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Objectives
1. Understand pathophysiology of common respiratory conditions in the newborn
2. Management of these conditions
3. Update on resuscitation devices4. Discuss case scenarios
Respiratory Problems in the Newborn Challenging problem Requires early recognition and
prompt therapy Associated with significant
morbidity and mortality
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
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
Fetal Physiology
In the fetus Alveoli filled
with lung fluid Lungs expand
with air after birth
NRP 2006
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
Nonpulmonary Conditions with RD Anemia Asphyxia Heart Disease Malformations
Metabolic conditions
Maternal drug abuse
Pneumothorax
History
Gestation: Term or Preterm Consistency of the amniotic
fluid: Clear or meconium stained
Risk factors for infection: PPROM, chorioamnionitis, HSV lesions
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)
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
Common causes of RD in Preterms Most common cause :
Respiratory Distress Syndrome (RDS)
Asphyxia Pneumonia Hypoglycemia Hypothermia
NRP 2006
Respiratory Distress Syndrome
Classic presentation: -grunting-retractions-flaring -cyanosis-tachypnea
CXR: mild granularity to ground-glass appearance
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)
Positive Pressure Support
1. CPAP (4-5 cm H20),
2. FiO2 (sats 85-93% in preterm and 90-98% in term infants)
3. HR<100, apnea/gasping or with cyanosis, give 40-60 breaths per minute
4. Adequate chest movement (start PIP at 20 cm H20 then increase to achieve chest rise)
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
Diagnostic Work-up
Chest X-ray Sepsis work-up - CBC/blood
culture Consider lumbar puncture as
clinically indicated Begin antibiotics
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
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?
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
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
Case # 2 continued
Place pulse ox: sats 81% Increased WOB with decreasing
saturations What is the cause?
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
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?
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
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
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
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
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
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