Respiratory Disorders

in the Newborn

PERINATOLOGY
 Introduction

Respiratory distress
 encountered frequently
 the most frequent indication for re-evaluation

Potentially life-threatening conditions

Early recognition, timely referral,
appropriate treatment essential

Aly H, Pediatrics in Review 2004;25:201-208

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 …introduction
The key to succesful management
 Complete maternal and newborn history
 Complete physical examination
 Recognize the common respiratory disorder
 Differentiate among various diagnostics
entities
 Identify those that are life-threatening

Aly H, Pediatrics in Review 2004;25:201-208

Definition

Characterized by one or more of the

following :
 Nasal flaring
 Chest retractions
 Tachipnea (RR > 60/min)
 Grunting

Aly H, Pediatrics in Review 2004;25:201-208

 …definition

Advanced degree of respiratory

distress :
 Cyanosis
 Gasping
 Choking
 Apnea
 Stridor

Aly H, Pediatrics in Review 2004;25:201-208

Evaluation of Respiratory
Distress Using Down’s Score
0 1 2

Respiratory < 60/min 60 – 80/min > 80/min

Rate
Retractions No retraction Mild Severe
retractions retractions
Cyanosis No cyanosis Cyanosis Cyanosis on
relieved by O2 O2
Air Entry Good bilateral Mild decrease No air entry
air entry in air entry
Grunting No grunting Audible by Audible with
stethoscope ear
 …evaluation

Score < 4 No respiratory distress

Score 4 -7 Respiratory distress

Score > 7 Impending respiratory failure

(Blood gases should be
obtained)
Initial assesment

To identify conditions that require

prompt support
 Obstructed airway (gasping,
choking,stridor)
 Insufficient breathing (apnea,poor resp.
effort)
 Circulatory collapse (bradycardia,
hypotension, poor perfusion)
 Poor oxygenation (cyanosis)
 …initial assesment

Manage the infants promptly

 Immediate oxygen support
 Possibly bag and mask ventilation
 Even intubation and mechanical
ventilation
History

Maternal history
 Drug abuse
 Diabetes Melitus
 Infections
…history

Obstetrical histories
 Gestational age (if preterm 
HMD/Hyaline Membrane Disease)
 Results of fetal assesment and fetal
monitoring during labor & delivery
 Complications at delivery  birth trauma,
presence of meconium, perinatal
depression, premature rupture of
membranes
 …history
Details of the presenting respiratory
symptoms
 Coughing and choking during feeding 
oropharyngeal aspiration and
tracheoesophageal fistula should be
considered If symptoms follow the feeding 
reflux with aspiration suspected  recurrent
emesis
 Gradually improving symptoms  TTN/
Transient tachypnea of the newborn
Gradual deterioration  pneumonia / sepsis
 Onset of distress
Preterm- Possible Etiology
Early progressive Respiratory distress
Syndrome(RDS) or
hyaline
membrane disease
(HMD)
Early transient Asphyxia, metabolic
causes, hypothermia

Anytime Pneumonia

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 Term- Possible Etiology
Early well looking TTN, polycythemia

Early severe distress MAS, asphyxia,

malformations
Late sick with Cardiac
hepatomegaly
Late sick with shock Acidosis

Anytime Pneumonia

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
Physical examination
Inspection is the first and most
important tool
 Apnea, poor perfusions, retractions,
cyanosis
 Inspiratory stridor  upper airway
obstruction Stridor (previous history of
intubation) airway injury, such as
subglottis stenosis
 Asymmetric chest movement + severe
distress  maybe tension pneumothorax
 Scaphoid abdomen  diaphragmatic hernia

Aly H, Pediatrics in Review 2004;25:201-208

 …physical examination

Auscultation
 Symmetry and adequacy of air exchange
 Abnormal breaths sound
 The presence of heart murmur

Chest transilumination  to detect

pneumothorax

Aly H, Pediatrics in Review 2004;25:201-208

 …physical examination

Chest examination
 Air entry
 Mediastinal shift
 Hyperinflation
 Hearts sounds

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 …physical examination

Suspect surgical cause

 Obvious malformation
 Scaphoid abdomen
 Frothing
 History of aspiration

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
Common Causes of RD -
Medical

 Transient tachypnea of the newborn (TTN)

 Hyaline membrane disease (HMD)
 Meconium aspiration syndrome (MAS)
 Air leak syndrome
 Pneumonia
 Congenital heart diseases
 Surgical Causes of Respiratory
Distress
 Tracheo-esophageal fistula
 Diaphragmatic hernia
 Lobar emphysema
 Pierre-Robin syndrome
 Choanal atresia

