Respiratory distress in

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                                                                                         NNF Teaching Aids:Newborn Care



Respiratory distress in 


a newborn baby 

Slide RD-l 


Respiratory distress in a newborn is a challenging problem. It accounts for 

significant morbidity and mortality. It occurs in 4 to 6 percent of neonates. 

Many of the conditions causing respiratory distress are preventable. Early 

recognition and prompt management are required. A few may need ventilatory 

support but this treatment is often not available and when available may be 



Slide RD-2 

Tachypnea vs respiratory distress 

It is important to recognise the difference between tachypnea and respiratory 

distress. Tachypnea alone means an increased respiratory rate of >60/min in a 

quiet resting baby. Respiratory rate should not be counted immediately after 

feeds. It should be counted in a calm child  for full one minute. Distress 

indicates more severe form of respiratory disease and it is associated with 

retractions and grunting. 


The usual manifestations of respiratory distress would include tachypnea, 

retractions and grunting. Central cyanosis, lethargy and poor feeding may also 



Slide RD-3 

Causes of respiratory distress 

Pulmonary disease is the most common cause of respiratory distress. But non 

pulmonary problems can also manifest with respiratory distress. These include 

cardiac (congenital heart disease, myocardial dysfunction) neurologic 

(asphyxia, intracranial bleed) and metabolic (hypoglycemia, acidosis). 






                                                                                         NNF Teaching Aids:Newborn Care



Slide RD-4, 5 

Causes of respiratory distress 

Respiratory distress in a newborn could be caused either by surgical or medical 

conditions. The common medical conditions are Respiratory distress syndrome 

(RDS), Meconium aspiration syndrome (MAS), Transient tachypnea of newborn 

(TTNB), pneumonia, aspiration, pulmonary hypertension, delayed adaptation, 

asphyxia and acidosis. Surgical conditions would include Pneumothorax, 

Diaphragmatic hernia, Tracheo esophageal fistula (aspiration), Pierre Robin 

Syndrome (upper airway obstruction due to glossoptosis), Choanal atresia and 

Lobar emphysema.  


Slide RD-6 


While stabilizing a baby with severe respiratory distress, it is important to get a 

good history. We need to know the gestation and if the baby is premature it is 

important to know if antenatal steroids have been given or not. A history to 

determine  the source of infection would include history of premature rupture 

of membranes (PROM), if onset of distress is early. Again in early onset distress 

one should find out the Apgar score and history of meconium stained liquor. 

The importance of determining the  time of onset of distress needs to be 

emphasized, as this may vary depending upon the etiology . It is important to 

know about the feeding problems. Feeding problems could be present in a 

severely distressed baby. If feeding problems are present such as choking or  

aspiration during a feed, one could think of aspiration pneumonia as a 



Slide RD-7 


To assess the severity of the distress the scoring system given in Table 1 could 

be used. Clinical monitoring is most important. An increasing score is more 

important than just an increase in rate. It is also important to distinguish 

between tachypnea and respiratory distress. Tachypnea is usually characteristic 

of a disease like transient tachypnea of newborn. Cardiac conditions and 

acidosis also usually manifest with tachypnea but could progress on to distress. 







                                                                                         NNF Teaching Aids:Newborn Care


Slide RD-8 

Assessment of respiratory distress 

Table 1: Score for respiratory distress 




1 2 

Resp. rate 




Central cyanosis 


None with 40% FiO


Need >40% FiO


Retractions None 



Grunting None Minimal 


Air Entry 



Very poor 


         A score of greater than 6 would indicate severe respiratory distress. 


Slide RD-9 

Chest examination 

Examination of the chest could be helpful in diagnosing the etiology. In MAS, 

the chest is hyperinflated. Air entry is usually decreased in severe RDS. 

Mediastinal shift could occur in pneumothorax or diaphragmatic hernia. Distant 

heart sounds could give a clue to the diagnosis of pneumothorax. 


Slide RD-10 

Approach in preterm 

In a preterm baby, early onset respiratory distress which is progressive is 

invariably due to RDS. However, if distress is transient, asphyxia, hypoglycemia 

and hypothermia could contribute. Other causes of distress which occur in term 

babies could also occur in preterm babies, but the most common and important 

cause in pre term babies is RDS.  Pneumonia could present at anytime after 



Slide RD-11 

Approach in term 

In term babies etiology could differ depending on the time of onset of distress. 

