Respiratory Distress

of the Newborn

Trauma & Emergency System

Perinatologi Division.Department of Child Health
Medical Faculty of Hasanuddin University

Pendahuluan
sering terjadi : 4 - 6 % bayi baru lahir
dapat mengancam jiwa
Diagnosis dini, waktu rujukan dan

tatalaksana yang tepat

penting

Aly H, Pediatrics in Review 2004;25:201-208

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

pemeriksaan awal :
Evaluasi beratnya gangguan napas (apnea,

respiratory effort)
Evaluasi kondisi lain yang berhubungan
langsung :
Circulatory collapse (bradycardia, hypotension,

poor perfusion)

Aly H, Pediatrics in Review 2004;25:201-208

Evaluation of Respiratory Distress of the

Newborn with Downes Score
0

Respiration
Rate

< 60x/min

60-80x/min

> 80x/min

Retraction

No Retraction

Mild Retraction

Severe Retraction

Cyanosis

No Cyanosis

Air entry

Good bilateral
air entry

Decrease in air
entry

No air entry

Grunting

No Grunting

Audible by
stethoscope

Audible without
stethoscope

Cyanosis relieved
Persistent
by O2
Cyanotic (with O2)

Evaluation of Respiratory Distress

of the Newborn with Downes Score
Score < 4

Mild Respiratory distress

Score 4 -7 Severe Respiratory distress

Score > 7

Impending respiratoty failure

(Blood gas analysis)

initial
assesment
Pemberian oksigen langsung membutuhkan :
Balon dan sungkup
Intubasi dan ventilator mekanik

persiapan :
Alat resusitasi dan sumber2
Dokter Senior dan tim resisitasi
Mengikuti Petunjuk alur resusitasi

Aly H, Pediatrics in Review 2004;25:201-208

History

Obstetrical histories
Gestational age (if
preterm steroid ?)
Maternal history
Results of fetal
Drug abuse
assesment and fetal
Diabetes melitus
monitoring during
Infections
labor & delivery
Complications at
delivery birth
trauma, presence of
meconium, perinatal
depression, premature
rupture
of 2004;25:201-208
membranes
Aly H, Pediatrics
in Review


history
Details of the presenting respiratory
symptoms
Coughing and choking during feeding
functional and structural should be considered.
If symptoms follow the feeding & recurrent
emesis reflux with aspiration suspected
Gradually improving symptoms TTN
Gradual deterioration pneumonia / sepsis
Onset of distress

Aly H, Pediatrics in Review 2004;25:201-208

Physical examination
Inspection is the first and most important tool
Apnea, poor perfusions, retractions, cyanosis
Inspiratory stridor upper airway obstruction
Stridor (previous history of intubation)
subglottis stenosis
Asymmetric chest movement + severe
distress maybe tension pneumothorax
Scaphoid abdomen diaphragmatic hernia

Aly H, Pediatrics in Review 2004;25:201-208

physical examination
Auscultation
Symmetry and adequacy of air exchange
Abnormal breaths sound
The presence of heart murmur
Chest transilumination to detect
pneumothorax

Aly H, Pediatrics in Review 2004;25:201-208

Differential diagnosis of
respiratory distress

Surgical causes
Medical causes

Suspect surgical cause

Obvious malformation
Scaphoid abdomen
Frothing
History of aspiration
Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

Surgical causes of respiratory

distress
Tracheo-esophageal fistula
Diaphragmatic hernia
Lobar emphysema
Pierre-Robin syndrome
Choanal atresia

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

Medical causes of respiratory

distress
Transient tachypnea of the newborn (TTN)
Hyaline membrane disease (HMD)
Meconium aspiration syndrome (MAS)
Air leak syndrome
Pneumonia
Congenital heart diseases

Aly H, Pediatrics in Review 2004;25:201-208

Preterm Possible Etiology

Early progressive

Hyaline membrane
disease

Early transient

Metabolic causes,
hypothermia

Anytime

Pneumonia

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

Term- Possible Etiology

Early well looking
Early severe distress
Late sick with
hepatomegaly
Late sick with shock
Anytime

TTN, polycythemia
MAS, asphyxia,
malformations
Cardiac
Acidosis
Pneumonia

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

..Differential diagnosis of
RDN
IntraPulmoner (Respiratory
Extra Pulmoner:
Cardiac diseases

diseases)

