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Respiratory Disorders in the Newborn
Perinatologi DivisionDepartment of Child HealthMedical Faculty
of Hasanuddin University
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IntroductionEncountered frequently Incidence 4 to 6 % of live
birthsPotentially life-threatening conditionsEarly recognition,
timely referral, appropriate treatment essentialAly H, Pediatrics
in Review 2004;25:201-208Deorari, A. RD in a newborn baby. Teaching
aids on newborn care. NNF. India. 2005
-
introductionThe key to succesful management :Complete maternal
and newborn historyComplete physical examination Recognize the
common respiratory disorderDifferentiate among various diagnostics
entitiesIdentify those that are life-threateningAly H, Pediatrics
in Review 2004;25:201-208
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DefinitionCharacterized by one or more of the following :Nasal
flaring Chest retractionsTachipnea (RR > 60/min) Grunting
Aly H, Pediatrics in Review 2004;25:201-208
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definitionAdvanced degree of respiratory distress
:CyanosisGaspingChokingApneaStridorAly H, Pediatrics in Review
2004;25:201-208
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Evaluation of RespiratoryDistress Using Downes Score
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evaluationScore < 4Mild respiratory distress
Score 4 -7Severe Respiratory distress
Score > 7 Impending respiratory failure (Blood gases should
be obtained)
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Initial assesmentConditions that require immediate support
:Obstructed airway (gasping, choking,stridor)Insufficient breathing
(apnea, poor respiratory effort)Circulatory collapse (bradycardia,
hypotension, poor perfusion)Poor oxygenation (cyanosis) Aly H,
Pediatrics in Review 2004;25:201-208
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initial assesmentImmediate oxygen support needed :Possibly bag
and mask ventilationEven intubation and mechanical ventilation
Aly H, Pediatrics in Review 2004;25:201-208
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initial assesmentBe prepared :Resuscitation equipment and
suppliesSenior physicians and other health care team
personnelResuscitation guideline should be followed in stepwise
mannerAly H, Pediatrics in Review 2004;25:201-208
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HistoryMaternal historyDrug abuseDiabetes melitusInfectionsAly
H, Pediatrics in Review 2004;25:201-208
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historyObstetrical historiesGestational age (if preterm steroid
?)Results of fetal assesment and fetal monitoring during labor
& deliveryComplications at delivery birth trauma, presence of
meconium, perinatal depression, premature rupture of membranesAly
H, Pediatrics in Review 2004;25:201-208
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historyDetails of the presenting respiratory symptomsCoughing
and choking during feeding functional and structural should be
considered. If symptoms follow the feeding & recurrent emesis
reflux with aspiration suspectedGradually improving symptoms TTN
Gradual deterioration pneumonia / sepsisOnset of distressAly H,
Pediatrics in Review 2004;25:201-208
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Preterm- Possible EtiologyDeorari, A. RD in a newborn baby.
Teaching aids on newborn care. NNF. India. 2005
Early progressive Hyaline membrane disease
Early transientMetabolic causes, hypothermiaAnytimePneumonia
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Term- Possible EtiologyDeorari, A. RD in a newborn baby.
Teaching aids on newborn care. NNF. India. 2005
Early well lookingTTN, polycythemiaEarly severe distressMAS,
asphyxia, malformationsLate sick with hepatomegalyCardiacLate sick
with shockAcidosisAnytimePneumonia
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Physical examinationInspection is the first and most important
toolApnea, poor perfusions, retractions, cyanosis Inspiratory
stridor upper airway obstruction Stridor (previous history of
intubation) subglottis stenosisAsymmetric chest movement + severe
distress maybe tension pneumothoraxScaphoid abdomen diaphragmatic
herniaAly H, Pediatrics in Review 2004;25:201-208
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physical examinationAuscultation Symmetry and adequacy of air
exchangeAbnormal breaths soundThe presence of heart murmur
Chest transilumination to detect pneumothoraxAly H, Pediatrics
in Review 2004;25:201-208
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physical examinationSuspect surgical causeObvious
malformationScaphoid abdomenFrothingHistory of aspiration
Deorari, A. RD in a newborn baby. Teaching aids on newborn care.
