In the prior module, you learned how to assess the health of a newborn through the physical exam. In this module, we will focus on the assessment of a newborn's 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 a 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 breathes 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 newborns 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 there breathing for no more than 10 seconds, followed by a series of rapid shallow breaths. This pattern of breathing is normal for newborns. A healthy newborn will also look comfortable while breathing. This means that in addition to a normal rate of breathing, the newborn will demonstrate symmetric chest rise, meaning the chest on each side will rise equally with each breath. Clear breathe 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 trouble breathing maybe due to low oxygen levels, rising carbon dioxide levels, blockage of the upper or lower airways, problems with the anatomy of the lungs or even problems unrelated to the lungs such as problems with the heart. The different signs of respiratory distress reflect attempts made by the newborns body to compensate for the cause of 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 retractions. Retractions are the sucking in of the neck muscles, rib muscles or abdominal muscles while breathing. With each breathe, the outline of the ribs under 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 breathe. Nasal flaring may also be present, which means that there's a widening of the nostrils with each breathe. When an infant has respiratory distress, you may hear sounds of distress even before you use a stethoscope. Grunting is a sound that can be heard when an infant exhales. Newborns grunt as an attempt to keep the small lower airways expanded. This is important because keeping the smaller parts of the airway expanded helps to ensure that 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 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 in newborns, one common sign I often hear 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 maybe a more common presenting sign up other problems such as 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 breathe sounds in a certain part of the chest. Newborns with respiratory distress right after birth may have decreased or diminished breathe sounds overall. Breathe sounds may be decreased at the bottoms of the lungs compared to the tops of the lungs. The breast sounds 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 size of plastic wrap together, that is what crackle sound like. Okay. That is a lot of information, let's try to put this altogether. Signs of respiratory distress indicating an abnormal longer breathing assessment for a newborn include; breathing faster than 60 breathes per minute, presence of retractions, nasal flaring or grunting or abnormal chest rise. The breast sounds could sound diminished or abnormal. Newborn's 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.
