1. Department of Child Health Medical School University of Sumatera Utara
Respiratory Distress
Neonatology Division
Department of Child Health Medical School
University of Sumatera Utara

2. Alarming Signs for RD Cyanosis Severe apnea (coma?) Stridor
Gasping efforts
Severe respiratory retractions
Poor perfusion (shock)

3. Evaluation of Respiratory Distress Using Down’s Score
Audible with ear
Audible by stethoscope
No grunting
Grunting
No air entry
Mild decrease in air entry
Good bilateral air entry
Air Entry
Cyanosis on O2
Cyanosis relieved by O2
No cyanosis
Cyanosis
Severe retractions
Mild retractions
No retraction
Retractions
> 80/min
60 – 80/min
< 60/min
Respiratory Rate 2 1
Learning Objective 1

4. Evaluation of Respiratory Distress Using Down’s Score
Score < 4 No respiratory distress
Score 4 -7 Respiratory distress
Score > Impending respiratory failure (Blood gases should be obtained)
Learning Objective 1

5. Be Prepared Resuscitation equipment and/or supplies
Involve others (team approach)
Have staff trained
ABC
Airway
Breathing
Circulation

6. Conditions Associated with Respiratory Distress

8. Investigations Chest X-ray Arterial blood gas
CBC (anemia, polycythemia, sepsis)
Glucose check (hypoglycemia)
Blood culture (sepsis, pneumonia)

9. Treatment After stabilization, treat the cause of RD Use CPAP
Avoid unnecessary exposure to oxygen
Antibiotics until sepsis is ruled out

10. Common Causes of RD Transient tachypnea of the newborn (TTN)
Hyaline membrane disease (HMD)
Meconium aspiration syndrome (MAS)
Air leak syndrome
Pneumonia
Congenital heart diseases

11. Transient Tachypnea of the Neonate (TTN)
Definition
A benign disease of near-term or term neonates who have respiratory distress shortly after delivery that resolves within 3-5 days.
Learning Objective 3

12. Pathogenesis of TTN How is lung fluid formed?
What is the function of lung fluids?
What happens to lung fluids during labor?
Does it matter the type of labor?

13. Transient Tachypnea of the Neonate (TTN) (cont)
Module: Neonatal Respiratory Disorders - Session 1
Transient Tachypnea of the Neonate (TTN) (cont)
Risk factors
Cesarean section without labor
Macrosomia
Male sex
Prolonged labor
Excessive maternal sedation
Low Apgar score (< 7 at 1 minute)
Learning Objective 3

14. Transient Tachypnea of the Neonate (TTN) (cont)
Clinical Presentation of TTN
The neonate is usually near-term or term, and shortly after delivery has tachypnea (>80 breaths/minute). The neonate may also have grunting, nasal flaring, rib retractions, and cyanosis. The disease usually does not last longer than 72 hours.
Learning Objective 3

16. Transient Tachypnea of the Neonate (TTN) (cont)
Chest X-ray:
Perihilar streaking, mild cardiomegaly, increased lung volume, fluid in the minor fissure, and perhaps fluid in the pleural space are common findings.
Learning Objective 3

17. Transient Tachypnea of the Neonate (TTN) (cont)
Management of TTN
Judicious use of oxygen
Fluid restriction
Feeding as tachypnea improves
Confirm the diagnosis by excluding other causes of tachypnea e.g. pneumonia, congenital heart disease, hyaline membrane disease, and cerebral hyperventilation.
Learning Objective 3

18. Transient Tachypnea of the Neonate (TTN) (cont)
Outcome and Prognosis of TTN
The disease is self-limited and there is no risk of recurrence or further pulmonary dysfunction. Respiratory symptoms improve as intrapulmonary fluid is mobilized, and this is usually associated with diuresis.
Learning Objective 3

19. Hyaline Membrane Disease (Respiratory Distress Syndrome)
Definition
Hyaline membrane disease (HMD) is also called respiratory distress syndrome (RDS). This condition usually occurs in a preterm neonate. Premature lungs are surfactant deficient.
Learning Objective 4

20. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Respiratory difficulties exhibited include:
Increasing tachypnea (> 60/min)
Chest retractions
Cyanosis on room air that persists or progresses over the first hours of life.
Decreased air entry
Grunting
Learning Objective 4

21. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Incidence
HMD occurs in about 25% of neonates born at 32 weeks gestation. The incidence increases with increasing prematurity.
Learning Objective 4

22. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Risk Factors of HMD
Increased Risk
Prematurity
Male sex
Neonate of diabetic mother
Learning Objective 4

23. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Risk Factors of HMD
Decreased Risk
Chronic intrauterine stress
Prolonged rupture of membranes
Maternal hypertension
Narcotic use
Intrauterine Growth Retardation (IUGR) or Small for Gestational Age (SGA)
Corticosteroids – Prenatal
Learning Objective 4

24. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Investigations for HMD (RDS)
Laboratory Studies:
Blood gases: hypoxia, hypercarbia, acidosis.
CBC and blood culture are required to rule out infection.
Serum glucose levels are usually low.
Chest X-ray Study:
Reveals ground glass appearance with air bronchograms.
Learning Objective 4

26. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Management of HMD (RDS)
General
Thermal regulation
Parenteral fluid
Antibiotics
Continuous monitoring
Learning Objective 4

27. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Continuous positive airway pressure (CPAP) is tried.
If under CPAP
PH < 7.2
Or PO2 < 40mmHg FiO2 > 60%
Or PCO2 > 60mmH
Base deficit > -10
Endotracheal intubation and mechanical ventilation.
Consider surfactant therapy
Learning Objective 4

28. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Caution: every 10 days on the ventilator is associated with 20% increased risk for cerebral palsy
Learning Objective 4

29. Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)
Specific Treatment
Surfactant replacement therapy if tracheal intubation is required
Outcome
RDS accounts for 20% of all neonatal deaths
Chronic lung diseases occurs in 29% in VLBW infants
Learning Objective 4

31. Meconium Aspiration Syndrome (MAS)
Definition
The respiratory distress secondary to meconium aspiration by the fetus in utero or by the neonate during labor and delivery.
Learning Objective 5

32. Meconium Aspiration Syndrome (MAS) (cont)
Pathogenesis: aspiration of meconium can cause:
Airway obstruction (ball and valve)
Severe inflammation
Pulmonary hypertension
Platelet activation
Learning Objective 5

33. Meconium Aspiration Syndrome (MAS) (cont)
Risk Factors of MAS
Post-term pregnancy
Maternal hypertension
Abnormal fetal heart rate
Biophysical profile  6
Pre-eclampsia
Maternal diabetes mellitus
SGA
Chorioamnionitis
Learning Objective 5

34. Meconium Aspiration Syndrome (MAS) (cont)
Clinical presentation of MAS
Meconium staining of amniotic fluid before birth.
Meconium staining of neonate after birth.
Respiratory distress leading to increased anteroposterior diameter of the chest.
Persistent pulmonary hypertension of the newborn (PPHN).
Learning Objective 5

35. Meconium Aspiration Syndrome (MAS) (cont)
Investigations for MAS
Laboratory studies
Blood gas analysis
Blood culture and CBC
Learning Objective 5

36. Meconium Aspiration Syndrome (MAS) (cont)
Investigations for MAS
Radiologic studies
Chest X-ray: findings include patchy infiltrates, coarse streaking of both lung fields, hyperinflation of the lung and flattening of the diaphragm.
Learning Objective 5

38. Meconium Aspiration Syndrome (MAS) (cont)
Management of MAS
Prenatal management:
Identification of high-risk pregnancy.
Monitoring of fetal heart rate during labor.
Amnioinfusion (?)
Learning Objective 5

39. Meconium Aspiration Syndrome (MAS) cont)
Management of MAS
Delivery room management: (if amniotic fluid is
meconium stained)
Obstetrical: Suction of the oropharynx by obstetrician before delivery of shoulders.
Pediatric: Visualization of vocal cords and tracheal suction if infant is not breathing.
Learning Objective 5

