What is the initial management for a newborn with respiratory distress?

Initial Management of Neonatal Respiratory Distress

Begin resuscitation with room air (21% oxygen) for term and late-preterm newborns (≥35 weeks), and initiate positive-pressure ventilation immediately if the infant remains apneic, gasping, or has a heart rate <100 bpm after initial steps. 1

Immediate Assessment and Initial Steps

Rapid Evaluation

• Assess within the first 30 seconds: Check for spontaneous breathing effort, heart rate, and tone 1
• Monitor oxygen saturation using pulse oximetry on the right hand/wrist (preductal) to guide oxygen titration 1
• Look for specific signs: Tachypnea (>60 breaths/minute), grunting, retractions, nasal flaring, and cyanosis indicate significant distress 2, 3

Gestational Age-Specific Oxygen Strategy

For Term and Late-Preterm Infants (≥35 weeks):

• Start with 21% oxygen (room air) - this is the recommended initial concentration 1
• Do NOT use 100% oxygen initially - this is associated with harm 1
• Titrate oxygen to achieve target saturations based on normal preductal values for healthy newborns 1

For Preterm Infants (<35 weeks):

• Begin with 21-30% oxygen and titrate upward as needed 1
• Avoid both hypoxemia and hyperoxemia, as preterm lungs are particularly vulnerable 1

Positive-Pressure Ventilation (PPV)

Indications for PPV

Initiate PPV immediately if any of the following persist after initial steps: 1, 4

• Apnea or gasping respirations
• Heart rate remains <100 bpm
• Persistent respiratory distress despite initial interventions

Ventilation Parameters

• Rate: 40-60 breaths per minute (one breath every 1-1.5 seconds) 1, 4
• Initial inflation pressure: Start at 20 cm H₂O, but be prepared to increase to 30-40 cm H₂O if needed 1, 4
• Apply PEEP of approximately 5 cm H₂O when using mechanical devices capable of delivering it 1, 5
• Monitor inflation pressure and individualize based on chest rise and heart rate response 1, 4

Primary Success Indicator

The heart rate is your most critical measure of effective ventilation - look for prompt improvement in heart rate as the primary indicator that ventilation is adequate 1, 4. If heart rate does not improve, assess chest wall movement and adjust pressure/technique 1

Equipment Selection

Ventilation Devices

Any of these three devices can effectively deliver PPV: 1

• Flow-inflating bag
• Self-inflating bag (note: requires optional PEEP valve to deliver PEEP) 1
• T-piece resuscitator (most consistent pressure delivery in mechanical models) 1

Alternative Airway Management

If bag-mask ventilation fails:

• Consider laryngeal mask airway for infants >2000g or ≥34 weeks gestation 1
• This is particularly useful when face-mask ventilation is unsuccessful and intubation is difficult 1

Respiratory Support Strategy for Spontaneously Breathing Infants

CPAP as First-Line Support

For spontaneously breathing preterm infants with respiratory distress:

• Initiate CPAP rather than routine intubation 1, 5
• This approach reduces the need for mechanical ventilation and surfactant use 1
• Caveat: CPAP increases pneumothorax risk (9% vs 3% with intubation) in very preterm infants 1

When Intubation and Surfactant Are Needed

If respiratory support with a ventilator becomes necessary:

• Use the INSURE technique (Intubation-Surfactant-Rapid Extubation) rather than prolonged ventilation 5, 2
• Administer surfactant early, then rapidly extubate to CPAP 1, 5
• This strategy is particularly effective for preterm infants with surfactant deficiency 1, 5

Escalation of Support

If Heart Rate Remains <60 bpm

After 90 seconds of PPV with lower oxygen concentration and heart rate remains <60 bpm:

• Increase oxygen to 100% until heart rate recovers 1
• This is the only scenario where 100% oxygen is recommended initially 1

When to Add Chest Compressions

If heart rate remains <60 bpm despite 30 seconds of adequate PPV with supplemental oxygen:

• Begin chest compressions at a 3:1 ratio (3 compressions: 1 ventilation) 4
• Achieve approximately 120 events per minute (90 compressions + 30 breaths) 4

Critical Pitfalls to Avoid

• Never start term infants on 100% oxygen - this causes harm without benefit 1
• Don't delay PPV - bradycardia in newborns results from inadequate lung inflation, and ventilation is the most effective resuscitation action 4
• Don't use inadequate pressure - if 20 cm H₂O doesn't achieve chest rise and heart rate improvement, increase to 30-40 cm H₂O 1
• Don't forget PEEP - it's beneficial for establishing functional residual capacity, especially in preterm infants 1, 5
• Monitor for pneumothorax when using CPAP in very preterm infants, as risk is increased 1