Respiratory Distress of the Newborn: Causes and ... - Trinity Health

Respiratory Distress of the Newborn: 

Causes and Treatment 

Respiratory Distress of the 

Newborn: Causes and Treatment 

Trinity Health 

Perinatal Medicine and Women’s Healthcare 

33 rd Annual Symposium 

Minot, ND 

September 21, 2012 

Tom George, MD 

Professor of Pediatrics 

Medical Director, NICU, University of Minnesota Amplatz Children’s Hospital 

Associate Director, Pediatric Residency Program 

Objectives 

At the end of this presentation, the attendee 

will be able to 

• Identify common causes of neonatal respiratory 

distress 

• Understand how to evaluate and methods to treat 

neonatal respiratory distress 

• Understand new issues in the treatment of neonatal 

respiratory distress 

Acute neonatal deterioration 

Respiratory causes 

• Upper airway 

• Pulmonary disease 

• Lower airway disease 

• Pulmonary compression 

1




Respiratory causes 

• Upper airway obstruction 

– nose: choanal stenosis 

– mouth/jaw: large tongue 

– larynx: cord paralysis 

– trachea: tracheomalacia, tracheal stenosis 

– extrinsic: cystic hygroma, vascular ring 

Interpreting neonatal x-rays 

• Also going to use this opportunity to 

review neonatal radiographic pathology 

Approach to reading x-rays 

• Make sure the x-ray belongs to the patient 

• Evaluate technique 

– What is the quality of the x-ray? 

– Technique- importance of positioning 

Rotation 

Lordosis 

2



What is the quality of the x-ray? 

Extrinsic 

Clutter 

Normal chest x-ray 

(Before we look at pulmonary pathology) 

Also can often see thymic shadow in newborns 


Respiratory causes - alveolar disease 

• Transient tachypnea of the newborn 

• Bacterial pneumonia 

• Surfactant deficiency - RDS 

3



Transient tachypnea of the newborn 

Early 

• Retained Alveolar Fluid 

• Often a retrospective diagnosis 

12 h later 

Group B Strep Pneumonia 

early 

12 hrs later 

Group B Strep Pneumonia 

early 

12 hrs later 

4



Surfactant Deficiency (RDS) 

• ‘Ground glass’ appearance 

• Air bronchograms 

• Symmetric disease 

• Predominantly in preterm 

infants, though it can occur 

in term infants, especially 

those delivered by C- 

section without labor, or 

elective sections before 39 

weeks 


Respiratory causes - lower airway 

• Meconium Aspiration Syndrome 

– Secondary Surfactant Inactivation 

Early Meconium Aspiration 

• Diffuse patchy 

infiltrates 

• Hyperinflation that 

places them at risk 

for airleaks 

• At risk for PPHN 

5



Late Meconium Aspiration 

Phrenic Nerve Injury 

• Brachial plexus injury 

• Can have associated phrenic nerve injury 

leading to respiratory distress 

Right Diaphragm Paralysis 

6



Air Leak Syndromes/ 

Primary Lung Compression 

• Pneumothorax 

• Congenital Diaphragmatic Hernia 

• Cystic Adenomatoid Malformation 

• Pleural Effusion 

• Thoracic Compression 

Right tension pneumothorax 

• Presents with acute 

hypoxemia, also possible 

bradycardia, hypotension 

• Decreased BS on right 

• Needle thoracentesis 

Right Pneumothorax 

after needle thoracentesis 

7



Congenital Diaphragmatic Hernia 

• Acute respiratory distress at birth 

• Intubation and NG to suction 

Congenital Adenomatoid Malformation 

Pleural Effusion 

8



Thoracic Compression 

Objectives 




distress 





Evaluation and Stabilization of the 

Newborn Infant in Respiratory Distress 

• Establish Airway (suctioning, mask, 

endotracheal tube) 

• Evaluate Breathing (bag if needed) 

• Maintain Circulation 

• Administer Drugs 

– Antibiotics - ampicillin and gentamicin 

(minimize cefotax use due to resistance) 

– IV flluids with dextrose 

• Maintain Environment (thermal regulation) 

9



Evaluation and Stabilization of the 

Neonate with Respiratory Distress 

• History, physical examination 

• Vital signs, with blood pressure 

• Pulse oximetry—SaO 2 / Arterial blood gases 

• Chest x-ray 

• CBC with differential, platelet count 

• Blood culture, other cultures as indicated 

Assessment of the acutely ill newborn 

• Respiratory: 

– Tachypnea – rate > 70-80 breaths/minute 

– Grunting, retractions, flaring of alae nasi 

– Reduced air entry 

– Apnea 

– Cyanosis 

–Stridor 


Assessment of the acutely ill newborn 

• Objective assessments 

– Vitals signs 

• If worried about a newborn, should be 

continuously monitored with cardiac/apnea 

monitors 

– Frequent reassessment 

10



Evaluation and Stabilization 

Respiratory Support for the Neonate 

Respiratory support should be provided for the infant 

with respiratory distress, especially if hypoxemia is 

present 

• Blow-by oxygen 

• Nasal cannula 

• Oxyhood 

• Mechanical ventilation 



• Blow-by oxygen: 

