PRESENTATIONRespiratory distress occurs in approximately 7percent of infants, and preparation is crucial forphysicians providing neonatal care.Kumar A, Bhat BV. Epidemiology of respiratorydistress of newborns. Indian J Pediatr. 1996;63:93–8.
The constellation of signs and symptoms can be theresult of pulmonary, cardiac, metabolic, infectious,renal, gastroenterological and neurologic pathologicprocesses. The circumstances of the newborns birth provideimportant clues to the diagnosis
Clinical presentation of respiratorydistress in the newborn includes;cyanosis,grunting, inspiratory stridor,nasal flaring, poor feeding,tachypnea (more than60 breaths per minute),Lethargy.retractions in the:intercostal, subcostal, orsupracostal spaces.
TRANSIENT TACHYPNEA OF THENEWBORNThe most common cause of neonatal respiratorydistress, constituting more than 40 percent of casesInfants are usually full term or slightly preterm. They are not at risk for other illnesses.Kumar A, Bhat BV. Epidemiology of respiratory distressof newborns. Indian J Pediatr. 1996;63:93–8.
A benign condition, it occurs when residualpulmonary fluid remains in fetal lung tissue afterdelivery.Prostaglandins released after delivery dilatelymphatic vessels to remove lung fluid as pulmonarycirculation increases with the first breath.
Fluid persistence may occur despite this mechanism,therefore rendering the new life to TTN.RISK FACTORS: maternal asthma,male sex, macrosomia,maternal diabetes,cesarean delivery.
CLINICAL PICTUREMost significant discriminatory findings are the onsetof the illness and the degree of distress exhibited bythe infant.Tachypnea immediately after birth or within twohoursSymptoms can last from a few hours to two days
Infants are neurologicallynormal.Chest radiography showsdiffuse parenchymalinfiltrates, a “wetsilhouette” around theheart, or intralobar fluidaccumulation.There should be no areasof consolidation.
TREATMENTIt is supportive with close observation because thecondition is usually self limited.Low flow supplemental oxygen may be necessary forseveral hours.Oral furosemide (Lasix) has not been shown tosignificantly improve status and should not be givenLewis V, Whitelaw A. Furosemide for transient tachypnea ofthe newborn. Cochrane Database Syst Rev. 2002;(1):CD003064.
Data suggest that prenatal administration of corticosteroids 48 hoursbefore elective cesarean delivery at 37 to 39 weeks gestation reducesthe incidence of transient tachypnea of the newborn; however, thishas not become common practice.Stutchfield P, Whitaker R, Russel I, for the Antenatal Steroids for TermElective Cesarean Section (ASTECS) Research Team. Antenatalbetamethasone and incidence of neonatal respiratory distress afterelective cesarean section: pragmatic randomized trial. BMJ.2005;331:662–4.
RESPIRATORY DISTRESSSYNDROME AKA HYALINEMEMBRANE DISEASE The most common cause of respiratory distress inpremature infants.It correlates well with structural and functional lungimmaturity.Occurs in 24 000 infants in the US annually.
RDS is most common in infants born at fewer than 28weeks gestation.It affects one third of infants born at 28 to 34 weeksgestation,But occurs in less than 5 percent of those born after34 weeks gestation.
Condition is more common in boys.The incidence is approximately six times in infantswhose mothers have diabetes because of delayedpulmonary maturity despite macrosomia.
PATHOPHYSIOLOGYImmature type II alveolar cells produce lesssurfactant, causing an increase in alveolar surfacetension and a decrease in compliance.Resultant atelectasis causes pulmonary vascularconstriction, hypoperfusion, and lung tissueischemia.Hyaline membranes form through the combination ofsloughed epithelium, protein, and edema.
CLASSIC FINDINGSCyanosis,Grunting,Nasal flaring,Intercostal and subcostal retractions Tachypnea
CHESTRADIOGRAPHFINDINGShomogenous opaque infiltratesand air bronchograms.airless lung tissue seen againstair-filled bronchi.decreased lung volumes also canbe detected.Kurl S, Heinonen KM, Kiekara O.The first chest radiograph inneonates exhibiting respiratorydistress at birth. Clin Pediatr(Phila). 1997:285–9.
TREATMENTRequires intervention mentioned in TTN.In addition;prenatal administration of corticosteroids between 24and 34 weeks gestation reduces the risk of respiratorydistress syndrome when the risk of preterm delivery ishigh.
Postnatal corticosteroid administration for respiratorydistress syndrome may decrease mortality risk, but itmay increase the risk of cerebral palsy.Inhaled nitric oxide may alleviate concomitantpersistent pulmonary hypertension of the newborn,but its use in preterm infants is experimental.
MECONIUM ASPIRATIONSYNDROMEMeconium-stained amniotic fluid occurs inapproximately 15 percent of deliveries.It causes meconium aspiration syndrome in the infantin 10 to 15 percent of those cases, typically in term andpost-term infants.
Meconium is composed of desquamated cells,secretions, lanugo, water, bile pigments, pancreaticenzymes, and amniotic fluid.It is sterile although when aspirated, is locallyirritative, obstructive, and a medium for bacterialculture.Meconium passage may represent hypoxia or fetaldistress in utero.
CLINICAL PRESENTATIONSymptoms similar to infants with TTN, but thepresentation may suggest a more severe condition.Infants have greater degrees of tachypnea, retractionand lethargy immediately after delivery.Some infants will have an asymptomatic period ofseveral hours before respiratory distress becomeapparent.
Arterial Blood Gases will reveal more acidosis,hypercapnia and hypoxemia than in infants with TTN. Hypoxia occurs because aspiration takes place inutero
TREATMENTGeneral treatment practices are often used for meconiumaspiration syndrome.Standard prevention and treatment for meconium aspirationsyndrome previously included suctioning the mouth and naresupon head delivery before body delivery. However, recent evidence suggests that aspiration occurs inutero, not at delivery; therefore, infant delivery should not beimpeded for suctioning.
After full delivery, the infant should be handed to aneonatal team for evaluation and treatment.Although infants previously have been given intubationand airway suctioning, current evidence favors expectantmanagement unless certain criteria (i.e., spontaneousrespiration, heart rate greater than 100 beats per minute,and reasonable tone) are absent.
MANAGEMENT OF DELIVERIESWITH MECONIUM-STAINEDAMNIOTIC FLUID