respiratory distress in newborn clinical approach,

1. Respiratory Distress in Newborn
Dr L S Deshmukh
DM ( Neonatology )
Professor and Head,
Dept. of Pediatrics
Govt. Medical College,
Aurangabad

2. Respiratory distress
• Cause of significant morbidity and
mortality
• Incidence 4 to 6% of live births
• Many are preventable
• Early recognition, timely referral,
appropriate treatment essential

3. Respiratory distress
• RR > 60/ min
• Retractions
• Grunt
• + Cyanosis
Note : RR should be recorded in a
quiet state for at least one minute.

4. RD IN NB - Causes
 Pulmonary
- Parenchymal
- Extraparenchymal
 Non Pulmonary
- Heart
- Metabolic
- Brain
- Blood
- Abdominal

5. RD in Newborn – Causes
Pulmonary
Parenchymal Extraparenchymal
* RDS (HMD) * Upper airway obstruction
* TTN (RDS II) (Cloanal atresia, stenosis)
* Aspiration (Blood * Pneumothorax
meconium) * Pleural effusion
* PPHN * Cong. Diaph. hernia
* Pneumonia * Diaphragmatic paralysis
* Pulm. hemorrhage
* Pulm. hypoplasia

6. RD in Newborn – Causes
Extrapulmonary
Heart Metabolic Brain Blood Abdominal
- CCF - Met. Acidosis - Haemorrhage - Hypovolemia - NEC
- PDA - Hypoglycemia - Edema - Hyperviscosity - Pneumo
- CCHD - Hypothermia - Drugs - Acute blood peritonium
- Vascular - Sepsis - Pain loss - Large
mass

7. Surgical causes of respiratory distress
• Tracheo-esophageal fistula
• Diaphragmatic hernia
• Lobar emphysema
• Pierre -Robin syndrome
• Choanal atresia

8. Approach to respiratory distress
History
• Onset of distress
• Gestation
• Antenatal history / steroids
• Predisposing factors- PROM, fever
• Meconium stained amniotic fluid
• Asphyxia

9. Mathai ss et al ,MJAFI 2007; 63 : 269-272

10. Preterm - Possible etiology
Early progressive - Respiratory distress
syndrome or hyaline
membrane disease
(HMD)
Early transient - Asphyxia, metabolic
causes, hypothermia
Anytime - Pneumonia

11. Term – Possible etiology
Early well looking - TTNB, polycythemia
Early severe distress - MAS, asphyxia,
malformations
Late sick with - Cardiac
hepatomegaly
Late sick with shock - Acidosis
Anytime - Pneumonia

12. RR
(bpm
Aspiration cong. Pneumonia, sev. HMD CDH
cardiac malformation
Approx. 6 Hours of age
Normal
60
Course of Neonatal Tachypnoea : Etiologic possibilities
Source : Baurn DJ, Birth Risks, Nastle Nutrition Workshop, 1993
TTNB
HMD

13. Evaluation of RD in NB – Clinical History
Antenatal History Most likely association
* Prematurity, IDMs * HMD
* PROM, maternal fever, * Pneumonia
Unclean vaginal exams,
UTI, diarrhoea
* Asphyxia/MSAF * Aspiration
* Caesarean delivery * TTN
* Polyhydramnios * Pulm. Hypoplasia
* Oligohydramnios * TE fistula, CDH
* H/o receiving steroids * RDS less
* Traumatic/breech delivery * ICH / Phrenic nerve paralysis

14. Evaluation of RD in NB – Clinical History
When did the symptoms begin?
 Best historical assistant
 Stridor at birth – Cong. Anomaly
 After increase feed volum. – GEF & aspiration
 After intubation – tube block, air leak
 After extubation – Trauma / atelectasis

15. Evaluation of RD in NB – Clinical History
Is the disorder new / chronic / recurrent?
 Chronic disorder – BPD
 Recurrent disorders
- Aspiration pneumonia
- Pulmonary hemorrhage
- Lobar atelectasis