40. Meconium Aspiration Syndrome (MAS) (cont)
General Management of Neonate with MAS
Empty the stomach contents to avoid further aspiration.
Correction of metabolic abnormalities e.g. hypoxia, acidosis, hypoglycemia, hypocalcemia and hypothermia.
Surveillance for end organ hypoxic/ischemic damage (brain, kidney, heart and liver).
Learning Objective 5

41. Meconium Aspiration Syndrome (MAS) (cont)
Respiratory Management of Neonate with MAS
Frequent suction and chest vibration.
Pulmonary toilet to remove residual meconium if intubated.
Antibiotic coverage (ampicillin and gentamicin).
Use CPAP.
Learning Objective 5

42. Meconium Aspiration Syndrome (MAS) (cont)
Outcome and Prognosis (MAS)
Mortality rate may be as high as 50%.
Survivors may suffer from bronchopulmonary dysplasia and neurologic sequelae.
Learning Objective 5

43. Air Leak Syndromes Definition
The air leaks syndromes (pneumomediastinum, pneumothorax, pulmonary interstitial emphysema and pneumopericardium) comprise a spectrum of diseases with the same underlying pathophysiology. Overdistension of alveolar sacs or terminal airways leads to disruption of airway integrity, resulting in dissection of air into surrounding spaces.
Learning Objective 6

44. Air Leak Syndromes (cont)
Incidence
Most commonly seen in neonates with lung disease who are on ventilatory support but can also occur spontaneously. The more severe the lung disease, the higher the incidence of pulmonary air leak.
Learning Objective 6

45. Air Leak Syndromes (cont)
Risk Factors for Air Leak Syndromes
Spontaneous 0.5%
Ventilatory support 15-20%
CPAP 5%
Meconium staining / aspiration
Surfactant therapy
Vigorous resuscitation (bag ventilation)
Learning Objective 6

48. Air Leak Syndromes (cont)
Clinical Presentation of Neonates with Air Leak
Syndromes
Respiratory distress or sudden deterioration of clinical course with alteration of vital signs and worsening of blood gases.
Asymmetry of thorax is present in unilateral cases.
Learning Objective 6

49. Air Leak Syndromes (cont)
Investigations for Air Leak Syndromes
The definitive diagnosis of all air leak syndromes is made radiographically by an A-P chest X-ray film and a lateral film.
Learning Objective 6

51. Air Leak Syndromes (cont)
Management of Air Leak Syndromes
General
Avoid ventilators
Careful use of manual bag ventilation
Specific
Decompression of air leak according to the type.
Do not needle the chest
Learning Objective 6

52. Apnea
Definition
Cessation of respiration accompanied by bradycardia and/or cyanosis for more than 20 seconds.
Incidence
50-60% of preterm neonates have evidence of apnea (35% with central apnea, 5-10% with obstructive apnea, and 15-20% with mixed apnea).
Learning Objective 7

53. Apnea (cont) Risk Factors of Neonatal Apnea Pathological apnea
Hypothermia
Hypoglycemia
Anemia
Hypovolemia
Aspiration
NEC / Distension
Cardiac disease
Lung disease
Gastro intestinal reflux
Airway obstruction
Infection, meningitis
Neurological disorders
Learning Objective 7

54. Apnea (cont) Investigations
Monitoring at-risk neonates less than 32 weeks gestational age.
Evaluate for a possible underlying cause.
Laboratory studies should include a CBC, blood gas analysis, serum glucose, electrolyte, and calcium levels.
Radiologic studies if chest disease is suspected
Learning Objective 7

55. Apnea (cont) Management of Apnea General Therapy
Perform tactile stimulation.
CPAP in recurrent and prolonged apnea.
Pharmacological therapy (caffeine or theophylline) may be required.
Monitor levels.
Learning Objective 7

56. Apnea (cont) Management of Apnea Specific Therapy
Treatment of the cause, if identified, eg. treatment of sepsis, hypoglycemia, anemia, and electrolyte abnormalities.
Learning Objective 7

57. Apnea (cont) Outcome and Prognosis
In most neonates apnea resolves without the occurrence of long-term deficiencies.
Learning Objective 7

58. THANK YOU