Respiratory Distress in

Newborn

Neonatal Respiratory Distress

Signs and symptoms

Tachypnea (RR > 60/min)
Nasal flaring
Retraction
Grunting
+/- Cyanosis
+/- Desaturation
Decreased air entry

Down score

Neonatal Respiratory Distress

Etiologies
Systemic

Pulmonary

Metabolic (e.g.,
hypoglycemia, hypothermia
or hyperthermia)

Transient
tachypnea of the
newborn (TTN)

metabolic acidosis

Respiratory
distress
syndrome (RDS)
Pneumonia
Meconium
aspiration
syndrome (MAS)
Air leak
syndromes
Pulmonary
hemorrhage

anemia, polycythemia

Cardiac
Congenital heart disease;
cyanotic or acyanotic
Congestive heart failure
Persistent pulmonary
hypertension of the newborn
(PPHN)
Neurological (e.g., prenatal
asphyxia, meningitis)

Anatomic
Upper airway
obstruction
Airway
malformation
Rib cage
anomalies
Diaphragmatic
disorders
(e.g., congenital
diaphragmatic
hernia,
diaphragmatic
paralysis)

Pulmonary
1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome

(MAS)
4- Pneumonia
5- Air Leak Syndromes

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

General Management of
Respiratory Distress
Supplemental oxygen or MV, if needed.
Continuously monitor with pulse oximeter.
Obtain a chest radiograph.
Correct metabolic abnormalities

(acidosis,hypoglycemia).
Obtain a blood culture & begin an

antibiotic coverage (ampicillin +

gentamicin)

General Management
Provide an adequate nutrion. Infants with

sustained RR >60 breaths/min should

not be fed orally & should be maintained
on gavage feedings for RR 60-80
breaths/min, and NPO with IV fluids or
TPN for more severe tachypnea

Pulmonary
1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome

(MAS)
4- Pneumonia
5- Air Leak Syndromes

Respiratory Distress Syndrome

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

Atelectasisareas not ventilated

Decrease alveolar ventilation
Reduce lung volume
Areas not perfused

Surfactant Function
Normal Expiration
With Surfactant

Abnormal Respiration
Without Surfactant

Compliance

Maximalvolume

Volume

Pressure

Openingpressures

17

Risk factors
Prematurity
Maternal diabetes
Multiple births
Elective cesarean section

without labor
Perinatal asphyxia
Cold stress
Genetic disorders

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

Management
Prevention:
Lung maturity testing: lecithin/sphingomyelin (L/S) ratio
Tocolytics to inhibit premature labor.
Antenatal corticosteroid therapy:

They induce surfactant production and accelerate

fetal lung maturation.
Are indicated in pregnant women 24-34 weeks'
gestation at high risk of preterm delivery within the
next 7 days.
Optimal benefit begins 24 hrs after initiation of
therapy and lasts seven days.

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.

Types of Surfactant
Natural Surfactants: contain appoproteins SPB & SP-C
Curosurf (extract of pig lung mince)
Survanta (extract of cow lung mince)
Infasurf (extract of calf lung)

Synthetic Surfactants:do not contain proteins

Exocerf
ALEC
Lucinactant (Surfaxin)

Surfactant Therapy for RDS

Improvement in compliance,

functional residual capacity, and

oxygenation
Reduces incidence of air leaks
Decreases mortality
30

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

Pulmonary
1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome

(MAS)
4- Pneumonia
5- Air Leak Syndromes

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

In the NICU:
Empty stomach contents to avoid further aspiration.
Suction frequently & perform chest physiotherapy.

Management
Consider CPAP, if FiO2 requirements >0.4; however

CPAP mayaggravate 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 todeteriorate.

Pulmonary
1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome

(MAS)
4- Pneumonia
5- Air Leak Syndromes

Pneumonia
Common organisms:
GBS
gramve 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.

44

Management
Initiate ampicillin and

gentamicin IV; modify

according to culture results
and continue therapy for 14
days.
If there is a fungal infection,

an antifungal agent is used.

Pulmonary
1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome

(MAS)
4- Pneumonia
5- Air Leak Syndromes

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).

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