Neonatal Respiratory Failure

Neonatal respiratory failure is one of the most common reasons newborns need intensive care, affecting their ability to breathe properly and maintain normal oxygen levels in the first hours or days of life.

Table of contents

• What Is Neonatal Respiratory Failure?
• Common Causes
• Signs and Symptoms
• How Is It Diagnosed?
• Treatment Options
• Possible Complications
• Outlook and Recovery

What Is Neonatal Respiratory Failure?

Neonatal respiratory failure is a serious breathing problem that occurs when a newborn baby cannot maintain normal oxygen delivery to the body’s tissues or cannot properly remove carbon dioxide from the tissues^[1]. This condition happens when there is an imbalance between how hard the baby’s breathing system needs to work and how strong the baby’s breathing muscles are^[1].

Doctors use specific measurements to determine if a baby has respiratory failure. A baby may be diagnosed with this condition if they have two or more of the following: carbon dioxide levels in the blood greater than 60 mmHg, oxygen levels below 50 mmHg or oxygen saturation below 80 percent even when breathing pure oxygen, and blood pH below 7.25^[1].

Newborn babies have less ability to handle breathing problems than older children and adults. Their airways are narrow and can easily collapse, their chest wall is soft and not fully developed, and they have less air stored in their lungs^[7]. These factors make newborns more likely to develop breathing failure, not only during lung illnesses but also during any serious illness.

Acute neonatal respiratory failure

Common Causes

The most common reason newborns need breathing support is respiratory distress syndrome (also called RDS), which happens when a baby’s lungs are not fully developed^[2][3]. This condition occurs mainly in premature babies whose lungs have not made enough of a slippery substance called surfactant. Surfactant coats the tiny air sacs in the lungs and helps keep them from collapsing^[2][3].

The earlier a baby is born, the more likely they are to develop respiratory distress syndrome. Most cases occur in babies born before 37 to 39 weeks of pregnancy^[3]. Around half of all babies born between 28 and 32 weeks develop this condition^[4]. A baby normally begins producing surfactant sometime between weeks 24 and 28 of pregnancy, and most babies produce enough to breathe normally by week 34^[4].

Other causes of neonatal respiratory failure include transient tachypnea of the newborn, meconium aspiration syndrome, pneumonia, sepsis, pneumothorax, persistent pulmonary hypertension of the newborn, and apnea of prematurity^[5][15]. Less common causes include congenital heart defects, airway malformations, and inborn errors of metabolism^[5].

Several factors can increase the risk of respiratory problems in newborns. These include having a brother or sister who had respiratory distress syndrome, being one of twins or triplets, the mother having diabetes, delivery by cesarean section before labor begins, and problems during delivery that reduce blood flow to the baby^[3][8].

Signs and Symptoms

The symptoms of neonatal respiratory failure are often noticeable immediately after birth and may get worse over the following few days^[4][5]. The most common sign is fast breathing, with a respiratory rate of more than 60 breaths per minute (normal is 40 to 60 breaths per minute)^[5][13].

Babies with respiratory distress may show these signs^[2][3][4]:

• A bluish color of the skin, lips, fingers and toes
• Grunting sounds with each breath
• Flaring of the nostrils with each breath
• Chest retractions, where the skin over the breastbone and ribs pulls in during breathing
• Rapid and shallow breathing
• Brief stops in breathing

The grunting sound is an important sign. It is a forced expiratory sound that indicates the baby has low lung volume. By breathing against a partially closed opening in the throat, the baby is trying to keep the air sacs open^[15][21].

How Is It Diagnosed?

Doctors can often diagnose respiratory distress by observing the baby and listening to their breathing. The initial evaluation includes a detailed history and physical examination, monitoring of vital signs, and measuring oxygen levels using a device called a pulse oximeter that attaches to the baby’s skin^[5][13].

A chest X-ray is very helpful in making the diagnosis. In babies with respiratory distress syndrome, the X-ray often shows a “ground glass” appearance of the lungs that is typical of the disease. This appearance often develops 6 to 12 hours after birth^[3][17].

