Respiratory

Distress in
Newborn
TBL3- C3&C4

01

compromisingfetalgrowth babysmallforgestationalag
stresscausingearlymeconiumpassage Beyond40weeks supply

CASE 1 t.geh YetsoYnfYniYnmum9esnPiration

The following blood gas were obtained:
Post- Term
Respiratory Distress
Parameters Reference Range
A 42-week gestation baby boy with a birth weight of 3.2 kg was
born with thick meconium stained liquor. The baby developed
pH 7.18 (L) 7.35 - 7.45
grunting five minutes after delivery and had to be transferred
to the special care nursery. Earlier in the delivery room, the pCO2 60 mmHg (H) 5 - 45 mmHg
attending doctor carried out oral suction and found meconium
beyond the vocal cords. Increased air pO2 80 mmHg 80-100 mmHg
trapping due
to meconium
obstruction
Clinically, the baby was tachypnoeic with a respiratory rate of BE -2 -2 - +2
70 per minute with subcostal recessions. The chest was
hyperinflated and there were fine crepitations over both lung
A decision was made to ventilate the baby. A chest
fields. He was initially put on head-box O2. X-ray showed characteristic changes. The
endotracheal tube and the tip of the umbilical artery
40weeks nosignoflabor Fluid - Inflammation in
response to catheter were placed appropriately.
elective section meconium/pneumonia
C /edema
Half an hour later, the baby suddenly turned
Dangers ofallowingmotherpostterm placentashrinks cyanosed on the ventilator.
compromisingfetalgrowth babysmallforgestationalan

DDX IAiÑ
Ball valueeffect
membrane
artificialrupture
notsureifthisiswhatI
heard
Provisional Dx: Meconium aspiration
Transient tachypnea of Persistent pulmonary
the newborn (wet lung hypertension of the newborn Cyanotic Congenital Heart Defect
syndrome
Meconium Aspiration Syndrome disease) (PPHN)

Term Postterm Full term- & near-term 437 Term & pre-term, postterm
10 12dayspostterm infants p erm
Clinical signs Onset: immediately Onset : immediately after Onset: within 24 hours after Onset: Can present shortly after
and after birth birth & within the next 2 birth birth
Possible Chest X-Ray? symptoms hours
● Bilateral diffuse grossly patchy ● Green amniotic ● Meconium aspiration ● “Blue babies”
opacities (atelectasis and fluid ● Tachypnoea is a risk factor ● Feeding problems/ failure to
consolidation) ● Low APGAR ● Increased ● Low APGAR score thrive
● Hyperinflation of lungs score breathing effort ● Signs of respiratory ● Exertional dyspnoea,
● Emphysema ● Tachypnea distress tachypnoea & fatigue
uterine
c ontractionsqueeze
● Spontaneous pneumothorax & ● Increased ● Cyanosis ● Hypoxemia
pneumomediastinum breathing effort ● Symptoms of heart failure
● Pleural effusions
Physical ● Lung rales and ● Diffuse crackles ● Prominent precordial ● Nail clubbing (later)
examination rhonchi ● Diminished/norma impulse & a narrowly ● Murmur
Persistent pulmonary hypertension of the newborn : l breathing sounds split & accentuated S2
Maladaptation: parenchymal lung diseases e.g. (MAS),
Pneumonia/sepsis, (RDS), asphyxia
 protocol
165 pediani
Investigations Management Pg164
• Chest x-ray 1) Supportive care
• Increased lung volumes, flattened Diaphragms ● Maintain normothermia, correct metabolic & hematologic abnormalities
• Asymmetrical patchy pulmonary opacities ● Sedation to avoid agitation with ventilator support; morphine infusion of 10-20
• Pleural effusion mcg/kg/hr
● In systemic hypotension, fluid bolus of 10 ml/kg of normal saline followed by
• Pneumothorax or pneumomediastinum
dopamine 5-20 mcg/kg/min or noradrenaline of 0.05-1 mcg/kg/min
• ABG 2) Mechanical ventilation
• Echocardiography ● Ventilation strategies with optimal PEEP & relatively low PIP / TV for adequate
lung expansion & limit barotrauma
• Pulmonary hypertension ● Target PaO2 55-80 mmHg, PaCO2 40-60 mmHg & pH 7.3-7.45
3) Inhaled Nitric Oxide (iNO)
impairedV Qcuztheinterfacefor
gasexchangegetsdamaged ● To prevent rebound pulmonary vasocontriction

