An approach to a newborn with

Respiratory distress
 Out line of presentation
• Definition
• Introduction
• Development of respiratory system
• Causes of respiratory distress
• Assessment of severity
• Surfactant and Hyaline membrane disease
• Meconium aspiration syndrome
• TTN
• Approach in diagnosis
• Management
• CPAP
• Summary
 Definition
• It is an illness characterized by
• Resp rate > 60/min
• Increased work of breathing
( inspiratory intercostal/ subcostal indrawing,
sternal retractions or expiratory grunt )
• With or without cyanosis

Ref:Rennie RM,Roberton Text book of neonatology,3 rd edtn 1999.Churchil livinstone

• The clinical presentation of respiratory
distress in the newborn includes apnea,
cyanosis, grunting, inspiratory stridor, nasal
flaring, poor feeding, and tachypnea (>60
breaths/min)
• There may also be retractions in the
intercostal, subcostal, or supracostal spaces.
 Introduction
• Respiratory distress constitutes the most
common cause of morbidity in new born
babies and pulmonary pathology is the most
frequent autopsy finding in the neonates
• Respiratory distress occurs in approximately 7
percent of infants
• Respiratory distress syndrome is the most
common diagnosis requiring IPPV
 Data at TUTH FY 2063/64
• Total newborns admitted :466
• 87 (19.55%) were respiratory cases :
 27 (5%) were attributed to RDS in premature
 41 (8.7%) Attributed to MAS
 1(0.21%) Was attributed to airleak
12(2.55%) were attributed to TTN
– 1.3%Cardiovascular
– 1.3% Persistent tachypnea turned out to be sepsis
later on
 Tachypnea Vs distress
• Tachypnea alone means fast breathing
(RR>60/min) in a quiet baby
• Rate should be counted full 1 minute and
shouldn’t be immediately after feeds
• Distress means a severe form associated with
recessions, grunts or cyanosis
• Respiratory distress is a compensated state
that may precede respiratory failure
Respiratory distress

Respiratory failure

Cardio pulmonary failure

Cardio pulmonary arrest

 Prenatal development
• Morphogenesis
– Embryomic period
• Starts at 4wks, ventral outpouching of endodermal foregut- 2
branches borrowing into mesenchyme separating foregut from
coelomic cavity
• Pulmonary vasculature- mesenchymal origin, aorta supplies
bronchial buds
– Pseudoglandular period
• 6th week Lungs act as exocrine gland, duct being lined by
epithelium filling lumen, septation occurs-trachea/ esophagus,
diaphragm forms
• Major airways form by this period
• Canalicular period
– 16th–26th epithelial growth predominates over
mesenchymal- becomes more tubular
– Some cells become cuboidal- type2 pneumocyte,
other become more flatter-type 1
• Saccular period- 26-28wk
• Alveolar period
• Adaptation to breathing
– Production of surfactant in alveoli
– Transformation of lung from secretory to gas
exchanging organ
– Establishment of parallel pulmonary circulation
• Surfactant forms hydrophobic lipid monolayer
over liquid film in air spaces
• Secretory granules called lamellar bodies are
1st seen at 24wks however detectable in
amniotic fluid at 30wks
• Apo-proteins helps in spreading
• Glucocorticoids, beta agonists increase synthesis of
both apo-proteins and lipid
• Thyroid hormone stimulates lipid
• Insulin, hyperglycemia, ketosis, androgens have
negative effect on both
• Production of fluid gradually decreases near term-
accelerated by labour which increase adrenergic
activity.
• Large amount of fluid is absorbed through
pulmonary vessels and lymphatics. Some is squeezed
out during labour
Assessment of surfactant maturity
• L/S ratio
– >2 – predict absence of RDS 95%
– <2 - predicts RDS with accuracy 54%
– Only 21% of newborn with l/s ratio 1.5-2 get RDS
– <1.5 80% develop RDS
• Amniotic fluid saturated lecithin concentration-
<0.5mg/dl- RDS
• Blood or meconium tend to elevate immature L/S
ratio
 Shake test
– 0.5ml amniotic fluid shaken with 0.5ml of 95%
ethanol
– After 15min persistence of bubble indicates
lung maturity
• No of bubbles related with prognosis
• Gastric aspirate can be used for shake test
• A negative GST had a specificity of 100%, sensitivity
of 70% and positive predictive value of 100% for
developing HMD.
Gastric aspirate shake test for diagnosis of surfactant deficiency in neonates with respiratory distress Authors: Chaudhari,
R.1; Deodhar, J.1; Kadam, S.1; Bavdekar, A.1; Pandit, A.1
Source: Annals of Tropical Paediatrics: International Child Health, Volume 25, Number 3, September 2005 , pp. 205-209(5)
 Respiratory causes
Condition Age at onset Associated/predisposing condition

