An approach

to
Respiratory
Distress in
Newborn
By Goh Kiam
Seong

HTAR, Klang

Plan

Introduction
Causes and
Classification
Respiratory
Distress Signs
Evaluation and
Investigation
General
Management

Introduction

Respiratory Distress in Newborn

= Abnormal respiratory signs in
neonates

Causes and Classification

Respiratory
Causes
Extrapulmonar
y

Respiratory
Distress in
Newborn

Medical
Management
Surgical

Upper Airway Obstruction

Respiratory

Causes

Choanal Atresia

Extrapulmona
ry

Pierre Robin Sequence

Laryngeal pathology
Rib cage
anomalies

Congenital
Diaphragmat
ic Hernia

Neuromuscul
ar diseases

PPHN

Congenital
Heart
Diseases

Shock

Anaemia

Polycythaemi
a

Hypoglycaem
ia

Hypothermia

Metabolic
acidosis

Intracranial
Birth
Trauma/
Encephalopa

Managemen
t
Medical

TTN
MAS
RDS/HMD
Pneumonia
Milk Aspiration
CHD
Shock
Anaemia
Polycythaemia
Hypoglycaemia
Hypothermia
Metabolic Acidosis

Surgical
Choanal atresia
Pierre Robin
Sequence
Air Leak Syndrome
Rib cage anomalies
Congenital
Diaphragmatic
Hernia
Air Leak Syndrome
Intracranial Birth
Trauma/
Encephalopathy

Respiratory Distress Signs

Tachypnoea

Retractions

Cyanosis

Respiratory
Distress in
Newborn

Nasal Flaring

Grunting

Tachypnoe
a

Cyanosis

Respirator
y Distress
in
Newborn

Nasal
Flaring

Retractions

Grunting

Respiratory Rate:

Tachypnoe
a

< 1 week up to 2 months: 60 or

more
2 to 12 months: 50 or more
12 months to 5 years: 40 or more

Tachypnoe
a

Cyanosis

Respirator
y Distress
in
Newborn

Nasal
Flaring

Retractions

Grunting

Tachypnoe
Retractions
a

Due to negative intrapleural

pressure generated
between the contraction of
diaphragm, respiratory
muscles and the mechanical
properties of lung and chest
wall
Suprasternal Retraction
SSR
Intercostal Retraction ICR
Subcostal Retraction SCR

Suprasternal Retraction
SSR

Subcostal Retraction
SCR

Intercostal

Tachypnoe
a

Cyanosis

Retractions

Respirator
y Distress
in
Newborn

Nasal
Flaring

Grunting

Grunting

Expiration through
partially closed vocal
cords to increase airway
pressure and lung volume
resulting in improved
ventilation-perfusion (V/P)
ratio
Low pitched expiratory
sound.
Protective phenomenon to
prevent collapse of alveoli:
PEEP

Video Baby Grunting

Grunting Baby pt. 2.flv

Tachypnoe
a

Cyanosis

Retractions

Respirator
y Distress
in
Newborn

Nasal
Flaring

Grunting

Nasal
Flaring

Narrow nasal space

contributes to total lung
resistance
Nasal flaring decreases
the work of breathing

Tachypnoe
a

Cyanosis

Retractions

Respirator
y Distress
in
Newborn

Nasal
Flaring

Grunting

Cyanosis

Clinical detection of
cyanosis depends on
total amount of
desaturated HB in blood
Anaemic infants may
have low PaO2 that is
missed clinically
Polycythaemic infants
with normal PaO2 can
appear cyanotic

Cyanotic
Baby

Pink Baby

What respiratory distress signs you

can see here in this child?

ntral cyanosis, +ICR, +SCR, +N

Evaluation and Investigation

History

Examinati
on

Investigat
ion

History

Examinatio
n

Investigati
on

Gestation/Delivery
Term LSCS
?TTN

Preterm (no
dexa)
?RDS

Postdate
(IOL,MSAF)
?MAS

Liquor

Oligohydram
nio
?Pulmonary
Hypoplasia

Polyhydramnios
?Cong Diaphr
Hernia
?Oesoph
atresia/TEF

MSAF
TMSL/MMSL/LM
SL
?MAS ?PPHN

Antenatal US Finding
Amniotic Fluid Index

Renal Agenesis
?Pulmonary Hypoplasia
?RDS

History

Examinatio
n

Leaking Liquor

Investigati
on

>18hrs
?Presumed
Sepsis

Maternal UTI
?Presumed
Sepsis

PPROM/PROM

Condition at birth
Distress
?Met
acidosis

Not vigorous
?Asphyxial Lung
Ds

Require resus at
birth
?Air Leak
Syndrome

Risk Factors
IDM
?Hypoglycaemia

GBS+ Mother
?Sepsis/Congenital
Pneumonia

Respirator
y Distress
at birth
Term Baby
TTN
MAS
Congenital
Pneumonia
Dev
Anomalies

Preterm Baby
RDS
Congenital
Pneumonia
TTN

later after
a period
of normal
function
Possible causes
Acquired/Nosoco
mial Pneumonia
Dev anomalies
CHD
IEM
Metabolic (Met
acidosis/
electrolytes)

History

Examinatio
n

Investigati
on

Vitals

General
Conditio
n
Oral
Cavity
Potter face:
abnormalfacieswith a
beaknose, receding chin,
broad nasal
bridge,epicanthal folds,
and large low set ears

Congenit
al
anomali
es

T
hypo/hyperthermi
c
RR tachy/apnoea
HR
tach/bradycardia
Pallor
SPO2 desaturate?
Plethoric
SGA/LGA
Macrosomic/hydro
ptic
Cleft palate
Excessive oral
secretion

