Pediatrics 1961 Rudolph 551 66

STUDIES
ON
THE
CIRCULATION
IN THE
The Circulation in the Respiratory

A. M.
Rudolph,
M.D.,
A. J. Rudolph,
J. E. Drorbaugh,
M.D.,
of
Pediatrics,
Medical
the Childrens
cilangeS
ROFOUND
system
occur
in the
adaptation
from
circulation.
It is not
that
possible
role
circulation
tory
the
production
been
Although
a!.
changes
The
after
animals
et
Dawes
by
only
of
and
pulmonary
whether
the
in the
normal
cardiovascular
and
circulatory
for
to
in
Studies
means
of the
circulation
evidence
of
separated
were
Group
signs
three
and
severity
nesccnt
be
A.
M.
Rudolph
by
and
is
babies
of
mongolism,
an
of
mild
of these
Established
grants-in-aid
(BP-2372)
signs.5
with
the
Public
no
eva-
Health
at
born
of
ages of these
weeks.
The
pelvic
of
route
five
at
in
14,
cases.
The
the time
of
study
was
The
2.073
and
3.181
birth
were
33
infants
were
not
re-
and
were
infants
The
Service,
and
an-
ages
kg.
mild
infants
infants
were
males
at time
of study
weights
were
and
to
with
were
Their
of
and
varied
between
gestational
ages
at
39
III included
Seven
three,
females.
of
and
weights
37
weeks;
were
American
General
by
The
of
Five
Heart
Their
ages
3 to
to 2.869
kg.
ranged
born
by
21
The
from
de-
pelvic
Association.
Medical
Association
group
infants
were
were
of this
were
1.278
severe
infants
mothers.
these
six
with
these
catheterization
age
of
of
diabetic
of
symptoms,
moderate
dis-
10 infants
distress.
time
gestational
of
infants
zero
these
to have
mild
respiratory
were
thought
to show
males
to
of nine
the
in the
weeks;
two of the nine
born
by pelvic
delivery
and seven
section.
Seven of these babies
were
Group
the
with
level
Four
2 to 11 hours,
Division
measured
midchest
All
females.
30
the
were
from
hours
Investigator
of
time
at the
five,
at
showed
and
(RG-5158)
by
heavier
those
diameter.
respiratory
the
with
the
mothers.
tress.
were
of
was
distress.
observed
basis
than
Gestational
36 to 41
II consisted
considered
and
two
either
or
evidence
Supported
Service
Four
by
and
at
level
newborn
respiratory
infants
distress
symptoms.
the
on
of
19
respiratory
unquestionable
Dr.
groups
duration
I comprised
of
carefully
distress,
are
section
in
of all infants
pressures
by cesarean
28
ages
of delivery
and
to appreciate
mothers
gestational
Group
syndrome
newborn
conducted
in
respiratory
into
same
diabetic
may
is important
of diabetic
respiratory
METHODS
of cardiac
catheterization
These
infants
were
infants.
for
AND
females.
teroposterior
infants.
MATERIAL
(It
infants
All
determine
of the
certain
were
at the
from
2
five
circula-
disturbance
production
distress
19
and
reference
is to
changes
with
function
responsible
of respiratory
on
study
the
markable.
is available.4
present
of
Their
ages
ranged
that
delivery
and
and
their weights
from 2.414
to
of these infants
were males
and
by cesarean
clinical
condition
been
al.2
information
infants
the
infants
have
Eight
nondiabetic
mothers.)
babies
ranged
from
changes
et
limited
of
delineate
tion
birth
Barclay
in human
purpose
further
respira-
membrane
of the
Hospital
microcephalic.
method
studies
Lying-In
to 34 hours
and
4.090 kg. Fourteen
the
postulated.
circulation
in
of
The
of the
of the
(hyaline
intensive
the
made
progression
be disturbed.
a disturbance
syndrome
has
disease)
the
such
in the
distress
in
may
of
to expect
normal
changes
M.D.,
M.D.,
infants
of diabetic
mothers.
time
of cardiac
catheterization
in
to a pulmonary
unreasonable
was
one
animal
Boston
Boston
Center,
cardiovascular
newborn
a placental
occasionally
circulatory
the
in
Auld,
Smith,
M.D.
the
School,
Medical
P. A. M.
C. A.
M.D.,
J. P. Hubbell,
Harvard
PERIOD
Distress Syndrome
M.D.,
A. S. Nadas,
and
Department
NEONATAL
Science,
for
the
Public
Aid
of
Health
Crippled
Children.
PRESENT
York
61,
ADDRESS:
New
(A.M.R.)
Department
of
Pediatrics,
Albert
Einstein
College
of
Medicine,
New
York.
PEDIATRICS,
April
1961
551
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 27, 2015
552
RESPIRATORY
DISTRESS
livery
and four by cesarean
section.
These
fants all had severe
symptoms,
and 8 of the
died
with
increasing
respiratory
symptoms
to 58 hours
following
the
catheterization
in10
3
study.
the presence
of severe
hyaline
membrane
disease
in these
infants.
There
was also no evidence
to indicate
that
the catheterization
procedure
had contributed
to the fatal outcome
of these infants.
The decisions
to perform
studies
on the infants were made only after careful
clinical
observation.
Radiologic
and electrocardiographic
studies
were carried
out for all the infants
with
respiratory
symptoms
and for the majority
of
those
with
no respiratory
distress.
The
procedure
was performed
after full discussion
with
Necropsy
and
confirmed
consent
of at
least
one
of the
parents.
No
medicaments
or anesthetics
were administered.
Oxygen
therapy
by inhalation
was continued
during
catheterization
in the 10 infants
with
severe
symptoms,
all of whom
were receiving
oxygen
before
the
procedure.
The
infants
without
symptoms,
or with mild symptoms,
did
not receive
oxygen.
In 15 newborn
infants
cardiac
catheterization was attempted
by inserting
the catheter
into the umbilical
vein, wih the aim of manipulating
it through
the ductus
venosus
into the
inferior
vena
cava
and then into the heart.
In
view of the tendency
for the catheter
to enter
portal veins, with difficulty
in maneuvering
beyond
the
ductus
venosus,
the
attempt
was
abandoned
in five instances.
In 10 infants,
ineluded
in this report,
the catheter
could
be
manipulated
into the heart,
but in only 2 of
these was it possible
to pass the catheter
into
the pulmonary
artery.
In the remaining
28 infants,
the catheter
was inserted
through
the
right saphenous
vein in the groin.
Under
local
procaine
anesthesia,
a small incision
was made
just
below
the
was
readily
isolated.
groin
and
the
A 50-cm-long
saphenous
No.
vein
4F
Leh-
man catheter
was inserted
in most instances,
but
in two
infants
a 35-cm-long
No. 3.5F
Lehman
catheter
was used in view of the small
size of the vein.
After the catheter
was passed
into the right
atrium
from the inferior
vena cava, an immediate attempt
was made
to enter
the superior
vena cava. The catheter
was then again
withdrawn
and manipulated
into the right ventricle.
A very careful
continuous
monitoring
of the
electrocardiogram
was then conducted
with the
aid of an oscilloscope,
and attempts
were made
SYNDROME
to pass the catheter