16. Evaluation of RD in NB – Clinical History
Does the NB have spontaneous cough?
 Spont. Cough, always abnormal in NB
 Causes of cough in NB : CRADLE
C cystic fibrosis
R respiratory infection
A aspiration (reflux, TE fistula)
D dyskinesia of cilia
L lung, airway, vascular malformation
E edema (heart failure, BPD)
Fletcher MA, 1998, Physical diagnosis in neonatology

17. Approach to respiratory distress
Examination
• Severity of respiratory distress
• Neurological status
• Blood pressure, CFT
• Hepatomegaly
• Cyanosis
• Features of sepsis
• Look for malformations

18. Evaluation of RD in NB – Downes’ Score
0 1 2
Cyanosis None In room air In 40% FiO2
Retractions None Mild Severe
Grunting None Audible with
stetho.
Audible without
stetho.
Air entry C;ear Decreased Barely audible
RR Under 60 60-80 Over 80 or
apnea
Score : > 4 = Clinical respiratory distress; monitor ABG
> 8 = Impending respiratory failure

21. Evaluation of RD in NB – RR
 Affected by various conditions
 Low rates – Decreased MV
 High rates – Wasted ventilation
 Rapid & shallow – Stiff lungs (RDS)
 Slow & Deep – Increased resistance (MAS)
 Isolated tachypnoea – Acidosis, sepsis, CCF

22. Evaluation of RD in NB – Grunting
 Classical in HMD, may be seen in
pneumonia, pulmonary edema & others.
 Expiration through partially closed glottis.
 Intermittent / continuous (Severity)
 Generates CDP of 2-3 cms H2O
 Maintains FRC

23. Evaluation of RD in NB – Cyanosis
 Total desat. Hb > 3.5 gm/dl
 Central cyanosis – always abnormal
 Acrocyanosis – May be normal
 Hyperoxia test – Pulm. Vs Cardiac
 Anemia / Polycythemia - Falacious

24. Hyperoxia test
test Method result diagnosis
Hyperoxia 100 % fio2 5-10
min
Pao2 increases
to > 100 torr
Pao2 increases
by < 20 torr
Parenchymal
lung disease
PPHN / CCHD
Hyperoxia-
hypervetilation
MV 100 % fio2
& VR 100-150 /
min
Pao2 increases
to > 100 torr
w HV
Pao2 increases
at critical Pco2
No increase in
Pao2 with HV
Parenchymal
lung disease
PPHN
CCHD

25. Evaluation of RD in NB – Physical Exam.
 Look for :
- Shrill cry / abn. tone (CNS disorder)
- Persistent frothing at mouth (TE fistula)
- Cyanosis, relieved on crying (choanal atresia)
- Seaphoid abd. (CDH)
- Single umbilical astery (CHD)
- Meconium staining of skin, nails or cord (MAS)

26. Evaluation of RD in NB – Retractions
Site of
retraction
Probable
region affected
Likely clinical association
Intercostal Pulmonary
parenchyma or
distal airway
Conditions of decreased
parenchymal compliance
MHD, TTN, Pneumonia
Subcostal Insertion of
diaphragm
Mild degree of retraction
are normal in neonates;
Airway obstruction or
parenchymal disease; in
the absence of intercostal
retractions, indicates
proximal airway obstruction

27. Evaluation of RD in NB – Retractions
Site of
retraction
Probable region
affected
Likely clinical association
Unilateral
subcostal
Decreased
movement of
opposite diaphragm
Isolated phrenic nerve weakness
Brachial palsy
Massive pleural effusion
Tension pneumothorax,
CDH
Suprasternal Obstruction in
upper airway
Choanal atresia or stenosis
Laryngeal stenosis or malacia
Obstruction of upper airway due
to secretions, edema
Sternal Sternal compliance
greater than pulm.
compliance
Proximal airway obstruction

28. Clinical Examination
 Color—pink, dusky, pale, mottled
– Central
– Peripherally
 Heart rate
 Pulses
– Distal vs Central
 Perfusion
– Capillary Refill Time (CRT)
– Blood Pressure

29. Clinical Examination
 Physical characteristics
– Flat nasal bridge, Simian crease, recessed chin, low
set ears
 Deformities
– Extra digits, gastroschesis, imperforate anus
 Muscular
– Hyoptonia vs Hypertonia
 Skeleton
– Choanal Atresia, Osteogenesis Imperfecta
 Other
– Scaphoid abdomen, hepatomegaly, situs inversus

