Newborn Respiratory Distress

 


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Am Fam Physician. 2015 Dec 1;92(11):994-1002.

Author disclosure: No relevant financial affiliations.

Newborn respiratory distress presents a diagnostic and management challenge. Newborns with respiratory distress commonly exhibit tachypnea with a respiratory rate of more than 60 respirations per minute. They may present with grunting, retractions, nasal flaring, and cyanosis. Common causes include transient tachypnea of the newborn, respiratory distress syndrome, meconium aspiration syndrome, pneumonia, sepsis, pneumothorax, persistent pulmonary hypertension of the newborn, and delayed transition. Congenital heart defects, airway malformations, and inborn errors of metabolism are less common etiologies. Clinicians should be familiar with updated neonatal resuscitation guidelines. Initial evaluation includes a detailed history and physical examination. The clinician should monitor vital signs and measure oxygen saturation with pulse oximetry, and blood gas measurement may be considered. Chest radiography is helpful in the diagnosis. Blood cultures, serial complete blood counts, and C-reactive protein measurement are useful for the evaluation of sepsis. Most neonates with respiratory distress can be treated with respiratory support and noninvasive methods. Oxygen can be provided via bag/mask, nasal cannula, oxygen hood, and nasal continuous positive airway pressure. Ventilator support may be used in more severe cases. Surfactant is increasingly used for respiratory distress syndrome. Using the INSURE technique, the newborn is intubated, given surfactant, and quickly extubated to nasal continuous positive airway pressure. Newborns should be screened for critical congenital heart defects via pulse oximetry after 24 hours but before hospital discharge. Neonatology consultation is recommended if the illness exceeds the clinician's expertise and comfort level or when the diagnosis is unclear in a critically ill newborn.

Newborn respiratory distress occurs in about 7% of deliveries.1 Respiratory distress syndrome, which occurs primarily in premature infants, affects about 1% of newborns, resulting in about 860 deaths per year.2 With increased survival of preterm and late preterm infants, management of respiratory distress in newborns has become challenging.3,4 Because early recognition improves the care of these newborns, clinicians must be familiar with its diagnosis and treatment.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Noninvasive ventilation, commonly using nasal continuous positive airway pressure, may replace invasive intubation because of improved clinical and financial outcomes.

B

15

Randomized controlled trial

The minimum required amount of surfactant is 100 mg per kg. Initial administration of 200 mg per kg can result in significant improvement in oxygenation and decreased need to retreat.

B

17, 18

Randomized controlled trials

The INSURE (intubate, administer surfactant, extubate to nasal continuous positive airway pressure) strategy should be used to reduce mechanical ventilation, air leak syndromes, and progression to bronchopulmonary dysplasia.

B

19

Cochrane review

Antenatal corticosteroids given between 24 and 34 weeks' gestation decrease respiratory distress syndrome risk with a number needed to treat of 11.

C

6

Consensus guidelines

The U.S. Department of Health and Human Services recommends screening newborns for critical congenital heart defects using pulse oximetry before hospital discharge, but at least 24 hours after birth.

C

53

Prospective study


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Noninvasive ventilation, commonly using nasal continuous positive airway pressure, may replace invasive intubation because of improved clinical and financial outcomes.

B

15

Randomized controlled trial

The minimum required amount of surfactant is 100 mg per kg. Initial administration of 200 mg per kg can result in significant improvement in oxygenation and decreased need to retreat.

B

17, 18

Randomized controlled trials

The INSURE (intubate, administer surfactant, extubate to nasal continuous positive airway pressure) strategy should be used to reduce mechanical ventilation, air leak syndromes, and progression to bronchopulmonary dysplasia.

B

19

Cochrane review

Antenatal corticosteroids given between 24 and 34 weeks' gestation decrease respiratory distress syndrome risk with a number needed to treat of 11.

C

6

Consensus guidelines

The U.S. Department of Health and Human Services recommends screening newborns for critical congenital heart defects using pulse oximetry before hospital discharge, but at least 24 hours after birth.

C

53

Prospective study


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient

The Authors

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CHRISTIAN L. HERMANSEN, MD, MBA, is senior physician leader of Lancaster (Penn.) General Health, medical director of Downtown Family Medicine in Lancaster, and associate director of the Lancaster General Hospital Family Medicine Residency Program....

ANAND MAHAJAN, MD, is a neonatologist at Lancaster General Health's Women and Babies Hospital.

Author disclosure: No relevant financial affiliations.

Address correspondence to Christian L. Hermansen, MD, MBA, Lancaster General Hospital, 555 North Duke St., Lancaster, PA 17602 (e-mail: clherman@lghealth.org). Reprints not available from the authors.

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