In the prior module, you learned how to asses the health of a newborn through the physical exam. In this module, we will focus on the assessment of a newborns lungs including signs of normal respiratory status versus abnormal respiratory status. Recognizing signs of respiratory distress in a newborn is critical to provide timely appropriate intervention in workup for newborn to improve his or her health outcome. How can you tell just by performing a physical exam of a newborn that the infant has healthy lungs and a healthy breathing pattern? Let's first start by describing what is normal for a newborn. How fast should a healthy newborn breathe? For adults, we take anywhere from 12 to 20 breaths per minute. Healthy newborns will breathe anywhere from 30 to 60 breaths per minute. That seems very fast compared to the rate at which we are breathing right now. It is important to note that you should count a newborn's breathing rate for a full 60 seconds. This is because newborns can sometimes breathe faster and then slower with this pattern of breathing called periodic breathing. Periodic breathing is a newborn breathing pattern where babies can pause their breathing for no more than ten seconds followed by a series of rapid, shallow breaths. This pattern of breathing is normal for newborns. A healthy newborn will also look comfortable breathing. This means that in addition to a normal rate of breathing. A newborn will demonstrate symmetric chest rise. Meaning, the chest on each side will rise equally with each breath. Clear breath sounds when listening to the chest and all lung fields. You should not hear or see any extra noises while breathing. Widening of the nostrils or use of the extra muscles of the ribs, neck or abdomen while breathing. Now that we have discussed normal breathing for a newborn, let's discuss abnormal breathing. Respiratory distress is the term used to describe trouble with breathing. The troubled breathing may be due to low oxygen levels, rising carbon dioxide levels. Blockage of the upper or lower airways. Problems with the anatomy of the lungs and even problems unrelated to the lungs such as problems with the heart. The different signs of respiratory distress reflect attempts made by the newborn's body to compensate for the distress. Although the signs of respiratory distress may be caused by a variety of things, let's focus on those related to the respiratory tract itself. First, we already discussed that a normal rate of breathing for newborns is anywhere from 30 to 60 breaths in a minute. Tachypnea, meaning, fast breathing would be a respiratory rate faster than 60 breaths per minute in a newborn. Bradypnea, meaning, slow breathing would be a breathing rate slower than 30 breaths per minute. Apnea is a term used to describe cessation of breathing in a newborn, which by definition would be no breathing for at least 20 seconds. In most cases of respiratory distress in newborns, the patient will demonstrate tachypnea. Besides breathing fast, newborns may also have visible retraction. Retractions are the sucking in of the neck muscles, rib muscles or abdominal muscles while breathing. With each breath, the outline of the ribs and or the bone in the middle of the chest called the sternum become more pronounced. The abdominal muscles will visibly rise and fall more noticeably with each breath. Nasal flaring may also be present, which means that there's a widening of the nostrils with each breath. When an infant has respiratory distress, you may here sounds of distress, even before you use your stethoscope. Grunting is a sound that can be heard when an infant exhales. Newborns grunt as an attempt to keep the small, lower airwaves expanded. This is important, because keeping the smaller part of the airwaves expanded helps to ensure the lungs can function appropriately and obtain oxygen to circulate to the rest of the body. Please press pause and click the link on the screen to listen to an example of grunting in a newborn. What does the chest wall look like during each breath? Both sides of the chest wall should rise and fall evenly. An infant with respiratory distress could demonstrate one side of the chest that appears larger than the other, which could indicate a collapse of the lung or a pneumothorax. The abdomen could appear sunken or flat compared to the chest, which could be suggestive of a serious condition called congenital diaphragmatic hernia. Congenital diaphragmatic hernia is a birth defect of the diaphragm. A detailed description of which is beyond the scope of this discussion. When I work with learners to teach respiratory distress of newborns, one common sign often here for respiratory distress is cyanosis. Cyanosis or blue coloration of the skin suggests low oxygen levels in the body, but why is cyanosis not included on my list of signs to look for with an infant in respiratory distress? If an infant has respiratory distress, a blue color change in the skin, particularly of the gums, tongue or around the lips or mouth is a late sign of difficulties breathing. Cyanosis may be a more common presenting sign of other problems such as Is heart problems. Okay, we have reviewed a lot of the visible signs of respiratory distress in a newborn. But what might you hear when listening to a newborn's lungs with your stethoscope if they are exhibiting respiratory distress? First, it may be difficult to hear breath sounds in a certain part of the chest. Newborns with respiratory distress right after birth may have decreased or diminished breadth sounds overall. Breath sounds may be decreased at the bottoms of the lungs compared to the tops of the lungs. The breath sound on one side of the chest could be more difficult to hear than the other side of the chest, which could again suggest a pneumothorax. If fluid is still present in the lungs of a newborn, one might hear crackles each time the infant inhales. Imagine peeling apart Velcro or rubbing the sides of plastic wrap together, that is what crackles sound like. Okay, that is a lot of information. Let's try to put this all together. Signs of respiratory distress indicating an abnormal lung or breathing assessment for a newborn include breathing faster than 60 breaths per minute, presence of retractions, nasal flaring or grunting or abnormal chest rise. The breath sounds can sound diminished or abnormal. Newborns with healthy lung and breathing assessments will not demonstrate these signs of distress. Your physical exam is one of the most important tools you can use to assess an infant who has respiratory distress. With the information discussed in this module, I hope you are able to identify the signs of respiratory distress in a newborn.