into the pulmonary
artery.
The catheter
was rapidly
withdrawn
if yentricular
ectopic
beats
were
induced;
consequently
in only 22 instances
was the pulmonary
artery
catheterized.
In the other
16 instances
the attempts
to enter
the pulmonary
artery
were abandoned
in view of the induction
of
numerous
ectopic
beats
during
these
manipulations.
The catheter
was also passed
through
the
ductus
ateriosus
in 20 of the 22 infants
whose
pulmonary
artery
was entered.
As the tip of
the catheter
was manipulated
beyond
the pulmonary
valve, it usually
preferentially
followed
a course
through
the ductus
arteniosus
into the
descending
aorta.
In view
of the relatively
small size of the vessels,
it was difficult
to assess
whether
the tip of the catheter
was located
in
the
main
pulmonary
artery,
in the
ductus
arteniosus
itself, or in the aorta.
Persistent
attempts
were
therefore
made
to direct
the
catheter
into the left or right main pulmonary
artery.
In the occasional
instance
in which
this
was not accomplished,
the pulmonary
arterial
pressure
and blood
sample
was obtained
in
the main
pulmonary
artery
just beyond
the
pulmonary
valve.
The left atrium

was entered
in 27 infants
by passage
of the catheter
through
the foramen ovale.
A pressure
gradient
between
left
and right atrium
was measured
as the catheter
was withdrawn
from the left to the right atrium.
Cineangiography
to establish
the presence
of a
ductal
left-to-right
shunt
was performed
in
seven
infants,
by injection
of 2 to 2.5 ml of
75%
sodium
diatrizoate
(Hypaque
sodium)
into
the
left atrium.
The fluoroscopic
examinations
during
manipulation
of the catheter
and the cineangiography
were performed
with the aid of a 5-in. Philips
roentgen
image
intensffier.
Pressures
were continually
monitored
with the use of a Statham
P 23
D pressure
transducer.
Electrocardiograms
and pressures
were recorded
on a Sanborn direct-writing
oscillograph.
Oxygen
saturation
was measured
by a spectrophotometric
method.6
RESULTS
The
I, the
tory
One
hours
hemodynamic
19 infants
observations
without
symptoms,
are presented
patient
was studied
both
of age.
Right
atrial
in group
significant
respirain Table
at 5 and
pressures
ranged
I.
26
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RESPIRATORY
554
from
3.0
sures
to + 4.5 mm
ranged
The
left
from
atnial
right
higher.
Hg
atrial
Right
were
measured
from
arterial
systolic
pres-
mm
higher
than
was
0.5
mm
systolic
in
16
of
to
80
mm
these
pressures
8 to
42
mm
with
an
arterial
tolic,
pressures
with
an
were
average
erage
of 45 mm
As
shown
30 to
a small
the
increase
atrial
level
caval
blood.
shunt
could
through
be due
rated
blood
suggested
interest
with
in
of
using
sible
any
the
ductus
evident
pulmonary
from
ranged
the
ratio
the
for
at
as
of
were
made
for
mixed
the pulmonary
in Tables
I, II
size
of the
whom
ductal
saturations
a pulmonary
venous
unsaturation
also
be
Table
in
nine
the
infants
respiratory
ratio
indicating
the
infants
Group
atrial
ranged
from
atrial
pressures
There
was
pressures
2.0
from
a
0.5
left-to-right
in four.
through
A very
small
ductus
was
the
other
four, with
a calculated
systemic
flow
ratio
varying
75
to
saturation
the
nine
ied
between
96%.
In
was
systemic
three
artery
instances,
somewhat
less
mild
to
infants.
from
The
40 and
and
left
9 mm
Hg.
pressure
0.5
systolic
group
Hg
atrial
ranging
to 6.5
mm
pressure
Pulmonary
in eight
of
pressures
60 mm
Hg,
erage
of 51 mm Hg; diastolic
ied from
20 to 35, with
an
var-
with
an av-
pressures
varaverage
of 37.2
mm
from
Hg. Systemic
arterial
pressures
ranged
48 to 100, with
an average
of 65.2 mm
Hg
in
systole,
average
and
of
41
mm
of a small
in two
atrial
level
atrial
saturation
than
caval
from
22
Hg
in
that
largest
pressure
right
atria,
pulmonary
the nine
diastole;
an
mean
from
35
Hg.
indicated
to
76,
the
shunt
respectively.
these
two
at the
artery
infants.
6.5
sampling
was possible
In four
there
between
cle and pulmonary