If the baby has tachypnea beginning at birth the causes could be TTNB or 

secondary to polycythemia. If the distress begins early but is more severe it 

may be due to MAS, pneumonia, asphyxia or malformations. 






                                                                                         NNF Teaching Aids:Newborn Care



If the distress occurs at the end of first week or later the cause would be most 

probably pneumonia. Presence of a cleft palate, history of a choking episode 

could indicate aspiration pneumonia. If however the baby has hepatomegaly or 

is in shock one needs to think of a cardiac cause. On the other hand if the baby 

is dehydrated and in shock, a possibility of metabolic acidosis needs to be 



Slide RD-12 

Suspect surgical cause 

We need to suspect surgical conditions if there are any obvious malformations 

(cleft palate, micrognathia) or if there is a scaphoid abdomen (diaphragmatic 

hernia) . Presence of frothing or history suggestive of aspiration may give a 

clue to the presence of a tracheo-esophageal fistula (TEF). Worsening of 

condition during resuscitation at birth by bag and mask ventilation -think of 

diaphragmatic hernia. 


The common malformations/surgical conditions which could present in the 

neonatal period include TEF, diaphragmatic hernia, lobar emphysema, choanal 

atresia and cleft palate. It is important to recognize these conditions early as 

immediate referral and appropriate management would improve prognosis. A 

baby with suspected TEF should not be fed and a baby with suspected 

diaphragmatic hernia should not be resuscitated with bag and mask. 



Slide RD- 13,14 


Investigations would obviously depend on the possible etiology. If PROM is 

present one should look for polymorphs in the gastric aspirate. The first gastric 

aspirate should be used for this test and the aspirate should be clear. Shake 

test is a simple bedside test and should be done in preterm babies with 

respiratory distress.  The gastric aspirate (0.5 ml) is mixed with 0.5 ml of 

absolute alcohol in test tube.  This is shaken for 15 sec. and allowed to stand 

for 15 minutes.  A negative shake test i.e. no bubbles or bubbles covering less 

than 1/3 rd of the rim indicates a high risk of developing RDS and the presence 

of bubbles at more than 2/3 of the rim indicates lung maturity and decreased 

risk of developing RDS.  Sepsis screen is indicated if infection is suspected. The 

most important investigation in a neonate with respiratory distress is a chest X-





                                                                                         NNF Teaching Aids:Newborn Care


ray( refer RD-20 ). An arterial blood gas if available is a good adjunct to plan 

and monitor respiratory therapy. 


Slide RD-15 

Principles of management 

Supportive therapy is most crucial in all neonates with respiratory distress and 

the same principles apply, whatever the cause. 


Monitoring is needed in all babies with respiratory distress. Clinical monitoring 

is most important as sophisticated equipment may not be available. The 

scoring system could be utilised to monitor babies. An increasing score would 

indicate worsening distress. 



All babies with significant distress should be kept on IV fluids ; blood pressure 

and blood sugar should be maintained. 



Other measures include oxygen therapy and if available ventilatory support or 

CPAP (continuous positive airway pressure).  Specific therapy is now available 

for RDS i.e. surfactant, but even with this ventilatory support will be needed.  


Slide RD-16, 17 

Oxygen therapy 

All babies with worsening or severe respiratory distress, with or without 

cyanosis should get oxygen. Oxygen should be warm  and humidified . It can 

be provided through nasal catheters or preferably through oxygen hood. The 

flow rate should be 2-5 L/min (40-70% O


) . Oxygen should be used with 

caution especially in preterm babies. Respect oxygen -it has both good and 

toxic effects and use it only if needed. Use lower concentration of oxygen to 

relieve cyanosis or distress.  Pulse oximetry is  a simple non-invasive method 

for measuring oxygen saturation.  Ideally all neonates with respiratory distress 

should be monitored using a pulse oximeter and oxygen should be 

administered if saturations are less than 90%.  Aim is to maintain saturation  

between 90-93% to avoid hyperoxia. 