The arterial blood gas showed:

Case 2 vitiitor aÑÉtionoforgan sothisbabyhasprematurelungs
●
●
pH 7.2 (L)
PCO2 55 mmHg (H)
time
before m
premature437weeks came out12weeks ● PO2 50 mmHg (L)
A 28 week baby boy was admitted to the neonatal unit. His mother was treated for vaginal discharge

in
● HCO3 15 mmol/L. (L) place
during the third trimester of pregnancy. He was born by SVD with birth weight of 980 gram. Apgar needlewas
score was 5 at 1 minute and 9 at 5 minute. He required minimal resuscitation. He was put on to nasal Interpretation :
CPAP with 25% oxygen. Over the next few hours, his condition deteriorated with increasing oxygen Mixed respiratory acidosis and metabolic acidosis
requirement. There was also subcostal recession and he frequently developed apneic episodes. The
baby was intubated and UAC and UVC were inserted. Likely Diagnosis:
tomeasureO2sat toprematurelungs
Respiratory distress syndrome due

to ofsurfactant
Hyalinemembranediseasedue lack
inprematurebabiesalveoliTypellnotdeveloped yet
The chest X-ray was done. The baby was treated with surfactant and antibiotics. But the baby
suddenly became bradycardic and oxygen saturation dropped to below 50 %. Transillumination test
showed bright hemithorax.
A chest drain resulted in re-inflation of the left lung. Later on, the baby required long ventilation to

tdevefihim .no
maintain the oxygenation
The baby remains on ventilation for total 24 days. Now he is weaned off the ventilation and progresses
onto low flow oxygen. He is gaining weight but he still requires 0.5 L/min low flow oxygen.

fngaamage

DDx
e­
shouldraisesuspicion
vaginaldischarge
1. Group B streptococcus pneumonia - The rapid onset of the symptoms, the low WBC Investigations
count with left shift, and the depicted chest x-ray findings,
1. GBS pneumonia confirmation
management: rapid recognition of symptoms, cardiorespiratory support, and prompt a. Blood culture / urine culture
institution of antibiotics, prevention strategies in the perinatal period; early screening in i. Blood agar plate (beta haemolytic, gram +ve cocci)
pregnancy and treatment with antibiotics just prior to delivery to eliminate GBS b. Blood test
colonization markedly decreases the risk to the infant. i. ↑ CRP
ii. Abnormal leukocyte count
Routes of transmission: Transplacental hematogenous spread; ascending infection through iii. Thrombocytopenia
ruptured membranes; aspiration of infected amniotic fluid c. Chest X-ray
d. Lumbar puncture
2. Transient tachypnea of newborn - Delayed resorption and clearance of fetal lung fluid. e. Swab-based screening**
CXR shows prominent perihilar streaking in the interlobular fissures due to retained
2. TRO Transient tachypnea of newborn
amniotic fluids, the disorder is transient with resolution within 72h after birth
a. Chest X-ray
3. Meconium aspiration syndrome - primary affects infants born at term and post term,
i. Prominent perihilar streaking (engorgement of the lymphatic system with retained lung
rarely before 34w of gestation - respiratory distress, barrel chest due to air trapping,
fluid)
yellow green staining amniotic fluid + low apgar score ii. Fluid in the fissures
iii. Small pleural effusions may be seen
3. TRO Meconium aspiration syndrome
a. Look for meconium staining on the vocal cords with a laryngoscope
Investigations Managements
1. GBS pneumonia confirmation 1. GBS pneumonia confirmation
a. FBC: Hb, TWBC with differential, platelets, Blood culture (>1ml of blood). a. Supportive care
b. Where available : i. Cardiopulmonary monitoring
i. Serial CRP 24 hours apart b. Broad spectrum antibiotics
ii. Ratio of immature forms over total of neutrophils + immature forms: i. IV Ampicillin
IT ratio > 0.2 is an early predictor of infection during first 2 weeks of life. ii. IV Gentamicin
c. Where indicated: c. Intravenous immunoglobulin (IVIG)*
i. Lumbar puncture, CXR, AXR, Urine Culture. i.
ii. Culture of ETT aspirate (Cultures of the trachea do not predict the d. Prophylaxis
causative organism in the blood of the neonate with clinical sepsis.) i. Intrapartum prophylactic antibiotics
1. 4 hours before delivery to prevent the vertical transmission of early onset GBS
illness to the newborn
2. Penicillin
3.