four there
was only
artery,
a small
gen
the
at
is of
had
between
5 and
in saturation
It
infants
gradients
Adequate
saturation
with
infants,
in whom
the right
was 5 to 8%, and 12% higher
measuring
spectively.
to 63,
left-to-right
saturation,
interest
ference
1.6:1.
in the
in all,
presence
through
with
this
+ 8 mm
pos-
shunt
data
II
in
to
from
of
of
should
symptoms.
Right
data
absence
hemodynamic
in
it was
evioxyand
showed
as a cause
of these
II presents
the
90%
the saturaIn one of
some
right-toof a disturbance
perfusion
in some
considered.
atrial
above
sample
of 91%, indicating
The possibility
systemic
pressures
ranged
with an average of 51.5 mm
Oxygen
saturation
data
there
was
no
difference
in
right
ventricle
left-to-right
to
cava,
saturation
artery,
significant
between
saturation
from
vena
samples
reliable
in the
to
arterial
blood
calculations
flow
infants
shunt
1.2:1
had
Since
the major
was in connection
and thus
presented
arteriosus
Oxygen
28 to
infants
inferior
reflect
significant
the
Hg;
of
arteriosus,
artery,
left-to-right
Left
Hg.
Right
ventricular
systolic
ranged
from
45 to 85 mm Hg.
arterial
pressure
was measured
to obtain
pulmonary
showed
inless
suggest-
shunt.
some
could
ventricular
the
pulmonary
dence
of any
gen saturation
samples
of a ventilation
sys-
a foramen
ovale,
but
it
to addition
of more fully satu-
eight
saturation,
atrial
represent
actually
shunt.
In the
venous
one
was
This
to systemic
III
pulmonary
a right-to-left
shunt,
In
gradient
venous
saturations,
to systemic
flows
and
than
ing
level.
saturation
vena
ductus
right
the
ductal
left
atrial
the
suggesting
right-to-left
to superior
from
pulmonary
75
of 35.5 mm
with an av-
saturation
at
saturation,
a small
as compared
in one instance.
in these
studies
the
48 to
I, several
atrial
of
saturation
left shunt.
Pulmoranged
Hg.
in Table
probably
stance,
left
these
and
average
average
pressure,
presence
from
of 61 mm
40 diastolic,
with
an
Hg; and 38 to 51 mean
the
the
blood
24.5; the mean

pressure
ranged
from
15 to
49 mm Hg, with
an average
of 35. The systemic
than
Pulmonary
infants
Hg.
SYNDROME
in all except
two infants,
in whom
tions were 80 and 82% respectively.
ranged
Hg,
Hg
pressures
68 mm Hg, with an average

of 50.5.
nary
arterial
diastolic
pressures
from
Hg.
except
in two cases;
in
were
equal,
and in the
pressure
33
atrial
+7.0
were
ventricular
ranged
left
to
pressures
by 1.0 to 4.5 mm
one the pressures
other
Hg;
-2.0
DISTRESS
the
left
mm
and
Hg
from
rethe
in eight
of
was no difright
ventri-
and in the other

increase
in oxy-
pulmonary
arterial
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556
RESPIRATORY
level,
indicating
the
presence
to-right
shunt
through
The
ratios
of pulmonary
were
1.2:1
to 1.6:1
Systemic
ranged
between
a saturation
gen
lower
than
the presence
shunt
through
atrial
saturation,
or
above,
two
The
10
in
85
atrium,
mdiright-to-left
was
90%
In
these
observations
on
are
Hg
pressures
and
the
left
mm
to right
Hg.
atrial
The
atrium
Right
ranged
arterial
of
Hg.
from
pressures
pressure
ranged
level.
The
shunt
through
ventricular
estimate
right-to-left
the
10
infants.
ever, a very
the
ductus
infants
Systemic
in
descending
the
other
five
was
above
pressures
were
mm
sure
was
recorded
pressure
varied
age of 46 mm
16 to 35,
and
there
is
Systemic
in
six
an
average
pressure
of 28.5
from
were
obtained
while
100%
20 to 45,
loosely-fitting
mask.
in oxygen
saturation
tively
noted
was
less
infants
significant
of 34
between
and
increase
11% respec-
superior
vena
cava
and right
atrium
in two infants,
indicating
the presence
of a left-to-right
shunt
through
the atrial
septum.
A further
increase
in saturation
the
was
noted
ventricular
streaming
anomalies
effect.
were
in one
level,
No
demonstrated
of these
possibly
congenital
infants
due
in those
to
cardiac
stud-
no
the
the
had
through
systemic
other
data
indicates
difference
about
was
about
mal
and
Hg
Hg
severe
dence
with
of a widely
patent
large
left-to-right
symptoms
instances,
lower,
lower
than
all
ductus
shunt,
an accompanying
of the
fants
with regard
studied,
weight,
great
in the
systolic
lower,
and
pressure
in the
The
norgroup
showed
evi-
arteniosus,
and
in sevright-to-left
diversity
to period
gestational
and
pres-
than
also
group.
also
pul-
arterial
arterial
lower
with
shunt.
In view
average
were
were
distressed
with
1.6: 1 or
with severe
arterial
systemic
10 mm
mildly
small
considerably
systemic
pressures
mean
left-
only
The
pulmonary
The
ductal
ductus
ratios
infants
groups.
10 mm
groups.
had
the
pressures
diastolic
pressures,
differed
mean
average
bedistress
distress.
no
flow
The
two
arterial
was
the
measured,
arterial
others
distress
sure
era!
at
in
it was
the
in all instances.
average
and
a
ductus
saturation
group
shunts
the
other
were
by
a very
the
of the hemodynamic
groups
of patients
and
to
monary
data
administered
A
from
an
atrial
in which
of each
respiratory
Hg;
with
saturation
the
oxygen,
mm.
left
and
pressures
and left and right
are
quite
similar.
About
shunt,
pulmonary
systolic
infants;
average
of 36 mm Hg.
In all these
cases
oxygen
breathing
pres-
(80%)
pulmonary
left-to-right
an aver-
arterial
esti-
oxygen
through
essentially
average
to-right
from 29 to 60, with an averHg; diastolic

