I will not be discussing any experimental or off-label uses for any therapies during this presentation

I will not be discussing any experimental or off-label uses for any therapies during this presentation.

• I will not be discussing any experimental or off-label uses for any therapies during this presentation.

• I have no relevant financial relationships to declare.

Formulate a differential diagnosis for the infant in respiratory distress.

• Formulate a differential diagnosis for the infant in respiratory distress.

• Describe initial stabilization measures for the infant in respiratory distress.

• Describe situations where ongoing respiratory distress requires transfer to a NICU for further management.

Respiratory distress is a frequent problem in the newborn period.

• Respiratory distress is a frequent problem in the newborn period.

• Most common indication for evaluation or re-evaluation of the newborn infant
• Affects as many as 7% of newborns
• Potentially life-threatening
• Must be promptly assessed and managed by an on-site provider in the delivery room or newborn nursery

apnea

• apnea

• cyanosis

• grunting

• stridor

• nasal flaring

• Image: Aly H. Pediatrics in Review (2004)

Pulmonary

• Pulmonary

• Transient Tachypnea of the Newborn (TTN)
• Respiratory Distress Syndrome (RDS)
• Meconium aspiration syndrome
• Pneumonia/sepsis
• Pneumothorax
• Persistent pulmonary hypertension (PPHN)

• Non-pulmonary

• Congenital cyanotic heart disease
• Congenital airway anomalies
• Other (neurologic, hematologic, metabolic, endocrine, maternal, etc.)

3.6-kg term newborn female (20 minutes old) has tachypnea and acrocyanosis. She is 40 weeks EGA delivered by scheduled repeat c-section and Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.

• 3.6-kg term newborn female (20 minutes old) has tachypnea and acrocyanosis. She is 40 weeks EGA delivered by scheduled repeat c-section and Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.

• Vitals are normal with the exception of a respiratory rate of 84 and exam is notable for slight subcostal retractions but otherwise normal. Over the next several hours, her respiratory rate steadily improves to the 40s and her acrocyanosis resolves.

Most common etiology of newborn respiratory distress.

• Most common etiology of newborn respiratory distress.

• 11/1000 live births
• Represents 40% of cases of newborn respiratory distress.

• Caused by delayed clearance of fetal lung fluid in both term and preterm infants

At birth:

• At birth:

• Air spaces rapidly clear fluid from lung expansion with air
• Promoted by:
• Labor
• Maternal epinephrine surge

History:

• History:

• C/S > NSVD

• Exam:

• Tachypnea +/-
• Grunting
• Nasal flaring
• Retractions
• Transient oxygen need

Chest X-ray:

• Chest X-ray:

• Increased interstitial markings (“wet lung”)
• Increased fluid in interlobar fissures

Usually benign, self-limited

• Usually benign, self-limited

• Occasionally requires therapy:

• Oxygen
• nCPAP
• Mechanical ventilation

1.2-kg male infant born vaginally at 32 weeks EGA

• 1.2-kg male infant born vaginally at 32 weeks EGA

• Apgars 6, 8

• Required bulb suctioning, brief PPV.

• Grunting, retractions, nasal flaring, acrocyanosis immediately after birth.

• VS: HR 178, RR 79, Mean BP 39 mmHg. O2 sat 74-78% in room air.

Lab:

• Lab:

• CBC unremarkable
• ABG:
• 7.26/67/58/19

• CXR: “Prominent reticulogranular pattern uniformly distributed with hypoaeration of lungs. Increased air bronchograms are observed.”

Also called hyaline membrane disease.

• Also called hyaline membrane disease.

• Most common cause of respiratory distress in preterm infants.

• Due to structural and functional immaturity of lungs.

