sheets
Radius 25 Radius 100 Radius 25
Surfactant
absent
Surfactant
present
Fluid-filled
airway
Terminal sac
(alveolus) Air Fluid
Air Fluid Collapsed terminal sac
(alveolus)
Negative pressure of 40 to 100 cm H
2
O
needed to inflate sac (alveolus) with air.
Inflated terminal
sac (alveolus)
During 1st breath After 3rd breath
Radius 25 Radius 100 Radius 50
Fluid-filled airway
Surfactant stored in type II
cells of terminal sac (alveolus)
Air Fluid
Air Fluid
Surfactant
Inflated terminal
sac (alveolus)
Before 1st breath
Minimum surface tension is 50 dynes/cm.
As much as 20 cm H
2
O of negative pressure
needed to inflate sac (alveolus) during fourth
and subsequent breaths.
Surface tension is 5 dynes/cm or less. Negative
pressure of only 2 cm H
2
O needed to inflate
sac (alveolus) to maximum diameter during
fourth and subsequent breaths.
Diabetes mellitus
(maternal)
Prematurity
Birth wt. 2.5 kg; RDS not likely
Birth wt. 2.5 kg; likelihood of
RDS increases in relation to
lower wt. (if viable)
A. Risk factors for development of respiratory distress syndrome (RDS) of newborn
B. Surfactant effects during lung inflation in the neonate
Cesarean birth
Perinatal asphyxia
(2nd born of twins

more susceptible)

During normal, quiet breathing, pleural pressure is always
negative. However, during active expiration, contraction of
expiratory muscles results in elevation of pleural pressure
above atmospheric pressure (see Fig. 14.7). Under these cir-
cumstances, during expiration, alveolar pressure is the sum of
the positive pleural pressure and the elastic recoil pressure
of the lungs. Pressure in the airways falls between the alveoli
and the opening of the mouth, reaching atmospheric pressure
at the mouth. Thus, at some point downstream from the
alveoli, an equal pressure point is reached, at which airway