30. Suspect surgical cause
• Obvious malformation
• Scaphoid abdomen
• Frothing
• History of aspiration

31. Evaluation of RD in NB – Chest Exam.
 Increased A-P diameter of chest
- Pneumothorax, emphysema or CDH
 Asymmetric chest movement
- Tension pneumothorax, pleural effusion, CDH,
Diaphragmatic paralysis, PIE.
 Auscultation
- Breath sounds ,
- Early, coarse crackles – Pneumonia & HMD
- Late crackles - PIE
 Wheezing – BPD, GER, Vascular rings, bronchomalacia
 Auscultatory percussion – Lobar atelectasis, effusion.
 Transillumination of the chest

32. RD in Newborn – Clinical Differences
Symptoms &
signs
Pulm.
disorder
CVS
disorder
CNS
disorder
Metabolic
disorder
Tachypnea + + + or apnea +
I/C Recession +++ ± - ±
Expiratory
grunt
+ - - -
Cyanosis + ++++ + -
Hepatomegaly + +++ - -
History Prematurity,
MSL,
PROM,
Polyhydram.
Rubella,
hydrops LFD
Breech
Hypotonia
birth asphyxia
Preterm
increase
protein intake
Seizures Rare Absent May occur Common
Auscultation ± Murmur - -

33. Investigations
• Gastric aspirate
• Polymorph count
• Sepsis screen
• Chest X-ray
• Blood gas analysis

34. Pulse oximetry
• Effective non invasive monitoring of
oxygen therapy
• Ideally must for all sick neonates and
those requiring oxygen therapy
• Maintain SaO2 between 90 – 93 %

37. Shake test
• Take a test tube
• Mix 0.5 ml gastric aspirate +
0.5 ml absolute alcohol
• Shake for 15 seconds
• Allow to stand 15 minutes for
interpretation of result

38. RD in Newborn – Differential Diagnosis
Condition Gestation History Clinical signs
RDS PT>FT APH/IDM asphyxia Retractions, grunt
Pneumoni
a
Any PROM, smelly
liquor, fever in
mother
Hypo/hyperthermia
leukocytosis or
neutropenia
MAS FT NSAF, asphysia
MA
Distended chest
Meconium staining
TTNB FT>PT C section Tachypnoea ++
PPHH Usually
FT
Asphyxia Profound cyanosis
CVS normal

39. X-Ray
 Structures
– Ribs
– Vertebra
– Liver
– Stomach/ intestine
– Lungs
– Heart
– Trachea
– Esophagus
39

40. X-Ray
 Lungs
– Lung Volume
– Expansion
– Densities
 Fluid/ collapse
(atelectasis)>>white
 Free Air>>dark
 Mass
 Heart shape and size
– Boot shaped
– Egg or Oval shaped
– cardiomegaly
40

41. Roentgen Finding in RD in the Neonate
Pulmonary infiltrates Aeration e/o PAL
Distributio
n
Characteristis
Hyaline
membrane
disease
Diffuse Fine reticulogranula
pattern with air
bronchograms
Hypoaeration Present usually
as a complication
of respirator
therapy
Transient
tachypnoea
Diffuse Symmetrical stringy
perihilar infiltration
Hypoaeration Uncommon
Meconium
aspiration
syndrome
Usually
diffuse
Bilat patchy, course
infiltrate & atelectasis
alternating with areas
of alveolar
emphysema
Hypoaeration Often seen in the
absence of
respiratory
therapy
Neonatal
pneumonia
Variable but
usually
asymmetrica
l & localized
Variable pattern
ranges from localized
to diffuse alveolar or
interstitial disease
Mild
hyperaeration
Uncommon