                                                                                         NNF Teaching Aids:Newborn Care


Slide RD-18 

Respiratory distress syndrome (RDS) 

If a preterm baby has respiratory distress within the first 6 hrs of birth and is 

cyanosed or needs oxygen to maintain oxygen saturation the diagnosis is RDS 

unless proved otherwise. X-ray findings would be a reticulo-granular pattern in 

mild disease and a "white out" picture in severe disease. 


Slide RD-19 


X-ray showing air bronchogram and hazy lung suggestive of HMD. 



Slide RD-20 


The basic problem in a preterm baby with RDS is surfactant deficiency. 

Surfactant is needed to decrease alveolar surface tension and keep them open. 

In a preterm baby, absence of surfactant leads to alveolar collapse during 

expiration. This affects gas exchange and the baby goes into respiratory 



Slide RD-21 

Predisposing factors 

Predisposing factors include -prematurity, asphyxia and maternal diabetes. 

Prolonged rupture of membranes (PROM) and intrauterine growth retardation 

are believed to enhance lung maturity. Drugs such as antenatal steroids 

enhance lung maturity and can prevent the neonate from developing RDS. 


Slide RD-22 

Antenatal corticosteroids  

Antenatal corticosteroid therapy is a simple and effective therapy that prevents 

RDS and saves neonatal lives.  Antenatal steroids will prevent the occurrence 

and severity of RDS in preterm babies between 24 and 34 weeks of gestation. 

Optimal effect of antenatal steroids is seen if delivery occurs after 24 hours of 

the initiation of therapy. Effect lasts for 7 days. Cases of preterm premature 

rupture of membrane (PPROM) at less than 32 weeks of gestation (in the 

absence of clinical chorioamnionitis), maternal hypertension and diabetes are 

not contra indications for administering antenatal steroids, if delivery is 

anticipated below 34 weeks of gestation. Dose recommended is Inj 





                                                                                         NNF Teaching Aids:Newborn Care


Betamethasone 12 mg 1M every 24 hrs x 2 doses; or Inj Dexamethasone 6 mg 

1M every 12 hrs x 4 doses.  Multiple courses of antenatal steroids are not 

beneficial and hence are not recommended



Preterm babies below 1 kg and 28 wks gestation should be referred to a 

suitable Level II NICU after stabilization. 


Slide RD-23, 24 

Surfactant therapy  

It is important to emphasize that surfactant therapy should be instituted only if 

there are facilities for ventilation.  The efficacy of surfactant in reducing the 

duration of ventilation is proven.  The main deterrent to its use is the cost 

factor.  Prophylactic surfactant use is recommended for any neonate< 28 

weeks and < 1000 gms.  This is not yet a routine practice in India.  Rescue 

therapy is using surfactant in a symptomatic neonate. This could be used in 

any neonate suspected / diagnosed to have RDS. 


Slide RD-25 

Meconium aspiration syndrome (MAS) 

Babies born through meconium stained liquor could have MAS and aspiration 

may occur in-utero, during delivery or immediately after birth. Thick meconium 

could block air passages and cause atelectasis and air leak syndromes. 


Slide RD-26 

The baby with MAS is usually post-term or small-for-date. There may be 

meconium staining of the umbilical cord, nails and skin. The chest may be 

hyperinflated and onset of distress is usually within the first 4-6 hours. 


Slide RD- 27 

X-ray shows fluffy shadows involving both lungs with hyperinflation as 

evidenced by pushed down diaphragm. 


Slide RD-28 

MAS prevention  

Immediate management of a baby born through meconium stained liquor is 

extremely important. Oropharynx should be suctioned before delivery of 





                                                                                         NNF Teaching Aids:Newborn Care


shoulders and all babies born through meconium stained liquor who are not 

vigorous at birth should be intubated and intratracheal suction should be done. 

However, vigorous and active babies need not undergo intratracheal 

suctioning.  A vigorous baby is defined as one who is breathing, has good 

muscle tone and heart rate  above 100 beats per minute. 


