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Respiratory Problems in the Newborn

Respiratory Problems in the Newborn. Objectives. Understand pathophysiology of common respiratory conditions in the newborn Management of these conditions Update on resuscitation devices Discuss case scenarios. Respiratory Problems in the Newborn. Challenging problem

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Respiratory Problems in the Newborn

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  1. Respiratory Problems in the Newborn

  2. Objectives • Understand pathophysiology of common respiratory conditions in the newborn • Management of these conditions • Update on resuscitation devices • Discuss case scenarios

  3. Respiratory Problems in the Newborn • Challenging problem • Requires early recognition and prompt therapy • Associated with significant morbidity and mortality

  4. Introduction • Most newborn babies are vigorous after birth • About 10% require some assistance • Only 1% need resuscitative measures (intubation, chest compressions, and/or medications) to survive NRP 2006

  5. Signs of a Compromised Newborn • Poor muscle tone • Depressed respiratory drive • Low HR • Low BP • Tachypnea • Cyanosis, nasal flaring, grunting, SCR and ICR NRP 2006

  6. Fetal Physiology In the fetus • Alveoli filled with lung fluid • Lungs expand with air after birth NRP2006

  7. Tachypnea vs Respiratory Distress • Normal respiratory rate: 40-60 per minute • Tachypnea: RR>60 in a quiet resting baby • Distress: RR>or <60 with retractions, grunting, central cyanosis, lethargy and poor feeding

  8. Common Respiratory Problems in the Newborn • TTN • RDS • MAS • Infection (e.g.pneumonia, sepsis) • PPHN

  9. Anemia Asphyxia Heart Disease Malformations Metabolic conditions Maternal drug abuse Pneumothorax Nonpulmonary Conditions with RD

  10. History • Gestation: Term or Preterm • Consistency of the amniotic fluid: Clear or meconium stained • Risk factors for infection: PPROM, chorioamnionitis, HSV lesions

  11. Physical Examination • Respiratory Rate –intermittent apnea and tachypnea and with distress • Cyanosis – place pulse ox • Retractions, Flaring, Grunting, Stridor • Auscultation - decreased aeration (RDS), distant heart sounds (Pneumothorax)

  12. Physical Examination • Cleft palate and micrognathia – aspiration, upper airway obstruction • Scaphoid abdomen and worsening with bag mask ventilation - CDH • Excessive frothing/secretions - TEF • Worsening condition at rest and improves with crying - Choanal atresia

  13. Common causes of RD in Preterms • Most common cause : Respiratory Distress Syndrome (RDS) • Asphyxia • Pneumonia • Hypoglycemia • Hypothermia NRP 2006

  14. Respiratory Distress Syndrome • Classic presentation: -grunting -retractions -flaring -cyanosis -tachypnea • CXR: mild granularity to ground-glass appearance

  15. Respiratory Distress Syndrome

  16. Initial Management • Check laryngoscope and ET tubes • Suction and CO2 detector • Pre-warmed radiant warmer, (Polyethlene bag/Saran wrap) • Suction mouth and nose • Perform tactile stimulation • Attach pulse oximeter to right upper extremity (preductal saturations)

  17. Flow-Inflating Bag T-Piece Resuscitators Self- Inflating Bag

  18. Positive Pressure Support • CPAP (4-5 cm H20), • FiO2 (sats 85-93% in preterm and 90-98% in term infants) • HR<100, apnea/gasping or with cyanosis, give 40-60 breaths per minute • Adequate chest movement (start PIP at 20 cm H20 then increase to achieve chest rise)

  19. Apnea • Commonly seen in preterm infants • Due to immature control of breathing • Other causes: hypoglycemia, anemia, infection, hypoxemia • Consider load with caffeine • May need CPAP or HFNC • Rarely need intubation and mechanical ventilation

  20. Diagnostic Work-up • Chest X-ray • Sepsis work-up - CBC/blood culture • Consider lumbar puncture as clinically indicated • Begin antibiotics

  21. Management • Respiratory therapy -PPV/oxyhood/HFNC/NCPAP/intubation • Transfer to a higher center when necessary • Monitor all babies - HR/RR/perfusion/BP/Urine output/hydration • NPO with OG to gravity • IV fluids; D10W 60ml/kg/d for term infants and 80ml/kg/d for preterm infants

  22. Case # 1 • 35yo mother, good prenatal care, serologies appropriate, admitted in labor, clear fluid • 39w, male infant, 3.8kg • Tachypneic with mild SCR, intermittent grunting • Saturation: 88-92% on RA • CXR, ABG,CBC, Blood culture sent, antibiotics started • What is the diagnosis?

  23. Transient Tachypnea of the Newborn • Delayed clearance of lung fluid • CXR: perihilar linear densities • Monitor respiratory status closely • Most do not require any respiratory support • May need HFNC or CPAP

  24. Case #2 • You are asked to attend a delivery • 32yo, G5P4, 38w, good prenatal care, serologies appropriate, admitted in labor, ROM with meconium stained fluid • Baby born SVD, floppy, pale • What do you do? • After above steps, infant noted to have spontaneous breathing with SCR, ICR, grunting

  25. Case # 2 continued • Place pulse ox: sats 81% • Increased WOB with decreasing saturations • What is the cause?

  26. Meconium Aspiration Syndrome • Meconium causes mechanical obstruction • Non vigorous: intubate and suction • Supportive respiratory therapy: CPAP/HFNC • UAC/UVC placement • NPO • Antibiotics • Sedation as indicated • Monitor closely

  27. Case #3 • 17y mother, presents in labor, G1P0, 40w • Good prenatal care • Serologies appropriate • GBS negative • Present with fever 101, mild abdominal tenderness • Infant born apneic, responds to resuscitation • SCR, ICR, flaring and grunting • What could be the likely cause?

  28. Infection/Neonatal Pneumonia • Prolonged rupture of membranes, chorioamnionitis • May present with RD, lethargy, poor feeding • CXR, CBC, blood culture, LP • CXR: similar to RDS with haziness all over • Antibiotics – Ampicillin and gentamicin as per neofax

  29. Pneumonia

  30. Case # 4 • 27yo mother, presented to OB clinic with spotting • Admitted to hospital, NRFHT • Crash C-section under GA • 41w, G1P0, O negative mother, GBS negative • Born floppy, responds to inititial resus • Admitted to term nursery • Respiratory distress with SCR, desaturations • Hypotensive, acidotic

  31. PPHN • Severe cyanosis, respiratory distress • Preductal>postductal saturations • Respiratory support with FIO2 as needed to maintain saturation above 95% • May be primary or associated with other causes: MAS, pneumonia • Echocardiogram: elevated RV pressure • Begin antibiotics

  32. Surgical Causes Examination of the neck, nose, mouth and throat

  33. Pneumothorax • Can occur spontaneously • Presentation: respiratory distress • Decreased breath sounds on affected side • Small, less symptomatic, clinically stable-conservative management –follow CXR • May conider 100% oxygen for nitrogen wash-out • More sick: may need emergent needling or chest tube placement

  34. Needle Thoracentesis • 22 gauge angiocatheter, or 23 gauge butterfly needle, 3-way stopcock, 10-20 ml syringe • Rapid improvement in respiratory distress and saturations and overall clinical appearance

  35. Congenital Diaphragmatic Hernia • Herniation of abdominal contents into the chest • AVOID bag and mask ventilation/CPAP • Intubate in delivery room and inform surgery immediately • Arrange transport to a tertiary center

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