Background Transient tachypnea of the newborn (TTN) is a self-limited disease common in infants throughout the world and is encountered

by all physicians who care for newborn infants. Infants with transient tachypnea of the newborn present within the first few hours of life with tachypnea, increased oxygen requirement, and ABGs that do not reflect carbon dioxide retention. When managing transient tachypnea of the newborn, observing for signs of clinical deterioration that may suggest other diagnoses and for the development of respiratory fatigue is important.

A supine anteroposterior chest radiograph of an infant with transient tachypnea of the newborn (TTN). Note the reticular appearance of the film with mild cardiomegaly and obvious interstitial fluid. Pathophysiology Noninfectious acute respiratory disease develops in approximately 1% of all newborn infants and results in admission to a critical care unit. Transient tachypnea of the newborn is the result of a delay in clearance of fetal lung liquid. In the past, respiratory distress was thought to be a problem of relative surfactant deficiency but is now characterized by an airspace-fluid burden secondary to the inability to absorb fetal lung liquid. In vivo experiments have demonstrated that lung epithelium secretes Cl- and fluid throughout gestation but develops the ability to actively reabsorb Na+only during late gestation. At birth, the mature lung switches from active Cl-(fluid) secretion to active Na+ (fluid) absorption in response to circulating catecholamines; more recently, evidence suggests glucocorticoids play a role in this switch.[1] Changes in oxygen tension augment the Na+ -transporting capacity of the epithelium and increase gene expression for the epithelial Na+ channel (ENaC). The inability of the immature fetal lung to switch from fluid secretion to fluid absorption results, in large part, from an immaturity in the expression of ENaC, which can be upregulated by glucocorticoids. Glucocorticoids induce lung Na+ reabsorption most likely through the EnaC channel in late gestational age fetal lung alveolar epithelia.[2] Both pharmacologic blockade of the lung's EnaC channel and genetic knockout experiments using mice deficient in the ENaC pore-forming subunit have demonstrated the critical physiologic importance of lung Na+ transport at birth. When Na+ transport is ineffective, newborn animals develop respiratory distress; hypoxemia; fetal lung liquid retention; and, in the case of the ENaC knockout

mice, death. Bioelectrical studies of human infants' nasal epithelia demonstrate that both transient tachypnea of the newborn andrespiratory distress syndrome (RDS) involve defective amiloride-sensitive Na+transport. Mature newborns who have normal transitions from fetal to postnatal life have mature surfactant and epithelial systems. Transient tachypnea of the newborn occurs in mature newborns with mature surfactant pathways and poorly developed respiratory epithelial Na+ transport, whereas neonatal RDS occurs in infants with both premature surfactant pathways and immature Na+transport. An infant born by cesarean delivery is at risk of having excessive pulmonary fluid as a result of not having experienced all of the stages of labor and subsequent lack of appropriate catecholamine surge, which results in low release of counterregulatory hormones at delivery. The end result is alveoli with retained fluid that inhibit gas exchange. Epidemiology Frequency United States Approximately 1% of infants have some form of respiratory distress that is not associated with infection. Respiratory distress includes both RDS (ie, hyaline membrane disease) and transient tachypnea of the newborn. Of this 1%, approximately 33-50% have transient tachypnea of the newborn. Mortality/Morbidity Transient tachypnea of the newborn is generally a self-limited disorder without significant morbidity. Transient tachypnea of the newborn resolves over a 24hour to 72-hour period. Race No racial predilection has been reported. Sex Risk is equal in both males and females. Age Clinically, transient tachypnea of the newborn presents as respiratory distress in full-term or near-term infants. History The maternal history in transient tachypnea of the newborn (TTN) consists of caesarian delivery without labor or precipitous delivery. Signs of respiratory distress (eg, tachypnea, nasal flaring, grunting, retractions, cyanosis in extreme cases) become evident shortly after birth. The disorder is indeed transient, with resolution usually occurring within 72 hours after birth.

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Physical Physical findings include tachypnea with variable grunting, flaring, and retracting. The infant is often described as having "quiet" tachypnea. Extreme cases may exhibit cyanosis. A study investigating the risk factors for duration of tachypnea in patients with transient tachypnea of the newborn reported that peak respiratory rate of more than 90 breaths per minute during the first 36 hours of life was associated with prolonged tachypnea lasting more than 72 hours.[3] Causes The disorder results from delayed absorption of fetal lung fluid following delivery. Transient tachypnea of the newborn is commonly observed following birth by cesarean delivery. Cesarean delivery Studies using lung mechanic measurements were performed in infants born by either cesarean or vaginal delivery. Milner et al noted that the mean thoracic gas volume was 32.7 mL/kg in infants born vaginally and 19.7 mL/kg in infants born via cesarean delivery.[4] Importantly, chest circumferences were the same. Milner et al noted that the infants born via cesarean delivery had higher volumes of interstitial and alveolar fluid compared with those born vaginally, even though the overall thoracic volumes were within the reference range. o Epinephrine release during labor affects fetal lung fluid. In the face of elevated epinephrine levels, the chloride pump responsible for lung liquid secretion is inhibited, and the sodium channels that absorb liquid are stimulated. As a result, net movement of fluid from the lung into the interstitium occurs. Therefore, caesarian delivery without labor and the subsequent lack of this normal surge in counter-regulatory hormones limits the excursion of pulmonary fluid. y Maternal asthma and smoking o Demissie et al performed a historical cohort analysis on singleton live deliveries in New Jersey hospitals from 1989-1992.[5] After controlling for confounding effects of important variables, infants of mothers with asthma were more likely to exhibit transient tachypnea of the newborn than infants of mothers in the control group. o Schatz et al studied a group of 294 pregnant women with asthma and a group of 294 pregnant women without asthma.[6] Both groups had normal pulmonary function test results and were matched for age and smoking status. transient tachypnea of the newborn was found in 11 infants (3.7%) of mothers with asthma and in 1 infant (0.3%) of a mother from the control group. No significant differences between asthmatic and matched control subjects in other transient tachypnea of the newborn risk factors were observed. y Male sex and macrosomia: These have also been associated with increased risk of transient tachypnea of the newborn.
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Other factors: Excessive maternal sedation, perinatal asphyxia, and elective cesarean delivery without preceding labor are frequently associated with transient tachypnea of the newborn. Laboratory Studies The following studies are indicated in transient tachypnea of the newborn (TTN)