pressure
from
with
mean
16 to 40, with
Hg.
(during
tween
infants
with
no respiratory
and
those
with
mild
respiratory
one-half
of 26.5
be
saturation
90%.
sures varied
an average
artery
through
in all
from 63 to 98%. The

saturation
of 63% had
shunt
The
to
also a
How-
could
oxygen
saturation
infants
systemic
arterial
atrial
pressures
age
difficult
this
ranged
lowest
atrial
systolic
pressures
ranged
from 23 to 52 mm
Hg, with
an average
of 38.5; diastolic
presbetween
9 and 30 mm Hg, with
of 19 mm Hg; mean
pulmonary
was
shunt
present
aorta
A comparison
from these
three
Their
arterial
left-to-right
there
was
instances.
arterial
the
6.5
whom
artery
the
ductiis
since
in some
in
mated.
that
was
pulmonary
of
large
left-to-right
arteriosus
was
left
pres-
Pulmonary
the
right-to-left
from
25 to 35 mm Hg. Pulmopressure
was
measured
in
saturation
at the
size
accurately,
shunt
large
from
systolic
noted
actual
a low
gradients
from
1 to
Oxygen
in the pulmonary
artery
in seven
An increase
in oxygen
saturation
of
in
presented
ranged
left
5.5 to 6-9 mm
sures
nary
necropsy.
arteriosus.
to 0 mm
from
at
measured
infants.
administration)
infant
with
86% respectively.
III
ied
seven
Left
instances.
and
Group
anwas
III.
atrial
the
aorta
measured,
hemodynamic
Right
6-9
infant,
arteniosus.
two
it was
one
infants
ductus
SYNDROME
4 to 19% was
to 95% by oxy-
two
where
in
In
descending
in all but
infants
Table
94%.
that in left
of a small
the
babies
babies.
saturation
raised
In
slightly
eating
and
administration.
saturation
four
oxygen
83
left-
ductus
arteriosus.
to systemic
flows
in these
of 86% was
terial
of a small
the
arterial
DISTRESS
of these
after birth
age and
in-
when
mode
ARTICLES
.
557
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RESPIRATORY
558
DISTRESS
TABLE
ANALYSIS
OF
AGE,
WEIGHT,
GF.STATIONAL
AGE
AND
RESPIRATORY
Cases
Average
These
DELIVERY
IN
INFANTS
WITH
AND
WITHOUT
Average
Gest.
Wt.
Average
(Ib)
Caesarian
Age
(hr)
Section
#{149}
37.3
7.5
18.0
35.8
6.5
5.4
distress
34
8 .0
observations
were
compiled
.S
from
early
studies
which
in
the
distress
Severe
S
OF
Normal
Mild
IV
MODE
DISTRESS*
Age
(no.)
SYNDROME
pulmonary
artery
was
by
entered
tile
catherer.
t Infant
of diabetic
of delivery,
mine
an
the
in
overlap
in
complete
ing
with
analysis
not
appear
significant,
that
any
as there
each
group.
analysis
factors
in
hemodynamic
first
IV)
it
these
factors
considerable
was
However,
produced
a more
some
interest-
A graph,
not
shown,
systolic
hours
at
there
crease
the
time
of
is a tendency
gradually
distressed
ably
pulmonary
pressure
study
to age
indicated
had
than
pressures
the
other
in
that
for the pressure

after
birth.
The
infants
lower
relating
or mean
relationship
of right
ventricular
The
greater
the
fants,
tolic
the higher
and pulmonary
those
with
that
it is not
order
right
to plot
ventricular
a larger
number
of
systolic
pressure
lated
to
as
In
tween
patients,
was re-
and
the
to
weight,
patent
ductus
between
mildly
The
tion
distressed
verely
at the
y
same
When
is plotted
(Fig.
2)
infant,
systolic
some
whereas
infants
had
with
a linear
age,
-0.45x
the
groups,
distressed
the
lower
se-
not
regression
of
right
ventricular
systolic
pressure
against
the weight
of the infants
the
higher
pressure.
overlap,
verely
distressed
and it is possible
is the
Also,
it
that
is
infants
that
right
the
that
there
is
the
se-
were smaller
infants
the lower
right
yen-
tricular
and
pulmonary
arterial
pressures
were related to this factor rather than to the
right
the
rise
age
and
shunt,
in
shown,
and
in
in the
The
as this
the
of
shunt
the
age.
does
of
the
also
on
infants
left-tothe
shunts
small
a small
in three
ac-
is
again
is no definite
re-
or gestational
immature
infants.
cineangiographic
with
and
in mixed
venous
large
left-to-right
there
large
relasatura-
saturation
of
weight
infants
difficult.
the
level,
size
depends
although
presence
very
gestational
distressed
that
no
be-
in oxygen
oxygen
the
to age,
it appears
showed
in
ventricular
arterial
represent
shunts
three
of
relationship
is
pulmonary
difference
truly
the
so
role
syndrome
6 demonstrate
weight,
lationship
ventricular
although
apparent
larger
the
right
the
tual
level
of saturation
blood.7
The
presence
45.
it is demonstrated
at the
infants
pressures
lower
arteriosus
tionship
were
distress,
distress
of
demonstrates
a suggestive
decrease
of pressure
with
age
with
a linear
regression
of y =
0.227x
+ 58 for the normal
and
Figure
insys( Fig.
of the infants,
gestational
age
and the presence
of a widely-
age
4, 5 and
in
the
pressures.
evaluation
Figures
shown
to
infants
to separate
the
1. This
age,
of
ventricular
pressures
respiratory
of the
sys-
to weight.
premature
that
all
26.
is similar
age
right
arterial
possible
ventricular
age
gestational
severe
relationship
for
8.2x
pressure
more
and
systolic
to gestational
the
distress
regression
of right
that
An
groups.
respiratory
by
pressure
consider-
two
the
linear
tolic
maturity
to deseverely
had
is represented
3). Again,
observations.
arterial
they
The
The
respira-
(Table
that
syndrome.
groups
dif-
severe
of
fact
to deter-
these
infants
At
made
of
striking
the
distress.
was
role
the
ference
did
were
attempt
possible
explaining
tory
mother.
are
studies
ductal
calculated
infants
age,
commoner
confirmed
shunt
shunt,
in whom
in
ARTICLES
559
80
0
0
70
60
0
0
0
0
o.
50
00
40
.
H
30
20
0 .JJ4Q
1.
FIG.
no
ductal
shunt
Relationship
was
right
of
found
demonstrated
the severely
by
ventricular
saturation
a very
distressed
20
systolic
The
lambs
large
shunt
infants.
of
pressure
elegant
have
the
after
Circulatory
life are
minutes
adjustments
hours
The
available
hemodynamic
mal
the
and
24
to
possibly
and
hours
extrauterine
the
several
this
pulmonary
of
life
is very
the
nor-
systems
meager.4
in
thus
decrease
right-to-left
of
Dawes3
that
in
in
blood
flow.
of
fetal
ventilation
pulmonary
results
vascular
a great
shunt.
ductus
and
temic
arterial
possibly
saturation
vascular
direction,
to
flow
from
provide
This left-to-right
arteriosus
has
aids
in-
Associated
pulmonary
to persist
in the
several
hours
after
lungs
unevenly
infant.
there
is a reversal
of the
the patent
ductus
arteriosus
fetal
shown
least
of
decreases
a left-to-right
through
the
8
regarding
infant
with
age
studies
and
resistance,
through
within
the first few
but are extended
over
information
status
of the
circulatory
first
Normal
Birth
not completed
after
birth
several
in the
to
in pulmonary
with
Changes
30
demonstrated
lungs
crease
DISCUSSION
Infant
MLD
25
resistance
Hemodynamic
HOURS
AGE
data,
and
in one of
N0i&
. SEVERE
I0
fetal
lamb
ventilation
shunt
been
for at
of the
in
increasing
sys-
when
the
are
lungs
expanded.#{176}
RESPIRATORY
560
DISTRESS
SYNDROME
0
80
0
70
60
0
S
0
0
50
I.?
0.1
0
S
40
S
.
0
30
S
20
NORMA1
0 FvILD
SEVERE
NORMAL,
MILD
AND SEVERE
Fic.
The
shunt
2. Relationship
presence
in
of
normal
inferred
ductal
dye
and
dilution
of Adams
a
very
James.8
and
cardiac
and
first
by
Prec
studies
that
left-to-right
systolic
content
blood
rise
blood.
a large
of
3.3
data
the
in
the
ductus
infants,
through
systemic
the ductus,
flow
ratio
studied,
aorta
tenial
sample
were inadequate,
shunt,
the
in one
remaining
the
when
was
the
catheter
the
was
in the
pulmonary
ar-
obtained,
in two the data
in one there
was no ductal
shunt
infant
was
there
minimal
was
a rise
and
in
in oxy-
shown
15 to
vascular
blood,
% in
pulmonary
this
and
appears
the
to rep-
data
small
in Figure
20
hours
systems
present
study
is functionally
eight
or
ventricular
atrial
shunt,
though
anatomically
ma! infants
in the
babies
vol
Although
ductal
the normal
newborn
infant.
Analysis
of their
data
suggests,
however,
that in three
of the
ductus
% in right
to right
are
dif-
to evaluate.
The
that
of infant.
of 2.8 vol
resent
is
in
to weight
as compared
arterial
ficult
there
shunt
pressure
a further
catheteriLind4
and
physiologic
suggested
ductal
was
KILOGRAMS
gen
left-to-rght
studies
The
Lind
large
ventricular
infants
and Cassels1#{176}and also by

zation
studies
by Adams
Rowe
of right
newborn
from
WEHT
patent,
first day
indicate
closed,
al-
in many
of life. In
left-to-right
shunt
norsome
occurs
with
a pulmonary
of 1.6 : 1 or less.
4, none
of age
showed
of the
with
infants
normal
a rise
to
As
over
cardioof
oxygen
ARTICLES
561
80
8
70
0
0
60
00
0
0
0
50
0
0
40
30
0
0
S
S
20
N0fV1AL
a MLD
S
SEVERE
30
31
FIG.
3.
32
33
Relationship
of right
34
35
36
AGE
WEOKS
systolic
ventricular
pressure
37
38
to gestational
39
age
40
41
of infant.
20#{149}
.
NORMAL
MLD
. SEVERE
0
15
Li
j:
10
o#{149}o
5
ci
15
AGE
Fic.
4.
Relationship
of difference
in oxygen
blood
20
25
HOURS
saturation
between
pulmonary
(RV) to age of infants.
artery
(PA)
and
mixed
venous
562
RESPIRATORY
DISTRESS
SYNDROME
20
NORMAL
MILD
. SEVERE
.
5
S
U-.
U0
#{149}5
0c0
I0
a:
0
0
5
0
0
0
0
0
0
0
0
0
4
WEIGHT
Fic.
5.
Relationship
saturation
of
in
greater
than
difference
the
The
findings
as compared
and Lind4
and Rowe
lated
to the
fact
oxygen saturation
between
blood (MV) to weight of
in
pulmonary
2%.
that
artery
difference
to
and
KILOGRAMS
in
those
James8
of
these
of Adams
may be re-
no premedication
employed
in our studies.
It is also
that in the studies
of Rowe
and
was
artery
(PA)
and
mixed
venous
youngest
infant,
strable
between
ductal
5 and
shunt,
whereas
five
11 days
had evidences
infants
of a
shunt.
These
findings,
of
dnidge
et al.1 indicate
be
interesting
James
the
pulmonary
infant.
aged
anatomically
ally
closed
2 days,
for
the
and
that
open,
first
had
no
demon-
those
the
ductus
although
Elmay
function-
7 to 10 days
of
life,
20
0
S
GROUPS
GROUP
I AND K
5
S
Li-
>
cr
.
0
5
S
0
0
0
0
0
30
32
33
FIG.
6. Relationship
of difference
in
oxygen
blood
36
34
GESTA110Ni
saturation
to gestational
GE
between
age
37
38
WEEKS
pulmonary
of
artery
(PA) and mixed
infant.
venous
563
ARTICLES
providing
physiologic
confirmation
anatomical
studies
ent observations
cultatory
of
also
demonstrated
by
Braudo
and
Rowe.14
ductus
arteriosus
commoner
was
by
and
authors
in
quite
unusual
was
The
The
pulmonary
greatly
in
fants
the
it had
adult
still
the
pulmonary
to
first
10
first
tion
day.
was,
lar
and
day.
pulmonary
The
height
pressure
normal
or
peared
that
of
mildly
presence
but
in
the
of
the
shunt
in
It
shunt
were
degree
ductal
Hemodynamic
The
tress
infants
with
status
mildly
temic
arterial
sures
were
and
patent
to
lower;
ductus
left-to-right
shunt
and
gested
that
all
were
associated
syndrome.
more
however,
and
systemic
May,
with
A
indicated,
the
Society
1959.
for
pulmonary
Pediatric
the
instan-
arterial
Research,
the
blood
Buck
Hill
the
ductus
distress
numbers
response
in
and
the
cannot
be
of
infants
circulatory
ad-
of possible
of
infant,
the
differ-
ductus
in the
of
has
lower
presFalls,
patent
The
the
been
cases
showed
The
of
lungs
distress
by
br18
of
in
hyaline
infants
hyaline
been
Craig17
to
contain
fibrin
failure
distress
by
Lendrum
to
be
90%
of
in
a physio-
of these
membrane.
has
and
infancy.
in a series
period
that,
ventricle,
of
syndrome
features
respiratory
membrane
dying
Gitlin
the
early
of cardiac
seems
left
be
patent
an excessive
with
suggested
what
synways.
may
produce
who
found
the neonatal
deficient
due-
A widely
of the
has
these
patent
arteriosus
failure
and
Shanklin,16
necropsies
in
presence
in
in several
ventricle,
development
supmur-
distress
relationship
syndrome
evaluated
patent
disease.
may
left
possible
logically
be
ductus
for
this
however,
noted
that
explained
ventricular
to the
accurately
respiratory
arteriosus
left
of
of a widely
be
on the
significance
may
to
could
load
the
distress
analysis
birth,
arteriosus
ductus
phenomena
although
small
variation
after
are
with
First,
had
with
respiratory
complete
that
in
the
the
responsible
sys-
the ductus.
of these
data
analysis
sug-
circulatory
of
of
drome
pres-
in many
a right-to-left
shunt
through
A preliminary
report
of some
has been
presented,#{176} and first
patent
respiratory
more
commonly
observed
in inrespiratory
distress
and suggested
normal
arteriosus
ges-
murs
fants
cir-
all
in
and
These
findings,
of Burnard,15
who
dis-
they
ces
view
tus
arterial
weight
of a widely
severe
that
the
ductus
infants.
The relationship
Their
pulmonary
age,
at present.
port those
Infants
the
infants.
considerably
a widely
large
compared
as
distressed
to
information
observation
re-
in their
more
apnot
respiratory
differences
necessary
the
Distress
severe
definite
respiratory
be
the
constric-
in
Respiratory
showed
culatory
and
Observations
Severe
the
will
deal
with
ences
tion.
with
to
it
rela-
systemic
premature
vascular
of
possible
and
pressures
age
in-
age.
justment
pres-
the
pulmonary
association
studied,
first
low
distress
gestational
distressed
appears
to be possibly
related
to the disease, but it could
be related
to immaturity.
In
ventricuarterial
pulmonary
respiratory
of comparable
arteriosus
was
end
determining
left-to-right
a decrease
in
infants.
factors
a great
The
to the
a ductal
procure
tational
pulmonary
related
distressed
the
of
sistance,
way
syndrome,
to
during
the
in no
absence
or
only
of
was
ence
pressure
blood
distress
in-
a sugges-
in right
arterial
some
the
however,
decrease
of
almost
pressure
at
severe
to establish
tionship
infants
whereas
levels
There
of a gradual
varied
In
arterial
systemic
with
In order
much
beyond
hours,
infants
fants.
rapidly,
a few
prematurity
differences.
be
the
of life.
very
respiratory
that
these
of patent
pressure
day
within
close
the
first
dropped
levels,
others,
arterial
severe
smaller
and of lower
the normal
and
mildly
by
age.
this
to the
were
than
murmur
to
be related
may
distress,
it is also possible
or immaturity
may explain
arteriand
noted
these
of life
hours
ductus
Burnard,13
The
sure
the
The presthe aus-
of patent
evidences
osus
of
Mitchell.12
corroborate
and
derived
found
in the
the respiratory
demonstrated
Lynch
and
from
Melthe
in-
RESPIRATORY
564
fants
blood
has
the
not
proteins.
found
presence
of hyaline
monary
edema,
studies
observed
variably
Although
a close
preceded
mation.
et
and
edema
has
been
infants
for-
tress
may
the
most
in
pul-
suggested
the
widely
tnicular
the
failure
as the
distress
sented
ductus
cause
syndrome.
evidence
that
of the
heart
is enlarged
if the
infant
recovers,
reduction
of size, adding
port
to
diac
heart
failure.
murmurs
with
respiratory
He
respirahas
the
possibility
yen-
Burnard2
and,
rapid
the
accompanying
pulmonary
of
left
of
undergoes
further
presence
than
in
in
may
be
adults
develop
until
atrial
pressure
pulmonary
are elevated
mm
left
Hg.
The
raised
usually
and
some
doubts
role
tricular
may,
however,
adult
vessels,
regarding
failure.
The
be
and
failure
has
with
congenital
rial pressures
pressure
is most
venous,
appreciate
the
and
transmural
tory
pulnot
the
were
raises
yen-
infants
than
not
ductus
distress
as
infants
syndrome.
cause
The
of
relationship
distress
pres-
sented
but
in
this
be
vasomotor
Third,
right
shunt
by
has
to
that
the
itself
the
respirahas
has
the
could
known,
of the
large
left-to-
may
be
be
It
of
affected
increase
the
size
ductus
by
a high
since
wall.
pressures
seems
the
pressure,
muscular
oc-
distress
entertained.
negative
possibly
the
ductus
response
can
cause
pre-
not
respiratory
be
a thick
to lack
The
response
is
intrathoracic
large
pulsations
in infants
to immaturity
severe
unlikely
of vaso-
be related
hypothesis
certainly
vessel
be
similarly
related
it is
may
be-
lack
The
prolonged
arteries
observed
through
pres-
constriction,
response
systems.
the possibility
that
arteriosus
in the
vessel
constriction.25
vasoconstrictor
it could
to
for
Furthermore,
arteriosus
itself
generalized
may
of umbilical
of the poor
pres-
may
the
with
with
levels,
and
pulmonary
same
constrictor
tone.
of the umbilical
negative
amount
of evidence
to implicate
a widely
the
undergo
of the
casioned
elevated.
Thus
a considerable
has been
accumulated
per-
arterial
shunt
its normal
transmural
pressuies
the
left-to-right
large
also
intrapleural
hours
by
pulmonary
normal
in infants
several
shown
a very
ventricuin
reach
high
negative
effective
left
atrial,
considerably
patent
of a high
process,
the
a state
of vasofor
as
unless
is a marked
resistance
car-
with
left atHg. It is also
that
significant;
distress,
may
the
observed
least
ductus.
ductus
of left
of left
at
low
there
vascular
ence
of a patent
possible
that the
distress
this
capillaries
of
permeable
evidence
been
to
sure
thus
tone
normally,
birth
the
soon
of the pulmonary
vessels
vasoconstriction
may allow
in
more
heart
disease,
of 10 to 15 mm
important
respiratory
the
it remains
that
infants
that
does
pressures
infants
with severe
respiratory
not
significantly
elevated,
lar
constrictor
that
is low
sure.
Inability
maintain
this
venous
and
left
to a level
of 25
atrial
indicate
the ventilatory
vessels
maintain
after
cause
objection
edema
that
or,
sup-
infants5
The
monary
disresponse.
pressure
infants
ensues.
Although
of pulmonary
sistence
a
of
has
also
indicated
are
commoner
in
distress
pre-
possibility
vasodilation
in these
and
in-
arterial
respiratory
of vasoconstrictor
of systemic
arterial
birth
implication
with
the
severe
od24
recovery
decrease
and
generalized
pressure
edema
and
cardiac
failure
possible
patent
have
several
systemic
indicated
indirect
after
finding.
has
by
demonstrated.
that
low
with
rather,
lack
Measurements
blood
striking
had
pressures
that
pres-
conclusively
observation
studied
blood
and
edema
instances
The
presence
of pulmonary
the possible
relationship
to
tory
the
been
the
in-
edema
congestion
and in some
fants
experimental
stressed
as yet,
Second,
pul-
membrane
have
al.21
ence
of intense
affected
infants,
pathologic
membranes
hyaline
Bound
monary
between
pulmonary
SYNDROME
not,
Landing19
association
Lynch2#{176}in his
that
DISTRESS
the
However,
developed
of the
shunt
through
a ductus
which
is partially
patent,
by opening
up small
pulmonary
blood
yessels.
et
But,
al.,
decrease
and since
tress
as has
been
alveolar
expansion
pulmonary
the lungs
syndrome
are
in
shown
is
by Dawes
necessary
to
vascular
resistance;
the respiratory
dis-
not
usually
well
ex-
565
ARTICLES
panded,
it is not
nism
is
very
likely
responsible
that
for
the
this
mecha-
large
ductal
therapeutic
membrane
basis
shunt.
conclusions
disease
can
of
the
limited
Nevertheless,
CONCLUSIONS
The
studies
on
normal
infants
that
pressure
several
drops
a few
be
circulatory
in the
demonstrated
blood
the
elevated
hours
after
birth
adult
levels
The
weight,
to
being
The
ductus
after
birth
in
age
under
first
of infants
with
than
in
lation,
but
since
infants
and
less
mature,
finding
could
not
All
infants
tress
normal
infants
syndrome
severe
also
babies
to
studied,
be
associated
tational
age.
tiation
between
ly
patent
the
with
the
The
possible
ductus
no
association
basis
role
arteriosus
failure,
of
presented.
with
be
The
ure
with
severe
mild
ventricurespira-
possible
of
with
first 10
respiratory
ducti,
with
some
of
a
to
dis-
large
instances,
arterial
were
lower
to the normal
respiratory
symptoms.
the
severely
dis-
be related
to the disbe due to prematurity
role
associated
ductal
be
no
arteriosus
for the
patent
characteristics
infants
evidences
alone.
patent
membrane
with
widely
tressed
infants
could
ease process,
but may
wide-
shunt
of
of left
with
is
discussed.
vasoconstrictor
responsible
for
arterial
hypotension
patent
ductus
ventricular
large
A
tone
systemic
as well
fail-
left-to-right
generalized
could
and
possibly
pulmonary
as for the
widely
arteriosus.
formahypothesis
of vasocon-
related
to prematurity,
and
pulmonary
blood
the ductus
arteriosus,
is
Obviously
those
widely
distress
possibly
systemic
as well
as
ges-
and
These
the
is considered.
The alternate
there
is a generalized
lack
also
hyaline
lack
tion
that
infants
had
with
appreci-
Some
showed
and systemic
arterial
pressures
in these
infants
as compared
study.
tory
striction
affecting
vessels
and
or
could
the
normal.
in
present
of left
the
groups
pulmonary
or
edema,
from
these
infants
not
The
the
as a cause
pulmonary
differ
of
did
and,
of the
syndrome
of
ably
systems
distress
shunts
differen-
prematurity
distress
the
circulatory
respiratory
distress,
distress.
shunts.
appear
weight
definite
respiratory
in
respiratory
respiratory
right-to-left
of
not
severe
mild
after
birth.
considered
and
mild
means
hours
were
left-to-right
with a large
number
of
did
birth
with
respiratory
on
finding
However,
ductus
made
lar
this
by
of
dis-
of
and
obtained
circulatory
had
10 had
The
this
use
were
stress
evidences
widely
patent
ductus
arteriosus
left-to-right
shunt.
In the small
The
smaller
respiratory
had
Nine
circu-
were
the
significance
be evaluated.
with
normal
systems.
first 30
infants
patency
of the
ductus
small
left-to-right
shunt
15 hours
after birth.
membrane
disarterial
pressures
with
these
respiratory
to
syndrome
measurements
in the
of these
in both
severe
distress
syndrome
(hyaline
ease)
revealed
pulmonary
lower
during
that
claimed.26
catheterization
to have
The
of infancy.
given
suggested,
been
Hemodynamic
and
after this period,

