Respiratory Distress Children neonate Case Scenarios newborn preterm term Tachypnea Subcostal, intercostal, sternal or suprasternal retractions Noisy respiration (grunt, stridor or wheeze) Nasal flaring Reduced air exchange cyanosis Downes' Score Silverman Anderson Retraction Score Fraction of inspired oxygen (FiO2) Surfactant Continuous Positive Airway Pressure (CPAP) High-flow nasal cannula oxygen (HFNC) Antenatal Corticosteroids Transient tachypnea of the newborn Respiratory distress syndrome Neonatal pneumonia Meconium aspiration syndrome Pneumothorax Congenital heart disease (VSD) CDH CHD TTNB HMD MAS PPHN

2. Contents
• Case Scenarios
• Introduction
• Clinical Presentation
• Pathophysiology
• Causes & Differential Diagnosis
• History & Physical Examination
• Investigations
• Management
• Summary of the Causes
• Summary

3. Case Scenario 1
• A 3.2-kg female infant is delivered by caesarean section at 38
weeks gestational age without a trial of labor.
• Her Apgar scores are 9 and 9 at 1 and 5 minutes, respectively.
• She develops tachypnea and subcostal retractions with nasal
flaring at 1 hour of life.
• Temperature is 36.6°C, pulse rate is 165 beats per minute, and
respiratory rate is 74 breaths per minute.
• Aside from increased work of breathing, her physical
examination findings are normal.
• The chest radiograph is shown in on the side
• She requires supplemental oxygen via nasal cannula with a
fraction of inspired oxygen (FiO2) of 0.3 for 36 hours.
• She then weans to room air. Her respiratory rate is 35 breaths
per minute, and she has no increased work of breathing.
Case

4. Case Scenario 2
• A 2.9-kg male infant is born by vaginal delivery at 39 weeks’
gestational age after rupture of membranes for 22 hours.
• Apgar scores are 8 and 8 at 1 and 5 minutes, respectively.
• He requires an FiO2 of 0.4 in the delivery room.
• He is tachypneic and has acrocyanosis.There are coarse
rales noted bilaterally.
• Temperature is 98.6°F (37°C), pulse is 144 beats per minute,
and respiratory rate is 65 breaths per minute.
• Despite being given CPAP, his grunting and tachypnea
worsen, and he requires intubation and ventilation for
progressive increased work of breathing, respiratory
acidosis, and oxygen requirement during the next 6 hours.
• The chest radiograph is shown on the side. Case

5. Case Scenario 3
• A 1.5-kg male is delivered via vaginal delivery because
of preterm labor at 33 weeks’ gestation.
• Apgar scores are 7 and 8 at 1 and 5 minutes,
respectively.
• The infant is cyanotic and requires CPAP immediately
after delivery.
• He has subcostal retractions, grunting, and nasal
flaring. Auscultation reveals decreased air entry in the
lung fields throughout.
• Temperature is 98.2°F (36.8°C), pulse is 175 beats per
minute, and respiratory rate is 70 breaths per minute.
• He requires an FiO2 of 0.4.
• His chest radiograph is shown on the side. Case

6. Introduction
• Respiratory distress refers to clinical presentations which are a non-specific
response to serious illness.
• Common emergency responsible for 30-40% of admissions in the neonatal
period.
• Affecting up to 7% of all term newborns.

7. Clinical presentation
One or more of the following ± Cyanosis :
• Tachypnea
• Subcostal, intercostal, sternal or suprasternal retractions
• Noisy respiration (grunt, stridor or wheeze)
• Nasal flaring
• Reduced air exchange
Age Respiratory Rate
Newborn 30-50
0-5 months 25-40
6 months – 5 years 20-30
6-10 years 15-30
11-14 years 12-20

