Respiratory Distress in
Neonates
Dr Ghamdi, Mohammad
Assistant Professor
Consultant Pediatrician & Neonatologist
NRP instructor
•
Objectives
After completing this lecture, audiences should be able
to:
1. Evaluate and diagnose the most common causes of
respiratory distress in the newborn
2. Differentiate between cardiac and respiratory causes of
respiratory distress in the neonate.
• 3. Differentiate between the normal chest radiograph
and the radiographic patterns of various respiratory
disorders
4. QUIZ
Pulmonary Causes for Respiratory
Distress in Neonates
• Parenchymal conditions
• Developmental abnormalities
• Mechanical abnormalities
Pulmonary Causes for Respiratory
Distress in Neonates
•
•
•
•
•
Parenchymal conditions
Transient tachypnea of the newborn
Respiratory distress syndrome
Pneumonia
Meconium aspiration syndrome
Pulmonary Causes for Respiratory
Distress in Neonates
•
•
•
•
•
Developmental abnormalities
Congenital diaphragmatic hernia
Lobar emphysema
Cystic adenomatoid malformation
Pulmonary sequestration
Pulmonary Causes for Respiratory
Distress in Neonates
Mechanical abnormalities
• Pneumothorax
• Pneumomediastinum
Respiratory Distress in Neonates
• The major signs of neonatal respiratory distress
are tachypnea and cyanosis, in which tachypnea
is defined as a respiratory rate consistently
greater than 60 breaths/min.
Respiratory Distress in Neonates
• Nasal flaring
(decrease airway resistance)
• Grunting.
• Chest retractions
Suprasternal ( upper airway obstruction)
Intercostal subcostal retraction
 Cyanosis
NORMAL LUNG
NORMAL LUNG
Pulmonary Causes for Respiratory
Distress in Neonates
•
•
•
•
•
Parenchymal conditions
Transient tachypnea of the newborn
Respiratory distress syndrome
Pneumonia
Meconium aspiration syndrome
Transient Tachypnea Of The
Newborn
• Described by Avery 1966.
• This relatively benign, self-limited disease also is
known as RDS type 2 or wet lungs.
• It occurs in approximately 11 per 1,000 live
more in boys, more in cesarean section, and in
infants who have perinatal asphyxia.
Transient Tachypnea Of The
Newborn
• Delayed clearance of fetal lung fluid.
• The syndromeis characterized by tachypnea that
appears shortly after birth and usually clears
within 1 to 5 days.
Transient Tachypnea Of The
Newborn
• TTN is characterized by the presence of diffuse
parenchymal infiltrates .
• Accumulation of fluid in the various intralobar
spaces.
Clinical Diagnosis Of TTN
• CXR
– Pulmonary
vascular
congestion (1)
– Perihilar
streaking (2)
– Incr lung volume
(3)
– Fluid in fissures
1
1,2
3
NORMAL LUNG
increased pulmonary interstitial
markings in both lung fields
Transient Tachypnea Of The
Newborn
• In most cases, the clinical course is benign, and
mechanical ventilation almost never is required.
Respiratory Distress Syndrome
• RDS is primarily a disease of preterm infants
Near-term infants may be affected.
• The condition is more common in boys .
• The incidence is approximately six times higher
in infants whose mothers have diabetes
Respiratory Distress Syndrome
• Multiple birth, cesarean section prior to the
onset of labor, perinatal asphyxia.
• Immature type II alveolar cells produce less
surfactant, causing an increase in alveolar surface
tension and a decrease in compliance.
Pathogenesis
surfactant
pulmonary vascular W
 pulmonary perfusion
atelectasis
hypoxia
hypercapnia
acidosis
respiratory
metabolic
surfactant
deficiency
capillary damage
alveolar necrosis
pulm vasospasm
Clinical Diagnosis Of RDS
• CXR
Ground glass
Air bronchograms
Decr lung
volume
1
2
1
2
3
3
4
5
6
7
NORMAL LUNG
Clinical Diagnosis Of RDS
Clinical Diagnosis Of RDS
Bell shaped thorax
4
Clinical Diagnosis Of RDS
Respiratory Distress Syndrome
• Infants who have RDS may do well with nasal
continuous positive airway pressure or may
require ventilation.