Slide RD-29 

Transient tachypnea of newborn (TTNB) 

Transient tachypnea of the newborn is a benign condition usually seen in term 

babies born by cesarean section. These babies are well and have only 

tachypnea with rates as high as 80-100/min. The breathing is shallow and 

rapid without any significant chest retractions. It occurs because of delayed 

clearance of lung fluid. Management is supportive and prognosis is excellent


Slide RD-30 

X ray shows clear lung fields with prominent right interlobar fissure with 

borderline cardiomegaly suggestive of transient tachypnoea of newborn 



Slide RD-31, 32, 33 

Congenital and postnatal pneumonia 

In developing countries, pneumonias account for more than 50 percent cases 

of respiratory distress in newborn. Primary pneumonias are more common 

among term or post term infants because of higher incidence of prenatal 

aspiration due to fetal hypoxia as a result of placental dysfunction. Preterm 

babies may develop pneumonia postnatally as a consequence of septicemia, 

aspiration of feeds and ventilation for respiratory failure. 


Clinical picture is characterized by tachypnea, respiratory distress with 

subcostal retractions, expiratory grunt and cyanosis. The condition may be 

heralded by apneic attacks rather than respiratory distress. Cough is rare in a 

newborn baby. The infant with congenital pneumonia is born with following 

predisposing factors (PROM> 24 hrs, foul smelling liquor, febrile maternal 

illness during peripartal period, prolonged/difficult delivery; single unclean or 

multiple vaginal examination(s) during labor). Respiratory distress is noticed 

soon after birth or during first 24 hours. Auscultaory signs may be nonspecific. 

The newborn may die from pneumonia without manifesting distress. Supportive 





                                                                                         NNF Teaching Aids:Newborn Care


treatment should be provided. Baby should be nursed in thermo-neutral 

environment and kept nil orally. Intravenous infusion preferably through 

peripheral vein should be started. Oxygen should be administered to relieve the 

cyanosis and gradually weaned off. Specific therapy in  the form of antibiotics 

should be started. In community acquired pneumonia, combination of ampicillin 

and gentamicin is appropriate while in hospital acquired pneumonia ampicillin 

and amikacin or a combination of cefotaxime and amikacin are appropriate. 


Pneumonia may be due to aspirations (TEF), gastro-esophageal reflux or may 

be of bacterial or viral etiology. Bacterial organisms are usually gram-ve or 



Parents often bring their children with complaints of noisy breathing. Most 

often this is due to nose block and could be treated with saline nose drops. 

However, we should distinguish this from stridor which could be a more serious 

problem. Other causes of upper airway problems presenting as distress would 

be bilateral choanal atresia



Slide RD-34 

Neonates who suffer asphyxia at birth may develop respiratory distress. The 

cause being asphyxia related injury to heart, brain or lungs


Slide RD-35 



Pneumothorax in neonates could be spontaneous, but is more often due to 

MAS or staphylococcal pneumonia. It is important to recognise pneumothorax 

because quick recognition and prompt treatment could be life saving. The 

distress is usually sudden in onset and heart sounds become less distinct. 

Immediate management in hemodynamically unstable neonate is by a needle 

aspiration and later chest tube drainage. 


Slide RD-36 


This X-ray shows pneumothorax on  left  side. 






                                                                                         NNF Teaching Aids:Newborn Care


Cardiac disease should be suspected when there is significant distress with 

cyanosis, tachycardia and hepatomegaly. Tachypnea may be marked but chest 

retractions are minimal. If the baby presents in shock and distress one should 

suspect cardiac disease 

Refer to topic on Danger signs in newborn . 


Slide RD-37 

Primary pulmonary hypertension in newborn  

One should suspect persistent / primary pulmonary hypertension also known as 

persistent fetal circulation in any neonate having severe respiratory distress 

and cyanosis.   Ruling out a cyanotic congenital heart disease is mandatory in 

such a situation.  Etiology of PPHN could be due to asphyxia, MAS or sepsis.  

Prognosis is poor and these neonates invariably need ventilatory support. 


Slide RD-38 


To sum up, there are many conditions causing respiratory distress. Early 

recognition of the etiology is important since management is usually 

complicated and needs level II or level III care. The situations which need 

referral are RDS, MAS, PPHN, malformations/surgical problems and cardiac 

disease. Distress due to pneumonia, TTNB and  mild distress due to any cause 

may be managed at the periphery. Progression of distress, whatever the 

etiology again needs referral. 





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