Assessment of the Neonate Fred Hill, MA, RRT. Reduction in Pulmonary Reserve Thorax is more flexible Thorax is more flexible Heart is larger in proportion.

Assessment of the Neonate

Fred Hill, MA, RRT

Reduction in Pulmonary Reserve

• Thorax is more flexible• Heart is larger in proportion

to thorax• Abdominal contents are

larger in proportion to thorax

Breathing and Coughing

• Newborns are “obligate nose breathers”

• Neonates lack a cough reflex• Smaller airways, but epithelial

cells are similar in size• Breathing rate = 30-50 vs 12-20;

premature = 40-60• Heart Rate = 100-140 vs 60-80

Upper Airway Anatomy

• Tongue is larger in proportion to oropharynx. More lymphoid tissues in pharynx.

• Larynx is more anterior and higher.• Epiglottis is larger and stiffer in proportion,

lies more horizontal, omega shaped• Cricoid cartilage is narrowest portion of

upper airway (~7 years changes to glottic area)

• Carina is only 4 cm below vocal cords• Tracheal diameter: 4 mm vs 16 mm

Other Considerations

• Ribs are more horizontal (not bucket handle). Rely primarily on diaphragmatic breathing.

• Breath sounds transmit well due to thin thoracic wall, but harder to localize sounds.

Newborn X Ray

Infant X Ray

Other Aspects of Newborn

• Higher metabolic rate: 100 cal/kg vs 40-50 cal/kg

• Reactions to medicines not predictable– High metabolic rate– Immature liver and kidneys

• High surface area to body weight ratio

Gestational Age Assessment

• Dubowitz Gestational Age Assessment– 11 physical signs– 10 neurologic signs– Useful in the first 5 days of life

• Ballard Gestational Age Assessment– 6 neurologic signs– 6 physical signs– Before 42 hours of life (ideal 30 to 42

hours)

Ballard Gestational Age Assessment

Physical Signs

• Skin• Lanugo• Plantar surface • Ear recoil• Breast tissue• Genitalia

Size for Gestational Age

• Two reasons for low-birth-weight infant– Prematurity– Growth retardation

• Size for gestational age– Appropriate for gestational age (AGA)– Large for gestational age (LGA)– Small for gestational age (SGA)

Weight vs Gestational Age: Boys

Weight vs Gestational Age: Girls

Signs of Respiratory Distress

• Synchrony of chest/abdomen movements

• Retractions– Lower chest (lateral ribs)– Xiphoid (substernal)

• Nasal flaring• Expiratory grunting• Cyanosis• Tachypnea

Respiratory Care Procedures

Fred Hill, MA, RRT

Endotracheal Tube Suctioning

• Two people– One to perform suctioning– One to monitor and provide support as

needed• Depth of catheter insertion

determined by length of ET tube; only to tip

• Size of suction catheter as per ETT size

• Suction pressure: -50 to -80 mm Hg

Suction Catheter Size

Endotracheal Tube Suction Catheter

2.5 5, 6

3.0 6-8

3.5 8-10

4.0 8-10

Suction Catheter Size

Nonintubated Suction Catheter

Preemie 5, 6

Term 6-8

Newborn to 6 months 8-10

Oxygen

• Hazards– Retinopathy of prematurity– Bronchopulmonary dysplasia

• Oxygen Hood (Oxyhood)– High flow device– Usually <0.6 FiO2– Flows >7 lpm– Appropriate temperature of gas

• Cannulas: always humidified with newborns, 1/8 to 1 lpm typical flows or 0.2 to 1 lpm

Oxyhood