Respiratory Distress in

Newborn

Neonatal Respiratory Distress

Signs and symptoms

Tachypnea (RR > 60/min)

Nasal faring

Retraction

Grunting

/! "yanosis

/! Desaturation

Decrease# air entry

Down score

Neonatal Respiratory Distress

Etiologies
Pulmonary
Transient
tachypnea of the
newborn (TTN)
Respiratory
distress
syndrome (RDS)
Pneumonia
Meconium
aspiration
syndrome (MS)
ir lea!
syndromes
Pulmonary
hemorrhage
Systemic
Metabolic (e.g.,
hypoglycemia, hypothermia
or hyperthermia)
metabolic acidosis
anemia, polycythemia
Cardiac
Congenital heart disease;
cyanotic or acyanotic
Congestive heart failure
Persistent pulmonary
hypertension of the newborn
(PP!)
!eurological (e.g., prenatal
asphy"ia, meningitis)
#natomic
"pper airway
obstruction
irway
malformation
Rib cage
anomalies

Diaphragmatic
disorders
(e#g#$ congenital
diaphragmatic
hernia$
diaphragmatic
paralysis)
Pulmonary

%& Transient tachypnea of newborn

'& (yaline membrane disease

)& Meconium aspiration syndrome

(MS)

*& Pneumonia

+& ir ,ea! Syndromes

Transient Tachypnea o$
Newborn

TTN (%nown as wet lung) is a relati&ely

mil#' sel$ limiting #isor#er o$ near!term
or term

Delay in clearance o$ $etal lung fui#

results in transient pulmonary e#ema(
The increase# fui# &olume causes a
re#uction in lung compliance an#
increase# airway resistance(
Transient Tachypnea o$
Newborn
Ris! factors-

)aternal asthma

"! section

)acrosomia' maternal #iabetes

*rolonge# labor' +,cessi&e maternal se#ation

-lui# o&erloa# to the mother'Delaye#

clamping o$ the umbilical cor# (
Transient Tachypnea o$
Newborn

.sually near!term or term

Tachypnea imme#iately a$ter birth or within 6

hrs a$ter #eli&ery' mil# to mo#erate
respiratory #istress(

These mani$estations usually persist $or /0!01

hrs' but can last up to 20 hrs

3uscultation usually re&eals goo# air entry

with or without crac%les

4pontaneous impro&ement o$ the neonate is

an important mar%er o$ TTN(
Transient Tachypnea o$
Newborn
.hest /&ray -

*rominent perihilar strea%ing (#ue to

engorgement o$ periarterial lymphatics)

-lui# in the minor 5ssure

*rominent pulmonary &ascular mar%ings

6yperinfation o$ the lungs' with #epression o$

#iaphragm

7 "hest ,!ray usually shows e&i#ence o$

clearing by /0!/8 hrs with complete resolution
by 18!20 hrs
9!ray
-lui# in
the
5ssure
-lui# in
the
5ssure
0eneral Management of
Respiratory Distress

4upplemental o,ygen or ):' i$ nee#e#(

"ontinuously monitor with pulse o,imeter(

;btain a chest ra#iograph(

"orrect metabolic abnormalities

(aci#osis'hypoglycemia)(

;btain a bloo# culture < begin an

antibiotic co&erage (ampicillin
gentamicin)
0eneral Management

*ro&i#e an a#e=uate nutrion( >n$ants with

sustaine# RR >60 breaths/min shoul#
not be $e# orally < shoul# be maintaine#
on ga&age $ee#ings $or RR 60!80
breaths/min' an# N*; with >: fui#s or
T*N $or more se&ere tachypnea
Pulmonary

%& Transient tachypnea of newborn

'& (yaline membrane disease

)& Meconium aspiration syndrome

(MS)

*& Pneumonia

+& ir ,ea! Syndromes

Respiratory Distress 4yn#rome

3lso calle# as hyaline membrane #isease

)ost common cause o$ respiratory #istress

in premature in$ants' correlating with
structural < $unctional lung immaturity(

primarily a?ects preterm in$ants@ its

inci#ence is in&ersely relate# to
gestational age an# birthweight(

/A!B0C o$ those between B0!B6 wee%sD

gestation' in about AC beyon# B2 wee%sE
gestation
*hysiologic abnormalities

4ur$actant #e5ciency! increase in

al&eolar sur$ace tension(

Fung compliance #ecrease# to /0!00C

o$ normal

3telectasisGareas not &entilate#

Decrease al&eolar &entilation

Re#uce lung &olume

3reas not per$use#

Normal Expiration
With Surfactant
Surfactant Function
Abnormal Respiration
Without Surfactant
17
Compliance
Pressure
Volume
Opening pressures
Maximal volume
Ris% $actors

