THE TERM NEONATE WITH

RESPIRATORY DISTRESS

N. Ambalavanan MD
University of Alabama at
Birmingham
Department of Pediatrics
Division of Neonatology
May 2003

Overview of talk

The emphasis is on evaluation

and diagnosis
Management will depend
mainly on the diagnosis

EVALUATION OF NEONATES
WITH RESPIRATORY DISTRESS

History

Premature delivery
Postmature delivery
Fetal distress
Meconium-stained
fluid
Maternal diabetes
Oligohydramnios/
polyhydramnios

Decreased fetal
movements
Traumatic
delivery
Drugs
Cesarean section
Vaginal bleeding

EVALUATION OF NEONATES
WITH RESPIRATORY DISTRESS
Physical Exam

Major signs:
cyanosis, tachypnea
grunting, retraction,
flaring
Stridor, wheezes,
hoarseness, and
other
airway findings

Cardiovascular
assessment
Blood pressure
Neurologic assessment
Abdominal assessment
Chest wall assessment
Temperature

EVALUATION OF NEONATES
WITH RESPIRATORY DISTRESS
Laboratory
Workup
Chest radiograph
Arterial blood gas
Blood glucose
Central
hematocrit
White blood cell
and differential

If indicated:
Blood culture
Echocardiogram
Other
diagnostic
imaging

Neonate with
respiratory
distress

Abnormal
Chest X-Ray
?

Yes

Common
Resp Distress Synd
Transient Tachypnea
Aspiration Syndr.
Pneumonia
Air leaks
Effusion
Pulmonary Edema

No

Uncommon
Diaphrag. Hernia
Trach-Esoph fistula
Perfusion,
Cysts, tumors
BP, HCT
Hypoplasia
Hemorrhage
Upper or lower
Cong. Lobar Emph.
airway
Lymphangiectasia
Sequestration
Cardiac problems
AV fistulae

Other or
Mixed findings

Look for
abnormalities
of:

Neuromuscular
Diaphragm or
Chest wall
Abdomen

Neonate with Acute Respiratory Distress

Yes

Abnormal
Lungs
by Chest
Radiograph

No

Abnormalities in

Common
Respiratory distress
syndrome
Transient
tachypnea
Pneumonia
Aspiration syndromes
Pneumothorax and
air leaks
Pulmonary edema
Pleural effusion
Pulmonary hemorrhage

Uncommon
Diaphragmatic hernia
Tracheoesophageal
fistula
Cysts and tumors
Congenital lobar
emphysema
Pulmonary hypoplasia
Accessory or sequestered lobes
Pulmonary
lymphangiectasia
Pulmonary
arteriovenous fistula

Perfusion
BP
HCT

Neuromuscular
Findings

Anemia
Polycythemia
Hypotension
Hypovolemia

Asphyxia
Intracranial
hemorrhage
Neuromuscular
disorders
Drugs

Airway
Findings

Upper Airway
Laryngeal
Lower airway

CVS
Findings
or Echo

Persistent fetal
circulation
Cyanotic congenital
hear disease
Obstructive lesions
Congestive heart
failure

Diaphragm
or Chest
Wall

Chest wall
disorders
Diaphragmatic
disorders

Abdominal
Findings

Ascites
Necrotizing
enterocolitis
Abdominal mass
Omphalocele
Gastroschisis

Other
or Mixed
Findings

Sepsis
Acidosis
Hypothermia,
cold stress
Hyperthemia
Hypoglycemia
Methemoglobinemia

NEONATE WITH ACUTE

RESPIRATORY DISTRESS

Abnormal lungs by chest radiograph

- common
Respiratory distress
syndrome
Transient tachypnea
edema
Pleural effusion
Aspiration syndromes

Pneumothorax
and air leaks
Pulmonary
Pneumonia

Respiratory Distress Syndrome

Meconium Aspiration Syndrome

ABNORMAL RADIOGRAPHIC
FINDINGS
RDS - reticulogranular, ground glass
appearance, decreased lung
volume, air bronchograms
TTN - fluid in fissure, interstitial fluid
Pneumonia - infiltrates
MAS - variable

