

Respiratory Distress in Newborn

Presented by : Dr. Walaa mousa

Definition
 Respiratory distress is common immediately after birth, and is
typically caused by abnormal respiratory function during the
transition from fetal to neonatal life.

 It is manifested by tachypnea, nasal flaring, intercostal or

subcostal retractions, audible grunting, and cyanosis.

 Neonatal respiratory distress may be transient; however,

persistent distress requires a rational diagnostic and
therapeutic approach to optimize outcome and minimize
morbidity.
 Neonatal Respiratory Distress 
Signs and symptoms
 Tachypnea (RR > 60/min)
 Nasal flaring
 Retraction
 Grunting
 +/- Cyanosis
 +/- Desaturation
 Decreased air entry
Differential Diagnosis
 
Neonatal Respiratory Distress Etiologies

Pulmonary Systemic
Metabolic (e.g.,
Anatomic
Transient tachypnea of hypoglycemia, hypothermia
the newborn (TTN) or hyperthermia)
Upper airway
metabolic acidosis obstruction
Respiratory distress
syndrome (RDS) Airway
anemia, polycythemia malformation
Pneumonia Rib cage anomalies
Cardiac
• Congenital heart disease;
Meconium aspiration Diaphragmatic
cyanotic or acyanotic
syndrome (MAS) disorders
• Congestive heart failure
• Persistent pulmonary (e.g., congenital
Air leak syndromes hypertension of the newborn diaphragmatic
(PPHN) hernia,
Pulmonary
hemorrhage diaphragmatic
Neurological (e.g., prenatal paralysis)
asphyxia, meningitis)
Determining Differential Diagnosis

What you need to know…

• History

• Presentation/ clinical assessment

• X-rays

• Lab values (ABG, Electrolytes, blood glucose, hematocrit

Sepsis work up which includes (CRP),
 
Down score
Treatment
 the initial treatment is aimed at resuscitation of the neonate,

 optimizing tissue oxygenation,

 decreasing the work of breathing,

 preventing hypoxia, hypercapnia and acidosis.

 supportive therapy

 Definitive management
Supportive therapy:
 supportive care and proper nursing care are very crucial for success of
management.

 Thermo-neutral environment : The neonate should be nursed in a

thermoneutral environment. Hypothermia will initiate the cascade of PPHN and
aggravate hypoxemia. Baby’s temperature should be maintained between 36.5
0-37.5 0C. VLBW neonates need incubator for their temperature maintenance
and for providing adequate humidity

 Electrolyte balance, fluids and normal acid-base balance should be maintained.

Preterm babies have higher insensible water loss (40-100 ml/kg). Fluid intake
should be titrated accurately by recording serial weight, intake/ output, serum
sodium and urine specific gravity.

 Antibiotics should be started in all cases of suspected sepsis or pneumonia.

 Calcium and glucose homeostasis should be ensured.

 Maintain normal mean arterial pressure. Hypotension should be

corrected by using appropriate fluid volumes and inotropes if
necessary

 Hypovolemia and anemia are to be treated adequately as

necessary. Hematocrit should be maintained above 40% in the
acute phase of the disease .

 Oral feeding is withheld initially. Once the baby stabilizes on the

respiratory support and respiratory rates are less than 70/min,
gavage feeding should be started
Definitive management
 Oxygen therapy

 Surfactant replacement

 (CPAP): any baby who is grunting, depending on the severity of

respiratory distress, should be given either continuous positive
airway pressure (CPAP) or intubated and put on ventilator
support with PEEP .

 Mechanical ventilation

 Chest tube for tension pneumothorax

 Surgery for tracheoesophageal fistula (TEF) , GDH

Transient Tachypnea of Newborn

 TTN (known as wet lung) is a relatively mild,

self limiting disorder of near-term or term
 Delay in clearance of fetal lung fluid results in
transient pulmonary edema. The increased
fluid volume causes a reduction in lung
compliance and increased airway resistance.
 Transient Tachypnea of Newborn