Prenatal and natal At birth Postmaturity ,SFD , FD ,MSL

aspiration

1-2 days PROM , foul smelling liquor, maternal

Intrauterine Pneumonia pyrexia

Post natal aspiration 1st week Preterm , untrained nurse ,cleft palate,
macroglossia , glossoptosis,
retropharyngeal tumor

Post natal pneumonia 1-3 week Aspiration, systemic infection

Hyaline membrane disesse 1-6 hrs Immaturity , birth asphyxia ,C/S, Mat
Diabetes

Massive Pulm hemorrhage 1st week SFD, Cold injury, DIC, Diabetic mother
 Respiratory causes
Condition Age at onset Associated/predisposing condition

Pneumothorax 1-2 days Aggressive resuscitation ,IPPV,

meconium aspiration, HMD,Stap
Pneumonia

Transient tachypnea 1st day Term baby ,C/S,Maternal-fetal

transfusion

Bronchopulmonary 2-3 weeks Prolong PPV , oxygen dependence , PDA

dysplasia

Pleural effusion At birth or Hydrops fetalis

later

Wilson Mikity syndrome 1-2 weeks VLBW

 Respiratory causes : congenital
Condition Age at onset Associated/predisposing condition
Upper airway At birth Choanal atresia , Pierre Robin syndrome,
nasopharyngeal syndrome, vascular
rings,
Esophagal atresia with 1st day Polyhydamnois, single umbilical artery,
tracheaooesophageal preterm or small for dates
fistula

Diaphragmatic hernia At birth Hypoplasia of lungs

Pulmonary agenesis At birth Potter facies, diaphragmatic hernia
Lobar emphysemia Variable May follow aspiration and
tracheomalacia
Pulmonary At birth Lymphoedema,chylous
lymphangiectasis ascites,anomalous pulm venous drainage
Cysts and tumors Variable Solitary or multiple cysts and tumors
 Systemic causes
Condition Age at onset Associated/predipsosing condition

Cardiac failure Variable Down syndrome ,rubella syndrome ,large

for dates ,anemia ,polycyathemia

CNS

CNS trauma or asphyxia At birth Difficult birth or precipitate labor

Diaphragmatic paralysis 1st day Breech delivery , Erbs palsy

Paralysis of intercostal !st week Myasthenia gravis ,Werdnig hoffman

muscles syndrome , cong polio,

Metabolic causes

Organic acidemias Variable Acidosis ,hypoglycemia ,elevated blood

ammonia,sizures,positive family history
 Approach In diagnosis History

• Prenatal : Period of gestation , maternal fever ,

• Mode of delivery
C-section- RDS, TTN
Breech presentation :TTN
Precipitate labour- TTN
• Intra partum period
PROM-pneumonia/sepsis
Birth Asphyxia - in MAS, RDS
Antepartum hemorrhage –RDS asprtn
Cord milking/delayed cord clamping -TTN
liquor meconium stained- MAS, PPHN
• Use of drugs at birth-maternal analgesia &
anesthesia, oxytocin
• Neonatal period -
Active resuscitation during neonatal period
Family history- other sibling suffering from
distress in neonatal period - RDS,PPHN
 General Assessment
• Appearance : cyanosed ,conscious or drowsy,
hypotonic
• Work of breathing :increased work of
breathing like nasal
flaring ,retractions,grunting,
stridor ,decreased or absent respiratorr
efforts
• Circulation: pallor or mottled
 Primary assessment
• Airway : clear.maintanable or not
• Breathing : rate,effort,tidal volume,airway and
lung sounds , pulse oxymetry
• Circulation : color,temp, heart rate , rhythm,
pulses , CRT
• Disability: resposive or not
• Exposure: to cold or excess heat (temp)
Secondary assessment
Signs and symptoms:fever,breathing diffuclty
Medications :esp maternal
Last meal: time,type of feeding
Events leading to presentations
Tertiary Assessment:
ABG,Chest xray, etc
• Mild -tachypnea, rales,Cyanosis
• Mod- grunting, retraction, nasal flaring,
• Severe-Profound cyanosis or pallor,bradycardia
irregular gasping respiration
• Chest - Depending on underlying condition
• CVS – Heart sounds & murmur
• P/A- Scaphoid abdomen ,Palpable liver
Evaluation of respiratory performance

