Respiratory Distress in the Newborn Erica Barrows-Nees, MS4 Respiratory Distress in the Newborn

Case A term 2900 gram baby is immediately noted to be in moderate respiratory distress with tachypnea and worsening cyanosis. Pulse oximeter measures 82%. On prenatal US, there was some suggestion of a mass in the left chest but this was attributed to artifact. Otherwise normal prenatal course.

Normal Newborn Respiratory Distress Differential Diagnosis

Horses Respiratory Distress Syndrome Meconium Aspiration Pneumonia

Zebras Spontaneous pneumothorax Persistent pulmonary hypertension Developmental Anomalies: Bronchopulmonary, Vascular, Cardiac, GI.

Bronchopulmonary Agenesis (Diaphragmatic Hernia Congenital Bronchial Atresia Congenital Lobar Emphysema CPAM Bronchogenic Cyst Tracheal bronchus Tracheal diverticulum Accessory cardiac bronchus

Vascular Proximal interruption of central pulmonary artery Anomalous origin of left pulmonary artery Anomalous pulmonary venous drainage Pulmonary AV malformations Cystic hygroma

Combined Bronchopulmonary and Vascular Hypogenetic lung syndrome Bronchopulmonary sequestration

Horses

Transient Tachypnea of the Newborn Chest X-ray: parenchymal infiltrates, “wet silhouette” around the heart, or intralobular fluid collection.

Premature infant with distress in the first few hours of life Premature infant with distress in the first few hours of life. Progressive over 48-72 hours, subsequently improves. Recovery accompanied by diuresis. Pathophysiology : decreased surfactant in immature lung tissue Pulmonary vascular constriction, hypoperfusion, lung tissue ischemia. If persistent, causes bronchopulmonary dysplasia.

Respiratory Distress Syndrome Chest X-Ray: Reticulogranular pattern, homogenous opaque infiltrates and air bronchograms. Treatment: corticosteroids between 24-34 weeks gestation if premature delivery risk is high.

Meconium Aspiration Meconium staining in 15% of deliveries, aspiration in 10-15% of those cases.   Usually represents hypoxia in utero Treatment: No role for Amnioinfusion. Suction by resuscitation protocol.

Meconium Aspiration Imaging Initial chest film: streaky, linear densities With disease progression, lungs appear hyperinflated with flattening of the diaphragms; alternating patchy densities and expanded areas. Severe disease homogeneous lung density similar to respiratory distress syndrome. Air leak in 10 to 30 percent of cases

Persistent Pulmonary Hypertension Term or post-term infant with severe hypoxemia (PaO2 <35-45mmHg on 100%) disproportionate to radiologic changes. Secondary to pneumonia/sepsis, hyperviscosity/polycythemia, interstitial pulmonary disease (meconium aspiration/pneumonia,) TTN, pulmonary hypoplasia (renal agenesis, diaphragmatic hernia,) SSRI use in the third trimester.

Term infant with distress and temperature instability at day 3 of life Term infant with distress and temperature instability at day 3 of life. OB history of prolonged rupture of membranes. Chest x-ray: Bilateral infiltrates, pleural effusion. Labs: Shock, poor perfusion, and absolute neutropenia (< 2000/mL) provide corroborating evidence for pneumonia.

Pneumonia Any gestational age Risk factors: prolonged rupture of the membranes, prematurity, maternal fever Presents later CXR: pleural effusions in 2/3 of cases Vaginal or rectal flora the most likely infectious agents (group B streptococci, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Klebsiella).

Spontaneous Pneumothorax Seen in 1-2% of normal newborns Associated with underlying diseases (RDS, meconium aspiration, pneumonia.) Renal ultrasound also indicated if pulmonary hypoplasia suspected.

Management

Resuscitation Assessment: Meconium? Activity? Warmth Oxygenation: blowby, NC, intubation

Management Options to Consider Surfactant Antibiotics if clinical suspicion (leukocytosis, neutropenia, hypoxemia) ECMO as a last resort Withhold oral feeds for RR > 80 breaths per minute

Case “mass in the chest” Congenital diaphragmatic hernia, Congenital cystic adenomatoid malformation (CCAM,)Pulmonary sequestration—Intralobar or Extralobar, Congenital Lobar Emphysema, Bronchogenic Cyst

Case