Blood tests are used to measure the amount of oxygen and carbon dioxide in the baby’s blood and to check for infection^[3][4]. These tests show low oxygen and excess acid in the body fluids when respiratory failure is present^[3].

Additional tests may be performed to rule out other causes of breathing problems, such as infection or heart defects. Blood cultures and other laboratory tests help evaluate for sepsis, which is a bacterial infection that affects the blood^[5].

• Lungs
• Airways
• Chest wall

Treatment Options

Babies with neonatal respiratory failure need immediate medical care at a hospital with specialists in newborn breathing problems^[3][17]. The main goals of treatment are to help the baby breathe, maintain adequate oxygen levels, and support the baby while their lungs develop and heal.

Oxygen therapy is the first step in treatment. Extra oxygen may be given in several ways^[2][3]:

• Through a small tube with prongs placed in the nostrils (nasal cannula)
• Through an oxygen hood placed over the baby’s head
• Through a mask over the nose or face

Many babies need more help breathing through a treatment called continuous positive airway pressure or CPAP. This machine gently pushes air or oxygen into the lungs through a mask or tubes in the nose to help keep the air sacs open^[2][3][17]. CPAP can often prevent the need for a breathing tube and mechanical ventilator^[3][5].

Babies with severe respiratory failure may need help from a ventilator, which is a breathing machine. For this treatment, doctors place a soft breathing tube down the baby’s windpipe. The ventilator then helps the baby breathe or breathes for them^[2][3].

A very important treatment for babies with respiratory distress syndrome is giving artificial surfactant. This medicine is delivered directly into the baby’s airway through a breathing tube^[3][4]. Evidence suggests that early treatment within 2 hours of delivery works better than if treatment is delayed^[4][16]. Many babies can be treated using a technique where they are briefly intubated to receive surfactant and then quickly placed back on CPAP without prolonged mechanical ventilation^[5][13].

Babies also receive fluids and nutrition through a tube connected to a vein. They need to be kept at an ideal body temperature in an incubator, and any infections must be treated right away^[3][17].

If mothers are at risk of delivering their babies early, before 34 weeks of pregnancy, doctors may give them steroid injections before delivery. These steroids help the baby’s lungs develop and make more surfactant before birth. This treatment is estimated to help prevent respiratory distress syndrome in one third of premature births^[4][5][16].

Possible Complications

Most babies with neonatal respiratory failure can be successfully treated, but some may develop complications. Air or gas can build up in the space around the lungs, a condition called pneumothorax. This pocket of air places extra pressure on the lungs, causing them to collapse and leading to additional breathing problems. Air leaks can be treated by inserting a tube into the chest to allow the trapped air to escape^[3][4][8].

Long-term complications may develop due to too much oxygen, high pressure delivered to the lungs, or periods when the brain or other organs did not get enough oxygen^[3][17]. These can include lung inflammation and scarring called bronchopulmonary dysplasia, bleeding in the brain that can cause permanent damage, bleeding in the lungs, and vision problems^[4][8].

Some infants with severe respiratory distress syndrome may die, most often between days 2 and 7 after birth^[3][17]. However, with modern treatment in hospitals, most newborns with respiratory distress do very well^[18].

Outlook and Recovery

The condition often gets worse for 2 to 4 days after birth and then improves slowly after that^[3][17]. Some babies with respiratory distress only need help with breathing for a few days. But some, usually those born extremely prematurely, may need support for weeks or even months^[4][16].

Many babies with milder symptoms get better in 3 to 4 days. Those who are very premature may take longer to recover^[9][27]. Premature babies often have multiple problems that keep them in hospital, but generally they are well enough to go home around their original expected delivery date^[4][16].

The hospital staff will make sure that the baby is ready to go home and will help parents get the support they need. If a baby is sent home with oxygen or other equipment, parents will receive instructions on how to use it properly^[1][22].

With improved treatment methods including antenatal corticosteroids, surfactants, and advanced respiratory care, outcomes for babies affected by neonatal respiratory failure have improved significantly^[6][11].