• Respiratory rate-
Tachypnea -1st manifestation of respiratory
distress
quite tachypnea -compensatory mechanism
for metabolic acidosis
Slow or irregular respiratory in-
hyothermia, fatigue, CNS depression
• Respiratory Mechanics-
• Increased work of breathing-
Flaring & retraction
• Head bobbing, grunting, stridor or prolonged
expiration are signs of significant alteration in
respiratory mechanics
• Air entry –
Tidal volume & effectiveness of ventilation are
clinically assessed by evaluation of chest expansion &
auscultation of breath sound
• Skin color & temperature-
Cyanosis central
mottling of skin of trunk
Pale, dusky or cold extremities
CRT
 Clinical RD Scoring system
Score 0 1 2

Resp rate <60 60-80 >80

Cyanosis None in room air None in 40% O2 Needs >40% 02

Retractions none mild Moderate to severe

Grunting none Audible with Audible without

stethoscope stethoscope

Air entry good decreased Barely audible

 Evaluation of cardiovascular
performance
• Heart rate
Sinus tachycardia is common response to
Hypoxemia
Inadequate tissue oxygenation in spite of
tachycardia

Tissue hypoxia & hypercapnia

Bradycardia
• Blood pressure
fall in decompensated shock
• Systemic perfusion
a. Volume of central & peripheral pulses
b. Skin-Prolonged CRT in Shock, fever or cold
Mottling, pallor, delayed CRT- poor peripheral
perfusion
Severe vasoconstriction - ashen color skin
c. Brain-Restlessness, irritability, Lethargy,
Hypotonia, generalized seizure & pupillary
dilatation, Posturing
d. Kidney-<1ml/kg/min absence of renal disease
is often a sign of poor renal perfusion or
hypovolemia
 Investigations
• Hyperoxia test: Exposure to 100% 02 for 5-10
minuntes
• Chest x-ray
• CBC, RBS
• Blood c/s
• ABG
• Serum electrolytes
• ECG/Echocardiography
 X-Ray
• Air bronchogram
– Pneumonia, RDS
• Diffuse parenchymal infiltrates
– TTN, MAS, pneumonia, pulmonary
lymphangiectasia
• Lobar consolidation
– Pneumonia
• Patchy areas alternating with emphysema
– MAS
• Pleural effusion
– Pneumonia, pulmonary lymphangectasia
• Reticular granular pattern
– RDS, pneumonia
• Loss of lung volume
– RDS, MAS
• Fluid in interlobar space- TTN
• Hyperinflation – TTN, MAS
• Atelectasis – MAS, RDS
• Pneumothorax – TTN, RDS
• Mediastianl shift :
– Diaphragmatic hernia
 Principles of management of
respiratory problems

• Establish airway
• Ensure oxygenation
• Assist ventilation; indications
respiratory acidosis , severe apnea
• Assess adequacy of ventilation:
• Correct metabolic abnormalities:
• Alleviate the systemic cause of distress :
Indication of ET intubations
• BMV ineffective
• Tracheal suctioning required for aspiration of thick
meconium
• Prolonged PPV required
• Functional or anatomic airway obstruction
• Excessive work of breathing which may lead to
fatigue & respiratory insufficiency
• Need for mechanical ventilatory support
 Hyaline membrane disease/RDS
• Commonest cause of neonatal mortality in preterm babies
• Approximately 50% of the neonates born at 26-28 weeks of
gestation develop RDS, whereas <30% of premature
neonates born at 30 to 30-31 weeks develop RDS in US
• Lack of surfactant due to immaturity of lungs
• Hypoperfusion of lungs leading to epithelial necrosis and
transudation of plasma
• Combination of end expiratory alveolar collapse,reduced
pulmonary compliance, pulmonary underperfusion and
increased capillary exudation leads to accumulation of co2
and acidosis

