Respiratory Distress

Respiratory distress is a serious breathing problem that can affect people of all ages, from premature newborns to critically ill adults, and requires immediate medical attention to prevent life-threatening complications.

Table of contents

• What is Respiratory Distress?
• Different Types of Respiratory Distress
• Signs and Symptoms
• Causes and Risk Factors
• How is it Diagnosed?
• Treatment Options
• Recovery and Living With Respiratory Distress

What is Respiratory Distress?

Respiratory distress, also called trouble breathing, occurs when a person has difficulty getting enough air into their lungs or getting oxygen to their body. This condition ranges from mild breathing difficulties to severe, life-threatening situations that require emergency medical care.

When respiratory distress occurs, the body’s organs may not receive the oxygen they need to work properly. Without adequate oxygen, vital organs such as the brain, heart, kidneys, and stomach can be damaged^[5].

Different Types of Respiratory Distress

Respiratory Distress Syndrome in Newborns

Respiratory distress syndrome (RDS) is a common breathing disorder that affects newborn babies, especially those born before their due date^[3]. RDS occurs most often in babies born before 28 weeks of pregnancy, though it can occasionally affect full-term newborns as well.

The condition happens because premature babies’ lungs are not fully developed and cannot make enough surfactant, which is a liquid produced in the lungs starting around 26 weeks of pregnancy^[4]. Surfactant coats the tiny air sacs in the lungs and helps keep them from collapsing. Without enough surfactant, the air sacs cannot stay open, making it difficult for oxygen to enter the blood and for carbon dioxide to be released.

The earlier an infant is born, the more likely they are to develop RDS and need extra oxygen and help breathing^[4]. Most newborns who have RDS survive, though these babies may need extra medical care after going home. Some babies develop complications from RDS or its treatment, including the development of another lung condition called bronchopulmonary dysplasia.

Acute Respiratory Distress Syndrome in Adults

Acute respiratory distress syndrome (ARDS) is a life-threatening lung injury that occurs when fluid builds up in the tiny air sacs in the lungs^[2]. These air sacs, called alveoli, have a protective membrane, but lung swelling damages that membrane. The fluid leaking into the air sacs keeps the lungs from filling with enough air, which means less oxygen reaches the bloodstream.

ARDS usually occurs in people who are already critically ill or have major injuries^[2]. The condition typically develops within a few hours to a few days of the injury or infection that caused it, and can worsen rapidly^[5]. ARDS affects about 200,000 people in the United States and 3 million people worldwide every year^[5].

Healthcare providers classify ARDS as mild, moderate, or severe based on how much oxygen is in the blood compared to how much oxygen needs to be given to achieve healthy levels^[5].

Signs and Symptoms

Symptoms in Newborns

Babies with respiratory distress syndrome may show signs within minutes or hours of being born^[7]. Common symptoms include:

• Fast breathing very soon after birth
• Grunting sounds with each breath
• Flaring of the nostrils with each breath
• Changes in color of lips, fingers, and toes
• Chest retractions, where the skin over the breastbone and ribs pulls in during breathing^[4]

Symptoms in Adults with ARDS

The seriousness of ARDS symptoms can vary depending on the underlying cause and whether there is existing heart or lung disease^[2]. Symptoms include:

• Severe shortness of breath
• Fast and labored breathing that is not usual
• Rapid heart rate
• Bluish color of fingernails and lips due to low oxygen levels in the blood^[5]
• Cough
• Chest discomfort
• Confusion and extreme tiredness^[2]

ARDS usually follows a major illness or injury, and most people who have ARDS are already in a hospital. However, if you have symptoms of ARDS and are not in a medical facility, go to the nearest emergency department right away or call 911^[2].

Causes and Risk Factors

Causes of Respiratory Distress in Newborns

While RDS is most common in babies born early, other newborns can develop it. Babies at greater risk include^[4]:

• Siblings who had RDS
• Twin or multiple births
• Babies delivered by cesarean section
• Babies whose mother has diabetes
• Babies with infection
• Babies who are sick at the time of delivery
• Babies experiencing cold, stress, or hypothermia (when the baby cannot keep their body temperature warm at birth)

Causes of ARDS in Adults

ARDS is always caused by an injury to the lungs, whether from illness or trauma. The most common causes include^[5]:

• Sepsis: The most common cause of ARDS, which happens when you have a serious infection in your lungs (pneumonia) or other organs with widespread inflammation
• Aspiration pneumonia: When stomach contents are breathed into the lungs, causing severe lung damage
• Blood transfusions: Receiving more than 15 units of blood in a short period increases ARDS risk
• COVID-19: The COVID-19 virus may develop into severe ARDS
• Pancreatitis: Severe inflammation in the pancreas
• Major trauma or burns: Accidents and falls may directly damage the lungs or trigger severe inflammation
• Inhalational injury: Breathing high concentrations of chemical fumes or smoke
• Drug overdose: An overdose on drugs like cocaine and opioids^[5]

How is it Diagnosed?