• Surfactant often improves pulmonary mechanics
significantly but has little effect on overall
outcome,which is favorable in most cases.
Radiographic Progression Of BPD
1d
10d
RDS Findings
Complete Opacification
5mo
20d
Cysitic Lucencies
Larger cysts, Increased
volume, Fibrosis strands
Meconium Aspiration Syndrome
• MAS is defined as respiratory distress in an
infant born through meconium-stained amniotic
fluid whose symptoms cannot otherwise be
explained.
Meconium Aspiration Syndrome
• Meconium is composed of desquamated
cells, secretions, lanugo, water, bile pigments,
pancreatic enzymes, and amniotic fluid.
Meconium Aspiration Syndrome
• Meconium-stained amniotic fluid occurs in
approximately 15 percent of deliveries, causing
meconium aspiration syndrome.
• Chemical pneumonitis
• Inactivation of surfactant
• Partial or complete airway obstruction
Meconium Aspiration Syndrome
•
•
•
•
Coarse infiltrates
Widespread consolidation
Hyperinflation
Pneumothorax and pneumomediastinum may be
present
Clinical Diagnosis Of MAS
• CXR
– Lung overinflation (1)
– Patchy/
splotchy
densities
(cloud like)
NORMAL LUNG
Meconium Aspiration Syndrome
Secondary pulmonary hypertension is a frequent
associated finding.
The management of MAS remains a challenge.
Persistent pulmonary hypertension
• Common clinical features are severe cyanosis
and tachypnea.
• The lung fields may appear clear with decreased
pulmonary vascularity.
• The heart size may be normal or increased.
Pneumonia
• Pneumonia may be acquired in utero, during
delivery (or perinatally), or postnatally in the
nursery or at home.
• It may be classified as either early- (7 d of age)
or late onset (7 d of age).
Pneumonia
• bacterial infection takes time to develop, with
respiratory consequences occurring hours to
days after birth.
• Risk factors for pneumonia include prolonged
rupture of membranes, prematurity,and maternal
fever
Pneumonia
• the chest radiograph may reveal classical patchy
infiltrates, but the findings also may be
indistinguishable from RDS.
• The presence of a pleural effusion supports the
diagnosis of pneumonia; it has been reported in
up to 67% of cases
Diagnosis Of Neonatal Pneumonia
• CXR
– Diffuse granular
pattern (less
uniform than
RDS) (1)
– Normal lung
volume (2)
– Pleural effusion
(?)
1
?
2
Pneumonia
NORMAL LUNG
Pneumonia
• Pneumonias that are acquired at birth most
often are caused by group B Streptococcus, but
Escherichia coli, Klebsiella sp, and Chlamydia
trachomatis also are seen.
Pneumonia
• Management
• includes oxygen therapy, ventilatory support,
antibiotics,and often vasopressor support such
as dopamine and dobutamine.
Pulmonary Causes for Respiratory
Distress in Neonates
•
•
•
•
•
Developmental abnormalities
Congenital diaphragmatic hernia
Cystic adenomatoid malformation
Lobar emphysema
Pulmonary sequestration
Congenital Diaphragmatic Hernia
• CDH occurs in 1 in 2,000 to 4,000 births.
• Males are affected more often (male:female
ratio of 1.5:1), and the recurrence risk in future
pregnancies is 2%.
• CDH is a developmental abnormality of the
diaphragm resulting in a defect that permits
abdominal viscera to enter the chest.
• Usually the defect occurs before the eighth week
of embryonic life.
Clinical Diagnosis Of CDH
• CXR
 Loops of bowel in
L thorax (may
initially be opaque,
a air)
 R mediastinal shift
 Pulmonary
hypoplasia
Decreased
contralateral
lung volume
Congenital Diaphragmatic Hernia
• In the delivery room, the neonate typically
presents with respiratory distress shortly after
birth.
• Physical examination may show the abdomen to
be scaphoid.
• Air entry is reduced on the affected side, and the
heart sounds are displaced.
Congenital Diaphragmatic Hernia
• Immediate treatment includes intubation and
mechanical ventilation, and a nasogastric tube
should be passed for decompression.
Congenital Diaphragmatic Hernia
• The presence of associated major malformations
increases the mortality markedly, as does liver
herniation
• If there are no other anomalies and the defect is
not part of a genetic syndrome, the prognosis
after neonatal surgical repair usually is good,
with overall survival rates for live born infants
of 60% to 80%.
