1. TTN vs. TTT (Time to Transport):
Assessment of Neonatal Respiratory Distress
Children’s/March of Dimes Neonatal Conference
May 17, 2010
Mark Bergeron, MD, MPH
Associates in Newborn Medicine, PA, St. Paul
Assistant Professor, Pediatrics, University of Minnesota Medical School

2. Disclosures
I will not be discussing any experimental or off-label uses for any therapies during this presentation.
I have no relevant financial relationships to declare.

3. Objectives
Formulate a differential diagnosis for the infant in respiratory distress.
Describe initial stabilization measures for the infant in respiratory distress.
Describe situations where ongoing respiratory distress requires transfer to a NICU for further management.

5. Respiratory distress is a frequent problem in the newborn period.
Introduction
Respiratory distress is a frequent problem in the newborn period.
Most common indication for evaluation or re-evaluation of the newborn infant
Affects as many as 7% of newborns
Potentially life-threatening
Must be promptly assessed and managed by an on-site provider in the delivery room or newborn nursery

6. Clinical Presentation
retractions
subcostal
intercostal
suprasternal
tachypnea
(> 60/min)
gasping
choking
apnea
cyanosis
grunting
stridor
nasal flaring

7. Image: Aly H. Pediatrics in Review (2004)

8. Narrowing the Differential
Pulmonary
Transient Tachypnea of the Newborn (TTN)
Respiratory Distress Syndrome (RDS)
Meconium aspiration syndrome
Pneumonia/sepsis
Pneumothorax
Persistent pulmonary hypertension (PPHN)
Non-pulmonary
Congenital cyanotic heart disease
Congenital airway anomalies
Other (neurologic, hematologic, metabolic, endocrine, maternal, etc.)

10. Case Studies

11. Case #1
3.6-kg term newborn female (20 minutes old) has tachypnea and acrocyanosis. She is 40 weeks EGA delivered by scheduled repeat c-section and Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.
Vitals are normal with the exception of a respiratory rate of 84 and exam is notable for slight subcostal retractions but otherwise normal. Over the next several hours, her respiratory rate steadily improves to the 40s and her acrocyanosis resolves.

12. Transient Tachypnea of the Newborn (TTN)
Most common etiology of newborn respiratory distress.
11/1000 live births
Represents 40% of cases of newborn respiratory distress.
Caused by delayed clearance of fetal lung fluid in both term and preterm infants

13. Guglani et al. Pediatrics in Review 2008
TTN Risk Factors
At birth:
Air spaces rapidly clear fluid from lung expansion with air
Promoted by:
Labor
Maternal epinephrine surge
Guglani et al. Pediatrics in Review 2008

14. TTN: Clinical Findings
History:
C/S > NSVD
Exam:
Tachypnea +/-
Grunting
Nasal flaring
Retractions
Transient oxygen need
Lab:
Mild respiratory acidosis or normal blood gas

15. TTN: Radiographic Findings
Chest X-ray:
Increased interstitial markings (“wet lung”)
Increased fluid in interlobar fissures
Image: Aly H. Pediatrics in Review (2004)

16. TTN: Typical Course
Usually benign, self-limited
Occasionally requires therapy:
Oxygen
nCPAP
Mechanical ventilation
Diuretics not effective
i.e. Lasix
Typically resolves by 2 days of age
No lasting sequalae

17. Case #2
1.2-kg male infant born vaginally at 32 weeks EGA
Apgars 6, 8
Required bulb suctioning, brief PPV.
Grunting, retractions, nasal flaring, acrocyanosis immediately after birth.
VS: HR 178, RR 79, Mean BP 39 mmHg. O2 sat 74-78% in room air.

18. Lab: Case # 2 Continued CBC unremarkable ABG:
7.26/67/58/19
CXR: “Prominent reticulogranular pattern uniformly distributed with hypoaeration of lungs. Increased air bronchograms are observed.”
emedicine.com

19. Respiratory Distress Syndrome (RDS)
Also called hyaline membrane disease.
Most common cause of respiratory distress in preterm infants.
Due to structural and functional immaturity of lungs.
Underdeveloped parenchyma
Surfactant deficiency
Type II pneumatocytes
Results in decreased lung compliance, unstable alveoli

20. RDS Continued Risk factors Prematurity <28 weeks GA (≈100%)
Perinatal depression
Male predominance
Maternal diabetes
C-section
Multiple birth

