Respiratory Distress in the Newborn

  • Core 1 (Pre-Clerkship)
    • Integrative Science
      • Pulmonology
        • Anatomy of the Respiratory System
        • Surfactant
        • Pediatric Pulmonary: Developmental lung disease, Neonatal Respiratory failure
  • Core 2 (Clerkship)
    • Pediatrics Clerkship 
  • Core 3 (Post Clerkship) Electives that may further knowledge - NICU, Pulmonary 

Clinical Vignettes:

A full-term neonate born 1 hour ago presents with tachypnea and nasal flaring. Delivered via SVD. Clear amniotic fluid and routine delivery. 

A post-term neonate born 15 minutes ago presents with nasal flaring, subcostal retractions, and hypoxemia. Delivered via SVD, fluid was meconium stained.  

A late pre-term neonate born 18 hours ago presents with hypothermia, tachypnea, and subcostal retractions. Delivered via SVD, mother had chorioamnionitis.  

A pre-term neonate born 3 hours ago presents with increasing tachypnea, as well as subcostal and intercostal retractions. Born at 30 weeks 6 days. Infant resuscitation notable for initial PPV for apnea, with de-escalation to CPAP 6 with oxygen blended in. Maternal history of severe pre-eclampsia, requiring magnesium and delivery.  

History

  • What are the symptoms? 
  • Onset and progression of symptoms? 
  • Infant age? 
  • Gestational age? Full term versus Premature 
  • Mode of delivery (vaginal vs c-section)? Any notable delivery details (amniotic fluid composition/presence of meconium, nuchal cord) or complications? 
  • What neonatal resuscitation was required? 
  • Maternal conditions? Maternal medications? 

Physical Exam

  • Vitals (All of them: fevers/temperature instability? Tachycardia vs bradycardia? Tachypnea versus bradypnea? Normotension? Normoxemia?) 
  • Respiratory exam: Rate, Respiratory effort? Signs of work of breathing (nasal flaring, retractions, grunting)? Auscultation? 
  • Other focused pieces of physical – Cardiac exam, example: respiratory distress can be related to cardiac disease if congenital heart disease; Abdominal exam, example: respiratory distress can be related to abdominal competition if mass lesions. 

  • Common causes (such as transient tachypnea of the newborn [TTN], respiratory distess syndrome [RDS], macrorphageg activating syndrome [MAS]) versus less common (infection, persistent pulmonary hypertension of the newborn [PPHTN], congenital anatomic abnormalities of the lung, non-pulmonary causes, pneumothorax) 
  • Pulmonary causes (TTN, RDS, MAS, pneumonia, persistent pulmonary hypertension of the newborn, pneumothorax) vs. non-pulmonary causes (sepsis, anemia vs polycythemia, congenital diaphragmatic hernia, neurologic issues, metabolic issues) 

Evaluation  

  • Labs (if indicated): blood gas; if suspicion respiratory distress may be due to infection, consider CBC with diff and blood culture. 
  • Imaging (if indicated): Chest X-ray; to evaluate lung expansion, lung fields (for consolidation/anatomic abnormalities), abnormal collections of fluid/air. More rarely, echocardiogram, abdominal XR. 
  • Other: continuous pulse oximetry (also consider need for differential saturations). 

Management 

  • [AB]CDE: ensure airway is intact (from a mental status perspective, patency perspective), breathing - if work of breathing, consider trial of CPAP or non-invasive positive pressure ventilation (NIPPV); if desaturations/hypoxemia, consider nasal cannula  
  • Further management depends on etiology:
    • Ex: if respiratory distress is secondary to transient tachypnea of newborn, no additional management needed
    • Ex: if respiratory distress is due to RDS (surfactant deficiency), may need respiratory support and surfactant administration
    • Ex: if respiratory distress is secondary to infection (sepsis, PNA), initiate antibiotics
    • Ex: if respiratory distress is secondary to cardiac disease, echocardiography may be needed, and treatment dependent on etiology
  • If respiratory distress is severe, may need HFNC (high flow nasal cannula), CPAP or BiPAP, or intubation. 

  • History and physical exam are some of the most helpful pieces of the puzzle for respiratory distress in a newborn. Gestational age matters! 
  • Think not just about the lungs, but about other systems that can affect the lung’s ability to function (ex: neurologic, cardiac, GI).  

Click the drop down to reveal the correct answers

Q1: A 6 hour old infant born at 38 weeks develops tachypnea and increased work of breathing with mild retractions. Birth history notable for meconium-stained fluid. Which of the following is the most likely cause of respiratory distress? 

  1. Bronchopulmonary dysplasia (BPD) 
  2. Pneumonia 
  3. Meconium aspiration syndrome (MAS) 
  4. Congenital diaphragmatic hernia (CDH) 

 

Q2: Which of the following would be the next best step in evaluating this infant? 

  1. Immediate intubation 
  2. Obtain chest X-ray 
  3. Reassurance that tachypnea and retractions are always normal in a newborn 
  4. Echocardiogram 

Answers:

Q1: (c) meconium aspiration is most likely of the listed answers in this situation due to the infant’s gestational age and meconium-stained fluid 

Q2: (b) CXR would be the next best step of these answer choices. Immediate intubation would not be indicated unless the infant has impending respiratory failure, which is not the case for mild retractions. CDH and pneumonia are less common causes of respiratory distress in newborns, but must be considered. BPD is found in pre-term infants due to sub-optimal intrauterine lung development. 

 

Articles 

  • Hermansen CL, Lorah KN. Respiratory distress in the newborn. Am Fam Physician. 2007 Oct 1;76(7):987-94. PMID: 17956068.
  • Pramanik AK, Rangaswamy N, Gates T. Neonatal respiratory distress: a practical approach to its diagnosis and management. Pediatr Clin North Am. 2015 Apr;62(2):453-69. doi: 10.1016/j.pcl.2014.11.008. PMID: 25836708. 

Video 

Podcasts  

    • Example: Incubator Podcast #168 “Managing Respiratory Distress Series - Episode 1 with Dr. Richard Polin”