Hypoplastic lungs

Congenital lobar emphysema

NEONATE WITH ACUTE

RESIRATORY
DISTRESS
Abnormal lungs by chest radiograph uncommon
Diaphragmatic hernia
Accessory or
Tracheoesophageal fistula sequestered lobes
Cysts and tumors
Pulmonary
Congenital lobar
lymphangiectasia
emphysema
Pulmonary
Pulmonary hypoplasia
arteriovenous
Pulmonary hemorrhage
fistula

Meconium Asp. Syndrome

with Pneumothorax

Small right pneumothorax

Pneumopericardium

Pneumomediastinum

AIR LEAKS

Pneumothorax
Pulmonary interstitial emphysema
Pneumomediastinum
Pneumopericardium
Pneumoperitoneum
Pulmonary venous air embolism
Subcutaneous emphysema
Others

Cystic adenomatoid malformation (CAM)

THORACIC CYSTS AND

TUMORS
Teratoma
Gastric cyst
Cystic hygroma
Hemangioma
Neurogenic tumor
Angiosarcoma
neuroblastoma
Mediastinal goiter
ganglioneuroma
Thymoma
neurofibroma
Mesenchymoma
Bronchial or bronchogenic cyst Lipoma
Intrapulmonary cyst
Cystic
adenomatoid
malformation

Pneumonia

ORGANISMS THAT MAY

CAUSE
PNEUMONIA
IN
Bacterial
Enterobacter
THE
NEONATE
Group
B Strep
E. coli
Klebsiella
S. aureus
S. epidermidis
Listeria

H. influenzae
S.
pneumoniae
Pseudomonas
Bacteroides
Others

ORGANISMS THAT MAY

CAUSE PNEUMONIA IN
THE
NEONATE
Viral
Cytomegalovirus
Adenovirus
Rhinovirus
Respiratory
syncytial virus

Parainfluenza
Enterovirus
Rubella
Herpes simplex
Varicella

ORGANISMS THAT MAY

CAUSE PNEUMONIA IN
Others
THE NEONATE

Candida (and other Chlamydia

Syphilis
fungi)
Pneumocystis
carinii
Ureaplasma
Tuberculosis
Mycoplasma

Chylothorax/Hydrothorax

PLEURAL EFFUSION

Hydrothorax* - hydrops, tumor,

pneumonia, congenital viral infection,
congestive heart failure, transient
tachypnea, Turner syndrome
Chylothorax* - spontaneous, complication
of thoracic surgery
Hemothorax* - traumatic, ruptured
vessel, disseminated intravascular
coagulation, and other bleeding diatheses

* Complications of central line placement may result

in any of these .

ABNORMALITIES IN PERFUSION,
BLOOD PRESSURE, AND
HEMATOCRIT
Anemia
Polycythemia
Hypotension
Hypovolemia

Paralyzed right diaphragm

from phrenic N. palsy

ABNORMALITIES WITH
NEUROMUSCULAR FINDINGS
Asphyxia
Intracranial hemorrhage
Neuromuscular disorders
Drugs

NEUROMUSCULAR DISORDERS
Myopathies
Myasthenia gravis
Werdnig-Hoffman disease
Spinal cord disorder
Poliomyelitis
Others

Left diaphragmatic hernia

ABNORMALITIES IN
DIAPHRAGM OR CHEST WALL
Diaphragmatic disorders
Chest wall disorders

DIAPHRAGMATIC DISORDERS

Diaphragmatic hernia
Congenital eventration of the
diaphragm
Diaphragm paralysis
Anterior diaphragmatic defect
Neuromuscular disorders
Accessory diaphragm
Agenesis of the diaphragm

CHEST WALL DISORDERS

Failure of sternal

fusion
Benign and
malignant tumors
Asphyxiating
thoracic dystrophy
Achondroplasia
Thanatophoric
dwarfism

Achondrogenesis
Chondroectodermal
dysplasia
Osteogenesis
imperfecta
Spondylocostal
dysplasia
Others