Neurological disorder
Other Miscellaneous Diseases

Aly H, Pediatrics in Review 2004;25:201-208

RESPIRATORY DISEASES
A. Airway Obstructions
Nasal Stenosis
Pierre Robins
Sequence
Vocal
Cord
paralysis
Vascular Rings

Choanal Atresia

Laryngeal
stenosis or
atresia
Hemagloma
Tracheobrochi
al stenosis

B. Disorders of the Chest Wall

and Diaphragm

Disorders
of the
chest wall

Congenital
diaphragma
tic hernia

C. Malformation of the
Mediastinum
and Lung Parenchyma
Congenital
Congenital
cystic
adenomatoid
malformation
Congenital
pulmonary
cyst

Neoplasms
(teratomas,
mediastinal,
neurablastoma

lobar
emphysema
Pulmonary
arterioveno
us
malformatio
ns
Bronchopulmona
ry

D. Air Leak Syndromes

Pulmonary
interstitial
emphysema

Pheumoperitoneum

Pneumomediastinum
Pneumopericardium

Pneumothorax

E.Pulmonary
Parenchymal and
Lung
Parenchymal
Vascular
Disease
Disease:

Persistent
pulmonary
hypertension of
the newborn

Pneumonia
Pulmonary
edema
Transcient
tachypnea of
newborn
Meconium
aspirationHyaline membrane disease
syndromeCongenital alveolar proteinosis

Cardiac Diseases
A. Cyanotic
Transposition of great arteries
Total anomalous pulmonary venous return
Ebsteins anomaly
Tricuspidal atresia
Severe congestive heart failure
Pulmonic stenosis
Tetralogy of Fallot

B. Acyanotic
Hypoplastic left heart syndrome
Interrupted aortic arch
Critical aortic coarctation
Patent ductus arteriousus

Neurological Disorder
Birth Trauma
Intravenricular hemorrhage
Meningitis
Primary seizure disorder
Obstructed hydrocephalus
Hypoxic ischemic encephalopathy
Infantile botulism
Spinal Cord injury
Muscular diseases (myasthenia gravis,
poliomyelitis)

Other Miscellaneous Diseases

Sepsis
Anemia or polycythemia
Hypo or hyperthemia
Hypo or hypernatremia
Hypoglycemia
Inborn errors of metabolism
Maternal medication (magnesium

sulfate or opiates) or drug abuse

Investigations
Complete blood count (anemia, polycythemia,

sepsis)
Chest X-ray
Arterial blood gas
Glucose check (hypoglycemia)
Blood culture (sepsis, pneumonia)

Aly H, Pediatrics in Review 2004;25:201-208

Treatment
After stabilization, treat the cause of

respiratory distress
Avoid unnecessary exposure to oxygen
Antibiotics until sepsis is ruled out

Aly H, Pediatrics in Review 2004;25:201-208

ETIOLOGY
Surfactant deficiency is the primary cause of HMD
Preterm newborn respiratory difficulty respiratory
distress persists/progresses over the first 48-96 h of life.

31

Avery & Oppenheimer : HMD 3,8 % kematian prematur

dengan berat badan lahir 1000-2000 gr.
Insiden : berbanding terbalik dgn usia gestasi dan berat lahir
Tertinggi : Preterm with GA 30 32 weeks, birth weight
1200 2000 gr

32

 Komposisi Surfactant yg utama : phospholipid (75%) , protein (10%).

Lipoprotein akan dilepas ke dalam jalan napas
Pulmonary Surfactant Substance
tegangan permukaan alveoli
pertahankan pengembangan alveoli pd tekanan fisiologi

Anti Atelectatic Factor

33

HMD the small air spaces collapse each expiration results in

progressive atelectasis
Decrease oxygenation

Hypoxemia
CO2 retention
Metabolic acidosis

Exudative proteinaceous material and epithelial debris, resulting from

progressive cellular damage, collect in the airway and directly decrease total
lung capacity .
Pathologic specimens this material stains typically as eosinophilic
hyaline membranes living the alveolar spaces and extending into small
airways Hyaline Membrane

34

Amniocentesis

L / S Ratio

<1

immature

+ 1,5

intermediate

>2

mature

HMD (-)

