
































Original Article Childhood AsthmA And its AssoCiAted FACtors Among Children

J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202240

Original Article

DOI: 103126/JNPS.V4113

1Associate Professor, Department of Paediatrics, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
2Assistant Professor, Department of Paediatrics, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
3Professor, Department of Paediatrics, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal

Incidence, Outcome and Predictors of Mortality in Respiratory 
distress syndrome (RDS): A Prospective Cohort Study at Tertiary 
Care Hospital in Nepal

Introduction: With advances in therapies during antenatal and perinatal 
period, there has been apparent decrease in incidence and mortality due to 
respiratory distress syndrome (RDS). However, there is paucity of data on exact 
incidence and outcome of RDS in resource limited setting. This study was 
conducted with the primary aim to describe the outcome of RDS and analyze 
the predictors for mortality.

Methods: A prospective observational study was conducted in the Neonatal 
Intensive Care Unit (NICU) and Neonatal Unit of Tribhuvan University Teaching 
Hospital (TUTH), Kathmandu, Nepal from October 2019 to April 2021. 

Results: A total of 94 preterm newborns developed RDS giving prevalence of 
20.5 per 1000 live birth cohort at TUTH. Incidence of RDS among preterm 
babies was 14.6%. The median duration of continuous positive airway 
pressure (CPAP) was 48 hours (Range 8 - 192 hours). Inhospital mortality rate 
was 15 (15.96%). Lower gestational age and premature rupture of membrane 
(PROM) were significantly associated with higher mortality whereas Normal 
Vaginal delivery (NVD) was associated with lower mortality. Logistic regression 
analysis for risk of dying for the cohort predicted that lower birth weight (AOR 
= 0.99; 95% CI = 0.99 - 0.99; P = 0:01), sepsis (AOR = 145.14; 95% CI = 
5.04 - 4175.15; P = 0:004) are independently associated with increased risk 
of dying whereas increase duration of NICU stay decreased the risk (AOR = 
0.71; 95% CI = 0.54 - 0.91; P = 0:01).

Conclusions: The mortality rate decreases with increasing gestational age 
and birth weight. A number of neonatal factors, either in isolation or in 
combination, were significantly associated with in-hospital mortality

Abstract

*Corresponding Author
Srijana Basnet
Associate professor,
Department of Paediatrics,
Institute of Medicine,
Maharajgunj Medical Campus,
Kathmandu, Nepal.
Email- drsrijanabasnet@yahoo.com

Article History 
Received On : 06 Apr, 2022
Accepted On : 15 Dec, 2022

Funding Sources: None

Conflict of Interest: None

Keywords: CPAP; Mortality; RDS; 
Surfactant

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i1.41183 Introduction

It is estimated that 15 million babies are born preterm, with 60% occurring in South 
Asia and sub-Saharan Africa and this number is rising.1,2 Respiratory distress syndrome 
(RDS) occurs in 60 - 80% of infants < 28 weeks, 50% of born between 28 – 32 weeks, 
15 - 30% of infant 32 - 36 weeks and rarely in those < 37 weeks gestational age.3,4 The 
incidence of RDS is reported to be 6.8 - 14.1% of preterm live births and contributed 
13.5% of total neonatal deaths in India.5,6 However, incidence of RDS and its mortality 
rate has substantially reduced by improved antenatal and intrapartum care of preterm 
pregnancies. Similarly, optimal respiratory support in the form of continuous positive 
airway pressure (CPAP) or mechanical ventilation and surfactant replacement therapy 

Copyrights & Licensing © 2022 by author(s). This is an Open Access article distribut-
ed under Creative Commons Attribution License (CC BY NC )

Srijana Basnet1, Surabhi Aryal2, Laxman Shrestha3



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 41

Original ArticleOutcOme Of RespiRatORy DistRess synDROme in nepal

(SRT) has been identified as important interventions that could save 
many premature babies suffering from RDS.7,8 But the important 
fact is that these recommendations are based on published trials 
done in high-income countries where care for premature babies 
in neonatal intensive care unit (NICU) is undertaken by trained 
doctors and nursing staff, facilities for round the clock monitoring, 
laboratory and radiological services and optimal CPAP devices 
are available. Without optimal equipment and skilled manpower, 
it is likely that these therapies may not be as effective and possibly 
less safe.