Acutely used for a non-intubated infant with 

hypoxemia 



• Nasal cannula - limited FiO 2 that can be delivered 

– STOP ROP effective FiO 2 conversion tables 

– OxygenbyNC.pdf 

• High Flow Nasal Cannula (HFNC) 

– To deliver CPAP, need higher flow of 3-4 lpm 

– Effective in some situations, particularly for transitioning 

infants off PPV with resolving RDS 

– Should be cautious about use in babies for initial 

treatment of RDS 

11





• Oxyhood - delivers FiO 2 of up to 90 - 100% 



• Mechanical ventilation 

– For acute deterioration, or for worsening clinical 

condition 



Indications for Mechanical Ventilation 

• Respiratory acidosis 

(pH < 7.25 with increasing PaCO 2 ) 

• Hypoxemia – 

saturations < ~ 85%, PaO 2 < 50 mmHg in FiO 2 > 60% 

• Apnea of prematurity 

12



Endotracheal Tube: 

Size, Length by Weight, Gestational age 

Weight (g) 

Below 1000 1 

Gestational 

Age (wks) 

Below 28 

Tube Size 

(mm) 

(Gestational Age ÷ 

2.5 10) 

Number at 

Lip to Tip 

6 + wt (cm) 

6.5 

1000-2000 

28-34 

3.0 

7-8 

2000-3000 

34-38 

3.0-3.5 

8-9 

Above 3000 

Above 38 

3.5-4.0 

>9 

Intubation: Atropine (0.02 mg/kg IV) → Morphine (0.1 mg/kg IV) 

→ Rocuronium(0.6 mg/kg IV) 

Endotracheal Tube in the Esophagus 

• Poor chest movement 

• Poor response to intubation - no 

improvement in color, heart rate, tone, 

respiratory effort 

• No mist in tube 

• Crying sounds around tube 

Endotracheal Tube in the Esophagus 

• Air heard entering stomach/gastric 

distension 

• No breath sounds 

•CO 2 detector - no expired CO 2 

– (Remains purple) 

13



Goals of respiratory support 

• Maintain adequate tissue oxygenation 

• Allow recovery without causing additional 

lung injury 


Mechanical Ventilation 

• Continuous positive airway pressure (CPAP) 

• Synchronized CPAP (SiPAP/rated CPAP) 

• Conventional mechanical ventilation (SIMV) 

• High frequency ventilation 


Continuous Positive Airway Pressure 

• CPAP maintains end-expiratory airway pressure, 

usually at 5 - 8 cm H 2 O: 

– increases resting lung volume thus improving 

oxygenation and ventilation 

– maintains upper airway patency 

– improves distribution of ventilation 

14




Continuous Positive Airway Pressure 

• Several methods to deliver CPAP: 

Nasal prongs 

Nasopharyngeal 

HFNC to deliver CPAP 

NIPPV 

• Effective in decreasing apneic events in infants 

on CPAP in premature infants (Lin 1998) 

• Most delivery systems are asynchronous and so 

use of higher rates should be considered 

carefully 

• Might prevent need for reintubation 

• Lower rate of BPD (Ramanathan 2012) 

• Not indicated for treatment of acute RDS 


Conventional Mechanical Ventilation 

Initial settings: 

• PIP (Peak Inspiratory Pressure) or TV (tidal volume): 

– 16 - 30 cm H 2 O pressure, adjust based on infant size,chest wall movement 

– Or TV instead of PIP for volume control ( ~ 5 cc/kg) 

• PEEP (Positive end-expiratory pressure): 

– 4 - 7 cm H 2 O pressure 

• IT (Inspiratory time): 0.35 - 0.5 seconds 

• Respiratory rate: 20 - 40 breaths per minute 

• Monitor response 

– oxygenation (saturations and amount of FiO 2 required) 

– ventilation (blood gas) 

15



Oxygenation 

• Oxygenation (saturations, PaO 2 ): 

- primarily determined by the 

Mean Airway Pressure (MAP) 

• MAP can be increased by: 

- increasing PIP, PEEP and/or IT 

Ventilation 

• Ventilation (PaCO 2 ): 

- primarily determined by the total 

volume of air that passes in and out of the 

alveoli, - the tidal volume (TV) delivered by 

the ventilator 

• TV typically increased by: 

- increasing the RR 

- can also PIP or PEEP 

Goals of Mechanical Ventilation 

Depends on the disease process: 

•In RDS: 

Oxygenation: saturation ~ 85 - 95% 

(PaO 2 50 - 80 mmHg) 

Ventilation: PaCO 2 45 - 60 mmHg 

in RDS as long as pH > 7.25 

• In PPHN/MAS: 