8. Noisy Breathing Characteristics
Type Definition Causes
Stridor Typically high-pitched.
Musical, monophonic, audible breath sound.
Types:
1. Inspiratory (above the vocal cords)
2. Biphasic (at the glottis or subglottis)
3. Expiratory (lower trachea)
Laryngeal obstruction:-
Laryngomalacia, vocal cord paralysis, subglottic
stenosis, vascular ring, papillomatosis, foreign
body, croup.
Wheezing High-pitched
Whistling sound, polyphonic
Typically expiratory
Loudest in chest
Lower airway obstruction:-
MAS, bronchiolitis, pneumonia, asthma, GERD.
Grunting Low- or mid-pitched
Expiratory sound
Forced expiration against a partially closed
epiglottis.
Compensatory symptom for poor pulmonary
compliance:-
TTN, RDS, pneumonia, atelectasis, congenital
lung malformation or hypoplasia, pleural
effusion, pneumothorax.

9. *With right to left shunting through the ductus and foramen ovale.
Prolonged
distress
Hypoxaemia,
hypercarbia
and acidosis
Pulmonary
vasoconstriction
and persistence
of fetal
circulation*
↑↑↑ Hypoxaemia
Multi-system
organ
dysfunction
Pathophysiology Unique to Newborn

11. Causes in Older Children

12. History
• Onset of distress
• Gestational age
• Antenatal corticosteroids
• Predisposing factor: PROM, fever (Congenital pneumonia or sepsis)
• Meconium stained amniotic fluid (MAS)
• Fetal distress prior to delivery (Asphyxia)
• Distress decreases with crying (Choanal atresia)
• Poor feeding or frothing at the mouth (Tracheo-esophageal fistula or aspiration)

13. Physical Examination
• Severity of respiratory distress
• Neurological status
• Blood pressure
• Hepatomegaly
• Cyanosis
• Features of sepsis
• Malformations
• Plethoric look
• Choanal atresia
• Air entry
• Mediastinal shift
• Adventitious sounds
• Hyperinflation
• Heart sounds

14. Downes' Score
Score 0-3 = Mild respiratory distress
Score 4-6 = Moderate respiratory distress
Score >6 = Impending respiratory failure
Score Respiratory
rate
Cyanosis Air entry Grunt Retraction
0 <60/min None in room
air
Normal None Nil
1 60-80/min No cyanosis
with O2
support
Decreased Audible with
stethoscope
Mild
2 >80/min Cyanosis in
spite of O2
support
Barely audible Audible
without
stethoscope
Moderate to
severe

15. Silverman Anderson
Retraction Score
Score 0-3 = Mild respiratory distress
Score 4-6 = Moderate respiratory distress
Score >6 = Impending respiratory failure

16. Investigations
Test Rationale
Chest radiograph To determine reticular granular pattern of RDS; to determine presence of
pneumothorax, cardiomegaly, life-threatening congenital anomalies .
Arterial blood gas To determine severity of respiratory compromise, hypoxemia, and hypercapnia
and type of acidosis; the severity determines treatment strategy.
Complete blood count Hemoglobin/hematocrit to determine anemia and polycythemia
White blood cell count to determine neutropenia/ sepsis
Platelet count and smear to determine DIC
Blood culture To recover potential pathogen.
Blood glucose To determine presence of hypoglycemia, which may produce or occur
simultaneously with respiratory distress; to determine stress hyperglycemia.
Echocardiogram, ECG In the presence of a murmur, cardiomegaly, or refractory hypoxia; to determine
structural heart disease or PPHN.
C-reactive protein Has a negative predictive value in assessing for infection.
Pulse oximetry Detects hypoxia and assesses the degree of oxygen requirement.

17. Management
• Supportive
1. Airway, Breathing and Circulation are the first
line of management.
2. Warm, humidified Oxygen is given with a
FiO2 meter and pulse oximeter monitoring to
determine the amount of oxygen required to
prevent O2 toxicity.
3. Maintain Temperature
4. Fluid and electrolyte management (Electrolyte
balance, fluids, calcium and glucose
homeostasis).
5. Maintain adequate Haemoglobin (PCV above
40% ).
6. All preterm babies with respiratory distress
should be started on Broad Spectrum
Antibiotics depending on the clinical situation.
Guidelines for monitoring oxygen saturation
levels by pulse oximetry
>95% Term baby, pulmonary
hypertension (PPHN)
88-94% 28-34 weeks preterm
85-92% Below 28 weeks gestational age
Fraction of inspired oxygen (FiO2):
Percentage of oxygen participating in gas-
exchange.
Natural air includes 21% oxygen, which is
equivalent to FiO2 of 0.21.