• Underdeveloped parenchyma
• Surfactant deficiency
• Type II pneumatocytes

• Results in decreased lung compliance, unstable alveoli

Risk factors

• Risk factors

• Prematurity
• <28 weeks GA (≈100%)
• 28-34 weeks GA (33%)
• >34 weeks GA (5%)
• Perinatal depression
• Male predominance
• Maternal diabetes
• C-section
• Multiple birth

Exam:

• Exam:

• Moderate to severe respiratory distress
• Tachypnea
• Grunting
• Apnea
• Retractions
• Nasal flaring
• Cyanosis

• Lab:

• Moderate hypoxia
• Respiratory acidosis
• Metabolic acidosis (delayed)

Prevention:

• Prevention:

• Antenatal bethamethasone
• Arrest of preterm labor

• Treatment

• Oxygen supplementation
• Assisted ventilation
• nCPAP
• mechanical ventilation
• FiO2 > .40
• Exogenous surfactant replacement
• Fluid restriction

4.2-kg female infant is cyanotic and tachypneic at 30 minutes of age following a vaginal delivery through meconium-stained amniotic fluid. Apgar scores were 3 and 6. She had a spontaneous but weak cry at birth and received some positive pressure ventilation followed by suctioning.

• 4.2-kg female infant is cyanotic and tachypneic at 30 minutes of age following a vaginal delivery through meconium-stained amniotic fluid. Apgar scores were 3 and 6. She had a spontaneous but weak cry at birth and received some positive pressure ventilation followed by suctioning.

• Vitals signs reveal a pulse of 169, respiratory rate of 115, and a mean BP of 55. Sats are 76% despite 100% O2 by headbox. She is barrel-chested, retracting, grunting, and has diminished coarse breath sounds bilaterally.

• She is electively intubated, lines placed and labs sent.

Lab:

• Lab:

• CBC: NL
• ABG: 7.19/72/36

• CXR:

Meconium staining of amniotic fluid complicates nearly 15% of all deliveries.

• Meconium staining of amniotic fluid complicates nearly 15% of all deliveries.

• Fetal distress
• Primarily term and post-term

• Meconium can be aspirated before, during or after delivery.

• Once aspirated, meconium causes

• Chemical pneumonitis
• Mechanical obstruction (“ball-valve”) with severe air-trapping
• Pneumothoraces (10-20%)
• Surfactant inactivation
• Severe hypoxemia and hypoventilation
• V/Q mismatch

Exam:

• Exam:

• Air trapping with barrel chest
• Moderate to severe respiratory distress
• Rales and/or rhonchi
• Hypoxia with cyanosis
• Hypoperfusion

• Lab:

• Acidosis
• Respiratory and metabolic

Prevention?

• Prevention?

• NRP

• Treatment:

• Oxygen
• Mechanical ventilation
• High-Frequency
• Jet
• Oscillator
• Surfactant replacement

3.9-kg male infant develops poor feeding, tachypnea and mild oxygen need at 14 hrs of life.

• 3.9-kg male infant develops poor feeding, tachypnea and mild oxygen need at 14 hrs of life.

• Exam: equal and clear breath sounds with tachypnea. Otherwise unremarkable.

• Labs: WBC 4.3 x 103, ABG NL, electrolytes and glucose acceptable.

• CXR:

Most common neonatal infection

• Most common neonatal infection

• Wide variety of presenting signs

• Varying degree of respiratory distress
• Lethargy, poor feeding
• Apnea
• Temperature instability
• High or low

• CXR: “Can look like anything!”

• Mild focal opacities
• Pleural effusion(s)
• Complete white-out
• Normal

Hematogenous vs. aspiration acquisition

• Hematogenous vs. aspiration acquisition

• Antenatal, perinatal, or postnatally acquired

• Common organisms:

• Antenatal: rubella, CMV, HSV, adenovirus, Toxoplasma gondii, Treponema pallidum, Mycobacterium tuberculosis, Listeria monocytogenes, Varicella zoster and others
• Perinatal: GBS, E. coli, Klebsiella, Chlamydia trachomatis
• Postnatal: adenovirus, RSV, Streptococcus, Staphylococcus, gram negative enterics

Transient oxygen need

• Transient oxygen need

• Gradual resolution of tachypnea

• Antibiotic (ampicillin, gentamicin) therapy 5-7 days unless complicated by sepsis or for specific organism requiring longer courses of therapy

