Respiratory Distress - newbornwhocc.org · Early progressive - Respiratory distress syndrome or hyaline membrane disease (HMD) Early transient - Asphyxia, metabolic causes, hypothermia

11RD-RD-Teaching Aids: NNF

Respiratory distressRespiratory distress

• Cause of significant morbidity and Cause of significant morbidity and mortalitymortality

• Incidence 4 to 6% of live birthsIncidence 4 to 6% of live births• Many are preventableMany are preventable• Early recognition, timely referral, Early recognition, timely referral,

appropriate treatment essentialappropriate treatment essential


Respiratory distressRespiratory distress

• RR > 60/ minRR > 60/ min**• Retractions Retractions • GruntGrunt• ++ Cyanosis Cyanosis

* Tachypnea* Tachypnea


Causes of respiratory distressCauses of respiratory distress

• PulmonaryPulmonary

• Cardiac- Congenital heart disease Cardiac- Congenital heart disease

• CNS- Asphyxia, IC bleedCNS- Asphyxia, IC bleed

• Metabolic-Hypoglycemia, acidosisMetabolic-Hypoglycemia, acidosis


Causes of respiratory distress - MedicalCauses of respiratory distress - Medical

• Respiratory distress syndrome (RDS)Respiratory distress syndrome (RDS)• Meconium aspiration syndrome (MAS)Meconium aspiration syndrome (MAS)• Transient tachypnoea of newborn (TTNB)Transient tachypnoea of newborn (TTNB)• Asphyxial lung diseaseAsphyxial lung disease• Pneumonia- Congenital, aspiration, nosocomialPneumonia- Congenital, aspiration, nosocomial• Persistent pulmonary hypertension (PPHN)Persistent pulmonary hypertension (PPHN)


Surgical causes of respiratory distressSurgical causes of respiratory distress

• Tracheo-esophageal fistulaTracheo-esophageal fistula

• Diaphragmatic hernia Diaphragmatic hernia

• Lobar emphysemaLobar emphysema

• Pierre -Robin syndromePierre -Robin syndrome

• Choanal atresiaChoanal atresia


Approach to respiratory distressApproach to respiratory distress

History History • Onset of distress Onset of distress • GestationGestation• Antenatal steroidsAntenatal steroids• Predisposing factors- PROM, feverPredisposing factors- PROM, fever• Meconium stained amniotic fluid Meconium stained amniotic fluid • AsphyxiaAsphyxia


Approach to respiratory distressApproach to respiratory distressExaminationExamination• Severity of respiratory distressSeverity of respiratory distress• Neurological statusNeurological status• Blood pressure, CFTBlood pressure, CFT• HepatomegalyHepatomegaly• CyanosisCyanosis• Features of sepsisFeatures of sepsis• Look for malformationsLook for malformations


Assessment of respiratory distressAssessment of respiratory distress

Score *Score * 0 0 1 2 1 2

3.3. Resp. rateResp. rate <60 <60 60-80 60-80 >80 >80

4.4. Central Central None None None with Needs None with Needs cyanosiscyanosis 40% 40% FiOFiO2 2 >>40% FiO40% FiO2 2

6.6. Retractions NoneRetractions None Mild Mild Severe Severe

7.7. GruntingGrunting None Minimal None Minimal Obvious Obvious

8.8. Air entryAir entry Good Good Decreased Decreased Very poor Very poor

* Score > 6 indicates severe distress* Score > 6 indicates severe distress


Approach to respiratory distressApproach to respiratory distress

Chest examinationChest examination

• Air entryAir entry

• Mediastinal shiftMediastinal shift

• Adventitious soundsAdventitious sounds

• HyperinflationHyperinflation

• Heart soundsHeart sounds


Preterm - Possible etiologyPreterm - Possible etiology

Early progressive - Early progressive - Respiratory distressRespiratory distress syndrome or hyaline syndrome or hyaline membrane disease membrane disease

(HMD)(HMD)

Early transient - Early transient - Asphyxia, metabolic Asphyxia, metabolic causes, hypothermiacauses, hypothermia