Risk factors:
 Maternal asthma

 C- section

 Macrosomia, maternal diabetes

 Prolonged labor, Excessive maternal sedation

 Fluid overload to the mother,Delayed clamping of the

umbilical cord .
Transient Tachypnea of Newborn
 Usually near-term or term
 Tachypnea immediately after birth or within 6 hrs
after delivery, mild to moderate respiratory distress.
 These manifestations usually persist for 12-24 hrs,
but can last up to 72 hrs
 Auscultation usually reveals good air entry with or
without crackles
 Spontaneous improvement of the neonate is an
important marker of TTN.
Transient Tachypnea of Newborn
Chest x-ray :
 Prominent perihilar streaking (due to engorgement of
periarterial lymphatics)
 Fluid in the minor fissure

 Prominent pulmonary vascular markings

 Hyperinflation of the lungs, with depression of

diaphragm
 ► Chest x-ray usually shows evidence of clearing by 12-
18 hrs with complete resolution by 48-72 hrs
chest X-ray: Transient Tachypnea of Newborn

Fluid in the
fissure
Respiratory Distress Syndrome (RDS)
 Also called as hyaline membrane disease
 Most common cause of respiratory distress in
premature infants, correlating with structural &
functional lung immaturity.
 primarily affects preterm infants; its incidence is
inversely related to gestational age and
birthweight.
 15-30% of those between 32-36 weeks‘ gestation,
in about 5% beyond 37 weeks' gestation
Physiologic abnormalities
 Surfactant deficiency- increase in alveolar
surface tension.
 Lung compliance decreased to 10-20% of
normal
 Atelectasis…areas not ventilated
 Decrease alveolar ventilation
 Reduce lung volume
 Areas not perfused
 Surfactant Function
Normal Expiration Abnormal Respiration
With Surfactant Without Surfactant
 Compliance

Maximal volume
Volume

Pressure Opening pressures

34
Risk factors
 Prematurity

 Maternal diabetes

 Multiple births

 Elective cesarean section without labor

 Perinatal asphyxia

 Cold stress
Decreased risk

 Chronic intrauterine stress

 Prolonged rupture of membranes
 Antenatal steroid prophylaxis
Clinical Manifestations
 Appear within minutes of birth may not be recognized for several
hours in larger preterm

 Tachypnea (>60 breaths/min), nasal flaring, subcostal and intercostal

retractions, cyanosis & expiratory grunting

 Breath sounds may be normal or diminished and fine rales may be

heard

 Progressive worsening of cyanosis & dyspnea. BP may fall; fatigue,

cyanosis and pallor increase & grunting decreases.

 Apnea and irregular respirations are ominous signs

 In most cases, symptoms and signs reach a peak within 3 days, after
which improvement occurs gradually.
 Chest x-ray:
Findings can be graded according to the severity:

 Grade 1 (mild cases): the lungs show fine

homogenous ground glass shadowing
 Grade 2: widespread air bronchogram become
visible
 Grade 3: confluent alveolar shadowing
 Grade 4: complete white lung fields with obscuring
of the cardiac shadow
Grade 1
Grade 2
Grade 3
Grade 4
Prevention
 Antenatal corticosteroid therapy consists of either :
□ Betamethasone 12 mg/dose IM for 2 doses, 24 hrs apart, or
□ Dexamethasone 6 mg/dose IM for 4 doses, 12 hrs apart

 Early surfactant therapy: prophylactic use of

surfactant in preterm newborn <27 weeks'
gestation.
 Early CPAP administration in the delivery room.
Treatment
 Administer oxygen

 Initiate CPAP as early as possible in infants with mild

RDS
 Start MV if respiratory acidosis (PaCO2 >60 mmHg,
PaO2 <50 mmHg or SaO2 <90%) with an FiO2 >0.5, or
severe frequent apnea.
 Administer surfactant therapy: early rescue therapy
within 2 hrs after birth is better than late rescue
treatment when the full picture of RDS is evident.
Surfactant Therapy for RDS

 Improvement in compliance, functional

residual capacity, and oxygenation
 Reduces incidence of air leaks
 Decreases mortality

45
Mode of administration of Surfactant

 Dosing may be
divided into 2
alliquots and
adminitered via
a 5-Fr catheter
passed in the
ET
Insure technique