Congenital Diaphragmatic Hernia

• Congenital Diaphragmatic Hernia

Esophageal atresia

• Esophageal atresia

• Tracheoesophageal fistula

Congenital Cystic Adenomatoid Malformation (CCAM)

• Congenital Cystic Adenomatoid Malformation (CCAM)

• Pulmonary sequestrations

Pneumothorax

• Pneumothorax

Cyanotic

• Cyanotic

• Transposition of the great arteries
• Total anomalous pulmonary venous return
• Tricuspid atresia
• Tetralogy of Fallot
• Truncus arteriosus
• Pulmonary atresia
• Severe CHF
• Ebstein’s anomaly
• Double outlet right ventricle

Presenting features

• Presenting features

• Murmur +/
• Tachypnea
• Cyanosis
• Active precordium
• Gallop rhythm
• Hypoperfusion
• Acidosis?
• Weak pulses
• Hepatomegaly

First:

• First:

• Airway
• Breathing
• Circulation

Identify life-threatening conditions that require prompt support

• Identify life-threatening conditions that require prompt support

• Inadequate or obstructed airway
• Gasping
• Choking
• Stridor
• Inadequate oxygenation
• Cyanosis
• Central vs. peripheral

Prolonged maternal rupture of membranes?

• Prolonged maternal rupture of membranes?

• Maternal GBS status?

• Maternal fever?

• Fetal distress?

• Meconium?

• Onset of respiratory distress?

• Immediate?
• Delayed?

Physical exam findings:

• Physical exam findings:

• Breath sounds
• Stridor
• Severity

• Laboratory data:

• CBC w/ differential
• Glucose
• Blood gas
• Blood culture
• CXR
• Hyperoxia test?

Supplemental oxygen:

• Supplemental oxygen:

• Blow by
• Head box
• Nasal cannula
• Face mask

• Monitoring

• HR, RR
• Pulse ox

• How long?

• 2 hrs?
• 4 hrs?
• Longer?

• NPO

Infants with TTN and no sepsis risk factors likely just need support and observation.

• Infants with TTN and no sepsis risk factors likely just need support and observation.

• Infants with possible meconium aspiration, RDS, sepsis or pneumonia require a sepsis evaluation with blood culture, cbc and IV antibiotics x 48hrs and repeat CXR(s).

• Unclear risk factors or presentation?

• Undertake sepsis evaluation

It depends…

• It depends…

• Failure to resolve in 2-4 hrs
• Worsening condition
• Perfusion
• Oxygen needs
• Distress
• Staff ability/comfort/availability
• IV access
• Airway
• Any suspicion of cardiac disease

Respiratory distress is common!

• Respiratory distress is common!

• Most do well with little intervention.

• Short differential dx

• When to transport is up to you!

• Every situation is unique

• Help is just a phone call away!

Neonatologist on-call (In-house 24/7)

• Neonatologist on-call (In-house 24/7)

• St. Paul NICU:
• [phone]
• [phone]
• Minneapolis NICU:
• [phone]
• [phone]

• Transport team

• Centralized Children’s Neonatal Transport Team in 2010
• Air
• Helicopter
• Fixed-wing plane
• Ground

Aly H. Respiratory disorders in the newborn: Identification and diagnosis. Pediatrics in Review 2004;25:201-207.

• Aly H. Respiratory disorders in the newborn: Identification and diagnosis. Pediatrics in Review 2004;25:201-207.

• Guglani L, Lakshminrusimha S, Ryan RM. Transient tachypnea of the newborn. Pediatrics in Review 2008;29:e59-e65.

• Hermansen CL, Lorah KN. Respiratory distress in the newborn. American Family Physician 2007;76:98-994.

• Additional suggested reading:

• Fidel-Rimon O, Shinwell ES. Respiratory distress in the term and near-term infant. NeoReviews 2005;6:e289-e296.

• Suggested resources:

• NRP Program, AAP/AHA

• S.T.A.B.L.E. Program

• www.newbornmed.com

• Provider resources

• Family resources

• Meet our neonatologists

• Articles

• NICU profiles