Management Case 3
1. GBS pneumonia confirmation A baby who was born at 39 weeks gestation by SVD after an uneventful
2. Empirical antibiotics
a. Start immediately when diagnosis is suspected and after all appropriate specimens taken. Do not pregnancy was noted to be grunting at 6 hours of life. On examination,
wait for culture results. the baby was noted to be mildly cyanosed and in respiratory distress
b. Trace culture results after 48 - 72 hours. Adjust antibiotics according to results. Stop antibiotics if with a respiratory rate of 65/minute. The apex beat was displaced and
cultures are sterile, infection is clinically unlikely (as in the patient improved due to other reasons
such as improving respiratory support or hydration, temperature control)
the breath sounds in the left lung were diminished. The abdomen was
c. Unnecessary antibiotics use > 5 days increases risk of NEC and nosocomial infection with more scaphoid in shape. A chest radiograph was done. Following which, the
resistant organisms or fungal infection in the pre term infants. To consider that not every CXR baby was intubated and ventilated. An urgent surgical referral was made.
haziness = pneumonia.
3. Empirical antibiotic treatment (Early Onset) congenitaldiaphragmaticherniasign
a. IV C.Penicillin/Ampicillin and Gentamicin
b. Specific choice when specific organisms suspected/confirmed.
c. Change antibiotics according to culture and sensitivity results
4. Empirical antibiotic treatment – (Late Onset)
a. For community acquired infection, start on
i. Cloxacillin/Ampicillin and Gentamicin for non-CNS infection, and
- C.Penicillin and Cefotaxime for CNS infection
• For hospital acquired (nosocomial) sepsis
• Choice depends on prevalent organisms in the nursery and its sensitivity.
- For nursery where MRCoNS/ MRSA are common, consider Vancomycin;
for non-ESBL gram negative rods, consider cephalosporin; for ESBLs
consider carbapenams; for Pseudomonas consider Ceftazidime.
- Anaerobic infections (e.g. Intraabdominal sepsis), consider Metronidazole.
- Consider fungal sepsis if patient not responding to antibiotics
especially if preterm/ VLBW or with indwelling long lines.
• Duration of Antibiotics
• 7-10 days for pneumonia or proven neonatal sepsis
• 14 days for GBS meningitis
• At least 21 days for Gram-negative meningitis
• Consider removing central lines
116
• Complications and Supportive Therapy
• Respiratory: ensure adequate oxygenation (give oxygen, ventilator support)
• Cardiovascular: support BP and perfusion to prevent shock.
• Hematological: monitor for DIVC
• CNS: seizure control and monitor for SIADH
• Metabolic: look for hypo/hyperglycaemia, electrolyte, acid-base disorder
Key Points • Therapy with IV immune globulin had no effect on the outcomes of
suspected or proven neonatal sepsis.
Differential Diagnosis
● 39 weeks gestation → Full term baby 1. Congenital diaphragmatic hernias
Clinical features:
● Respiratory distress: ● Respiratory distress (Nasal flaring, tachypnea, cyanosis, intercostal retractions, grunting)
○ Grunting at 6 hours of life ● Barrel-shaped chest
○ Mildly cyanosed ● Scaphoid abdomen
● Auscultation of bowel sounds in the chest
○ Respiratory rate of 65/minute → Tachypnea (*Normal: 25-50/minute) ● Absent breath sounds on the ipsilateral side
● Displaced apex beat → Mediastinal shift ● Mediastinal shift: Shift of heart sounds/ Apex beat to the right side
● Possible syndromic dysmorphism (Craniofacial, spinal dysraphism, cardiac)
● Diminished breath sounds in left lung
● Abdomen scaphoid in shape 2. Pneumothorax
● Baby was intubated and ventilated Clinical features:
● Cyanosis
● Urgent surgical referral was made ● Tachypnea
● Flaring of nostrils
● Grunting with breathing
● Irritability
● Restlessness
● Use of additional chest and abdominal muscles to aid breathing (Retractions)
 3. Persistent pulmonary hypertension of the newborn (PPHN)
Clinical features:
● Tachypnoea, tachycardia, hypotension
Investigation
● Grunting or moaning when breathing
● Retractions gamed Antenatal ultrasound
● Cyanosis common ● most cases are diagnosed on routine antenatal ultrasound
● Low oxygen saturation even after getting oxygen
notas
● findings:
4. Congenital pulmonary airway malformation (Previously known as congenital cystic adenomatoid malformation) -absence of intra-abdominal stomach
Clinical features: -presence of abdominal contents in the thorax
● Respiratory distress (Grunting, tachypnea, cyanosis, use of accessory muscle)
● Tracheal deviation -peristalsis may be noted in the chest
● Mediastinal shift: Shift of heart sounds Chest X-Ray
● Decreased air entry on the affected side ● Bowel loops within the chest
● Hemoptysis, dyspnea, chest pain, cough, fever, failure to thrive
● Mediastinal shift and compression of the contralateral lung
5. Bronchogenic cysts ● In doubtful cases, a nasogastric tube is inserted and a chest X-ray is taken: the feeding tube will
Clinical features:
● Usually asymptomatic be seen in the thorax
● Trouble with breathing Prognostic Antenatal Investigations:
● Trouble with swallowing ● Fetal MRI: assessment of lung volume and liver herniation in moderate and severe CDH
● In some cases, failure to drain can cause airway compression with significant respiratory distress or recurrent
respiratory tract infections ● Fetal Echocardiography: to define intracardiac anatomy, assess pulmonary artery size and
severity of pulmonary hypertension
Provisional Diagnosis: Congenital diaphragmatic hernia