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
Investigations
 Chest X-ray
 Complete blood count (anemia,
polycythemia, sepsis)
 Arterial blood gas
 Glucose check (hypoglycemia)
 Blood culture (sepsis, pneumonia)
Treatment

 After stabilization, treat the cause of

RD
 Use CPAP
 Avoid unnecessary exposure to
oxygen
 Antibiotics until sepsis is ruled out

Aly H, Pediatrics in Review 2004;25:201-208

 Transient Tachypnea of the
Neonate (TTN)
Definition
 Respiratory distress of near term or
term neonate
 Transient pulmonary edema resulting
from delayed clearance of fetal lung
fluids
 Pathogenesis
 Lung fluids produce actively in utero by
chloride pump  water & chlor to alveolar
space
 2-3 d before delivery  transformation
process  pulmonary epithelium changes to
Na-absorbing  lung fluid away from
alveolar space
 Low oncotic pressure  favors fluid
movement from alveolar space into the
interstitium
 …pathogenesis

 Prostaglandin secretion  lymphatic

dilation  accelerates fluid clearance from
interstitium
 Lung expansion  water to interstitium 
gradually remove from lung by the
lymphatic system and pulmonary blood
vessels
 Risk Factors

 Cesarean section without labor

 Macrosomia
 Male sex
 Prolonged labor
 Excessive maternal sedation
 Low Apgar score (< 7 at 1 minute)
 Clinical Presentation

 Tachipnea shortly after delivery

 May have grunting, nasal flaring, rib retractions,
and cyanosis
 Respiratory symptoms improve as pulmonary
fluid is mobilized, and this is usually associated
with diuresis
 Usually does not last longer than 72 hours
Chest X-Ray

 Increased interstitial markings and

occasionally fluids in the interlobar
fissure
 Occasionally pleural effusion and
signs of alveolar edema may be
seen

Aly H, Pediatrics in Review 2004;25:201-208

Management

 Oxygen therapy  some infants may

need NCPAP
 Feeding as tachypnea improves
 Prognosis

 Self-limited disease
 There is no risk of recurrence or
further pulmonary dysfunction
Hyaline Membrane Disease

Definition
 Hyaline membrane disease (HMD) is also
called respiratory distress syndrome (RDS)
 This condition usually occurs in a preterm
neonate
 Premature lungs are surfactant deficient
 Incidence

 About 25% of neonates born at 32

weeks gestation
 The incidence increases with
increasing prematurity
Predisposing Factors

 Prematurity
 Male sex
 Neonate of diabetic mother
 Asphyxia
 Protective Factors
 Chronic intrauterine stress
 Prolonged rupture of membranes
 Maternal hypertension
 Narcotic use
 Intrauterine Growth Retardation (IUGR) or
Small for Gestational Age (SGA)
 Corticosteroids – Prenatal
 Clinical Manifestation
 Increasing tachypnea (> 60/min)
 Chest retractions
 Cyanosis on room air that persists or
progresses over the first 24-48 hours
of life.
 Decreased air entry
 Grunting
Investigations
 Laboratory Studies:
 Blood gases: hypoxia, hypercarbia, acidosis
 CBC and blood culture are required to rule
out infection
 Serum glucose levels are usually low
 Chest X-ray Study:
 Reveals ground glass appearance with air
bronchograms
Management

Resuscitation by experienced
pediatric staff :
 Prompt gentle stimulation and inflation to
produce and maintain the FRC by CPAP
and intubation
 Give surfactant as soon after intubation
as possible
 Minimise heat loss
Nasal CPAP
Meconium Aspiration Syndrome
(MAS)
The respiratory distress secondary to
meconium aspiration by the fetus in
utero or by the neonate during labor
and delivery
MAS 
 10-26% of all deliveries and
 mostly in term and postterm deliveries and
 may represent fetal hypoxemia
Pathogenesis

Aspiration of meconium
 Airway obstruction (ball and valve)

 Chemical pneumonitis with activation

of several inflammatory mediators
 Inactivation of lung surfactan
 …pathogenesis

Aspiration of meconium
 Thin MAS  chemical pneumonitis
 Thick MAS atelectasis, airway blockage,
airleak syndrom
 Risk Factors

 Post-term pregnancy
 Maternal hypertension
 Abnormal fetal heart rate
 Biophysical profile  6
 Pre-eclampsia
 Maternal diabetes mellitus
 SGA
 Chorioamnionitis
Clinical Presentation
 Meconium staining of amniotic fluid before
birth
 Meconium staining of neonate after birth
 Varying degree of respiratory distress and
is likely to have a barrel chest with audible
rales
 Persistent pulmonary hypertension of the
newborn
 Pneumotorax (10%-20% infants with MAS)
Laboratory Studies

