Respiratory Distress in the Newborn

Description

Diagnostic criteria

General and supportive measures

Medicine treatment

Referral

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ICD-10 code: P22.9

DESCRIPTION

Newborn experiencing difficulty with breathing.

Causes of respiratory distress include:

Pulmonary causes	Extrapulmonary causes
- respiratory distress syndrome (surfactant deficiency), - meconium aspiration, - pneumonia, - pneumothorax, - transient tachypnoea of newborn - pulmonary haemorrhage, - pulmonary hypertension, - hypoplastic lungs, and - diaphragmatic hernia.	- sepsis, - cardiac failure irrespective of cause, - hypothermia/hyperthermia, - hypoglycaemia, - anaemia, - polycythaemia, - hypovolaemic shock, and - perinatal hypoxia.

Respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS) congenital pneumonia and transient tachypnoea of the newborn (TTN) are the most common causes of respiratory distress in newborns. 

DIAGNOSTIC CRITERIA

Clinical

• Pulmonary and/or extrapulmonary disorders presenting with two or more of the following signs in a newborn baby:
  • tachypnoea (≥ 60 breaths/minute),
  • expiratory grunting,
  • intercostal and sternal retractions (recession), and
  • central cyanosis while breathing room air.

Investigations

• Chest X-ray to determine the underlying pathology.
• Echocardiography, if available, to exclude cardiac causes of respiratory distress.
• Haematocrit, blood glucose and temperature.

GENERAL AND SUPPORTIVE MEASURES

• Identify and treat the underlying cause, e.g. Chest tube and underwater drainage of a pneumothorax.
• Admit to a neonatal high care/intensive care facility, if available.
• Handle the neonate as little as possible.
• Nurse a non-intubated infant in the prone position.
• Keep in a neutral thermal environment (incubator or infant crib with overhead heater). Keep the room temperature at 26–28°C, and anterior abdominal wall skin temperature at 36.5–37.5°C
• Monitor:
  • blood pressure,
  • respiratory rate,
  • peripheral perfusion,
  • heart/pulse rate,
  • haematocrit,
  • acid-base status,
  • blood glucose,
  • body temperature,
  • blood gases,
  • SaO₂,
  • minerals and electrolytes,
  • fluid balance.
• Nutrition:
  • Provide adequate IV dextrose to maintain blood glucose ≥ 2.6 mmol/L.
  • Commence oro/nasogastric feeding as soon as possible after birth.
  • If enteral feeding is not possible 24 hours after birth, start IV hyperalimentation.
• Ventilation (non-invasive or invasive) is needed if:
  • An oxygen saturation of at least 90% or PaO₂ of at least 60mmHg (8 kPA) cannot be maintained with an inspiratory oxygen concentration of ≥ 60% with or without nasal CPAP;
  • The PaCO₂ rises to > 55 mmHg (7.5 kPa) with uncompensated respiratory acidosis (pH ≤ 7.20), irrespective of oxygen saturation or PaO₂.
    
    (1 kPa = 7.5 mmHg; 1 mmHg x 0.133 = 1  kPa)

MEDICINE TREATMENT

To eliminate central cyanosis and to maintain oxygen saturation of haemoglobin 90–95%:

• Oxygen, warmed and humidified via nasal cannula.
  • If a pulse oximeter or facility for blood gas analysis is available, oxygen, humidified via nasal cannula to maintain oxygen tension in the blood at 60– 80 mmHg.
  • If a pulse oximeter or facility for blood gas analysis is not available, regulate the inspired oxygen concentration in such a way that the least amount of oxygen that will prevent central cyanosis is used.
  • Keep PaO₂ at 60–80 mmHg (8 - 10.5 kPa) and PaCO₂ at 35–45 mmHg (4.5 – 5.5 kPa) (arterial blood gas analysis).

Nasal CPAP is needed if the neonate has a good respiratory drive with a PCO₂ of ≤ 55 mmHg but unable to maintain a SaO₂ of 90–95% on an inspiratory oxygen concentration of ≥ 60% (FiO₂) and pneumothorax has been excluded.

Administer nasal CPAP at 4–6 cmH2O and monitor SaO₂, blood gas and acid-base status.

OR

• Oxygen/air mixture, high-flow, warmed and humidified via nasal prongs. (Under specialist supervision.)
  • Do not exceed 6 L/minute. The flow/minute (L/min) approximates the pressure generated in cm of water.

Stabilise circulation and blood pressure

• Neonatal maintenance solution, IV infusion, 60–80 mL/kg/24 hours (day 1 of life) and adapt to daily maintenance requirements.