Congenital Cystic Adenomatoid
Malformation
• CCAM consists of a multicystic mass of dilated
bronchiolar like spaces that proliferate at the
expense of alveoli.
• The result is the formation of a rubbery lesion
that enlarges following air and fluid trapping.
Congenital Cystic Adenomatoid
Malformation
• Males and females are affected equally.
Approximately 50% of the cases present as lifethreatening respiratory distress in the neonatal
period.
• The condition is more common on the right
side, and usually only one lobe is involved.
Congenital Cystic Adenomatoid
Malformation
Congenital Cystic Adenomatoid
Malformation
• Treatment is by surgical resection of the lesion.
The survival rate has been reported to be 100%
in neonates who do not have hydrops fetalis, but
is much lower in those who have hydrops.
Congenital Lobar Emphysema
• CLE is characterized by air trapping and
overdistention of segments and lobes of the
lungs.
• Clinical symptoms include respiratory distress,
mediastinal shift.
• The upper lobes are involved in 90% of the
cases.
• The diagnosis can be made by simple chest
radiograph
Congenital Lobar Emphysema
Congenital Lobar Emphysema
• It is more common in males (2:1). Sometimes
the lesion can be mistaken for pneumothoraxor
CDH.
• There are associated anomalies in 14% to 40%
of cases (cardiovascular)
• The prognosis is favorable
Pulmonary Sequestration
• Lobar sequestration is composed of abnormal
lung tissue that has no connection with the
normal tracheobronchial tree.
• It is more common in males (3 to 4 times), and
50% of patients have respiratory distress due to
compression of the rest of the lung parenchyma.
Pulmonary Sequestration
• In more than 65% of cases, there are associated
anomalies, including CDH (20% to 30%),.
• The definitive treatment is resection of the
lesion.
Pulmonary Causes for Respiratory
Distress in Neonates
Mechanical abnormalities
• Pneumothorax
• Pneumomediastinum
Pneumothorax
• A pneumothorax (pneumo=air; thorax=chest) is
a collection of air in the pleural cavity
surrounding the lung. It is caused by the rupture
of one or more alveoli which allows air to
escape from the lung.
• The pneumothorax compresses the lung and
prevents normal lung expansion during
inspiration. Usually a pneumothorax occurs on
one side only but it may be bilateral
Pneumothorax
• Clinical Features
• sudden deterioration with desaturation
• increase in respiratory distress and/or diminished chest
movements
• circulation may become compromised
• blood gases may show hypoxia, respiratory and/or
metabolic acidosis.
• Clinical signs include
• unequal or decreased air entry
• displaced apex beat
Pneumothorax
• WHO IS AT RISK OF PNEUMOTHORAX?
• 1. All infants with respiratory distress, whatever
the cause.
• 2. Infants with meconium aspiration are at
increased risk.
• 3. Infants that need intubation and ventilation at
resuscitation.
• 4. Infants that are intubated and are ventilated in
the nursery.
Pneumothorax
• The suspected clinical diagnosis can be
confirmed by:
A chest X-ray which will show air in the pleural
space.
Pneumothorax
 Outline of
affected lung
 Mediastinal
shift
 Air above
diaphragm
?
• Transillumination of
the chest. The chest
wall on the side of the
pneumothorax
transilluminates well
while the chest wall
on the normal side
does not
Pneumothorax
• Transillumination is unreliable in :
infants with increased thickness of the chest
wall e.g. term infants and oedema
infants with pulmonary interstitial
emphysema (who may show a 'false positive'
result)
QUIZ
QUIZ
QUIZ


Select tube size based on weight and
gestational age
Consider shortening tube to 13-15 cm
Tube Size (mm)
Weight
(inside diameter)
(g)
Gestational Age
(wks)
2.5
Below 1,000
Below 28
3.0
1,000-2,000
28-34
3.5
2,000-3,000
34-38
3.5-4.0
Above 3,000
Above 38
Tip-to-lip measurement
Depth of insertion
Weight (kg)
(cm from upper lip)
1*
2
3
4
7
8
9
10
* Babies weighing less than 750 g may require only 6 cm
insertion.