 Intubation-
 surfactant-
 extubation to CPAP
Meconium Aspiration Syndrome

Risk Factors:
 Post-term pregnancy

 Pre-eclampsia, eclampsia, maternal hypertension,

 Maternal diabetes mellitus

 IUGR

 Evidences of fetal distress (e.g.,abnormal biophysical

profile)
Clinical Manifestations
 Meconium staining amniotic fluid (meconium stained
nails, skin & umbilical cord )
 Some infants may have mild initial respiratory
distress, which becomes more severe hours after
delivery.
 Pneumothorax and/or pneumomediastinum

 PPHN in severe cases

 Hypoxia to other organs (e.g., seizures, oliguria)

Pathophysiology
Chest x-ray: Areas of hyperexpansion mixed with patchy
densities and atelectasis
Management
In the DR or OR:
 Visualization of the vocal cords & tracheal suctioning before
ambu-bagging should be done only if the baby is not vigorous
Management
 Consider CPAP, if FiO2 requirements >0.4; however CPAP may
aggravate air trapping and must be used cautiously.
 Mechanical ventilation: in severe cases (paCO2 >60 mmHg
orpersistent hypoxemia (paO2 <50 mmHg).
 Correct systemic hypotension (hypovolemia, myocardial
dysfunction).
 Manage PPHN, if present

 Manage seizures or renal problems, if present.

 Surfactant therapy in infants whose clinical status continue to

deteriorate.
Pneumonia
Common organisms:
 GBS

 gram–ve organisms (e.g. E.Coli,

Klebsiella,Pseudomonas)
 , Staph. aureus, Staph. epidermidis

 Candida.

 acquired viral infections (e.g., HSV, CMV).

Clinical Manifestations
 Early manifestations may be nonspecific (e.g., poor
feeding, lethargy, irritability, cyanosis, temperature
instability
 Respiratory distress signs may be superimposed upon RDS
or BPD.
 In a ventilated infant, the most prominent change may be
the need for an increased ventilatory support.
 Signs of pneumonia (dullness to percussion, change in
breathsounds, rales or rhonchi) are difficult to appreciate.
Chest x-rays: infiltrates or effusion
Chlamydia pneumonia with features of an interstitial
pneumonitis and characteristic widespread interstitial changes.

57
Management

 Initiate ampicillin and gentamicin IV;

modify according to culture results
 If there is a fungal infection, an
antifungal agent is used.
Air Leak Syndromes
Risk Factors:
 MV,MAS, surfactant therapy without
decreasing pressure support in ventilated
infants
 vigorous resuscitation,

 prematurity

 pneumonia
Clinical Manifestations
 Spontaneous pneumothorax may be asymptomatic or
only mildly symptomatic (i.e., tachypnea and ↑O2
needs).
 In unilateral cases, chest asymmetry is noted,
mediastinum shift to the opposite side.
 If the infant is on ventilatory support will have sudden
onset of clinical deterioration (i.e., cyanosis,
hypoxemia, hypercarbia & respiratory acidosis
associated with decreased breath sounds and shifted
heart sounds).
Tension pneumothorax
 (a life-
threatening
condition) →
↓cardiac
output and
obstructive
shock; urgent
drainage prior
to a radiograph
is mandatory.
Chest x-ray: Right-sided pneumothorax
Right-sided tension pneumothorax with mediastinal shift. Both
lungs demonstrate opacification of alveolar collapse.
Left-sided pneumothorax under tension. There is pulmonary interstitial
emphysema in the right lung and a small basal right pneumothorax.
Others
Pneumomediastinum

 It can occur with aggressive ETT insertion, Ryle's feeding tube

insertion, lung disease, MV, or chest surgery (e.g., TEF).

Pneumopericardium

Pneumoperitoneum

Subcutaneous emphysema

Systemic air embolism

Chest x-ray with Pneumomediastinum
Massive Pneumoperitoneum in MV neonate
Chest x-ray with pneumopericardium
Severe bilateral PIE affecting the right more than the left lung; there is gross
cardiac compression. A chest drain is in situin the right hemithorax.
Management
 Conservative therapy: close observation of the
degree of respiratory distress as well as oxygen
saturation, without any other intervention aiming
at spontaneous resolution and absorption of air.
 Needle aspiration should be done for suspected
cases of pneumothorax with deteriorating general
condition until intercostal tube is inserted.
 Decompression of air leak according to the type
(intercostal tube insertion in case of pneumothorax).
Thank You …

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