It has been more than a decade that CPAP and SRT are in use 
for the management of RDS at level III NICU in Nepal. However, 
these technologies for RDS treatment are used inconsistently in 
different health care settings and there has been wide variation in 
the optimal care that the newborn receive in NICU.

Thus, it is crucial for us to analyze the impact of providing special 
care and respiratory support to preterm infants on RDS related 
survival and to identify important factors contributing to mortality. 
Therefore, this study was designed with the aim to determine the 
incidence, describe the outcome and evaluate the predictors of 
mortality among preterm infant delivered at tertiary care center 
of Nepal. 

Methods
This is a prospective cohort study was conducted over one and half 
year period between October 2019 to April 2021, at Tribhuvan 
University Teaching Hospital (TUTH), Kathmandu, Nepal after 
approval from institutional research committee. All neonates born 
before 37 weeks of gestation delivered at TUTH and clinically 
diagnosed as RDS based on the need of respiratory support 
within six hours for at least for 24 hours were enrolled in the study. 
Respiratory support was given if at least two out of five clinical signs 
(Respiratory Rate < 60 / min, expiratory grunting, suprasternal / 
intercostal / subcostal retraction, cyanosis at room air, flaring of 
the alae nasi) were present. The neonates were excluded if they 
were < 22 weeks of age or < 500 gm, and had any one of the 
following; perinatal asphyxia requiring endotracheal intubation at 
birth, major or life threatening congenital abnormality, suspected 
heart disease in antenatal echocardiography, delivered through 
meconium stained liquor, confirmed diagnosis of congenital 
pneumonia or early onset (within 72 hours) sepsis. All eligible 
premature babies fulfilling inclusion criteria and admitted in NICU 
were enrolled in the study after obtaining written consent from 
their parents. All these babies were monitored for the signs of 
respiratory distress using Silverman’s Anderson scale and were 
followed up every day until discharge. A detailed history, clinical 
examination and hospital course were recorded in pre designed 
study Performa. Respiratory support for RDS was provided as per 

the NICU protocol of the department which are as follows

•	 For newborn < 30 weeks’ gestation and less than 1500 gm 
who do not need intubation for stabilization, was started on 
prophylactic CPAP immediately after birth even in absence of 
signs of respiratory distress. 

•	 For newborn < 30 week gestation and more than 1500 
gm, they were observed for signs of respiratory distress 
using Silverman’s scoring. If they developed any signs of 
respiratory distress, they were put on oxygen by head box. If 
RDS score was ≥ 3 CPAP was started.

All new born started on CPAP were re-assessed every 15 minutes. 
CPAP was increased up to 7 cm H2O unless RDS score is ≤ 
3. Even after nCPAP of at least 7 cm for at least 15 minutes, if 
the infant requires FiO2 < 0.30 to maintain oxygen saturation 
between 88 - 92% or RDS score persistently remain < 3, early 
rescue surfactant was given. The SRT preferably be given within 
two hours after birth. Primary outcomes were death or discharge 
from hospital and the secondary outcome were BPD defined as 
oxygen dependency at twenty eight days of life. Other outcome 
includes neonatal sepsis, pneumothorax and retinopathy of 
prematurity. Data collected were entered into SPSS version 26 for 
analysis. Descriptive statistics were used for continuous variables 
whereas frequency listings and percentages were used to 
describe categorical variables. The log-rank test was used to test 
for associations among various GA and birth weight categories 
presented in the Kaplan-Meier survival curves. The Fischer’s exact 
and Pearson’s Chi square tests were used to test for associations 
among socio-demographic and treatment variables with the 
outcome death. A p-value < 0.05 was considered statistically 
significant at 95% confidence interval. Multiple logistic regression 
(odds ratio) was used to determine independent variables for the 
outcome death.