NNF. India. 2005
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Differential diagnosis of respiratory distress Pulmoner
(Respiratory diseases)Extra Pulmoner:Cardiac diseasesNeurological
disorderOther Miscellaneous DiseasesAly H, Pediatrics in Review
2004;25:201-208
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A. Airway ObstructionsNasal StenosisPierre RobinsSequenceVocal
Cord paralysisVascular RingsChoanal AtresiaLaryngeal stenosis or
atresiaHemaglomaTracheobrochial stenosisRESPIRATORY DISEASES
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B. Disorders of the Chest Wall and DiaphragmDisorders of the
chest wallCongenital diaphragmatic hernia
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C. Malformation of the Mediastinum and Lung Parenchyma
Congenital cystic adenomatoid malformation Congenital pulmonary
cystNeoplasms (teratomas, mediastinal, neurablastoma Congenital
lobar emphysemaPulmonary arteriovenous
malformationsBronchopulmonary sequestrations
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D. Air Leak SyndromesPulmonary interstitial
emphysemaPheumoperitoneumPneumothoraxPneumomediastinum
Pneumopericardium
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Pulmonary Parenchymal and Vascular DiseaseLung Parenchymal
Disease:Persistent pulmonary hypertension of the
newbornPneumoniaPulmonary edemaTranscient tachypnea of
newbornMeconium aspiration syndromeHyaline membrane
diseaseCongenital alveolar proteinosis
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Cardiac DiseasesA. CyanoticB. AcyanoticHypoplastic left heart
syndromeInterrupted aortic archCritical aortic coarctationPatent
ductus arterioususPulmonic stenosisTetralogy of FallotTransposition
of great arteriesTotal anomalous pulmonary venous returnEbsteins
anomalyTricuspidal atresiaSevere congestive heart failure
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Neurological DisorderBirth TraumaIntravenricular
hemorrhageMeningitisPrimary seizure disorderObstructed
hydrocephalusHypoxic ischemic encephalopathyInfantile
botulismSpinal Cord injuryMuscular diseases (myasthenia gravis,
poliomyelitis)
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Other Miscellaneous DiseasesSepsisAnemia or polycythemiaHypo or
hyperthemiaHypo or hypernatremiaHypoglycemiaInborn errors of
metabolismMaternal medication (magnesium sulfate or opiates) or
drug abuse
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Medical causes of respiratory distress Transient tachypnea of
the newborn (TTN)Hyaline membrane disease (HMD)Meconium aspiration
syndrome (MAS)Air leak syndromePneumoniaCongenital heart
diseases
Aly H, Pediatrics in Review 2004;25:201-208
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Surgical causes of respiratory distressTracheo-esophageal
fistulaDiaphragmatic herniaLobar emphysemaPierre-Robin
syndromeChoanal atresiaDeorari, A. RD in a newborn baby. Teaching
aids on newborn care. NNF. India. 2005
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InvestigationsComplete blood count (anemia, polycythemia,
sepsis) Chest X-rayArterial blood gasGlucose check
(hypoglycemia)Blood culture (sepsis, pneumonia)Aly H, Pediatrics in
Review 2004;25:201-208
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TreatmentAfter stabilization, treat the cause of respiratory
distressAvoid unnecessary exposure to oxygenAntibiotics until
sepsis is ruled outAly H, Pediatrics in Review 2004;25:201-208
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Transient Tachypnea of the Neonate (TTN)Aly H, Pediatrics in
Review 2004;25:201-208Respiratory distress of near term or term
neonateTransient pulmonary edema resulting from delayed clearance
of fetal lung fluids
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PathogenesisLung fluids produce in utero by chloride pump water
and chlor to alveolar space2-3 d before delivery transformation
process pulmonary epithelium changes to Na-absorbing lung fluid
away from alveolar spaceLow oncotic pressure favors fluid movement
from alveolar space into the interstitium
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pathogenesisProstaglandin secretion lymphatic dilation
accelerates fluid clearance from interstitiumLung expansion water