Anytime - PneumoniaAnytime - Pneumonia


Term – Possible etiologyTerm – Possible etiology

Early well lookingEarly well looking - - TTNB,TTNB, p polycythemiaolycythemiaEarly severe distress Early severe distress - MAS, asphyxia, - MAS, asphyxia,

malformations malformations Late sick with - CardiacLate sick with - Cardiac hepatomegaly hepatomegaly Late sick with shock Late sick with shock - Acidosis - AcidosisAnytime Anytime - Pneumonia - Pneumonia


Suspect surgical causeSuspect surgical cause

• Obvious malformationObvious malformation

• Scaphoid abdomenScaphoid abdomen

• FrothingFrothing

• History of aspirationHistory of aspiration


InvestigationsInvestigations

• Gastric aspirateGastric aspirate

• Polymorph countPolymorph count

• Sepsis screen Sepsis screen

• Chest X-rayChest X-ray

• Blood gas analysisBlood gas analysis


Shake testShake test

• Take a test tube

• Mix 0.5 ml gastric aspirate + 0.5 ml absolute alcohol

• Shake for 15 seconds

• Allow to stand 15 minutes for interpretation of result


Respiratory distress - Respiratory distress - ManagementManagement

• Monitoring Monitoring • SupportiveSupportive

- - IV fluidIV fluid- Maintain vital signs- Maintain vital signs- Oxygen therapy- Oxygen therapy- Respiratory support- Respiratory support

• SpecificSpecific


Oxygen therapy*Oxygen therapy* IndicationsIndications

• All babies with distressAll babies with distress• CyanosisCyanosis• Pulse oximetry SaOPulse oximetry SaO22 < < 90%90%

MethodMethod• Flow rate 2-5 L/ minFlow rate 2-5 L/ min• Humidified oxygen by hood or nasal prongsHumidified oxygen by hood or nasal prongs

* Cautious administration in pre-term* Cautious administration in pre-term


Pulse oximetryPulse oximetry

• Effective non invasive monitoring of Effective non invasive monitoring of oxygen therapyoxygen therapy

• Ideally must for all sick neonates and Ideally must for all sick neonates and those requiring oxygen therapythose requiring oxygen therapy

• Maintain SaOMaintain SaO22 between 90 – 93 % between 90 – 93 %


Respiratory distress syndrome (RDS)Respiratory distress syndrome (RDS)

• Pre-term babyPre-term baby

• Early onset within 6 hoursEarly onset within 6 hours

• Supportive evidence: Negative shake testSupportive evidence: Negative shake test

• Radiological evidenceRadiological evidence


X-ray - RDSX-ray - RDS


Pathogenesis of RDSPathogenesis of RDS

• Decreased or abnormal surfactantDecreased or abnormal surfactant

• Alveolar collapse Alveolar collapse

• Impaired gas exchangeImpaired gas exchange

• Respiratory failureRespiratory failure


RDS - Predisposing factorsRDS - Predisposing factors

• Prematurity Prematurity • Cesarean bornCesarean born• Asphyxia Asphyxia

• Maternal diabetesMaternal diabetes

RDS - Protective factorsRDS - Protective factors• PROMPROM• IUGRIUGR• SteroidsSteroids


Antenatal corticosteroidAntenatal corticosteroid - - Simple therapy that saves neonatal livesSimple therapy that saves neonatal lives

• Preterm labor 24-34 weeks of gestation Preterm labor 24-34 weeks of gestation irrespective of PROM, hypertension and irrespective of PROM, hypertension and diabetesdiabetes

• Dose:Dose:Inj Betamethasone 12mg IM every 24 hrs X Inj Betamethasone 12mg IM every 24 hrs X 2 doses; or Inj Dexamethasone 6 mg IM 2 doses; or Inj Dexamethasone 6 mg IM every 12 hrs X 4 dosesevery 12 hrs X 4 doses

• Multiple doses not beneficialMultiple doses not beneficial


Surfactant therapy - IssuesSurfactant therapy - Issues

• Should be used only if facilities for Should be used only if facilities for ventilation availableventilation available

• CostCost

• Prophylactic Vs rescueProphylactic Vs rescue


Prophylactic therapyProphylactic therapy Extremely preterm <28 wks Extremely preterm <28 wks <1000 gm <1000 gm Not routine in IndiaNot routine in India

Rescue therapyRescue therapy Any neonate diagnosed to have RDSAny neonate diagnosed to have RDS

Surfactant therapy - Issues

Dose 100mg/kg phospholipid Intra trachealDose 100mg/kg phospholipid Intra tracheal


