Neonatal respiratory distress and respiratory distress syndrome
Respiratory distress is a clinical syndrome of tachypnoea, grunting, nasal flaring, retractions, cyanosis or oxygen requirement. Respiratory distress syndrome (RDS) is primarily surfactant deficiency in preterm lungs, but a distressed newborn may also have transient tachypnoea, pneumonia/sepsis, meconium aspiration, pneumothorax, pulmonary hypertension, congenital heart disease, airway obstruction or metabolic disease.
Stabilise airway, breathing, oxygenation and temperature first; diagnose the cause in parallel.
Recognition and severity
- Count respirations for a full minute when calm; note grunting, nasal flaring, chest indrawing, apnoea, cyanosis and fatigue.
- Check heart rate, perfusion, temperature, glucose and oxygen saturation with a good waveform.
- Assess feeding: tachypnoea, choking or exhaustion may require temporary tube/IV support.
- Use an objective respiratory score where available, but follow the clinical trajectory rather than a number alone.
Differential diagnosis
| Condition | Clues | Priority action |
|---|---|---|
| RDS | Preterm, early onset, grunting, diffuse reticulogranular pattern | CPAP, oxygen titration, surfactant pathway |
| Transient tachypnoea | Term/late preterm, caesarean, early tachypnoea, improves within hours | Support, exclude sepsis/heart disease |
| Pneumonia/sepsis | Risk factors, temperature instability, poor feeding, diffuse signs | Cultures when feasible and prompt antibiotics |
| Meconium aspiration | Meconium-stained fluid, hypoxia, coarse breath sounds | Respiratory support, pulmonary hypertension assessment |
| Pneumothorax | Sudden deterioration, asymmetry, shock, reduced air entry | Urgent decompression if tension physiology |
| PPHN/heart disease | Disproportionate cyanosis, pre/postductal difference, murmur | Oxygen, echo/referral and specialist management |
Initial stabilisation
- Warm, position airway and provide gentle stimulation.
- Use pulse oximetry, target oxygen according to gestational age and current protocol, and avoid hyperoxia.
- For spontaneous breathing with distress, commence nasal CPAP if available and appropriate; ensure a skilled team and backup ventilation.
- If apnoea, gasping or inadequate effort, provide positive-pressure ventilation and escalate to intubation if ineffective.
- Check glucose, blood gas, perfusion and temperature; treat hypoglycaemia and shock.
Investigations
- Blood gas for ventilation, oxygenation, pH and lactate when moderate/severe distress.
- Chest radiograph for uncertain diagnosis, severe disease, suspected pneumothorax, tube position or persistent oxygen need.
- Full blood count, blood culture and inflammatory assessment when sepsis is possible; do not withhold antibiotics in an unstable high-risk infant.
- Glucose, electrolytes, calcium and haemoglobin according to severity.
- Echocardiography when cyanosis is disproportionate, oxygen response is poor, PPHN/heart disease is suspected or there is persistent pulmonary hypertension.
RDS management
Non-invasive support
Early CPAP maintains functional residual capacity and reduces atelectasis. Use appropriately sized prongs/mask, humidification, gastric decompression when needed and frequent checks for leaks, nasal injury and worsening fatigue.
Surfactant
Give surfactant early to eligible preterm infants with worsening RDS or escalating oxygen/pressure requirements using the local INSURE/LISA or intubation protocol. Confirm airway expertise, dosing and monitoring; avoid delaying for a radiograph when clinical criteria are met.
Mechanical ventilation
Use lung-protective ventilation for failure of non-invasive support, recurrent apnoea, severe acidosis or exhaustion. Monitor gases, pressures, oxygen requirement and ventilator-associated injury; wean as the lung improves.
Supportive care
Thermoregulation, minimal handling, caffeine when indicated for prematurity/apnoea, safe nutrition, infection prevention, pain control and fluid/electrolyte monitoring are essential.
Complications and reassessment
- Air-leak syndrome, pulmonary haemorrhage, PPHN, sepsis, atelectasis and ventilator-associated injury.
- Monitor work of breathing, oxygen requirement, blood gases, perfusion, urine output, abdominal distension and feeding tolerance.
- Sudden deterioration requires immediate check of airway, tube/circuit, pneumothorax, sepsis, hypoglycaemia and haemodynamic status.
- Discharge requires stable temperature, feeding, oxygenation, no significant apnoea and a follow-up plan.
References
- SlideShare: Respiratory distress syndrome.
- WHO recommendations on care of preterm/low-birth-weight infants and newborn respiratory support.
- Current neonatal respiratory-support and surfactant protocols.