www.emedicine.com:Respiratory Distress Syndrome

Last Updated: October 20, 2006 Author: Arun K Pramanik, MD,
• RDS frequently occurs in the following
individuals:
– Male infants
– Infants born to mothers with diabetes
– Infants born by means of cesarean delivery
– Second-born twins
– Infants with a family history of RDS

www.emedicine.com:Respiratory Distress Syndrome

Last Updated: October 20, 2006 Author: Arun K Pramanik, MD,
 Secondary HMD
– Intrapartum asphyxia
– Pulmonary infections (eg, group B beta-hemolytic
streptococcal pneumonia)
– Pulmonary hemorrhage
– Meconium aspiration pneumonia
– Oxygen toxicity along with barotrauma or
volutrauma to the lungs
– Congenital diaphragmatic hernia and pulmonary
hypoplasia
www.emedicine.com:Respiratory Distress Syndrome
Last Updated: October 20, 2006 Author: Arun K Pramanik, MD,
• Clinical triad of tachypnea,expiratory grunt
and inspiratory retractions in a prematurely
born asphyxiated newborn
• Maternal diabetes and LSCS make babies
prone for HMD
• Symptoms appear at birth or within 6 hours of
life and gradual worsening of retractions
pathology

Gross features:
 Lungs are solid,
airless, and reddish
purple. Microscopic
features:  Alveoli are
poorly developed and
frequently collapsed
and pink hyaline
membranes line
respiratory
bronchioles, alveolar
ducts and random
alveoli.
 Surfactant replacement therapy
• Shown to be successful in ameliorating RDS
• Preparations: bovine(survanta),Intrasurf(calf lung
extract),curosurf (porcine),human
• Prophylactic or early rescue <2 hrs of age is preferred
in very premature babies
• Administration : 4 ml (100mg phospholipid)/kg
through tube through Et tube in quarters
• A/E:Desaturation,apnea,bradycardia
• Complication: pulmonary hemorrhage
 Meconium aspiration syndrome
• One of the most common causes of
respiratory distress
• About 10 % of babies born through MSAF
• Uncommon <34 weeks babies
• Thickly stained amniotic fluid with particulate
matter and yellow staining of skin ,cord amd
nails are associated with greater risk
• Pathophysiology is complex
• Airway obstruction
• Chemical pneumonitis
• Surfactant dysfunction
• In preterm MSAF may occur due to fetal
diarrhea while in term and post term it is an
indicator of fetal hypoxia
 Transient Tachypnea of newborn
• Also called wet lung disease or type II RDS
• Common among term babies born by caeserian
section
• Risk Factors :
delayed cord clamping or cord milking
macrosomia
male
prolonged labour,
excessive maternal sedation or iv fluid
adminstration
Mx of neonatal resp distress
 CPAP
• Continuous Positive Airway Pressure
• Current modalities of ventilatory assistance1
– CPAP
– Mechanical ventilation
– High frequency ventilation
• Nasal CPAP-simple, cost effective, suitable for
developing countries1
Continuous Positive Airway Pressure (CPAP)

Can correct ventilatory insufficiency by-

 Diminishing atelectasis
 Improving functional residual capacity (FRC)
 Correcting ventilation-perfusion abnormalities
 Decreasing pulmonary edema
 Reducing intrapulmonary shunting
 Effects produced
• Increases trans pulmonary pressure and
functional residual capacity
• Prevents alveolar collapse
• Conserves surfactant
• Increases airway diameter and splints the
airway
• Splints the diaphragm
 Summary
• The common problem in neonates specially
preterm
• Work of breathing differentiates from TTN
• Commonest causes are HMD , MAS, Cong
Pneumonea
• Oxygen and assisted positive pressure
ventillation, are key for treatment
 References
• Cloharty,Eichanwald,Stark :Manual of neonatal care 5th
edition2004
• Meharban Singh : Care of the newborn 6th edition 2004
• Larsans human embryology
• Nelson Text book of pediatrics 17th edition 2004
• Avery,Fietcher,Mcdonald<Neonatology 4th edition 1994
• www.emedicine.com