21. Respiratory Distress Syndrome: Clinical Finings
Exam:
Moderate to severe respiratory distress
Tachypnea
Grunting
Apnea
Retractions
Nasal flaring
Cyanosis
Lab:
Moderate hypoxia
Respiratory acidosis
Metabolic acidosis (delayed)
X-ray:
Low lung volumes
Diffuse atelectasis: “ground glass opacities”
Air bronchograms
Difficult to distinguish from pneumonia
emedicine.com

22. RDS: Typical Course Prevention: Antenatal bethamethasone
Arrest of preterm labor
Treatment
Oxygen supplementation
Assisted ventilation
nCPAP
mechanical ventilation
FiO2 > .40
Exogenous surfactant replacement
Fluid restriction
Outcome
Peak severity 1-3 days
Recovery coincides with diuresis beginning at 72 hrs
Severe cases evolve into bronchopulmonary dysplasia (chronic lung disease)
Extreme prematurity
Prolonged mechanical ventilation
Sepsis

23. Case #3
4.2-kg female infant is cyanotic and tachypneic at 30 minutes of age following a vaginal delivery through meconium-stained amniotic fluid. Apgar scores were 3 and 6. She had a spontaneous but weak cry at birth and received some positive pressure ventilation followed by suctioning.
Vitals signs reveal a pulse of 169, respiratory rate of 115, and a mean BP of 55. Sats are 76% despite 100% O2 by headbox. She is barrel-chested, retracting, grunting, and has diminished coarse breath sounds bilaterally.
She is electively intubated, lines placed and labs sent.

24. Case # 3 Continued Lab: CXR: CBC: NL ABG: 7.19/72/36
Image: Aly H. Pediatrics in Review (2004)

25. Meconium Aspiration Syndrome (MAS)
Meconium staining of amniotic fluid complicates nearly 15% of all deliveries.
Fetal distress
Primarily term and post-term
Meconium can be aspirated before, during or after delivery.
Once aspirated, meconium causes
Chemical pneumonitis
Mechanical obstruction (“ball-valve”) with severe air-trapping
Pneumothoraces (10-20%)
Surfactant inactivation
Severe hypoxemia and hypoventilation
V/Q mismatch

26. Meconium Aspiration Syndrome: Clinical Presentation
Exam:
Air trapping with barrel chest
Moderate to severe respiratory distress
Rales and/or rhonchi
Hypoxia with cyanosis
Hypoperfusion
Lab:
Acidosis
Respiratory and metabolic
CXR:
Hyperinflation/overdistension
Diffuse, patchy intraparenchymal opacities

27. Meconium Aspiration Syndrome: Typical Course
Complications
Sepsis/pneumonia
Airleaks
Pneumothorax/pneumopericardium
Persistent pulmonary hypertension (PPHN)
Treated with inhaled Nitric Oxide (iNO)
ECMO
Resolution
Days to weeks
Mortality 10-12%
Prevention?
NRP
Treatment:
Oxygen
Mechanical ventilation
High-Frequency
Jet
Oscillator
Surfactant replacement

28. Case #4
3.9-kg male infant develops poor feeding, tachypnea and mild oxygen need at 14 hrs of life.
Exam: equal and clear breath sounds with tachypnea. Otherwise unremarkable.
Labs: WBC 4.3 x 103, ABG NL, electrolytes and glucose acceptable.
CXR:
indyrad.iupi.edu

29. Congenital Pneumonia: Clinical Presentation
Most common neonatal infection
Wide variety of presenting signs
Varying degree of respiratory distress
Lethargy, poor feeding
Apnea
Temperature instability
High or low
CXR: “Can look like anything!”
Mild focal opacities
Pleural effusion(s)
Complete white-out
Normal

30. Pneumonia: Epidemiology
Hematogenous vs. aspiration acquisition
Antenatal, perinatal, or postnatally acquired
Common organisms:
Antenatal: rubella, CMV, HSV, adenovirus, Toxoplasma gondii, Treponema pallidum, Mycobacterium tuberculosis, Listeria monocytogenes, Varicella zoster and others
Perinatal: GBS, E. coli, Klebsiella, Chlamydia trachomatis
Postnatal: adenovirus, RSV, Streptococcus, Staphylococcus, gram negative enterics

31. Congenital Pneumonia: Typical Course
Transient oxygen need
Gradual resolution of tachypnea
Antibiotic (ampicillin, gentamicin) therapy 5-7 days unless complicated by sepsis or for specific organism requiring longer courses of therapy

33. Other Pulmonary Causes of Respiratory Distress

34. Other Pulmonary Causes of Respiratory Distress
Congenital Diaphragmatic Hernia

35. Other Pulmonary Causes of Respiratory Distress
Esophageal atresia
Tracheoesophageal fistula

36. Other Pulmonary Causes of Respiratory Distress
Congenital Cystic Adenomatoid Malformation (CCAM)
Pulmonary sequestrations