Prematurity

Maternal diabetes

Multiple births

Electi1e cesarean section

without labor

Perinatal asphy/ia

.old stress

0enetic disorders
Decreased risk

"hronic intrauterine stress

*rolonge# rupture o$
membranes

3ntenatal steroi# prophyla,is

.linical Manifestations

3ppear within minutes o$ birth may not be recogniHe# $or

se&eral hours in larger preterm

Tachypnea (>60 breaths/min)' nasal faring' subcostal an#

intercostal retractions' cyanosis < e,piratory grunting

Ireath soun#s may be normal or #iminishe# an# 5ne rales

may be hear#

*rogressi&e worsening o$ cyanosis < #yspnea( I* may $all@

$atigue' cyanosis an# pallor increase < grunting #ecreases(

3pnea an# irregular respirations are ominous signs

>n most cases' symptoms an# signs reach a pea% within B

#ays' a$ter which impro&ement occurs gra#ually(
.hest /&ray- 5n#ings can be gra#e# accor#ing
to the se&erity

Gra#e / (mil# cases)J the lungs show 5ne

homogenous groun# glass sha#owing

Gra#e 0J wi#esprea# air bronchogram

become &isible

Gra#e BJ confuent al&eolar sha#owing

Gra#e 1J complete white lung 5el#s with

obscuring o$ the car#iac sha#ow
Chest "$ray%
&rade '
0rade '
0rade )
0rade *
Management
Prevention:

Fung maturity testingJ lecithin/sphingomyelin (F/4) ratio

Tocolytics to inhibit premature labor(

3ntenatal corticosteroi# therapyJ

7 They in#uce sur$actant pro#uction an# accelerate
$etal lung maturation(
7 3re in#icate# in pregnant women 01!B1 wee%sE
gestation at high ris% o$ preterm #eli&ery within the ne,t
2 #ays(
7 ;ptimal bene5t begins 01 hrs a$ter initiation o$
therapy an# lasts se&en #ays(
Prevention:

3ntenatal corticosteroi# therapy consists o$ either J

K Ietamethasone /0 mg/#ose >) $or 0 #oses' 01 hrs apart'
or
K De,amethasone 6 mg/#ose >) $or 1 #oses' /0 hrs apart

+arly sur$actant therapyJ prophylactic use o$

sur$actant in preterm newborn L02 wee%sE
gestation(

+arly "*3* a#ministration in the #eli&ery

room(
Treatment

3#minister o,ygen

>nitiate "*3* as early as possible in in$ants

with mil# RD4

4tart ): i$ respiratory aci#osis (*a";0 >60

mm6g' *a;0 LA0 mm6g or 4a;0 LM0C)
with an -i;0 >0(A' or se&ere $re=uent apnea(

3#minister sur$actant therapyJ early rescue

therapy within 0 hrs a$ter birth is better than
late rescue treatment when the $ull picture o$
RD4 is e&i#ent(
Types of Surfactant
NNatural Surfactants: contain appoproteins
SP&2 3 SP&.

"urosur$ (e,tract o$ pig lung mince)

4ur&anta (e,tract o$ cow lung mince)

>n$asur$ (e,tract o$ cal$ lung)

NSynthetic Surfactants:do not contain proteins

+,ocer$

3F+"

Fucinactant (4ur$a,in)
30
Surfactant Therapy for RDS
Surfactant Therapy for RDS

>mpro&ement in compliance'
$unctional resi#ual capacity' an#
o,ygenation

Re#uces inci#ence o$ air lea%s

Decreases mortality
Mode of administration of
Surfactant

Dosing may
be #i&i#e#
into 0
alli=uots an#
a#minitere#
&ia a A!-r
catheter
passe# in
the +T
4nsure techni5ue

>ntubation!

sur$actant!

e,tubation to "*3*
Pulmonary

%& Transient tachypnea of newborn

'& (yaline membrane disease

)& Meconium aspiration syndrome

(MS)

*& Pneumonia

+& ir ,ea! Syndromes

Ris! 6actors-

*ost!term pregnancy

*re!eclampsia' eclampsia' maternal

hypertension'

