Neonatal Respiratory Distress

1. 
Respiratory Distress in Newborn

2. Neonatal Respiratory Distress
Signs and symptoms
 Tachypnea (RR > 60/min)
 Nasal flaring
 Retraction
 Grunting
 +/- Cyanosis
 +/- Desaturation
 Decreased air entry

3. 
Down score

4. 
Neonatal Respiratory Distress Etiologies
Pulmonary
Transient tachypnea
of the newborn (TTN)
Respiratory distress
syndrome (RDS)
Pneumonia
Meconium aspiration
syndrome (MAS)
Air leak syndromes
Pulmonary
hemorrhage
Systemic
Metabolic (e.g.,
hypoglycemia, hypothermia
or hyperthermia)
metabolic acidosis
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)

5. Pulmonary
 1- Transient tachypnea of newborn
 2- Hyaline membrane disease
 3- Meconium aspiration syndrome (MAS)
 4- Pneumonia
 5- Air Leak Syndromes

6. TransientTachypnea 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.

7. TransientTachypnea 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 .

8. TransientTachypnea 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.

9. TransientTachypnea 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

10. chest X-ray:TransientTachypnea of Newborn
Fluid in the
fissure
Fluid in the
fissure

11. 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)

12. 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

13. Pulmonary
 1- Transient tachypnea of newborn
 2- Hyaline membrane disease
 3- Meconium aspiration syndrome (MAS)
 4- Pneumonia
 5- Air Leak Syndromes

14. 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

15. 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

16. Normal Expiration
With Surfactant
Surfactant Function
Abnormal Respiration
Without Surfactant

17. 17
Compliance
Pressure
Volume
Opening pressures
Maximal volume

18. Risk factors
 Prematurity
 Maternal diabetes
 Multiple births
 Elective cesarean section without labor
 Perinatal asphyxia
 Cold stress
 Genetic disorders

19. Decreased risk
Chronic intrauterine stress
Prolonged rupture of membranes
Antenatal steroid prophylaxis

20. 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.

21. 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
Chest x-ray:

22. Grade 1

23. Grade 2

24. Grade 3

25. Grade 4

26. 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.

27. 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.

28. 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.

29. Types of Surfactant
Natural Surfactants: contain appoproteins SP-B & 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)

30. 30
SurfactantTherapy for RDSSurfactantTherapy for RDS
Improvement in compliance, functional
residual capacity, and oxygenation
Reduces incidence of air leaks
Decreases mortality

31. Mode of administration of Surfactant
 Dosing may be
divided into 2
alliquots and
adminitered via
a 5-Fr catheter
passed in the
ET

32. Insure technique
 Intubation-
 surfactant-
 extubation to CPAP

33. Pulmonary
 1- Transient tachypnea of newborn
 2- Hyaline membrane disease
 3- Meconium aspiration syndrome (MAS)
 4- Pneumonia
 5- Air Leak Syndromes

34. Risk Factors:
 Post-term pregnancy
 Pre-eclampsia, eclampsia, maternal hypertension,
 Maternal diabetes mellitus
 IUGR
 Evidences of fetal distress (e.g.,abnormal biophysical
profile)
Meconium Aspiration Syndrome

35. 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)

36. Pathophysiology

37. Chest x-ray: Areas of hyperexpansion mixed with patchy
densities and atelectasis

38. 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.

39. 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.

40. Pulmonary
 1- Transient tachypnea of newborn
 2- Hyaline membrane disease
 3- Meconium aspiration syndrome (MAS)
 4- Pneumonia
 5- Air Leak Syndromes

41. PneumoniaPneumonia
Common organisms:
 GBS
 gram–ve organisms (e.g. E.Coli,
Klebsiella,Pseudomonas)
 , Staph. aureus, Staph. epidermidis
 Candida.
 acquired viral infections (e.g., HSV, CMV).

42. 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.

43. Chest x-rays: infiltrates or effusion

44. 44
Chlamydia pneumonia with features of an interstitial
pneumonitis and characteristic widespread interstitial changes.

45. 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.

46. Pulmonary
 1- Transient tachypnea of newborn
 2- Hyaline membrane disease
 3- Meconium aspiration syndrome (MAS)
 4- Pneumonia
 5- Air Leak Syndromes

47. Air Leak Syndromes
Risk Factors:
 MV,MAS, surfactant therapy without
decreasing pressure support in ventilated
infants
 vigorous resuscitation,
 prematurity
 pneumonia

48. 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).

49. Tension pneumothorax
 (a life-
threatening
condition) →
↓cardiac
output and
obstructive
shock; urgent
drainage prior
to a radiograph
is mandatory.

50. Chest x-ray: Right-sided pneumothorax

51. Right-sided tension pneumothorax with mediastinal shift. Both
lungs demonstrate opacification of alveolar collapse.

52. Left-sided pneumothorax under tension.There is pulmonary interstitial
emphysema in the right lung and a small basal right pneumothorax.

53. 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

54. Chest x-ray with Pneumomediastinum

55. Massive Pneumoperitoneum in MV neonate

56. Chest x-ray with pneumopericardium

57. 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.

58. 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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