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

3. 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.

4. Normal Newborn Respiratory Distress
Differential Diagnosis

5. Horses
Respiratory Distress Syndrome
Meconium Aspiration
Pneumonia

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

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

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

9. Combined Bronchopulmonary and Vascular
Hypogenetic lung syndrome
Bronchopulmonary sequestration

10. Horses

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

12. Premature infant with distress in the first few hours of life
Premature infant with distress in the first few hours of life. Progressive over 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.

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

14. 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.

15. 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

16. 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.

17. 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.

18. 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).

19. 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.

20. Management

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

22. 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

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

24. Case