ABG o An ABG assessment is important to ascertain the degree of gas exchange and acid-base balance. o Consider an intraarterial catheter, such as an umbilical artery catheter, if the infant's inspired fraction of oxygen exceeds 40%. o Hypoventilation is very uncommon, and partial carbon dioxide tensions are usually normal because of the tachypnea. However, a rising carbon dioxide tension in an infant with tachypnea may be a sign of fatigue and impending respiratory failure or a complication such as a pneumothorax. y Pulse oximetry o Continuously monitor infants with pulse oximetry for assessment of oxygenation. o Pulse oximetry allows the clinician to adjust the level of oxygen support needed to maintain appropriate saturation. Imaging Studies y Chest radiography y Chest radiography is the diagnostic standard for transient tachypnea of the newborn. y The characteristic findings include prominent perihilar streaking, which correlates with the engorgement of the lymphatic system with retained lung fluid, and fluid in the fissures. Small pleural effusions may be seen. Patchy infiltrates have also been described. y Follow-up chest radiography may be necessary if the clinical history suggests meconium aspiration syndrome or neonatal pneumonia or if respiratory status worsens. Medical Care y Medical care of transient tachypnea of the newborn (TTN) is supportive. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status improves. y Supportive care includes intravenous fluids and gavage feedings until the respiratory rate has decreased enough to allow oral feedings. Supplemental oxygen to maintain adequate arterial oxygen saturation, maintenance of thermoneutrality, and an environment of minimal stimulation are the therapies necessary in these infants. ABG assessments should be periodically repeated, especially if the infant's condition worsens. Similarly, chest radiography should be repeated if clinical decompensation is observed.
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As transient tachypnea of the newborn resolves, the infant's tachypnea improves, oxygen requirement decreases, and chest radiography shows resolution of the perihilar streaking. Infants with transient tachypnea of the newborn may have signs that last from a few hours to several days. Rarely, an infant develops a worsening picture of respiratory distress after several days. This may require more aggressive support including the use of continuous positive airway pressure (CPAP) or mechanical ventilation. A clinical trial that examined the role of inhaled epinephrine for the treatment of transient tachypnea of the newborn found no adverse events when inhaled epinephrine was administered to full-term newborns with moderate-to-severe transient tachypnea of the newborn.[7] More importantly, they did not detect any difference in rate of resolution of tachypnea in placebo and inhaled epinephrine groups. At this time, inhaled epinephrine is not recommended for infants with transient tachypnea of the newborn. Medical Care Medical care of transient tachypnea of the newborn (TTN) is supportive. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status improves. Supportive care includes intravenous fluids and gavage feedings until the respiratory rate has decreased enough to allow oral feedings. Supplemental oxygen to maintain adequate arterial oxygen saturation, maintenance of thermoneutrality, and an environment of minimal stimulation are the therapies necessary in these infants. ABG assessments should be periodically repeated, especially if the infant's condition worsens. Similarly, chest radiography should be repeated if clinical decompensation is observed. As transient tachypnea of the newborn resolves, the infant's tachypnea improves, oxygen requirement decreases, and chest radiography shows resolution of the perihilar streaking. Infants with transient tachypnea of the newborn may have signs that last from a few hours to several days. Rarely, an infant develops a worsening picture of respiratory distress after several days. This may require more aggressive support including the use of continuous positive airway pressure (CPAP) or mechanical ventilation. A clinical trial that examined the role of inhaled epinephrine for the treatment of transient tachypnea of the newborn found no adverse events when inhaled epinephrine was administered to full-term newborns with moderate-to-severe transient tachypnea of the newborn.[7] More importantly, they did not detect any difference in rate of resolution of tachypnea in placebo and inhaled epinephrine groups. At this time, inhaled epinephrine is not recommended for infants with transient tachypnea of the newborn. Consultations Infants with transient tachypnea of the newborn occasionally may require consultation by a neonatologist.

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Consider this consultation if the fraction of inspired oxygen exceeds 40%, ifmetabolic acidosis or respiratory acidosis is present, if CPAP or mechanical ventilation is required, if the infant begins to display fatigue (periodic breathing or apnea), or if the infant fails to improve by age 48-72 hours. Diet Infants with transient tachypnea of the newborn are generally supported by intravenous fluids or gavage feedings. Infants with significant distress have poor bowel motility and require intravenous therapy. Oral feedings are withheld until the respiration has improved a\\\

How to Prevent Transient Tachypnea Of Newbor There are no guidelines for preventing transient tachypnea because the exact cause is not known. But there are several things you can do to help ensure you will give birth to a healthy baby: Eat a healthful diet, one that is low in saturated fat and rich in whole grains, fruits, and vegetables. Have regular prenatal check-ups. Don't smoke. If you smoke, quit. Avoid drugs and alcohol

clear lungs are seen

Radiograph of a neonate at age 4 days. Normal heart size and clear lungs are seen