ABNORMAL AIRWAY
Upper airway
Laryngeal
Lower airway

AIRWAY DISORDERS
Upper Airway
Choanal atresia/stenosis
Cystic hygroma
Trauma
Thyroglossal duct cyst
Hemangioma
Micrognathia
Teratoma
Macroglossia
Encephalocele
Benign and malignant
tumors

AIRWAY DISORDERS
Laryngeal
Laryngomalacia
Vocal cord paralysis
malignant
Hemangioma
Atresia, stenosis, or web
Congenital laryngeal
stridor

Cystic lesion
Benign and
tumors
Acquired lesion

AIRWAY DISORDERS
Lower Airway
Tracheomalacia
Tracheoesophageal
fistula
Hemangioma
malignant
Vascular ring
Congenital tracheal
stenosis

Bronchial atresia
Abnormal branching
Cystic lesion
Benign and
tumors
Acquired lesion

Dextrocardia with
complex congenital heart disease

Total Anomalous Pulmonary Venous Return

with Obstruction

Transposition of Great Arteries

(TGA)

ABNORMALITIES IN
CARDIOVASCULAR FINDINGS
OR ECHOCARDIOGRAM

Persistent fetal circulation

Cyanotic congenital heart disease
Obstructive lesions
Congestive heart failure

ABNORMALITIES IN
ABDOMINAL FINDINGS

Ascites
Necrotizing enterocolitis
Abnormal mass
Omphalocele
Gastroschisis

OTHER ABNORMALITIES
OR MIXED FINDINGS

Sepsis
Acidosis
Hypothermia, cold stress
Hyperthermia
Hypoglycemia
Methemoglobinemia

Neonate with
respiratory
distress

Abnormal
Chest X-Ray
?

Yes

Common
Resp Distress Synd
Transient Tachypnea
Aspiration Syndromes
Pneumonia
Air leaks
Effusion
Pulmonary Edema

No

Uncommon
Diaphrag. Hernia
Trach-Esoph fistula
Cysts, tumors
Hypoplasia
Hemorrhage
Cong. Lobar Emph.
Lymphangiectasia
Sequestration
AV fistulae

Look for
abnormalities
of:

Perfusion,
BP, HCT
Neuromuscular

Upper or lower
airway
Cardiac problems

Other or
Mixed findings

Diaphragm or
Chest wall
Abdomen

Management

Management depends on diagnosis

Maintenance of adequate gas exchange

Surgery

Maintain Airway
Oxygenation and Carbon dioxide elimination
Adequate pH
Adequate cardiac output and perfusion
Pneumothorax/Cysts/Diaphragmatic hernia

Supportive therapy

Thermoregulation, Nutrition, Fluid and Electrolyte

balance, etc
Antimicrobial therapy

Maintenance of gas exchange

Respiratory management depends on

diagnosis
Usual sequence:
No support O2 hood CPAP Mechanical
ventilation (conventional)
High Frequency ventilation add Nitric
Oxide ECMO
Surfactant may be useful in term infants with
respiratory failure
(Lotze et al. J Pediatr 132:40, 1998; Greenough. Eur J
Pediatr 159:635, 2000)

Indications for mechanical

ventilation

Clinical: Absolute: Apnea (intractable),

gasping, cyanosis not responsive to O 2
by hood
Relative: Severe tachypnea / retractions
Laboratory (while on CPAP or FiO 2 > 0.7):
pH < 7.25 with PCO2 > 60 mm Hg
(or) PO2 < 45- 50 and / or SpO2 < 85 %
Other: Surgical procedures,
compromised airway

Term infants with PPHN

Confirm diagnosis of PPHN
Correct underlying abnormalities (hypothermia, acidosis,
hypocalcemia, hypoglycemia, polycythemia)
Conservative mechanical ventilation
Trial of hyperventilation
If low PO2, trial of rescue therapies

Metabolic HFV Surfactant

Alkalosis ?
NO, PGD2,
PGI2, Tolazoline,
Adenosine

Vasodilators ECMO