[Music]
respiratory distress in the newborn by
dr. Megan Connelly learning objectives
by the end of this video the viewer will
understand the differential diagnosis
for newborn respiratory distress and
will learn the epidemiology
pathophysiology presentation diagnosis
and management for the most common
etiology x' your page to the nursery to
examine a newborn described as being in
respiratory distress immediately you
start running through the differential
diagnosis in your head what history do
you need to know to guide your thinking
history that you'll find useful to know
includes how old is the baby
what is the gestational age was the
delivery vaginal or via cesarean section
is this a preterm term or post term
infant were there any sepsis risk
factors was mother well prior to
delivery was mother Group B Strep
positive or negative did mother receive
any antibiotics while in labor was the
amniotic fluid clear or meconium stained
for an infant to transition to life
outside the uterus multiple physiologic
changes must occur very rapidly his
alveoli must transitioned from being
filled with fluid to air he must begin
to breathe in a regular pattern
he must decrease his pulmonary vascular
resistance so that pulmonary blood flow
is increased most infants are able to do
this with no aid but approximately 10
percent will require assistance at birth
the differential diagnosis for
respiratory distress in the newborn is
long but with a basic history you are
able to better narrow down the diagnosis
and determine the appropriate treatment
path transient tachypnea of the newborn
TTN is the most common etiology
accounting for 60% of cases of
respiratory distress GTN is due to
excess fluid in the lungs due to
impaired clearance of the fetal lung
fluid at birth risk factors for TTN
include infants born at less than 39
weeks of age as well as infants born via
caesarean section without labor male
infants and infants born to mothers with
gestational diabetes most commonly these
infants
within the first few minutes two hours
after birth with tachypneic which in an
infant is a respiratory rate greater
than 60 breaths per minute nasal flaring
grunting and retractions on auscultation
lung fields may be clear or crackles may
be appreciated frequently these infants
have some cyanosis but very rarely do
they need more supplemental oxygen than
40% fio2 TTN is a clinical diagnosis but
on chest x-ray you can often see fluid
in the inter lobar fissure as well as
hyper expanded lungs with flattened
diaphragms prominent vasculature in a
sunburst pattern and sometimes alveolar
edema appearing as fluffy densities in
most infants the respiratory symptoms
will resolve by 48 to 72 hours of life
if the respiratory distress resolves
within the first two to six hours after
birth these symptoms may be due to a
brief delay in lung fluid absorption and
is often termed delayed transition
instead neonatal pneumonia neonatal
pneumonia accounts for 11% of cases of
neonatal respiratory distress
pneumonia is more commonly seen in
infants born prematurely other risk
factors include maternal
chorioamnionitis and rupture of
membranes of greater than 18 hours early
onset pneumonia which occurs within
three days of birth is vertically
transmitted from the mother via
aspiration of infected amniotic fluid
or transplant
mission of organisms via the placental
circulation
common pathogens of early onset
pneumonia include Group B Strep
which is the most common as well as
ecoli Klebsiella and herpes simplex
virus symptoms of early onset pneumonia
include respiratory distress poor
feeding apnea tachycardia and poor
perfusion diagnosis of neonatal
pneumonia is made via laboratory
findings suggest of infection such as an
elevated white blood cell count and
characteristic findings on chest x-ray
which often shows bilateral alveolar
densities with air Branca Graham's the
empiric treatment of early onset
pneumonia is often with epsilon and
gentamicin late onset pneumonia is often
hospital-acquired with a major risk
factor being receipt of respiratory
support another possible etiology of
late onset pneumonia is chlamydia
trachomatis
which has a very long incubation period
and causes pneumonia at two to four
weeks of life respiratory distress
syndrome respiratory distress syndrome
RDS is a disease most commonly seen in
premature infants with the frequency
decreasing significantly after 37 weeks
gestational age RDS is due to the
deficiency of pulmonary surfactant in
the immature lung surfactant is a
phospholipid that decreases the alveolar
surface tension which helps with
alveolar expansion and decreases risk of
atelectasis not all infants may appear
ill immediately after birth but if RDS
is untreated they will progressively
worsen over the first 48 hours of life
symptoms include tachypnea nasal flaring
grunting retractions and cyanosis in
particular infants with RDS often grunt
in order to generate positive pressure
to keep alveoli open chest x-ray
typically demonstrates low lung volumes
as well as a classic diffuse
ground-glass
appearance with air Branca Graham's many
studies have demonstrated that RDS is
both less common and less severe if
corticosteroids are administered to the
mother prior to
preterm delivery all neonates at risk
for RDS should receive respiratory
support that reduces alveolar
atelectasis most commonly CPAP if
persistent severe respiratory distress
is noted infants are intubated and
surfactant is given via the endotracheal
tube
meconium aspiration syndrome in four to
nine percent of infants born through
meconium stained amniotic fluid
meconium aspiration syndrome mas is
diagnosed affected infants are
frequently small-for-gestational-age or
post term infants pass meconium in utero
due to stress most commonly fetal
hypoxia the pathophysiology of mas is a
complex combination of many factors
these include the release of cytokines
and other Perot inflammatory factors
following the aspiration of sterile
meconium into the lungs as well as
obstruction of the Airways
leading to distil gas trapping with
subsequent alveolar rupture
and the deactivation and decreased
synthesis of surfactant these infants
frequently have market to kit Nia
retractions
grunting and flaring as well as cyanosis
their respiratory symptoms develop
immediately after birth the chest x-ray
typically shows hyperinflation with
flattened diaphragms as well as diffuse
patchy densities alternating with areas
of expansion treatment consists
primarily of respiratory support some
infants will be ill enough to require
extracorporeal membrane oxygenation or
ECMO other less common etiology zuv
newborn respiratory distress include
persistent pulmonary hypertension of the
newborn pneumothorax congenital heart
disease congenital diaphragmatic hernias
and pulmonary congenital defects case
study you arrive at the warmer and see a
three hour old infant born at 37 weeks
he's breathing sixty to eighty breaths
per minute with mild nasal flaring and
intercostal retractions pulse oximetry
is reading 90% on room air his mother
was negative for Group B Strep and the
infant was born via scheduled repeat
cesarean section with rupture of
membranes at the time of delivery on
auscultation he has good air entry
bilaterally but scattered crackles are
appreciated his heart rate is regular
and no murmur is appreciated he is pink
and well perfused your differential
diagnosis includes TT n RDS and much
less likely a pneumothorax or pneumonia
you place him on 30% fio2 with
normalization of his oxygen levels to
greater than 95 percent an improvement
in his to give Nia and nasal flaring a
chest x-ray is obtained that shows fluid
in the inter lobar fissure and mildly
hyper expanded lungs you feel confident
given his response to minimal
respiratory support as well as the x-ray
findings that this infant has T TN and
should improve over the next day or two
you