AND/OR

• Sodium chloride 0.9%, 10–20 mL/kg over 1–2 hours.
  • For preterm infants restrict to 10 mL/kg.

AND/OR

• Fresh frozen plasma, 10–20 mL/kg over 1–2 hours.

OR

• Lyophilised plasma, 10–20 mL/kg over 1–2 hours.

Inotropic support

• Dopamine, IV, 5–15 μg/kg/minute, continued until blood pressure has stabilised.
  • Response to inotropic support will be unsatisfactory if the circulating blood volume is not corrected.

Anaemia

Click on the image to enlarge

• If anaemia is present according to thresholds in figure 1 above: Packed red cells, IV, 10–15 mL/kg over 3-4 hours in haemodynamically stable patients. More rapid transfusions may be appropriate in bleeding and haemodynamically unstable patients.

Metabolic acidosis

If pH ≤ 7.0 and the metabolic acidosis does not respond to normalisation of PaO₂, PaCO₂, blood pressure, volume expansion (hydration) and correction of anaemia:

• Sodium bicarbonate, 4.2%, IV, administered slowly.
  • 1 mmol = 2 mL
  • HCO₃ needed (mmol) = base excess x 0.3 x body mass (kg).
  • (½ correct base deficit initially.)

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CAUTION
Do not administer Ca⁺⁺ containing infusions with sodium bicarbonate solution.

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Respiratory distress syndrome (Surfactant deficiency)

In consultation with a paediatrician.

If surfactant deficiency is suspected or present, provide respiratory support.

• Mild surfactant deficiency: nasal CPAP 4–6 cmH2O.
• Moderate surfactant deficiency: ‘in-out’ surfactant followed by nasal CPAP 4– 6 cmH2O. Intubate infant and administer surfactant via naso- or orotracheal tube. Ventilate for a few minutes with a T-Piece resuscitation device or resuscitation bag with a CPAP generating device. Extubate baby and put on nasal CPAP 4– 6 cmH2O. Babies may be put on nasal CPAP directly after ‘in-out’ surfactant administration, omitting the ventilation step following ‘in-out’ surfactant.
• The LISA (Less Invasive Surfactant Administration) method may be used if the doctor is competent in the procedure. Baby is intubated with a size 8 feeding tube whilst on CPAP. The surfactant is administered through the feeding tube slowly over 5 minutes.
• Severe surfactant deficiency: intubate baby and ventilate with a ventilator. Administer surfactant via the naso- or orotracheal tube. If a ventilator is not available, then ‘in-out’ surfactant followed by nasal CPAP can be used.

Short term intubation ('In-out' endotracheal surfactant administration)

• Nasal CPAP as required.
• If inadequate oxygenation on nasal CPAP, pre-oxygenate with bag-mask or Tpiece ventilation to maintain preductal saturation between 90–95%.
• Intubate orally, give surfactant and follow with gentle manual ventilation or CPAP, as required, for 5 minutes:
  • Surfactant, 100 mg/kg.
• Extubate and recommence nasal CPAP.

Infection

• If infection, e.g. bronchopneumonia, is present or suspected, give antibiotics after blood cultures have been taken.
• Consider the antibiotic sensitivity profile of micro-organisms in a particular hospital when prescribing antibiotics.
• Aminoglycoside, e.g.:
  • Gentamicin, IV, for 5–7 days in the first week of life.
    • If < 32 weeks gestation of age: 5 mg/kg/36 hours.
    • ≥ 32 weeks gestation of age: 5 mg/kg/24 hours.
    • After first week, 5 mg/kg/24 hours for all gestations.

PLUS

• Ampicillin, IV, for 5–7 days.

Gestational Age	Postnatal Age	Dose
≤ 34 weeks	≤ 7 days	50 mg/kg/dose every 12 hours
	8 to 28 days	75 mg/kg/dose every 12 hours
>34 weeks	≤ 28 days	50mg/kg/dose every 8 hours

Review after 48 hours. If infection is confirmed, or very strongly suspected, continue for 5–7 days.

Where available, gentamicin doses should be adjusted on the basis of therapeutic drug levels.

• Trough levels (taken immediately prior to next dose), target plasma level < 1 mg/L.
• Peak levels (measured 1 hour after commencement of IV infusion or IM/IV bolus dose), target plasma level > 8 mg/L.

REFERRAL

• No improvement or deterioration despite adequate treatment.
• Development of respiratory failure and need for ventilatory support.

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter  19: Prematurity And Neonatal Conditions, 19.2 Newborn, 19.2.2 Respiratory Distress In The Newborn