googlePottersyndrome
Management Predict the respiratory problems in a premature
newborn in contrast to a postdate newborn
● Initial Resuscitation we
-direct endotracheal intubation and ventilation without face mask-bag ventilation ● PRETERM AND FULL-TERM
-low ventilatory pressures are to be used to prevent pneumothorax PDAIARYEH INFANT
● PRETERM INFANT 37m ○ Bacterial sepsis (GBS)*
● Gastric decompression ○ Respiratory distress syndrome (RDS)* ○ Transient tachypnea*
-insertion of nasogastric tube and continuous suction to decompress stomach/bowel and ○ Erythroblastosis fetalis ○ Spontaneous pneumothorax
reduce lung compression ○ Nonimmune hydrops ○ Congenital anomalies (e.g.,
● Inotropic support ○ Pulmonary hemorrhage congenital lobar emphysema,
- to maintain blood pressure ● FULL-TERM INFANT 140week cystic
● Surfactant administration ○ Persistent pulmonary hypertension of ○ adenomatoid malformation,
-in infants born< 34 weeks of gestation and X-ray findings suggesting neonatal respiratory the neonate* diaphragmatic hernia)
distress syndrome ○ Meconium aspiration pneumonia* ○ Congenital heart disease
● Surgical repair(thoracotomy or laparotomy) ○ Pulmonary hypoplasia
○ Polycythemia
-after the infant is stabilized, often after 24-48 hours ○ Viral infection (e.g., herpes
○ Amniotic fluid aspiration
simplex, CMV)
● ○ Inborn metabolic errors
PI d