Sats > 90%; PaCO 2 more normal - 40-50 mmHg 

16



Respiratory - Customized Goals 

• Preterm infant 

– Hypocarbia associated with PVL 

– Hyperoxia associated with ROP 

– Volutrauma associated with pneumothorax, IVH and BPD 

• Term infant with pulmonary hypertension 

– Hypercarbia and hypoxemia increase PVR and shunting 

• Term infant with congenital heart disease 

– Vary parameters to optimize tissue perfusion and 

oxygenation, generally normal pCO 2 

Synchronized Intermittent 

Mechanical Ventilation 

• Synchronizes IMV breaths by sensing a 

spontaneous breath and delivers a mechanical 

breath synchronized with the infants inspiratory 

phase 

• Sensing is typically via flow sensing systems 

• Still set TV or PIP, PEEP, IT and RR 

SIMV- proven and potential benefits 

• Studies have found: 

– improved oxygenation and ventilation in infants 

crossed-over between SIMV and IMV, with 

higher PaO 2 and lower PaCO 2 

– less cerebral blood flow velocity variability, 

particularly of concern in premature infants 

• Decreased agitation with “fighting the vent” 

• Decreased need for sedation/paralysis 

17



It’s not just the the respiratory support 

• Nutrition 

• Optimizing PEEP/MAP 

• Fluid management 

• Addressing infectious disease issues 

• Surfactant for post-surfactant slump 

Katz & Klein, J Perinat 2006;26:414 

Objectives 




distress 





Changing trends 

• Use of early CPAP to avoid intubation 

• iNO in preterm infants 

• Oxygen use in the DR 

18



CPAP 

• SUPPORT trial 

– Significant percentage of infants who don’t need 

intubation with early, optimal CPAP to prevent collapse 

of alveoli 

– A trial of nasal CPAP should be considered as an 

alternative to routine DR intubation 

• If intubation is needed: 

– consider early extubation after surfactant to optimal 

CPAP in preterm infants 

Inhaled Nitric Oxide 

• Valuable tool in the treatment of Persistent Pulmonary 

Hypertension of the Newborn 

• PPHN occurs in ~1/1400 live births causing severe 

and labile hypoxemia 

• FDA approved for hypoxemic respiratory failure in 

term and near-term infants, decreases need for ECMO 

• iNO diffuses from alveolus to pulmonary vascular 

smooth muscle 

• increases cGMP levels 

• leads to muscle relaxation and vasodilation 

Inhaled Nitric Oxide in Preterm Infants 

• 3 large trials 

– One study shows benefit in larger babies, one study shows 

decreased CLD (iNO started later), one shows no benefit 

– Questions remain about when to start, how long to treat, dose 

– NICH consensus 2010: routine use not recommended 

– Select use for premature infants with pulmonary 

hyptertension/pulmonary hypoplasia with pulmonary 

hypertension 

• TOLSURF trial now ongoing 

– iNO combined with 5 doses of late surfactant starting 

DOL 7-14 for intubated patients < 28 weeks 

19



Oxygen use in the DR 

• NRP recommendations: 

Current evidence is insufficient to resolve 

all questions regarding supplemental 

oxygen use during neonatal resuscitation 

Pre-ductal and Post-ductal O2 Saturation in 

Healthy Term Neonates after Birth 

Mariani et al J Peds 2007 

Oxygen use in the DR – term infants 

• Research suggests that 21% oxygen might be 

as effective as 100% oxygen 

• Recommendations: 

- start resuscitation with room air 

- then oximetry could guide the 

concentration of oxygen needed 

20



SpO2 values in the first 20 minutes after birth in extremely low gestational age 

neonates randomly assigned to the low-oxygen (Lox) group (initial FIO2 after 

birth: 30%) or the high-oxygen (Hox) group (initial FIO2 after birth: 90%) 

Escrig, R. et al. 

Pediatrics 

Copyright ©2008 American Academy of Pediatrics 

Oxygen use in the DR – preterm infants 

• Optimum saturation in preterm infants in the 

first minutes of life is not known 

• A high oxygen saturation in preterm infants 

might be damaging 

• Titrate oxygen to achieve balance of need for 

sufficient oxygen to correct hypoxemia 

against excessive oxygen levels 

Oxygen use in the DR – preterm infants 

• Delivery centers have placed blenders in the DR 

• Some start at 21% and increase 

• Some start at < 100% and as needed 

• Awareness of saturations is important 

• Even a few breaths of high oxygen results in 

inflammatory cytokines 

• Effect on retinal vessels 

21



AAP recommendations 

• Oxygen blenders in the DR 

• One team member attaches oximeter probe 

to right wrist 

• Start oxygen at < 100%; we start at 30%. 

Summary 

• Reviewed common causes of neonatal 


• Reviewed how to evaluate and treat neonatal 


• Reviewed newer issues in the treatment of 


Thank you 

Questions/comments welcome! 

tgeorge@umn.edu 

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Respiratory Distress of the Newborn: Causes and ... - Trinity Health

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