Synopsis
Stabilise a newborn with respiratory compromise, use gestation, timing and physiology to distinguish common causes, and escalate oxygen, non-invasive support, surfactant, ventilation and cause-specific treatment safely.
- Respiratory distress is tachypnoea, recession, grunting, nasal flaring, cyanosis or apnoea; rate alone does not describe severity.
- Stabilise temperature, airway, breathing, circulation and glucose before pursuing a perfect diagnosis. Attach preductal saturation and use ECG when resuscitation is needed.
- Gestation and onset organise the differential: preterm early distress suggests RDS; term caesarean birth suggests transient tachypnoea; meconium suggests aspiration.
- RDS results from surfactant deficiency and usually worsens over the first hours with low-volume granular lungs and increasing oxygen or pressure need.
- Transient tachypnoea follows delayed fetal-lung-fluid clearance, usually causes mild early tachypnoea and improves within 24–72 hours; it remains a diagnosis of exclusion.
- First-line respiratory support for spontaneously breathing preterm babies is CPAP where clinically appropriate; invasive ventilation is reserved for failure or another indication.
- Give surfactant early to a preterm baby who needs invasive ventilation for RDS; use a minimally invasive method in suitable babies who do not need an endotracheal tube for other reasons.
- After stabilisation, target SpO2 91–95% in preterm babies. In term babies prescribe an individual target and investigate cyanosis rather than reflexively using prolonged 100% oxygen.
- A preductal-postductal difference supports ductal shunting but does not by itself distinguish persistent pulmonary hypertension from structural heart disease; urgent echocardiography is definitive.
- Treat the cause: antibiotics for suspected infection, drainage for tension pneumothorax, prostaglandin through a specialist pathway for duct-dependent disease, and pulmonary-hypertension support in intensive care.
- Repeated blood gases, oxygen exposure and radiographs should answer a clinical question; use the least injurious support compatible with effective gas exchange.
- Failure to improve as expected should reopen the differential, including airway obstruction, air leak, congenital anomaly, cardiac disease, metabolic acidosis and neurological depression.
Key red flags
Apnoea, gasping, falling heart rate, reduced respiratory effort or altered responsiveness signals exhaustion and need for ventilation rather than observation.
Sudden asymmetric chest movement, unilateral reduced breath sounds, cardiovascular collapse or abrupt oxygen deterioration raises tension pneumothorax.
Persistent central cyanosis, weak femoral pulses, shock or a large preductal-postductal saturation difference raises congenital heart disease or persistent pulmonary hypertension.
A scaphoid abdomen, displaced heart sounds or antenatal diaphragmatic abnormality suggests congenital diaphragmatic hernia; avoid bag-mask inflation.
Temperature instability, poor perfusion, hypotonia, feed intolerance or maternal infection risk with respiratory signs raises neonatal sepsis and requires timely antimicrobials.
Bilious secretions, copious frothy saliva or inability to pass an orogastric tube suggests oesophageal atresia or another surgical airway-feeding disorder.
Investigation priorities
Quantify oxygenation and deterioration while initial support is delivered.
Management branches
A newborn has respiratory distress or cyanosis.
- Warm, position, assess breathing and heart rate and call neonatal help.
- Apply preductal oximetry, support airway and breathing with blended oxygen and CPAP or ventilation as indicated.
- Check glucose and gas while examining rapidly for tension pneumothorax, diaphragmatic hernia, shock and congenital heart disease.