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priority is evaluating the patient (history and a physical examination) for presence of a stable airway Any newborn presenting with a new onset of stridor should be admitted for a complete evaluation Bedside fiberoptic laryngoscopy can be performed, allowing the ENT surgeon to observe the mobility of the vocal cords and diagnose paralysis in most cases Supplementary testing such as a modified barium swallow may be required to look for aspiration in cases with feeding difficulties Clinicians should order additional testing in cases where there is suspicion of underlying conditions These include cranial MRI or CT scan for diagnosis of neurologic and brainstem disorders, CT scan of chest and x-ray films of the neck for mediastinal pathology, or echocardiogram for cardiac disease Other Disorders That Produce Neonatal Respiratory Distress Goals of Treatment Respiratory distress is one of the most common presenting symptoms for newborns Most respiratory conditions (pneumonia, intrathoracic tumors, congenital lung disorders, chest wall deformities) produce respiratory distress; however, clinicians must also bear in mind that other extrapulmonary causes (cardiac disease, neuromuscular disorders, diaphragmatic disorders, anemia, polycythemia, metabolic acidosis, and neonatal sepsis) can present in this manner Classical neonatal respiratory disorders (respiratory distress syndrome, meconium aspiration syndrome, transient tachypnea of the newborn, persistent pulmonary hypertension, and congenital pneumonia) usually appear in the first few hours to days following birth and would generally be treated in the neonatal intensive care unit A small group of neonates may present after discharge with pneumonia (late-onset GBS, chlamydial, respiratory syncytial virus [RSV], and Haemophilus influenzae ) or exacerbation of bronchopulmonary dysplasia (BPD) These conditions can present with nonspecific symptoms of poor feeding, hypothermia, and lethargy They will be discussed below Perinatal history (prematurity, prolonged rupture of membranes, GBS status, mode of delivery, complications following delivery) should be elicited from the mother Physical examination will reveal signs of respiratory distress (nasal flaring, grunting, retractions, head bobbing, cyanosis, and tachypnea) The neonatal chest wall is very compliant; small changes in the aeration of the lungs or minor secretions obstructing the bronchi can cause significant retractions Other respiratory signs such as paradoxical motion can be seen in cases with diaphragmatic paralysis Asymmetry of chest wall motion could signify pneumothorax or a large effusion Care should be taken to auscultate both lungs (rales, wheezing) and examine the cardiovascular system (murmurs, gallops, distal pulses, and capillary refill) Pulse oximetry may show desaturation Blood gas analysis is very useful to detect hypercarbia and can differentiate between respiratory and metabolic acidosis, which can inform the next steps in management Stabilization of the infant with supplemental oxygen, nasal cannula, or intubation and mechanical ventilation should be the first priority Chest x-ray is useful for defining etiology After appropriate emergency treatment, infants requiring respiratory support should be admitted Additional information can be found in Chapter 71 Respiratory Distress CLINICAL PEARLS AND PITFALLS Acute exacerbations of BPD spells are characterized by wheezing and diminished air entry They can be triggered by mild viral infections, changes in the weather, or even crying Neonates with BPD have long-term scarring and fibrosis It is important to compare current chest x-rays with previous ones, if available, to differentiate chronic lung changes from new pathology Neonates normally have a large thymic shadow on CXR Clinicians can mistake this for infiltrates Ex-premature infants (36 weeks corrected gestational age (gestational age plus weeks postnatal) The original disease was described by Northway in 1967 as chronic respiratory failure (hypoxia and hypercarbia) in preterm newborns following prolonged highpressure mechanical ventilation (mechanical trauma) and oxygen toxicity with distinct chest x-ray changes (severe fibrosis and alternating areas of atelectasis and hyperinflation) Respiratory distress syndrome, infection, increased circulation in the lung, and increase in fluid from a patent DA are thought to be contributing factors With the widespread use of CPAP and surfactant therapy and improvements in mechanical ventilators, the incidence of BPD has decreased (25% to 42% in infants born less than 1.5 kg) Smaller, sicker premature newborns are more prone to the disease Changes in neonatal ventilation and care have produced the “new BPD.” This is a milder form with chest x-ray (CXR) showing diffuse haziness instead of the severe cystic form ( Fig 96.36 ) The pathologic destruction of lung tissue decreases lung compliance and increases airway resistance Changes in pulmonary function may persist well into adolescence Infants with BPD can present in the ED with acute exacerbations due to respiratory infections, resulting in catastrophic respiratory failure Viral illnesses (e.g., viral upper respiratory infections, RSV bronchiolitis) are common during the first year of life; but respiratory tract infections caused by bacteria and fungi can also occur with similar consequences Infection will trigger more inflammation, increased airway reactivity, plugging by secretions, and acute airway obstruction Respiratory distress, apnea, and desaturations can be presenting symptoms History of prematurity with prolonged ventilation and discharge on supplemental oxygen or tracheostomy with mechanical ventilation can be elicited from the parents Coarse breath sounds, crackles, and wheezing may be heard on auscultation Often decreased airflow into the chest can occur during episodes termed “BPD spells.” Spells can be triggered by the slightest agitation such as stooling or secretions, particularly when the baby is sick Pulse oximetry reveals desaturations and hypoxemia, often requiring an increase in FiO2 above baseline Asking the parents about the baby’s baseline requirements under normal conditions will help determine if the baby is currently requiring more oxygen supplementation Arterial blood gas may show chronic respiratory insufficiency (chronic CO2 retention) with hypoxia if the baby is desaturating Chest x-ray of a neonate with severe BPD may show extensive scarring and fibrosis of the lung ( Fig 96.37 ) Care must be taken to compare the current film with the previous films to determine if any new lesions have developed It can be very challenging for a clinician or radiologist to make that decision without looking at older films Neonates normally have a large thymic shadow on CXR Care should be taken not to mistake this with infiltrates An echocardiogram will help determine the extent of pulmonary hypertension Management is targeted at stabilizing the infant’s cardiorespiratory status, giving oxygen supplementation and escalating respiratory support as needed Bronchodilators (albuterol, ipratropium) may relieve reactive airway component in BPD Occasionally steroids may be helpful BPD patients are extremely sensitive to fluid overload Be cautious when giving intravenous boluses in this population Clinicians should also check and correct any underlying anemia to maximize oxygen delivery Any infant with BPD with acute exacerbation should be admitted to an intensive care unit for continuous monitoring FIGURE 96.36 Bronchopulmonary dysplasia Typical bubbly appearance with bubbles of various sizes is seen in advanced bronchopulmonary dysplasia A clip is also apparent on the film where the patent ductus arteriosus (PDA) has been ligated (Reprinted with permission from Brant WE, Helms CA Brant and Helms Solution Philadelphia, PA: Lippincott Williams & Wilkins; 2006.) ... ventilation should be the first priority Chest x-ray is useful for defining etiology After appropriate emergency treatment, infants requiring respiratory support should be admitted Additional information... life Ask the family if they are receiving their monthly shots during RSV season Referral to their pediatrician is recommended if they are not up to date on prophylaxis Chronic Lung Disease or Bronchopulmonary