Results
During the study period, there was 4578 live delivery and 
among them 644 (10%) were preterm. 94 developed RDS giving 
prevalence of 20.5 per 1000 live birth cohort. Incidence of 
RDS among preterm babies was 14.6%. A total of 739 inborn 
newborns were admitted to NICU and neonatal unit and RDS 
accounted for 12.7% of all neonatal admissions for the study 
period. As demonstrated in table 1, among 94 premature 
neonates with RDS, 49 (52.1 %) were males. The mean gestation 
was 31.96 ± 2.04 weeks and mean birth weight was 1581.61 ± 
430.69 grams. Majority of them were between 28 to < 34 weeks 
of gestation. Incidence of RDS was highest among preterm babies 
between 28 to < 32 weeks (80.49%). 



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Table 1. Neonatal demographic characteristics and maternal risk factors for premature delivery

Characteristics Study population (N = 119)

Gender 
Male, n (%) 
Female, n (%)

49 (52.1)
45 (47.9)

Mode of delivery
NVD, n (%)
LSCS, n (%)

25 (26.6)
69 (73.4)

Birth weight at admission (grams)
<1000, n (%)
1000 - 1499 grams, n (%)
1500 - 2500 grams, n (%)

6 (6.4)
39 (41.5)
49 (52.1)

Mean Gestational age (± SD) 31.96 (2.04)

Gestational age (weeks)
< 28, n (%)
28 to < 32, n (%)
32 to < 34, n (%)
34 to < 37, n (%)

3 (3.2)
33 (35.2)
33 (35.2)
25 (26.6)

Gestational age (weeks)
28 <
to < 32 28
to < 34 32
to < 37 34

Mean Birth weight in grams (± SD)
1181.67 (189.24)
1332 (338.73)
1670.91 (376.13)
1841.21 (432.86)

Weight for gestational age according to WHO fetal growth chart
Appropriate for gestational age (AGA), n (%)
Small for gestational age (SGA), n (%
Large for gestational age (LGA), n (%)

37 (39.4)
53 (56.4)
4 (4.3)

(%) Resuscitation required, n 17 (18.1)

Mean Maternal age (± SD) 28.98 (4.64)

Parity 
Primgravida, n (%)
Multigravida, n (%)

48 (51.1)
46 (48.9)

Antenatal Steroids 
Complete, n (%)
Incomplete, n (%)
None, n (%)

54 (57.4)
26 (27.7)
14 (14.9)

PROM for more than 18 hours, n (%) 24 (25.5)

Pregnancy Induced Hypertension (PIH), n (%) 29 (30.9)

Gestational Diabetes Mellitus (GDM), n (%) 6 (6.4)

Table 2 shows incidence of RDS and comparison of respiratory 
support given to neonates according to the gestational age. 
Incidence of RDS was highest in gestational age between 28 to 
< 32 weeks (80.49%). Majority of the enrolled preterm babies 
(86.18%) were managed on CPAP. INSURE was done in 50 

(52.6%) babies and one them required repeat dose. There were 
15 (15.96%) deaths during the study period with six (40%) 
occurring within the first week of life.



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Table 2. Incidence of RDS and Comparison of treatment in different gestational age 

Gestational age (weeks) < 28 (n = 3) 28 to < 32 (n = 33) 32 to < 34 (n = 33) 34 to < 37 (n = 25) Total (n = 94)

Incidence of RDS among Preterm babies, (%) 21.43 80.49 40.74 4.93 14.6

Primary respiratory support
O2, only, n (%)
CPAP, n (%)
Mechanical Ventilation (MV), n (%)

0
2 (66.7)
1(33.3)

1 (3.03)
30 (90.91)
2 (6.61)

4 (12.13)
28 (84.85)
1 (3.03)

3 (12)
21 (84)
1 (4)

8 (8.4)
81 (86.18)
5 (5.2)

SRT, n (%) 3 (100) 23 (69.7) 11 (30) 13 (52) (52.6) 50

MV required, n (%)
Primary respiratory support, n (%)
CPAP failure, n (%)
After 96 hours of life, n (%)

2 (66.7)
1
1
0

14 (42.43)
2
6
6

2 (6.07)
1
1
0

8 (32)
1
5
2

26 (28.43)
5
13
8

Death, n (%)
Early
Late

2 (66.7)

2

10 (30.31)
4
6

1 (3.04)

1

2 (8)
2

15 (15.96)
6
9

The  median  duration  of  CPAP  was  48 hours  (range  8  - 192  
hours). The median duration of hospital stay was 14 days (range 
4 - 54 days). The most common complication was sepsis followed 
by apnea. (Table 3).