to interstitium gradually remove from lung by the lymphatic system
and pulmonary blood vessels Aly H, Pediatrics in Review
2004;25:201-208
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Risk factors
Cesarean section without laborMacrosomiaMale sexProlonged
laborExcessive maternal sedation Low Apgar score (< 7 at 1
minute)Aly H, Pediatrics in Review 2004;25:201-208
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Clinical presentationTachipnea shortly after birth May have
grunting, nasal flaring, rib retractions, and cyanosis Symptoms
improve as lung fluid mobilized, and usually associated with
diuresisFull recovery expected within 2 to 5 days Aly H, Pediatrics
in Review 2004;25:201-208
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Chest X-Ray
Increased interstitial markings and occasionally fluids in the
interlobar fissurePleural effusion and signs of alveolar edema may
be seenAly H, Pediatrics in Review 2004;25:201-208
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ManagementAly H, Pediatrics in Review 2004;25:201-208Oxygen
therapy some infants may need NCPAP Feeding as tachypnea
improves
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PrognosisAly H, Pediatrics in Review 2004;25:201-208Self-limited
disease There is no risk of recurrence or further pulmonary
dysfunction
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Hyaline membrane disease= Respiratory Distress Syndrome
Also called respiratory distress syndrome (RDS) Usually occurs
in a preterm neonateSurfactant deficiency
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Incidence About 25% of neonates born at 32 weeks gestationThe
incidence increases with increasing prematurityAly H, Pediatrics in
Review 2004;25:201-208
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Predisposing factors
PrematurityMale sexNeonate of diabetic motherAsphyxiaAly H,
Pediatrics in Review 2004;25:201-208
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Protective Factors Chronic intrauterine stress Prolonged rupture
of membranes Maternal hypertensionNarcotic useIntrauterine Growth
Retardation (IUGR) or Small for Gestational Age
(SGA)Corticosteroids PrenatalAly H, Pediatrics in Review
2004;25:201-208
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Clinical Manifestation Increasing tachypnea (> 60/min)Chest
retractionsCyanosis on room air that persists or progresses over
the first 24-48 hours of life.Decreased air entryGrunting
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Investigations
Laboratory studies: Blood gases: hypoxia, hypercarbia,
acidosisCBC and blood culture are required to rule out
infectionSerum glucose levels are usually lowChest X-ray
study:Reveals ground glass appearance with air bronchograms
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ManagementResuscitation by experienced pediatric staff :Prompt
gentle stimulation and inflation to produce and maintain the FRC by
CPAP and PPVGive surfactant as soon as possibleMinimize heat
lossThe Royal Womens Hospital, Clinicians Handbook, 2007
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Surfactant therapyShould be used only if facilities for
ventilation availableCostProphylactic Vs RescueDeorari, A. RD in a
newborn baby. Teaching aids on newborn care. NNF. India. 2005
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surfactant therapyProphylactic therapyExtremely preterm < 28
wks < 1000 gmRescue therapyAny neonate diagnosed to have RDS
Dose 100 mg / kg phospoholipid intra trachealDeorari, A. RD in a
newborn baby. Teaching aids on newborn care. NNF. India. 2005
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Radiologic appearance before and after surfactant therapy
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Transportation to NICUAfter resuscitation transferred to NICU
without any deterioration Keep warm and avoid hypoxemia by giving
O2, CPAP or IPPV as neededUse pulse oximeter for adequacy of O2
Neonatal Respiratory Disorders 2nd ed, 2003, 247-71
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transportation to NICUIf longer transport is needed Neonatal
transport team Assisted ventilation preferred than CPAPAdequate
cardiorespiratory monitoringSurfactant given before
transportationStabilization needed after surfactant