Identify and recognise the signs of respiratory

distress in newborn
Newborn infants with respiratory problems develop the
following signs of respiratory distress:
● tachypnoea (>60 breaths/min)
● increased work of breathing, with chest wall recession
● (particularly sternal and subcostal indrawing) and
Differential diagnosis
● nasal flaring
● expiratory grunting
● cyanosis if severe.
 Transient Tachypnea of Newborn Neonatal Infection
Etiology Etiology
- Delayed resorption and clearance of fetal lung fluid Early onset infection/sepsis
- Cause: chorioamnionitis, bacterial colonisation of maternal genital tract
Risk factors - Pathogen: group B streptococcus, E.coli
- Cesarean delivery, especially before onset of labour
- Delivery before 39 weeks gestation Late onset infection/sepsis
- Small gestation for age infant - Cause: nosocomial infection
- Pathogen: group B streptococcus, E.coli
Clinical features
- Tachypnea Risk factors
- Increased breathing effort Maternal
- Diffuse crackles, diminished or normal breathing sounds on auscultation - Fever
- Premature rupture of membrane
Investigations - Infections
- Chest x-ray: fluid in lung fissures and increased lung volumes
Fetal
Treatment - Premature birth, low birth weight, low APGAR score
- Supportive care: supplemental oxygen, neutral thermal environment, adequate nutrition - Asphyxia

Clinical features
Respiratory Distress Syndrome
- Irritability, lethargy, poor feeding
- Temperature changes Etiology
- Tachypnea with intercostal retractions and nasal flaring - Delayed maturation of Clinical features
- Reduced oxygen saturation with cyanosis pulmonary surfactant
At delivery or within 4 hours of birth
Investigations Risk factor - tachypnoea over 60 breaths/minute
- Blood culture or urine culture - Preterm birth- before - chest wall recession (sternal and subcostal
- Blood tests indrawing)
28 weeks gestation
- Lumbar puncture: for possible meningitis - nasal flaring
- Gestational diabetes
- Chest x-ray: signs of pneumonia - expiratory grunting
- Male
- cyanosis if severe
Management
- Supportive care
- Broad spectrum antibiotics: IV ampicillin and gentamicin

Investigations
Treatment and Management
Meconium aspiration syndrome
1. Arterial blood gas Etiology Clinical features Management
1. To start with 21%–30%
2. Chest x-ray shows - Intrauterine passage of - Green amniotic fluid - Endotracheal
oxygen in preterm infants,
- diffuse granular or ‘ground glass’ appearance meconium and aspiration leading - Low APGAR score suction
avoiding oxygen saturation
of the lungs and an air bronchogram to airway obstruction, chemical - Tachypnea - Mechanical
over 95%
pneumonitis, as well as - Increased breathing effort ventilation
2. Non-invasive respiratory
predisposing to infection - Hypoxia (Non-vigorous
support (continuous
- Lung rales and rhonchi baby)
positive airway pressure
Risk Factors - Maintain Spo2
(CPAP) or high-flow nasal
- Postterm Investigations >95%
cannula therapy)
- Perinatal asphyxia - Chest X-ray show patchy - Consider
3. Endotracheal administration
- Placental insufficiency opacities with antibiotics if:
of artificial surfactant
- Oligohydramnios hyperinflation - Child is
- Cesarean delivery unwell,
- Maternal hypertension and Persistent
diabetes symptoms, Risk
- Maternal for infection
infection/chorioamnionitis