Meconium aspiration syndrome (MAS)Meconium aspiration syndrome (MAS)

• Meconium stainingMeconium staining - Antepartum, intrapartum- Antepartum, intrapartum• ThinThin - Chemical pneumonitis- Chemical pneumonitis• ThickThick - Atelectasis, airway blockage, air - Atelectasis, airway blockage, air

leak syndromeleak syndrome


Meconium aspiration syndromeMeconium aspiration syndrome

• Post term/SFDPost term/SFD

• Meconium staining – cord, nails, skinMeconium staining – cord, nails, skin

• Onset within 4 to 6 hoursOnset within 4 to 6 hours

• Hyperinflated chestHyperinflated chest


X-ray - MASX-ray - MAS


MAS - PreventionMAS - Prevention

• Oropharyngeal suction before delivery of Oropharyngeal suction before delivery of shoulder for shoulder for all all neonates born through neonates born through MSAFMSAF

• Endotracheal suction for Endotracheal suction for non vigorous* non vigorous* neonates born through MSAFneonates born through MSAF

**Avoid bag & mask ventilation till trachea is Avoid bag & mask ventilation till trachea is clearedcleared


Transient tachypnoea of newborn Transient tachypnoea of newborn (TTNB)(TTNB)

• Cesarean born, term babyCesarean born, term baby

• Delayed clearance of lung fluidDelayed clearance of lung fluid

• Diagnosis by exclusionDiagnosis by exclusion

• Management: supportiveManagement: supportive

• Prognosis - goodPrognosis - good


X-ray- TTNBX-ray- TTNB


Congenital pneumoniaCongenital pneumonia

Predisposing factorsPredisposing factors PROM >24 hours, foul smelling liquor, PROM >24 hours, foul smelling liquor,

Peripartal fever, unclean or multiple per Peripartal fever, unclean or multiple per vaginal vaginal

TreatmentTreatment Thermoneutral environment, NPO, IV Thermoneutral environment, NPO, IV

fluids, Oxygen, antibiotics-fluids, Oxygen, antibiotics-(Amp+Gentamicin)(Amp+Gentamicin)


X-ray – Congenital pneumoniaX-ray – Congenital pneumonia


Nosocomial pneumoniaNosocomial pneumonia

Risk Factor Risk Factor : Ventilated neonates: Ventilated neonates : Preterm neonates: Preterm neonates

Prevention Prevention : Handwash: Handwash: Use of disposables: Use of disposables

: Infection control : Infection control measures measures

Antibiotics Antibiotics : Usually require higher : Usually require higher antibiotics antibiotics


Respiratory distress in a neonate with Respiratory distress in a neonate with asphyxiaasphyxia

• Myocardial dysfunctionMyocardial dysfunction

• Cerebral edema Cerebral edema

• Asphyxial lung injury Asphyxial lung injury

• Metabolic acidosisMetabolic acidosis

• Persistent pulmonary hypertensionPersistent pulmonary hypertension


PneumothoraxPneumothorax

EtiologyEtiologySpontaneous, MAS, Positive pressure Spontaneous, MAS, Positive pressure

ventilation (PPV)ventilation (PPV)

Clinical featuresClinical featuresSudden distress, indistinct heart soundsSudden distress, indistinct heart sounds

ManagementManagement Needle aspiration, chest tubeNeedle aspiration, chest tube


X-ray - PneumothoraxX-ray - Pneumothorax


Persistent pulmonary Persistent pulmonary hypertension (PPHN) hypertension (PPHN)

CausesCauses• Primary Primary • Secondary: MAS, asphyxia, sepsis Secondary: MAS, asphyxia, sepsis

Management Management • Severe respiratory distress needing Severe respiratory distress needing

ventilatory support, pulmonary ventilatory support, pulmonary vasodilatorsvasodilators

• Poor prognosis Poor prognosis


Respiratory distressRespiratory distress (needing referral) (needing referral)

• RDS (HMD)RDS (HMD)• MASMAS• Surgical or cardiac causeSurgical or cardiac cause• PPHNPPHN• Severe or worsening distressSevere or worsening distress

Documents

Respiratory Distress - newbornwhocc.org · Early progressive - Respiratory distress syndrome or hyaline membrane disease (HMD) Early transient - Asphyxia, metabolic causes, hypothermia