Table 3. Duration of respiratory support and Morbidity profile of 
survived newborns

Duration of respiratory support:
Median duration of CPAP (Range)
Median duration of MV (Range)
Median duration of respiratory support 
(Range)

Median  duration  of  hospital  stay   

48 (8 - 192) Hours
96 (32 - 264) Hours
96 (22 - 632) Hours
14 (4 - 54)days  

Complications:
Retinopathy of prematurity (%)
Bronchopulmonary Dysplasia (%)
Pneumothorax (%)
Sepsis (%) 
Apnea (%)

3 (3.2)
1 (1.1)
3 (3.2)
27 (28.7)
10 (12.7)

Survival by gestational age is illustrated in figure 1 by Kaplan 
Meier graph. For those with GA of 32 weeks and above, survival 
was 97%, 95% and 95% on day 10, 20 and 30 respectively. 
However, for those with GA below 32 weeks, survival was 
80%, 66% and 61% on day 10, 20 and 30 respectively. From 
the log rank test, survival distribution of different GA categories 
comparing those born with a GA of < 32 weeks and  ≥ 32 weeks 
was statistically significant (P = 0.015) indicating that having a 

GA above 32 weeks is significantly associated with better survival.

Figure 1. Chance of survival by gestational age

Table 4 describes the maternal characteristics and risk factors 
for survivors versus non-survivors. Lower gestational age (P = < 
0.001) and PROM (OR 3.19; 95%CI 1.02 ± 10.05; P = 0.04) 
were significantly associated with higher mortality whereas NVD 
(OR 0.240, 95% CI 0.08 ± 0.76; P = 0.01) is associated with 
lower mortality. 



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Table 4. Comparison of maternal characteristics between survivors and non-survivors

Survivor N (%) Non survivor N (%) Relative Risk P Value

Total 79 (84.05) 15 (15.96)

Maternal age 29.02 ± 4.81 28.81 ± 3.77 0.88

Parity 1.7722 ± .98644 1.8667 ± .91548 0.74

Delivery Mode NVD 17 (21.5) 8 (53.34) 0.240 (0.08 ± 0.76) 0.01

Mean Gestational age ± SD (weeks)
< 28 (n= 3)
28 to < 32 (n = 33)
32 to < 34 (n = 33) 
34 to < 37 (n = 25)

32.33 ± 1.81
1 (33.3)
23 (69.7)
32 (97)
13(92)

30.0 ± 2.14
2 (66.7)
10 (30.3)
1(3)
2(8)

<0.001

Maternal PIH 24 (30.4) (33.33) 5 1.15 (.354 ± 3.72) 0.82

Maternal Heart disease 4 (5.06) 1 (6.67) 1.34 (0.14 ± 12.90) 0.80

Maternal GDM 5 (6.33) 1 (6.67) (9.76 ± 0.12) 1.06 0.97

PROM 17 (21.52) 7 (46.67) (10.05 ± 1.02) 3.19 0.04

Twin Pregnancy 8 (10.12) 1 (6.67) (5.48 ± 0.08) 0.64 0.67

APH 11 (13.93) 1 (6.67) (3.71 ± 0.05) 0.45 0.45

Table 5 depicts the finding of logistic regression analysis for risk 
of dying for the cohort. Lower birth weight (AOR = 0.99; 95% 
CI = 0.99-0.99; P=0:01), sepsis (AOR = 145.14; 95%CI = 
5.04 - 4175.15; P = 0:004) were independently associated with 
increased risk of dying whereas increase duration of NICU stay 
decreased the risk (AOR = 0.71; 95%CI = 0.54 - 0.91; P = 0:01). 