42. X-ray - RDS

43. RDS
43

44. 44

45. X-ray - MAS

46. MAS
46

47. MAS
47

48. TTN
48

49. X-ray- TTNB

50. X-ray – Congenital pneumonia

51. X-ray - Pneumothorax

53. Pneumonia/ Sepsis
53

54. Pneumothorax
54

55. Pneumothorax
 Right lateral decubitus view of
pneumothorax
55

56. Pneumopericardium
56

58. Gomella, 2004

60. Respiratory distress - Management
• Monitoring
• Supportive
- IV fluid
- Maintain vital signs
- Oxygen therapy
- Respiratory support
• Specific

61. Oxygen therapy*
Indications
• All babies with distress
• Cyanosis
• Pulse oximetry SaO2 < 90%
Method
• Flow rate 2-5 L/ min
• Humidified oxygen by hood or nasal prongs
* Cautious administration in pre-term

62. Antenatal corticosteroid
- Simple therapy that saves neonatal lives
• Preterm labor 24-34 weeks of gestation
irrespective of PROM, hypertension and
diabetes
• Dose:
Inj Betamethasone 12mg IM every 24 hrs X
2 doses; or Inj Dexamethasone 6 mg IM
every 12 hrs X 4 doses
• Multiple doses not beneficial

63. Surfactant therapy - Issues
• Should be used only if facilities for
ventilation available
• Cost
• Prophylactic Vs rescue

64. Prophylactic therapy
Extremely preterm <28 wks
<1000 gm
Not routine in India
Rescue therapy
Any neonate diagnosed to have RDS
Surfactant therapy - Issues
Dose 100mg/kg phospholipid Intra tracheal

65. Transient Tachypnea of the
Newborn
 History
– Common with C-Section delivery
– Maternal analgesia
– Maternal anesthesia during labor
– Maternal fluid administration
– Maternal asthma, diabetes, bleeding
– Perinatal asphyxia
– Prolapsed cord
65

66. TTN presents:
 Respiratory Assessment
–Tachypnea 60-150 bpm
–Nasal flaring
–Grunting
–Retracting
–Fine Rales
–Cyanotic
66

67. TTN
 X-Ray findings
– Prominent Perihilar streaking
– Hyperinflation
– Fluid in fissure
 Labs
– CBC within normal limits
– ABG/CBG showing mild to moderate
hypercapnia, hypoxemia with a respiratory
acidosis
67

68. TTN
 Have delayed reabsorption of fetal lung
fluid which eventually will clear over
several hours to days
 Treatment: Treat signs and symptoms.
Support infant, may need O2, is probably
too tachypneic to PO feed so start IV fluids
 Be patient!!
68

69. Congenital pneumonia
Predisposing factors
PROM >24 hours, foul smelling liquor,
Peripartal fever, unclean or multiple per
vaginal
Treatment
Thermoneutral environment, NPO, IV
fluids, Oxygen, antibiotics-
(Amp+Gentamicin)

70. Nosocomial pneumonia
Risk Factor : Ventilated neonates
: Preterm neonates
Prevention : Handwash
: Use of disposables
: Infection control
measures
Antibiotics : Usually require higher
antibiotics

71. Respiratory distress in a neonate with
asphyxia
• Myocardial dysfunction
• Cerebral edema
• Asphyxial lung injury
• Metabolic acidosis
• Persistent pulmonary hypertension

72. Pneumothorax
Etiology
Spontaneous, MAS, Positive pressure
ventilation (PPV)
Clinical features
Sudden distress, indistinct heart sounds
Management
Needle aspiration, chest tube

73. Persistent pulmonary
hypertension (PPHN)
Causes
• Primary
• Secondary: MAS, asphyxia, sepsis
Management
• Severe respiratory distress needing
ventilatory support, pulmonary
vasodilators
• Poor prognosis

74. Pneumothorax and other
Air Leaks
 History
– What happened in the delivery room?
– Was positive pressure given?
– Large amount of negative pressure generated
with the 1st breath?
74

75. Pneumothorax/ Air Leaks
 Respiratory Assessment
– Tachypnea
– Nasal flaring
– Grunting
– Retractions
– BS absent or decreased
75

76. Pneumothorax/ Air Leak
 Clinical Assessment
– Cyanotic
– Pale, gray
– Heart Rate
 Tachycardia
 Bradycardia
 PEA
– Pulses
 Normal
 Poor
 absent
76