 Complete blood count

 Blood gas analysis
 Blood culture
Chest X-Ray

 Patchy areas of atelectasis

alternating with areas of
overinflation
 Hyperinflation of the lung and
flattening of the diaphragm
Management

Prenatal management
 Identification of high-risk pregnancy

 Monitoring of fetal heart rate during

labor
 …management
Delivery room management
 Placed under radiant warmer  suction the
hypopharinx to clear any residual meconium
 Depressed infants (depressed respiration, HR
< 100 beat / min, poor muscle tone 
tracheal visualization and suctioning should be
performed
 …management
General management

 Empty the stomach contents to avoid

further aspiration
 Correction of metabolic abnormalities e.g.
hypoxia, acidosis, hypoglycemia,
hypocalcemia and hypothermia
 Surveillance for end organ hypoxic/ischemic
damage (brain, kidney, heart and liver)
 …management
Respiratory management

 Frequent suction and chest vibration

 Pulmonary toilet to remove residual
meconium if intubated
 Antibiotic coverage
 Ventilatory support
 ECMO
Prognosis

 Mortality rate may be as high as 50%.

 Survivors may suffer from
bronchopulmonary dysplasia and
neurologic sequelae.
 Air Leak Syndromes

Definition
 Comprise a spectrum of diseases with the
same underlying pathophysiology
 Overdistension of alveolar sacs or terminal
airways leads to disruption of airway integrity,
resulting in dissection of air into surrounding
spaces
 Incidence

 Most common in neonates with lung

disease who are on ventilatory
support but can also occur
spontaneously
 The more severe the lung disease,
the higher the incidence of pulmonary
air leak
Risk Factors

 Spontaneous 0.5%
 Ventilatory support 15-20%
 CPAP 5%
 Meconium staining / aspiration
 Surfactant therapy
 Vigorous resuscitation (bag
ventilation)
Clinical Manifestation

 Respiratory distress or sudden

deterioration of clinical course with
alteration of vital signs and
worsening of blood gases.
 Asymmetry of thorax is present in
unilateral cases.
Investigations

 The definitive diagnosis of all air

leak syndromes is made
radiographically by an A-P chest X-
ray film and a lateral film.
 Management

General
 Avoid ventilators
 Careful use of manual bag ventilation

Specific
 Decompression of air leak according to the
type.
 Do not needle the chest
 Congenital and Postnatal
Pneumonia

 Developing countries  pneumonia > 50%

cases of respiratory distress
 Term and post term  primary pneumonia
because of prenatal aspiration due to fetal
hypoxia as a result of placental disfunction
 Preterm  postnatal pneumonia as
consequence os septicemia, aspiration of
feeds and ventilation for respiratory failure

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 Clinical Manifestation

 Tachipnea, respiratory distress with

subcostal retractions, expiratory grunt
and cyanosis
 Lethargy, poor feeding, jaundice,
apneic attacks, temperature instability
 Cough  rare in newborn baby

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 Management

Supportive treatment should be

provided
 Thermoneutral environment

 NPO  IV fluids given  peripheral

vein
 Oxygen given to relieve cyanosis

 Antibiotics started

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 Congenital Pneumonia
 PROM > 24 hours, foul smelling
liquor, peripartal fever, prolonged /
difficult delivery, single or multiple
unclean vaginal examination
 Respiratory distress  soon after
birth / during first 24 hours
 Auscultation  non spesific

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
X-ray- Congenital Pneumonia
 Nosocomial Pneumonia
 Risk factor : Ventilated neonates
: Preterm neonates
 Prevention : Hand wash
: Use of disposables
: Infection control
measures
 Antibiotics : Usually require
higher antibiotics
Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 Respiratory Distress in a Neonate
with Asphyxia

 Myocardial dysfunction
 Cerebral edema
 Asphyxial lung injury
 Metabolic acidosis
 Persistent pulmonary hypertension

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
 Persistent Pulmonary Hypertension
of the Newborn (PPHN)

 Causes
 Primary
 Secondary: MAS, asphyxia, sepsis
 Management
 Severe respiratory distress needing
ventilatory support, pulmonary
vasodilators
 Poor prognosis

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
Congenital Heart Disease
(CHD)

 May present with cyanosis and

heart failure
 CHD and pulmonary disease can
coexist
 Differentiation between heart and
lung disease are cumulative