patent
and may
say
be
point.
repeatedly
have
to
distress
view
been
results
38 infants
Nineteen
be detecthours.
Al-
stimuli
circulatory
of cardiac
infants.
may
to 15
appropriate
7 to 10 days
Studies
birth
arteriosus
gradually
closes
normal
newborn
infants,
but
shunt
first
10
should
respiratory
has
presented.
fair
SUMMARY
to
and
seems
or
appears
in mature
though
functionally
closed
the ductus
is anatomically
reopen
good
hours
level
a small
left-to-right
able
during
the
the
at least
gradually
the
the
digitalis
and
pressure
attacking
arterial
within
information
it
consideration
from
have
for
gestational
higher
of
period
pulmonary
to near
days.
status
neonatal
the
remains
related
serious
in regard
to hyaline
be reached
on the
far
reaching
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STUDIES ON THE CIRCULATION IN THE NEONATAL PERIOD: The

Circulation in the Respiratory Distress Syndrome
A. M. Rudolph, J. E. Drorbaugh, P. A. M. Auld, A. J. Rudolph, A. S. Nadas, C. A. Smith
and J. P. Hubbell
Pediatrics 1961;27;551
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1961 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.
STUDIES ON THE CIRCULATION IN THE NEONATAL PERIOD: The

Circulation in the Respiratory Distress Syndrome
A. M. Rudolph, J. E. Drorbaugh, P. A. M. Auld, A. J. Rudolph, A. S. Nadas, C. A. Smith
and J. P. Hubbell
Pediatrics 1961;27;551
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/27/4/551
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1961 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Pediatrics 1961 Rudolph 551 66

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Pediatrics 1961 Rudolph 551 66

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STUDIES

The Circulation in the Respiratory

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to pass the catheter

The left atrium

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cle and pulmonary

the saturaIn one of

24.5; the mean

68 mm Hg, with an average

and in the other

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from 29 to 60, with an averHg; diastolic

from 63 to 98%. The

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for the pressure

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and Cassels1#{176}and also by

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(PA) and mixed

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The presthe aus-

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after this period,

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Prec, K. J., and Cassels,

ation with prolonged

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STUDIES ON THE CIRCULATION IN THE NEONATAL PERIOD: The

including high resolution figures, can be found at:

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STUDIES ON THE CIRCULATION IN THE NEONATAL PERIOD: The

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