)aternal #iabetes mellitus

>.GR

+&i#ences o$ $etal #istress (e(g('abnormal

biophysical pro5le)
)econium 3spiration
4yn#rome
.linical Manifestations

)econium staining amniotic fui# (meconium

staine# nails' s%in < umbilical cor# )

4ome in$ants may ha&e mil# initial

respiratory #istress' which becomes more
se&ere hours a$ter #eli&ery(

*neumothora, an#/or pneumome#iastinum

**6N in se&ere cases

6ypo,ia to other organs (e(g(' seiHures'

oliguria)
Pathophysiology
Chest x-ray: Areas of hyperexpansion mixed with patchy
densities and atelectasis
.hest /&ray
Management
4n the DR or 7R-

:isualiHation o$ the &ocal cor#s < tracheal

suctioning be$ore ambu!bagging shoul# be #one
only i$ the baby is not &igorous
4n the N4."-

+mpty stomach contents to a&oi# $urther aspiration(

4uction $re=uently < per$orm chest physiotherapy(

Management

"onsi#er "*3*' i$ -i;0 re=uirements >0(1@ howe&er

"*3* mayaggra&ate air trapping an# must be use#
cautiously(

)echanical &entilationJ in se&ere cases (pa";0 >60

mm6g orpersistent hypo,emia (pa;0 LA0 mm6g)(

"orrect systemic hypotension (hypo&olemia'

myocar#ial #ys$unction)(

)anage **6N' i$ present

)anage seiHures or renal problems' i$ present(

4ur$actant therapy in in$ants whose clinical status

continue to#eteriorate(
Pulmonary

%& Transient tachypnea of newborn

'& (yaline membrane disease

)& Meconium aspiration syndrome

(MS)

*& Pneumonia

+& ir ,ea! Syndromes

Pneumonia
Pneumonia
.ommon organisms-

GI4

gramO&e organisms (e(g( E.Coli'

Klebsiella,Pseudomonas)

' Staph. aureus' Staph. epidermidis

Candida(

ac=uire# &iral in$ections (e(g(' 64:'

"):)(
.linical Manifestations

+arly mani$estations may be nonspeci5c (e(g(' poor

$ee#ing' lethargy' irritability' cyanosis' temperature
instability

Respiratory #istress signs may be superimpose#

upon RD4 or I*D(

>n a &entilate# in$ant' the most prominent change

may be the nee# $or an increase# &entilatory
support(

4igns o$ pneumonia (#ullness to percussion' change

in breathsoun#s' rales or rhonchi) are #iPcult to
appreciate(
.hest /&raysJ in5ltrates or
e?usion
45
Management

>nitiate ampicillin an#

gentamicin >:@ mo#i$y
accor#ing to culture results
an# continue therapy $or /1
#ays(

>$ there is a $ungal in$ection'

an anti$ungal agent is use#(
Pulmonary

%& Transient tachypnea of newborn

'& (yaline membrane disease

)& Meconium aspiration syndrome

(MS)

*& Pneumonia

+& ir ,ea! Syndromes

ir ,ea! Syndromes
Ris! 6actors-

):')34' sur$actant therapy without

#ecreasing pressure support in
&entilate# in$ants

&igorous resuscitation'

prematurity

pneumonia
.linical Manifestations

4pontaneous pneumothora, may be

asymptomatic or only mil#ly symptomatic
(i(e(' tachypnea an# Q;0 nee#s)(

>n unilateral cases' chest asymmetry is note#'

me#iastinum shi$t to the opposite si#e(

>$ the in$ant is on &entilatory support will ha&e

su##en onset o$ clinical #eterioration (i(e('
cyanosis' hypo,emia' hypercarbia <
respiratory aci#osis associate# with #ecrease#
breath soun#s an# shi$te# heart soun#s)(
Tension pneumothora/

(a li$e!
threatening
con#ition) R
Scar#iac
output an#
obstructi&e
shoc%@ urgent
#rainage
prior to a
ra#iograph is
man#atory(
.hest / ray
7thers
Pneumomediastinum

>t can occur with aggressi&e +TT insertion' RyleEs $ee#ing

tube

insertion' lung #isease' ):' or chest surgery (e(g(' T+-)(

Pneumopericardium
Pneumoperitoneum
Subcutaneous emphysema
Systemic air embolism
)assi&e *neumoperitoneum in ):
neonate
Than% Tou G