Table 5. Logistic regression model for mortality in RDS

Adjusted OR 95% CI P value

Birth weight 0.99 0.99 - 0.99 0.01

Male Sex 0.41 0.04 - 4.06 0.45

 Need of resuscitation at
birth

0.23 .01 - 5.75 0.36

Pneumothorax 36 .01 - 36 0.38

Sepsis 145.14 5.04 – 417.51 0.004

SRT 0.34 .026 - 4.320 0.41

MV needed 0.01 0.01- 0.01 0.99

Length of NICU stay 0.71 0.54 - 0.91 0.01

 Duration of respiratory
support

1.00 0.99 - 1.01 0.47

Apnea 0.97 .02 - 76.76 0.99

Discussion
The incidence of RDS among preterm in our study was 14.6% 
which was similar to the incidence reported from India.5,6 Lower 
the gestational age higher would be RDS incidence. However, we 
observed higher incidence of RDS among infant born between 28 
- 32 weeks as compared to those < 28 week ((80.49 Vs 21.43%). 
This contrast finding of the study may be  due to the fact that 
only newborn admitted in NICU or neonatal unit were enrolled in 
the study and considering poor outcome of extremely premature 

babies in our setup, most of the family opted not to treat their 
babies. In the present study, the neonatal mortality rate due to RDS 
was 15.94%. Various studies done in NICU of medical colleges 
of India over last 10 years have reported the mortality rate as 
44.7% to 15%.9-11 In the retrospective study done over three 
months period at NICU of tertiary center in Western Nepal among 
preterm newborn, the RDS prevalence was found to be 14% with 
mortality rate of 46.15%.12 In a similar study done in Kenya in 
2015, the mortality rate due to RDS was found to be 72.3%. 

In our study CPAP was provided in 86.18% and 5.2% of the 
preterm babies were mechanically ventilated as a primary 
respiratory support. In the study done by Sambhaji S W et al,11 
87% of newborn received CPAP and 13% received ventilation as 
compared to study done by Phirke DS et al13where 78% received 
CPAP and 22% were ventilated. In our NICU, we follow protocol of 
providing prophylactic CPAP for newborn born less than 30 weeks 
and early CPAP for those born above 30 weeks. This might be the 
plausible explanation for less frequent mechanical ventilation.

Incidence of BPD and ROP observed in this study is low compared 
to the findings from western world.14 This could be due to low 
survival rate among babies less than 28 weeks in our center. 
Nevertheless, resuscitation in room air and meticulous FiO2 
monitoring while providing respiratory support could decrease the 
oxidative stress and related pulmonary and eye injury.  Gestational 
age is a key factor in the survival of preterm babies world-wide. 
This is demonstrated in the present study as well where we found 
significant association between lower GA and birth with higher 
mortality in bivariate analysis. Two thirds of the babies less than 
28 weeks died hence our biggest challenge is to save lives of 
babies less than 28 weeks.

In the present study, sepsis was observed in 28.7% of neonates 
and was strongly associated with neonatal mortality. Studies 
in India have shown the incidence of sepsis ranging 31.8% to 
43.5%.11,15 Sepsis was the most common co- morbidity among 
newborn with RDS receiving SRT. Mortality due to sepsis among 



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babies with RDS ranges from 25 to 49% in the other studies done 
in India.9,16 Sepsis rate in our study is higher than that observed 
in Korean study17and studies from Greece18 indicating importance 
of infection prevention practices for improving preterm survival.

This is one of the few prospective studies on the outcome of RDS at 
tertiary care center of Nepal. However, there are few limitations of 
the study. Chest x-ray was not evaluated in present study as most 
of the time chest X-ray was taken after surfactant administration 
and radiologist report was not available for many of them. Since, 
our NICU protocol for starting respiratory support is based on the 
clinical monitoring, we did not analyze admission ABG which was 
not available in many newborns. Similarly, due to limited oxygen 
blender we could not also keep record of highest FiO2 requirement 
in all newborns. Hence, findings of chest X-ray, FiO2 requirement 
and ABG parameters could not be done analyzed as predictors 
of mortality.
  

Conclusions
Our study provides gestational age specific incidence of RDS at 
tertiary care center of Nepal. Lower gestational age, birth weight 
and PROM were significantly associated with higher mortality 
whereas NVD is associated with lower mortality. Considerable 
attention should be directed toward prevention of infection for 
better survival of preterm babies with RDS.  

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