Aly H, Pediatrics in Review 2004;25:201-208

 Clinical Manifestation

 Visible hyperactive precordial impulse

 Gallop rhythm
 Poor capillary refill
 Weak pulse
 Decreased/delayed pulse in lower extremities
 Hepatomegaly
 Abnormal vascularity or cardiomegaly on CXR

Aly H, Pediatrics in Review 2004;25:201-208

 …clinical manifestation
 Single second heart sound
 Usually do not have hypercapnia unless
associated with lung disease
 Do not present with chest retraction, but
tachypnea is common
 Oxygen saturation is decreased
 Hyperoxygenation test will not produced
significant increase in PaO2 in most infants
who have cyanotic CHD

Aly H, Pediatrics in Review 2004;25:201-208

 Cyanotic Heart Pulmonary Disease
Disease
History Previous sibling who has CHD Maternal fever
Diagnosis of CHD by prenatal Meconium stained amniotic
ultrasonography fluid
Preterm fluid

Physical Cyanosis Cyanosis

findings Gallop rhythm Severe retraction
Single record heart sound Split second heart sound

Large liver Fever

Mild respiratory distress

Arterial Normal or decreased PCO2 Increased PCO2

Blood Gases Decreased PO2 Decreased PO2
 Cyanotic Heart
Disease
Chest Increased heart size
Radiograph Decreased pulmonary
vascularity (except in
transposition of the great
vessels and total anomalous
pulmonary venous return)
Pulmonary Disease
Normal heart size
Abnormal pulmonary
parenchyma, such as :
Total whiteout or patches of
consolidation in pneumonia
Fluid in the fissures in TTN

Ground glass appearance in

HMD
Hyperoxyg PaO2 < 150 mm Hg PaO2 > 150 mm Hg (except in
enation severe PPHN)
test Normal heart and vessels
Abnormal heart or vessels
Echocardio
graphy
Respiratory Distress Needing
Referral
 RDS (HMD)
 MAS
 Surgical or cardiac cause
 PPHN
 Severe or worsening distress
Apnea

Definition
 Cessation of respiration accompanied
by bradycardia and / or cyanosis for
more than 20 seconds
Incidence

 50-60% of preterm neonates have

evidence of apnea (35% with central
apnea, 5-10% with obstructive apnea,
and 15-20% with mixed apnea)

Aly H, Pediatrics in Review 2004;25:201-208

Risk Factor
Pathological apnea
 Hypothermia

Cardiac disease
 Hypoglycemia
 Anemia
 Lung disease
 Hypovolemia  Gastro intestinal reflux
 Aspiration
 Airway obstruction
 NEC / Distension
 Infection, meningitis
 Neurological disorders

Aly H, Pediatrics in Review 2004;25:201-208

 Investigations
 Monitoring at-risk neonates less than 32 weeks
gestational age
 Evaluate for a possible underlying cause
 Laboratory studies should include a CBC, blood
gas analysis, serum glucose, electrolyte, and
calcium levels
 Radiologic studies if chest disease is suspected

Aly H, Pediatrics in Review 2004;25:201-208

Management

General therapy
 Perform tactile stimulation
 CPAP in recurrent and prolonged apnea

 Pharmacological therapy (caffeine or

theophylline) may be required

Aly H, Pediatrics in Review 2004;25:201-208

 …management

Specific therapy
 Treatment of the cause, if
identified, eg. treatment of sepsis,
hypoglycemia, anemia, and
electrolyte abnormalities

Aly H, Pediatrics in Review 2004;25:201-208

Prognosis

 In most neonates apnea resolves

without the occurrence of long-term
deficiencies

Aly H, Pediatrics in Review 2004;25:201-208

Summary
1. Evaluate the severity of respiratory
distress using the Down's Score
2. Identify common neonatal respiratory
disorders, including:
 Transient Tachypnea of the Newborn (TTN)
 Respiratory Distress Syndrome (RDS)
 Meconium Aspiration Syndrome (MAS)
 Air leak syndromes
 Apnea
 Pneumonia
 …summary
3. Identify the risk factors, clinical
presentation, required laboratory and
radiological investigations, and
management of TTN, RDS, MAS, Air
Leak Syndromes, Pneumonia, Apnea
 Guidelines for early management of
RDS (Advances in Perinatal Medicine, 1997, 360-70)
Gestational Age (Weeks)
< 28 28 - 31 32
Especially if no Consider if no
antenatal antenatal
steroids, known steroids, lung
lung immaturity, immaturity,
male sex and male sex, and When needing
need for need for IPPV and > 30-
intubation in intubation in 40% oxygen
resuscitation resuscitation

Prophylaxis Rescue