37. Other Pulmonary Causes of Respiratory Distress
Pneumothorax
Neopix (pedialink.org)

38. Non-Pulmonary Causes of Respiratory Distress: Congenital Heart Disease

39. Congenital Heart Disease
Cyanotic
Transposition of the great arteries
Total anomalous pulmonary venous return
Tricuspid atresia
Tetralogy of Fallot
Truncus arteriosus
Pulmonary atresia
Severe CHF
Ebstein’s anomaly
Double outlet right ventricle
Acyanotic
Hypoplastic left heart syndrome
Interrupted aortic arch
Critical aortic stenosis
Patent ductus arteriosus
VSD/ASD
AV canal defect
Coarctation of the aorta*
Valvular defects
* May present as cyanotic or acyanotic

40. Congenital Heart Disease
CXR
Heart size/shape
Ebstein’s anomaly
Tetralogy of Fallot
CHF
Abnormal lung vascularity
Increased
Decreased
Echocardiogram
EKG
Presenting features
Murmur +/
Tachypnea
Cyanosis
Active precordium
Gallop rhythm
Hypoperfusion
Acidosis?
Weak pulses
Hepatomegaly

41. Differentiating CHD from Pulmonary Disease
Aly H. Pediatrics in Review (2004)

42. Management of the Newborn with Respiratory Distress

43. Initial Assessment: “ABCs”
Next:
Stabilize
Gather data
Generate DDx
Finally:
Consult?
Manage or Transfer
First:
Airway
Breathing
Circulation

44. Initial Assessment, continued
Identify life-threatening conditions that require prompt support
Inadequate or obstructed airway
Gasping
Choking
Stridor
Inadequate oxygenation
Cyanosis
Central vs. peripheral
Inadequate ventilation
Tachypnea
Grunting
Nasal flaring
Retractions
Inadequate perfusion
Pallor
Capillary refill

45. Prolonged maternal rupture of membranes? Maternal GBS status?
Clues from the History?
Prolonged maternal rupture of membranes?
Maternal GBS status?
Maternal fever?
Fetal distress?
Meconium?
Onset of respiratory distress?
Immediate?
Delayed?

46. Objective Data Physical exam findings: Breath sounds Stridor Severity
Laboratory data:
CBC w/ differential
Glucose
Blood gas
Blood culture
CXR
Hyperoxia test?

47. Management Supplemental oxygen: Blow by Head box Nasal cannula
Face mask
Monitoring
HR, RR
Pulse ox
How long?
2 hrs?
4 hrs?
Longer?
NPO

48. Hermansen CL, Lorah KN. American Family Physician. 2007.

49. Unclear risk factors or presentation?
Management
Infants with TTN and no sepsis risk factors likely just need support and observation.
Infants with possible meconium aspiration, RDS, sepsis or pneumonia require a sepsis evaluation with blood culture, cbc and IV antibiotics x 48hrs and repeat CXR(s).
Unclear risk factors or presentation?
Undertake sepsis evaluation

50. So when to transport?! It depends… Failure to resolve in 2-4 hrs
Worsening condition
Perfusion
Oxygen needs
Distress
Staff ability/comfort/availability
IV access
Airway
Any suspicion of cardiac disease

51. Respiratory distress is common! Most do well with little intervention.
Take-Home Points
Respiratory distress is common!
Most do well with little intervention.
Short differential dx
When to transport is up to you!
Every situation is unique
Help is just a phone call away!

52. How to Arrange Transport?
Neonatologist on-call (In-house 24/7)
St. Paul NICU:
(800)
(651)
Minneapolis NICU:
(800)
(612)
Transport team
Centralized Children’s Neonatal Transport Team in 2010
Air
Helicopter
Fixed-wing plane
Ground

53. References
Aly H. Respiratory disorders in the newborn: Identification and diagnosis. Pediatrics in Review 2004;25:
Guglani L, Lakshminrusimha S, Ryan RM. Transient tachypnea of the newborn. Pediatrics in Review 2008;29:e59-e65.
Hermansen CL, Lorah KN. Respiratory distress in the newborn. American Family Physician 2007;76:
Additional suggested reading:
Fidel-Rimon O, Shinwell ES. Respiratory distress in the term and near-term infant. NeoReviews 2005;6:e289-e296.
Suggested resources:
NRP Program, AAP/AHA
S.T.A.B.L.E. Program

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