Diagnosis in Newborns

RDS is common in premature newborns, but doctors may need to run tests to rule out other types of breathing problems. Healthcare providers will suspect RDS in a premature baby who has trouble breathing and needs oxygen soon after birth^[7].

The diagnosis is made after examining the baby and seeing the results of chest X-rays and blood tests^[4]. A chest X-ray of the lungs can confirm the diagnosis.

Diagnosis of ARDS in Adults

There is no specific test for ARDS. Healthcare professionals base the diagnosis on physical exams, chest X-rays, and oxygen levels^[11]. It is also important to rule out other diseases and conditions, such as certain heart problems that can lead to similar symptoms.

Tests that may be used include:

• Chest X-ray to show which parts of the lungs have fluid and how much
• CT scan to give detailed information about the structures within the heart and lungs
• Blood tests from an artery to measure oxygen levels
• Tests of secretions from the airway if lung infection is suspected
• Heart tests such as electrocardiogram or echocardiogram to rule out heart problems^[11]

Treatment Options

Treatment for Newborns with RDS

To help prevent respiratory distress syndrome, doctors can give steroid medicines to pregnant women who are likely to deliver their babies early (before 37 weeks of pregnancy)^[7]. Steroids help the baby’s lungs mature and make more surfactant before the baby is born.

Babies with RDS need extra oxygen, which may be given in several ways^[4]:

• Nasal cannula: A small tube with prongs placed in the nostrils
• Continuous Positive Airway Pressure (CPAP): A machine that gently pushes air or oxygen into the lungs to keep the air sacs open
• Ventilator (for severe RDS): A machine that helps the infant breathe when they cannot breathe well enough without help. A breathing tube is placed down the infant’s windpipe through a process called intubation

Surfactant replacement therapy is also used, where surfactant medicine is given directly into the baby’s breathing tube to coat the air sacs and help them stay open^[7]. Many babies with milder symptoms get better in 3 to 4 days, though those who are very premature may take longer to recover.

Treatment for Adults with ARDS

The goal of treatment for ARDS is to improve oxygen levels and treat the underlying cause^[9]. Although no specific therapy exists for ARDS, treatment includes supportive care, mechanical ventilation using low tidal volumes, and conservative fluid management.

Oxygen therapy is the main treatment for ARDS. Depending on how serious the symptoms are, doctors may suggest^[9]:

• Noninvasive ventilation such as BiPAP or CPAP machines
• A ventilator to help restore blood oxygen levels
• Prone positioning (lying on the stomach) to improve oxygenation in severe cases^[8]

Doctors may also recommend medicines to relieve symptoms, treat the underlying cause, or prevent complications. Because infection is often the underlying cause of ARDS, early administration of appropriate antimicrobial therapy is essential^[15].

The only treatment found to improve survival in ARDS through large controlled trials is a mechanical ventilation strategy using low tidal volumes (6 mL/kg based on ideal body weight)^[15]. In select, severe cases where standard treatments are not working, doctors may use extracorporeal membrane oxygenation (ECMO), which improves gas exchange and modestly improves survival by allowing the lungs to rest^[12].

Recovery and Living With Respiratory Distress

Recovery from Newborn RDS

Most newborns who have RDS survive. However, these babies may need extra medical care after going home^[3]. Some babies have complications from RDS or its treatment, and close follow-up with healthcare providers is important.

Recovery from ARDS in Adults

The road to recovery from ARDS can be long and complex. Recovery after leaving the hospital can take many weeks or months, particularly for older adults^[16]. The longer a patient was on a ventilator, the longer it may take to recover strength and return to familiar routines.

Many survivors experience physical and psychological challenges after hospitalization, including^[18]:

• Muscle weakness or atrophy
• Psychological issues such as PTSD, anxiety, and depression
• Ongoing respiratory symptoms

With treatment, an estimated 60% to 75% of those who have ARDS will survive the disease^[13]. Of the people who survive ARDS, some fully recover, but others have lasting lung damage^[2].

Healthcare teams can support recovery by recommending^[16]:

• Keeping regular appointments to monitor recovery
• Taking all medicines regularly as prescribed
• Working with therapists or other healthcare providers to gain strength and speed recovery
• Participating in pulmonary rehabilitation programs that involve exercise training, education, and counseling

Post-intensive care rehabilitation programs are vital to address recovery concerns. A multi-disciplinary approach involving physiotherapists, occupational therapists, psychologists, and respiratory therapists can facilitate recovery and improve quality of life^[18].