Neonatal Respiratory

Distress
Peiwen Chen, MSIII
Pediatrics Clerkship

June 17, 2014
Tachypnea
Decreased air entry
Retractions
Grunting
Stridor
Nasal flaring
Decreased gas exchange hypoxemia, cyanosis
Clinical Manifestations
Respiratory distress is common immediately after birth as part of the
transition to extra-uterine life.
However, persistent problems lead to significant morbidity and mortality
in the neonatal period.
Physiological changes during delivery
These changes ultimately redirect gas exchange
from the placenta to the lung:
Replacement of alveolar fluid with air
Onset of regular breathing
Increase in pulmonary blood flow

~10% of neonates require resuscitative efforts.
Differential diagnosis
Common etiologies
Transient tachypnea of newborn (TTN)
Meconium aspiration syndrome (MAS): full-term
Persistent pulmonary hypertension (PPH): full-term
Respiratory distress syndrome (RDS): pre-term
Pneumonia
Congenital heart disease
Transient tachypnea of newborn
Pathophysiology:
Inadequate alveolar fluid clearance at birth mild
pulmonary edema
Clinical features:
Tachypnea beginning shortly after birth, self-
resolves by day 2 of life
Diagnostic features:
CXR showing increased interstitial markings, fluid
in the fissures
Management:
Supplemental O
2
, CPAP
Meconium aspiration syndrome
Pathophysiology:
Airway obstruction, chemical pneumonitis,
inactivation of lung surfactant due to meconium
Clinical features:
Variable: mild distress severe hypoxemia
Barrel chest with rales + rhonchi
Diagnostic features:
CXR showing areas of atelectasis alternating
with areas of hyperinflation
Management:
Suctioning of the airways, supplemental O
2

Persistent pulmonary HTN
Pathophysiology:
Abnormally elevated pulmonary vascular
resistance, causing right-to-left shunting of blood
Clinical features:
Respiratory distress in first 24h of life; cyanosis
(labile PaO
2
); prominent precordial impulse,
narrowly split S
2
with P
2
accentuation
Diagnostic features:
Pre/post-ductal O
2
gradient >10%
Management:
Supplemental O
2
, inhaled NO, ventilatory support
Respiratory distress syndrome
Pathophysiology:
Insufficient pulmonary surfactant due to
prematurity
Clinical features:
Respiratory distress at birth, hypoxemia,
respiratory acidosis
Diagnostic features:
CXR showing ground glass atelectasis, + air
bronchograms
Management:
Antenatal steroids, mechanical ventilation,
endotracheal surfactant replacement
Pneumonia
Most common neonatal infection
Clinical features:
Respiratory distress, lethargy, poor feeding,
jaundice, apnea, temperature instability
-Early-onset: GBS, HSV
-Late-onset: Chlamydia, RSV
Diagnostic features:
CXR showing localized, diffuse (GBS), or white-
out (in utero infection)
Management:
Empiric antibiotics until pneumonia or sepsis is
ruled out
Congenital heart disease
Clinical features:
Respiratory distress at birth, hypoxemia/cyanosis,
hyperactive precordial impulse, gallop rhythm,
poor peripheral perfusion, hepatomegaly, single S
2
,
no correction of PaO
2
with 100% oxygen
Diagnostic features:
CXR showing cardiomegaly, increased
pulmonary vascular markings
Management:
Surgical repair
Congenital heart disease
Thank you!
References:
Adams JM, Stark AR. Persistent pulmonary hypertension of the newborn. In: UpToDate,
Post TW (Ed), UpToDate, Waltham, MA.
Aly H. Respiratory disorders in the newborn: identification and diagnosis. Pediatrics in
Review, 25(6), 201-208.
Martin R, Saker F. Overview of neonatal respiratory distress: disorders of transition. In:
UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
Rogido M, Sola A, Miller LT. Neonatology. BRS Pediatrics. Ed. LJ Brown, Ed. LT Miller.
LWW, 2004. 89-118.
Saker F, Martin R. Pathophysiology and clinical manifestations of respiratory distress
syndrome in the newborn. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.