Pierre Robin
Potter face

History

Examinatio
n

Investigati
on

CVS/Lun
g

Abdome
n

Meconium
stained Nail

Scaphoid abdomen

Umbilical
Meconium stained
cord/
Nails

Tone/
Reflexes
Meconium

Dextrocardi,murmu
rs
In-drawing
sternum
Air entry

Hypotonia
Poor sucking reflex
Incomplete Moro

Silverman Anderson Score for

Premature Baby

Score

Upper
Chest
Retractio
n

Lower
Chest
Retractio
n

Xiphoid
Retractio
n

Nasal
Flaring

Grunting

Synchrono
us

None

None

None

None

Lag on
Just visible Just visible Minimal
Stethosco
Inspiration
pe
Score > 6 = impending Respiratory Failure
See-Saw
Mark
Mark
Mark
Naked ear

Downes Score for Term Baby

Score

Respirato Cyanosis
ry Rate

Air entry

Retractio
n

Grunting

<60

None

Good

None

None

60-80

In air

Decrease

Minimal

Stethosco
pe

>80/
apnoea

In 40% O2

Barely
audible

Moderate/
severe

Naked ear

History

Examinatio
n

Investigati
on

Look for:
O2 Saturation
Metabolic/
respiratory
acidosis/
alkalosis
Blood counts
(Hb/TWC/Plt/Ht)
Glucose level
Sepsis
causative agent
Collapse/Air
Leak/CDH/
Cardiomegaly

SPO2
monitori
ng

VBG/
ABG

FBC

DXT

Blood
C+S/LP

CXR
Portabl

General Management

Respiratory
Support

Supportive
Care
Definitive/Spec
ific Therapy

O2 Delivery
PEEP/ Mechanical
ventilation (CPAP/SiPAP)
Intubation and suction

HR monitoring
Continuous SPO2
monitoring
Temp/DXT
monitoring
I/O charting
Feeding (PO/TPN)
Cot/Incubator
nursing
According to
diagnosis

Upper Airway Obstruction

Respiratory

Causes

Choanal Atresia

Extrapulmona
ry

Pierre Robin Sequence

Our topics today

Laryngeal pathology

Rib cage
anomalies

Congenital
Diaphragmat
ic Hernia

Neuromuscul
ar diseases

PPHN

Congenital
Heart
Diseases

Shock

Anaemia

Polycythaemi
a

Hypoglycaemi
a

Hypothermia

Metabolic
acidosis

Intracranial
Birth
Trauma/
Encephalopa

Pierre Robin Sequence

(PRS)

Definition

PRS is a facial difference caused by

underdevelopment of the lower jaw
Characterised by:
Micro- and retrognathia
glossoptosis
respiratory obstruction
With or without cleft palate.
Incidence = 1:8500-14000 birth
=

PRS is a sequence not

syndrome!
Because underdeveloped lower jaw
begins a sequence of events which
leads to abnormal position of
tongue and cleft palate.

Aetiology

Unknown
Recently
identify may
be caused by
genetic
anomalies at
chromosome
s 2, 11, or 17
35

PRS is often part of an

underlying disorder or
syndrome
Stickler syndrome
Velocardiofacial syndrome
Fetal Alcohol syndrome
Treacher Collins Syndrome

Pathophysiology
At 12 -14/52 GA
Movement of the head
causes the jaw to "pop
out' of the collar bones

Only from this time,

jaw of the fetus grows
as it would normally

9-11/52 GA

Tongue moves
down and
away from roof
of the mouth

Allow space for

the side of
palate to shift
to the midline
to close

In PRS

Small jaw keeps

tongue
positioned
higher and
posteriorly in
mouth than
normal

Interfering
normal
closure of
palate

U shaped
cleft palate

How to diagnose?
Only by examining the patient at birth

Complication
Difficulties in breathing and feeding.

GERD more prevalent in

children with Robin
sequence. (Dudkiewicz, CPCJ Mar 2000)

Our tactics

Position: Keep in prone or

lateral position
Feeding: Tube feeding or
Haberman feeder
Nutrition: Increase daily
calorie intake
SPO2 monitoring

Other considerations
Endotracheal intubation/tracheostomy
Tongue lip adhesion
Ophthalmology follow up if suspect
Sticker syndrome (possible retinal
detachment)
Mandibular distraction (distraction
osteogenesis)
Cleft palate reparation (6.5 mo- 2 yo)

Choanal Atresia
Choanal atresia is a congenital disorder where
choana is blocked by abnormal bony or soft
tissue formed during fetal development
Cause: unknown (thin tissue separating the
nose and mouth area during fetal
development remains after birth)
Most common nasal abnormality in newborn
(1 in 7,000 live births)
:= 1 : 2
>50% associated with other congenital
disorder
Diagnosed shortly after birth

Types

Unilateral
Bilateral
Membranous
Osseous

Symptoms and Signs

Cyanosis
during feeding

Pink while
crying

Inability to nurse and breathe at

same time
Inability to pass a catheter through
each side of the nose into the throat
Persistent one-sided nasal blockage
or discharge

Associated conditions

Coloboma
Heart defects
Retardation of growth
or mental development
Genital/urinary
abnormalities
Ear
anomalies/deafness

IF associated with all these ~ CHARGE syndrome (defect in Chromosome

8 CHD7 gene)

Tests that may be done

include:

CT scan
Endoscopyof the nose
Sinus x-ray

Endoscopic view of choanal atresia.mt: middle

turbinate; it: inferior turbinate; ns: nasal septum; a:
atresia "plate".

Management
Secure the airway (laryngeal mask,
intubationortracheostomymay be
needed)
If infant can learn to mouth breathe,
can delay the need for immediate
surgery.
Otherwise, surgery to remove the
obstruction required (transnasal or
transpalatal).