Home / Respiratory / Approach to Respiratory Distress
RESPIRATORY · FOUNDATIONS
The commonest reason a newborn needs SCN. A structured way to recognise respiratory distress, stabilise the baby, and work through the differential - lungs, heart, sepsis or surgical.
RECOGNISE IT
Respiratory distress is increased work of breathing, usually with tachypnoea and often an oxygen requirement. The signs are the same whatever the cause - spot them early.
Respiratory rate >60/min - the earliest and most sensitive sign.
Expiration against a partly closed glottis to generate the baby's own PEEP. Always take it seriously.
Intercostal, subcostal and sternal recession, nasal flaring and head bobbing - the visible effort of breathing.
Central cyanosis or a low SpO₂, often needing oxygen. Watch the baby who was working hard and goes quiet - that can be tiring, not improving.
FIRST MOVES
You do not need the diagnosis to start. Support the baby, cover the dangerous causes, and escalate early.
Position the airway, give oxygen to the target SpO₂, and start CPAP early if the work of breathing or oxygen needs are climbing.
Target SpO₂ ~91-95% and avoid hyperoxia (ROP, oxidative injury). Little improvement on oxygen points away from lung disease.
Early-onset sepsis is indistinguishable from RDS or TTN. Take a sepsis screen and start antibiotics if the baby is unwell or has risk factors.
Keep warm, check the glucose, gain IV access, minimal handling - and call for senior help or NETS early.
THE DIFFERENTIAL
Most respiratory distress is lung disease - but always ask whether it could be heart, sepsis or surgical. Timing, gestation and the CXR do most of the work.
| Cause | Typical baby | Onset | Key clue | CXR |
|---|---|---|---|---|
| TTN | Term / late-preterm, elective LSCS | First 1-2h | Mild, self-limiting; settles 24-72h | Wet lung: streaky, fluid in the fissure |
| RDS | Preterm | Minutes to hours | Worsens over hours; surfactant deficiency | Ground-glass, air bronchograms, low volumes |
| MAS | Term / post-term, meconium liquor | From birth | Meconium-stained, often needs resus; PPHN risk | Patchy, hyperinflation |
| Pneumonia / sepsis | Any; PROM, GBS, maternal fever | Any, often early | Looks septic; mimics RDS exactly | Variable; may look like RDS |
| Pneumothorax | Any; ventilated or MAS | Sudden | Sudden deterioration, asymmetric chest | Lucency, collapsed lung ± shift |
| PPHN | Term / post-term | First 24h | Labile, differential cyanosis; poorly O₂-responsive | Clear, or the underlying lung disease |
| Cardiac (duct-dependent, TGA) | Term | Hours to days | Cyanosis out of proportion; failed hyperoxia test | Often normal, or "egg on a string" |
| CDH / surgical | Term, often antenatal dx | From birth | Scaphoid abdomen, shifted heart sounds; do not bag-mask | Bowel in the chest, mediastinal shift |
AT THE BEDSIDE
A few bedside findings narrow things down quickly.
Preterm and worsening = RDS. Term and settling = TTN. Meconium from birth = MAS. A sudden change = pneumothorax.
A gap (pre-ductal higher than post-ductal by >3%) points to a duct-level shunt - think PPHN or a left-heart obstruction.
100% oxygen for ~10 min: PaO₂ rises well = lung disease; it stays low = cyanotic heart disease or severe PPHN. The cornerstone of lung vs heart.
The most useful single test: wet lung (TTN), ground-glass (RDS), patchy (MAS / pneumonia), lucency (pneumothorax), bowel in the chest (CDH).
DO NOT MISS
These are the ones that catch people out - and where early action changes the outcome.
Profound cyanosis and a failed hyperoxia test. Start prostaglandin and call cardiology / NETS.
Cover early - early-onset sepsis looks exactly like RDS. Antibiotics after cultures; do not be reassured by a well-looking baby with risk factors.
Sudden deterioration, asymmetric chest, shift. Transilluminate, and needle-decompress if the baby is in extremis.
Scaphoid abdomen and distress from birth. Large NG on free drainage, do not bag-mask, intubate and call for help.
The conditions behind respiratory distress, and the physiology and support that underpin it: