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

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 obstructionAirway malformationRib 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 fissureFluid 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

Atelectasis…areas not ventilated

Decrease alveolar ventilation

Reduce lung volume

Areas not perfused

Normal Expiration With Surfactant

Surfactant Function

Abnormal RespirationWithout Surfactant

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Compliance

Pressure

Volume

Opening pressures

Maximal volume

Risk factors Prematurity

Maternal diabetes

Multiple births

Elective cesarean section without labor

Perinatal asphyxia

Cold stress

Genetic disorders

Decreased risk

Chronic intrauterine stressProlonged rupture of membranesAntenatal 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.

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:

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 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)

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Surfactant Therapy for RDSSurfactant Therapy for RDS

Improvement in compliance, functional residual capacity, and oxygenation

Reduces incidence of air leaks

Decreases mortality

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

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

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

PneumoniaPneumoniaCommon organisms: GBS

gram–ve 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

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

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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