77. Pneumothorax/ Air Leak
 Perfusion
– Capillary Refill (CRT)
– Blood Pressure if monitoring Arterial Line,
narrowing pulse pressure
 Deformities of Chest Wall
– Asymmetry of chest
 CHEST X-Ray speaks for itself!!
77

78. Congenital Diaphragmatic Hernia
Congenital Cystic Adenomatoid
Malformation
 Ideally diagnosed in utero
 Develops during pseudoglandular stage,
but CCAM can form up to 35 weeks
 Normally compromised at delivery
requiring immediate intubation
 CDH more commonly found on Left side
78

79. CDH
79

80. CDH/ CCAM
 Respiratory Assessment
– Tachypneic
– Retractions
– Nasal flaring
– Grunting
– Breath Sounds
 Decreased on the affected side
 May hear bowel sounds in chest with CDH
80

81. CDH
 Clinical Assessment
– Scaphoid Abdomen- classic sign
– Color
 Cyanotic
– Heart Rate
 Fast, slow or normal
– Perfusion
 Depends upon the severity
– X-Ray—Best diagnostic tool
 Bowel, stomach, liver in chest
– ABGs
 Acidosis, hypoxemia and hypercarbia
81

82. Left Congenital Diaphragmatic
Hernia
82

83. CCAM
83

84. Airway Abnormalities
 Occur less frequently than pulmonary
parenchymal diseases
 Presentation is often quite dramatic with
significant respiratory distress
 Stridor may be an important key to
diagnosing the abnormality
84

86. Evaluation of RD in NB
 History and physical examination
 Dawnes’ or RDS score (clinical)
 Arterial blood gases
Pulse oximetry – SaO2
 Chest x-ray
 Serum glucose and calcium; central
hematocrit, WBC and differential; platelet
count.
 Maternal vaginal culture
 Newborn surface (e.g. earcanal, gastric
aspirate) smears, cultures (?), blood culture,
urine culture (?). CSF culture (?)

87. Respiratory distress syndrome (RDS)
• Pre-term baby
• Early onset within 6 hours
• Supportive evidence: Negative shake test
• Radiological evidence

88. Pathogenesis of RDS
• Decreased or abnormal surfactant
• Alveolar collapse
• Impaired gas exchange
• Respiratory failure

89. RDS - Predisposing factors
• Prematurity
• Cesarean born
• Asphyxia
• Maternal diabetes
RDS - Protective factors
• PROM
• IUGR
• Steroids

91.  Table 1. Potential Pulmonary Causes for Respiratory Distress in Neonates
 Parenchymal conditions
 Transient tachypnea of the newborn
 Meconium aspiration syndrome and other aspirations
 Respiratory distress syndrome
 Pneumonia
 Pulmonary edema
 Pulmonary hemorrhage
 Pulmonary lymphangiectasia


92. Developmental abnormalities
 Lobar emphysema
 Pulmonary sequestration
 Cystic adenomatoid malformation
 Congenital diaphragmatic hernia
 Tracheoesophageal fistula
 Pulmonary hypoplasia

93. 
Airway abnormalities Choanal atresia/stenosis
 Laryngeal web
 Laryngotracheomalacia or bronchomalacia
 Subglottic stenosis
 Mechanical abnormalities Rib cage anomalies (eg, Jeune syndrome)
 Pneumothorax
 Pneumomediastinum
 Pleural effusion
 Chylothorax


94. Respiratory distress
(needing referral)
• RDS (HMD)
• MAS
• Surgical or cardiac cause
• PPHN
• Severe or worsening distress

95. Meconium aspiration syndrome (MAS)
• Meconium staining
- Antepartum, intrapartum
• Thin
- Chemical pneumonitis
• Thick
- Atelectasis, airway blockage, air
leak syndrome

96. Meconium aspiration syndrome
• Post term/SFD
• Meconium staining – cord, nails, skin
• Onset within 4 to 6 hours
• Hyperinflated chest

97. MAS - Prevention
• Oropharyngeal suction before delivery of
shoulder for all neonates born through
MSAF
• Endotracheal suction for non vigorous*
neonates born through MSAF
*Avoid bag & mask ventilation till trachea is
cleared