18. Role of Surfactant
• Surfactant is the drug of choice in a baby with HMD.
• It lubricates the lungs, allowing the air sacs to slide
against one another without sticking when the infant
breathes by equalizing the pressure to the alveoli.
• This may be given after the baby has been stabilized
either as:
1. Prophylaxis if the baby is less than 28 weeks of
gestation.
2. Rescue therapy within the first two hours of onset of
severe symptoms in older babies.
• Surfactant is given in a dose of 100 mg/kg through the
endotracheal tube in small aliquots with intermittent
bagging and it should be followed by ventilatory support.
• Complications: Bradycardia, oxygen desaturation, air
leaks, intraventricular hemorrhage (IVH), and
periventricular leukomalacia.

19. Respiratory Support
• Continuous Positive Airway Pressure (CPAP): Given
when the baby continues to breathe spontaneously
but with difficulty.
• Either by using:
a) Short nasal prong
b) Nasopharyngeal prong
c) Endotracheal prong : preferred as others markedly
increases the work of breathing and tires the infant.
• CPAP should be started early in a preterm with HMD.
• Indications:
1. Term baby with Downes’ or Silvermann score of >6
at birth.
2. Preterm baby with Downes’ or Silvermann score of
>3 at birth.

20. Continuous Positive Airway Pressure (CPAP)

21. • High-flow nasal cannula oxygen (HFNC)
• It delivers warm humidified oxygen at high
flow rates (between 15 and 60 L/min)
through a small nasal interface.
• Humidification at high flow rates contributes
to remarkably good tolerance.
• Because HFNC oxygen therapy is both
relatively simple to apply and comfortable,
its use has become almost routine without
necessarily being subjected to careful clinical
evaluation.
• The broad indication for HFNC oxygen
therapy is acute hypoxemic respiratory
failure.
Respiratory Support

22. Antenatal Corticosteroids
• Antenatal Corticosteroids are primarily used to speed up lung development in
preterm fetuses.
• It stimulates the synthesis and release of surfactant.
• Decreases the incidence of HMD by 50%.
• It is given between 24-34 weeks of gestation for patients.
• Indications: Preterm premature rupture of membranes (PPROM), Symptomatic preterm
contractions, Hypertensive disorders of pregnancy and other causes.
• Dosage:
Betamethasone 12mg IM every 24 hours X 2 dose.
Or Dexamethasone 6 mg IM every 12 hours X 4 doses. (more likely to cause periventricular
leukomalacia than Betamethasone).
• Multiple doses are not beneficial.

23. Management
Supportive
Supportive and Maintain
temperature and
Surfactant
Supportive and
Oropharyngeal and
Endotracheal suction
Supportive and Antibiotics
for bacterial causes
Supportive and Needle
aspiration and Chest tube
Ventilatory support and
maintain temperature
Supportive and Surgery
Supportive

24. Transient tachypnea of
the newborn
Respiratory distress
syndrome
Neonatal pneumonia
Meconium aspiration
syndrome
Pneumothorax Congenital heart disease
(VSD)

27. References
• NelsonTextbook of Pediatrics 20th edition
• Nelson Essentials of Pediatrics 16th edition
• Oxford Handbook of Paediatrics 2nd edition
• Www.reference.medscape.com
• Www.ncbi.nlm.nih.gov
• Www.aafp.org
• Www.pediatrics.aappublications.org
• Www.abclawcenters.com
• Www.radiopaedia.org
• Www.obgyn.onlinelibrary.wiley.com
• Www.en.wikipedia.org