Persistent pulmonary hypertension of newborn
Etiology
- Elevated pulmonary
vascular resistance →
right-to-left shunting
through the foramen
ovale and patent ductus
arteriosus (bypassing the
lungs) → pre- and
postductal oxygenation
gradient (e.g., preductal
O2 saturation is often
higher than postductal).
- Associated with
abnormal prenatal
development of or
perinatal maladaptation
of pulmonary vasculature
Risk factor Investigation
- Perinatal asphyxia - Pulmonary hypertension
- Prolonged premature rupture of on echocardiography
the membranes
- Infection
- Neonatal pneumonia Management
- Meconium aspiration syndrome - Supportive care
(supplemental O2)
Clinical features - Continuous pulse
- Low APGAR scores oximetry screening
- Cyanosis and signs of - Severe cases: inhaled
respiratory distress nitric oxide (potent
- Heart examination: prominent vasodilator that improves
precordial impulse and a oxygenation and reduces
narrowly split and right-to-left-shunting )
accentuated S2 - Last resort:
Extracorporeal life
support
ventilate surfactantgiven but borondayborg
shipsbreathing
Apnea of prematurity (AOP) 28week duetoapneas
Etiology Investigation
02 caffeine
- Immaturity of fetal brain areas - Usually not necessary, since AOP is atheophiline
responsible for breathing clinical diagnosis of exclusion. given
- Imaging may be used to rule out other
Risk factors causes of apnea (e.g., sepsis, intracranial
- Preterm delivery hemorrhage).
- Extremely low birth weight
Management
Clinical features - Supportive care (e.g., supplemental
- Episodes of breathing pauses oxygen, neutral thermal environment,
(usually > 20 seconds) that are maintaining a physiological neck position,
frequently accompanied by avoidance of excessive nasal suctioning)
hypoxemia and/or bradycardia - Nasal CPAP
- Methylxanthine therapy (e.g., caffeine,
theophylline)

● Temperature control: Monitoring of body temperature should be

considered, especially when resuscitation is prolonged, to avoid
Steps In neonatal resuscitation ●
the small risk of inducing hyperthermia.
Clearing the airway of meconium: Aspiration of meconium
before delivery, during birth or during resuscitation can cause
● The goals of neonatal resuscitation are to prevent the morbidity and mortality severe meconium aspiration pneumonia (MAS). In the case of
associated with hypoxic-ischaemic tissue (brain, heart, kidney) injury and also meconium-stained amniotic fluid and a non-vigorous newborn,
to re-establish adequate spontaneous respiration and cardiac output. endotracheal suction by brief intubation or suction under direct
vision is advised.
● Endotracheal intubation:
A rapid assessment of newly born infants who do not require resuscitation can ○ When tracheal suctioning for meconium is required
generally be identified by the following four characteristics: ○ If bag-mask ventilation is ineffective or prolonged
○ When chest compressions are performed
○ When endotracheal administration of medications is
● Was the infant born after a full-term gestation?
desired
● Is the amniotic fluid clear of meconium and evidence of infection?
● Is the infant breathing or crying? ● Administration of Oxygen
● Does the infant have good muscle tone? ● Medications: if the heart rate remains < 60 bpm despite
adequate ventilation with 100% oxygen and chest compressions,
administration of epinephrine or volume expansion, or both, may
If the answer to any of these assessment questions is ‘no,’ there is a general agreement that the
be indicated.
infant should receive one or more of the following four categories of action in sequence: ○ Epinephrine:
● Initial steps in stabilisation (provide warmth, position, clear airway, dry, stimulate, ○ Volume expansion: Volume expansion must be considered
re-position) when blood loss is suspected or the infant appears to be in
● Ventilation shock (pale skin, poor perfusion, weak pulse) and not
● Chest compressions responding to other resuscitative measures.
● Administration of epinephrine and / or volume expansion

Thanks

CREDITS: This presentation template was created by

Slidesgo, and includes icons by Flaticon and
infographics & images by Freepik