35

36

- Peripheral air bronchogram

-Uniform reticulogranular pattern
- Ground glass appearance

Increased risk

Decreased risk

Prematurity
Male sex
Familial predisposition
Cesarean section without
labor
Perinatal asphyxia
Chorioamnionitis
Hydrops
Maternal diabetes

Chronic intrauterine stress

Prolonged rupture
membranes
Maternal hypertension
Narcotic/cocaine use
IUGR / SGA
Corticosteroids
Thyroid hormone
Tocolytic agent

MANAGEMENT
A. PREVENTION

Antenatal corticosteroid
to enhance fetal pulmonary maturity
The recommended glucocorticoid : 12 mg betamethasone IM 24 h.
Antenatal ultrasonography are accurate assessment of gestational
age & fetal being
Continuous fetal monitoring to signal the need for intervention when
fetal distress is discovered
Tocolytic agent prevent & treat preterm labor
Assessment of fetal lung maturity (L/S ratio) & phosphatidylglycerol
39

surfactant
Harus ada alat penyokong ventilasitherapy
Harga
Prophylactic Vs Rescue
Prophylactic therapy

Extremely preterm
< 28 wks
< 1000 gm

Rescue therapy

Any neonate diagnosed to have RDS

Dose 100 mg / kg phospoholipid intra
tracheal
Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

Radiologic appearance before

and after surfactant therapy

PROGNOSIS
The survival of infants with HMD improved greatly
Prognosis for survival with or without respiratory and neurologic
sequelae dependent on birth weight and gestational age.
Major morbidity : BPD, NEC, severe IVH

Respiratory distress due to aspiration

of meconium by the fetus in utero or by
the neonate during labor and delivery
Incidence
10-26% of all deliveries
mostly in term and postterm deliveries
may represent fetal hypoxemia
44

Patophysiology
Meconium :

the first intestinal discharge of the newborn infant

is composed of epithelial cells, fetal hair, mucus, and bile.

Intrauterine stress in utero passage of meconium into

amniotic fluid

The

meconium-stained amniotic fluid aspirated by the

fetus when fetal gasping / deep breathing movements are

stimulated by hypoxia & hypercapnea

..Pathophysiolo
gy
The meconium in the trachea airway obstruction as

well as an inflammatory response severe respiratory

distress.
Mother with meconium stained amniotic fluid carefully

monitored during labor

Risk Factors
Postterm pregnancy
Preeclampsia-eclampsia
Maternal hypertension
Maternal diabetes mellitus
Abnormal fetal heart rate
Intrauterine growth retardation
Abnormal biophysical profile
Oligohydramnion
Maternal heavy smoking
Chronic respiratory / cardiovascular disease

Clinical Presentation
Meconium stain amniotic fluid before birth
Meconium staining of neonate after birth
Varying degree of respiratory distress; barrel

chest; audible rales

Persistent pulmonary hypertension of the
newborn
Pneumotorax (10%-20% infants with MAS)

Aly H, Pediatrics in Review 2004;25:201-208

Clinical Presentation
A. General features

Infant Postmaturity

Respiratory distress at birth / in the transition period

Perinatal asphyxia they may have respiratory
depression with poor respiratory effort & decreased
muscle tone

B. Airway obstruction
Apneic, gasping respiration, cyanosis, poor air exchange
Later, the meconium is driven down to more distal airways,
the smaller airways are affected, resulting in air trapping and
scattered atelectasis
C. Respiratory distress
Tachypnea, nasal flaring, intercostal retraction, increased AP
diameter of the chest and cyanosis.
D. Other pulmonary abnormalities
Decreased air exchange, rales, rhonchi/ wheezing

 Clinical presentation
Laboratory : arterial blood gas level metabolic acidosis
Chest radiograph :
hyperinflation of the lung fields and flattened
diaphragms
Irregular patchy infiltrates
Pneumothorax / pneumomediatinum

51

Management
Prenatal management
Identification of high-risk pregnancy
Monitoring of fetal heart rate during labor

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Management
Delivery room management
Placed under radiant warmer Suction
infants mouth, pharinx and nose as soon
as complete delivered
Suction the hypopharinx to clear any
residual meconium
Depressed infants (depressed respiration,
HR < 100 beat / min, poor muscle tone)
tracheal visualization and suctioning should
be performed
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Management
Respiratory management
Supplemental oxygen
Mechanical ventilation

Aly H, Pediatrics in Review 2004;25:201-208

Management
General management
Antibiotics
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)

