Respiratory Distress in the Newborn

Aka: Respiratory Distress in the Newborn, Newborn Respiratory Distress, Neonatal Respiratory Distress

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II. Risk Factors

  1. Cesarean delivery
  2. Premature delivery

III. Signs

  1. Tachypnea
    1. Respiratory Rate >60 per minute
    2. A normal newborn Respiratory Rate: 40 to 60 bpm
  2. Increased work of breathing
    1. Nasal flaring
    2. Grunting
    3. Intercostal retractions (or subcostal retractions)
  3. Other findings
    1. Cyanosis
    2. Decreased feeding
    3. Hypothermia
    4. Hypoglycemia

IV. Causes

  1. See Neonatal Distress Causes
  2. Common (all are immediate onset except Pneumonia, Neonatal Sepsis)
    1. Transient Tachypnea of the Newborn
    2. Respiratory Distress Syndrome in the Newborn
    3. Meconium Aspiration Syndrome
    4. Delayed transition
    5. Pneumonia (e.g. Group B Streptococcal Pneumonia)
    6. Neonatal Sepsis
    7. Pneumothorax in the newborn
  3. Less common
    1. Anemia
    2. Persistent Pulmonary Hypertension of the Newborn
      1. Onset of Dyspnea within first 24 hours
    3. Congenital malformations
      1. Pulmonary hypoplasia
      2. Diaphragmatic Hernia
      3. Esophageal atresia
      4. Airway obstruction (e.g. Choanal Atresia, Tracheomalacia, Macroglossia)
      5. Congenital Heart Disease
    4. Neurologic conditions
      1. Hydrocephalus
      2. Intracranial Hemorrhage
      3. Maternal agents causing sedation and central respiratory depression
    5. Metabolic disorders
      1. Hypoglycemia
      2. Hypocalcemia
      3. Inborn Errors of Metabolism

V. Evaluation

  1. See Newborn History
  2. See Newborn Exam
    1. Observe for apnea or Tachypnea
    2. Observe for Cyanosis
    3. Auscultate for cardiac murmurs suggestive of Congenital Heart Defect
    4. Auscultate lungs for asymmetry suggestive of Pneumonia or Pneumothorax
    5. Specific pattern of periodic breathing is normal
      1. Normal Respiratory Rate (40 to 60 bpm) with interspersed pauses of 5-10 seconds
      2. Respiratory pauses >20 seconds is apnea (NOT normal)
      3. Other periodic breathing patterns may be abnormal

VI. Labs

  1. See Neonatal Sepsis
  2. Serum Glucose
  3. Blood Culture
  4. Capillary gas (sufficient in most cases unless high oxygen needs) or Arterial Blood Gas
  5. Complete Blood Count with Platelets and differential
  6. C-Reactive Protein (C-RP)

VII. Imaging

  1. Chest XRay

VIII. Diagnostics

  1. Pulse Oximetry
    1. Pre-ductal (right hand)
    2. Post-ductal (left leg)
  2. Findings suggesting diagnosis OTHER THAN Neonatal Sepsis
    1. Immature to total Neutrophil ratio <0.2
      1. High Negative Predictive Value, but 50% False Positive Rate if elevated
      2. Murphy (2012) Pediatr Infect Dis J 31(1):16-9
    2. C-RP <10 mg/L
      1. Negative Predictive Value 94% in first 48 hours of life
      2. Himayun (2009) Internet J Pediatr Neonatol 11(2)
        1. http://ispub.com/IJPN/11/2/5613

IX. Management

  1. See Newborn Resuscitation
  2. General Measures
    1. Supplemental Oxygen
    2. Mild Tachypnea can be observed for 10-20 minutes
    3. Maintain warm environment
    4. Obtain finger-stick Blood Glucose
    5. Withold oral feedings when Respiratory Rate is rapid (>80/minute)
    6. Consider neonatology Consultation
  3. Supplemental Oxygen
    1. Blended oxygen with FIO2 <50% to keep Oxygen Saturation >90% is preferred
    2. FIO2 approaching 100% is associated with an increased neonatal mortality
      1. Saugstad (2008) Neonatology 94(3): 176-82 [PubMed]
  4. Ventilation
    1. Non-invasive ventilation
      1. N-CPAP
      2. Nasal intermittent Positive Pressure Ventilation
    2. Standard invasive ventilation Endotracheal Intubation
      1. Non-invasive ventilation (as above) is preferred if adequate
      2. Intubation may also be initiated in RDS for surfactant delivery
        1. Then Extubation, weaning to N-CPAP
  5. Follow specific management for suspected causes
    1. See each specific condition for guidelines
    2. Antibiotics for suspected Neonatal Sepsis or Neonatal Pneumonia
    3. Surfactant for Respiratory Distress Syndrome in the Newborn
    4. Needle decompression of Pneumothorax
  6. Indications for NICU transfer or Consultation
    1. Condition worsens or fails to improve within 2 hours
    2. Supplemental Oxygen requirements >40%
    3. Chest XRay abnormalities

X. References

  1. Hermansen (2007) Am Fam Physician 76(7): 987-94 [PubMed]
  2. Hermansen (2015) Am Fam Physician 92(11): 994-1002 [PubMed]
  3. Hein (1998) J Fam Pract 46:284-9 [PubMed]

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