Aly H, Pediatrics in Review 2004;25:201-208

 Benign disease of near-term, term or large premature

infants who have respiratory distress shortly after delivery,
usually resolves within 3-5 days

57

PATHOPHYSIOLOGY
Delayed resorption of fetal lung fluid

tachypnea and retraction

infants delivered by elective cesarean section are at risk
because of lack of the normal vaginal thoracic squeeze, which
forced lung fluid out
Pulmonary immaturity

Mature L/S ratio but negative phosphatidylglycerol (completed

lung maturation)
Mild surfactant deficiency

Risk Factors
Elective cesarean section delivery
Male sex
Macrosomia
Excessive maternal sedation
Prolonged labor
Birth asphyxia
Breech delivery
Infant of diabetic mother
Prematurity
Very low birth weight neonates

Usually near term, term, or large and premature and shortly

after delivery has tachypnea (> 60x/min up to 100-120x/min)
Grunting
Nasal flaring
Rib retraction
Varying degrees of cyanosis

60

Laboratory :
L/S ratio in amniotic fluid, arterial blood gas,
complete blood cell count
Chest X-ray :
Hyperexpansion of the lungs
Prominent perihilar streaking
Mild/moderately enlarged heart
Depression (flattening) of diaphragm
Fluid in the minor fissure
Prominent pulmonary vascular markings
61

 Hyperexpansion of the lungs

Prominent perihilar streaking
Mild/moderately enlarged heart
Depression (flattening) of
diaphragm
Fluid in the minor fissure

O2
Antibiotics initially broad spectrum
Feeding :
o RR > 60x/min not be fed by mouth
o RR < 60x/min oral feeding is permissible
o RR 60 80 x/min feeding should be by nasogastric tube
o RR > 80x/min Intravenous nutrition

63

TTN is self-limited
Usually lasts only 2-5 days
No risk of further pulmonary dysfunctions

64

 Apnea is the absence of respiratory gas flow for a period

of 20 seconds or greater or of shorter duration if
associated with bradycardia or significant desaturation
Preterm baby are prone to episodes of apnoea, which are
more frequent in very small babies (less than 1,5 kg at
birth or born before 32 weeks gestation) but they become
less frequent as the baby grows.
65

Classification of apnea
1.

Central apnea of CNS origin and is characterized by the

absence of gas flow with no respiratory effort

2.

Obstruction apnea is continued by respiratory effort not

resulting in gas flow

3.

Mixed apnea is combination 1 & 2

Periodic breathing : 3/ more periods of apnea lasting within

20 seconds period of otherwise normal respiration, is also
common in newborn period

PATHOPHYSIOLOGY
Immaturity of respiratory control
Sleep-related response
Muscle weakness
All of these factors point to an immature respiratory control

mechanism in the preterm infant

Pathologic states
Hypothermia and hyperthermia
Metabolic disturbances
Sepsis
Anemia
Hypoxemia
CNS abnormalities
Necrotizing enterocolitis
Drug withdrawal and drug effects
Gastroesophageal reflux

Apnea within 24 h after delivery

Apnea after the first 24 h of life

Lethargy
Hypothermia/ hyperthermia
Cyanosis
Respiratory effort
69

Chest X-ray :
Atelectasis
Pneumonia
Air leak

70

O2
CPAP
Pharmacologic therapy
Theophylline
Caffeine
Mechanical ventilation
If apnea is severe and is associated with hypoxia/
significant bradycardia intubation and mechanical
ventilation may be indicated
71

Aminophylline
Neonatal Apnoea
Loading dose
IV : 6 mg/kg/dose
Maintenance dose
Commence
1 kg
24 hrs after loading
1 kg
12 hrs after loading
IV :
Age 7 days 2.5 mg/kg/dose
Age 8-14 days 3 mg/kg/dose
Age >14 days 4 mg/kg/dose

12 hrly
12 hrly
12 hrly

Caffeine Citrate
Neonatal Apnoea
Loading dose

IV, Oral : 20 mg/kg

Maintenance dose
(commence 24 hrs after loading dose)
IV, Oral : 5 mg/kg/daily
Maintenance dose can be increased to a
maximum of 10 mg/kg/day

The best indicator for prognosis is depend on the CAUSE

Apnea of prematurity has an excellent prognosis,
whereas that associated with IVH has a poorer prognosis

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