treatmentNeonatal Respiratory Disorders 2nd ed, 2003, 247-71
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Stabilization on the NICUUnder radiant warmer not longer than
1-2 hours to place IV and arterial lines, and to do CXR and
abdominal X ray After stabilization the infants should be placed in
humidified incubatorNeonatal Respiratory Disorders 2nd ed, 2003,
247-71
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stabilization on the NICUIn the first hour organize :A
thermoneutral environmentClear airwayOxygen saturation 88-92% (not
too high)Maintain lung volume if recession CPAP or PPV as
necessaryMaintain adequate breathing or ventilationThe Royal Womens
Hospital, Clinicians Handbook, 2007
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stabilization on the NICUBlood tests: arterial gases, full blood
examination, cultures, cross matchChest X-ray IV 10% dextrose to
prevent hypoglycemiaMinimal handlingDont feedThe Royal Womens
Hospital, Clinicians Handbook, 2007
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stabilization on the NICURespiratory support :Head box (heated
and humidified) if minimal recession and FiO2 30%Consider PPV if
FiO2 >60% and/or high and rising PaCO2The Royal Womens Hospital,
Clinicians Handbook, 2007
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stabilization on the NICUIndications for insertion an arterial
catheter :O2 requirement >30%Likely to require several blood
gasesBlood pressure monitoringThe Royal Womens Hospital, Clinicians
Handbook, 2007
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stabilization on the NICUMetabolic acidosis :pH 7.25 and BE >
- 8 with normal PaCO2Treat underlying cause before bicarbonate, eg
hypoxia, hypotension, hypovolemia, septicemiaImprove when the baby
is ventilatedUse bicarbonate if other treatment dont work and
severe acidosisThe Royal Womens Hospital, Clinicians Handbook,
2007
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stabilization on the NICULow blood pressure :Not due to blood
loss give 10-20 mL/kg of normal saline over 30 minIf this does not
work use dopamineBlood loss is corrected by a similar volume blood
transfusionThe Royal Womens Hospital, Clinicians Handbook, 2007
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Fluid managementPeripheral vein or umbilical vein 10% dextrose
and calcium 60 mL/kg/dayAdjust fluid intake by assessing sodium and
glucose levelKeep blood glucose above 2.0 mmol/LTPN on day 2 or 3
if respiratory distress persistNo oral feeds until minimal
respiratory distressThe Royal Womens Hospital, Clinicians Handbook,
2007
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fluid managementRadiant warmer and phototherapy IWLPDA
indication for fluid restrictionDiuretics are not recommended
Kavvadia V, et al, J Perinat Med 1998;26:469-74
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Ventilatory supportCPAP and PPV reduce mortality in neonates
with RDSCPAP should be used for baby with vigorous spontaneous
respiration (initial pressure 5-6 cm H2O, sometimes higher pressure
of 7-8 cm H2O needed)The Royal Womens Hospital, Clinicians
Handbook, 2007
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ventilatory supportIPPV should start at high rates (60-80/min),
peak pressure 20 cm H2O or less, inspiration time 0,3-0,4 seconds,
PEEP levels 3 cm H2O (increased if RDS is severe). Inspiratory time
and ventilator rates should be manipulated to have synchronyInfants
requiring mechanical ventilation may need sedation with morphine
Suction is rarely needed early in the course of RDSHalliday HL,
Croatian Medical Journal 1998;39:165-70
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ventilatory supportAfter surfactant therapy ventilator setting
must be adjusted downwardThe lowest ventilator setting should be
used to reduce BPDHFOV is not recommended as starting treatment for
infants with RDSAdequate humidification of inspired gases is very
important Handerson-Smart DJ, et al, The Cochrane Library, Issue 1,
2003
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Nasal CPAP
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Sudden deterioration in ventilated infantThe Royal Womens
Hospital, Clinicians Handbook, 2005PneumothoraxEndotracheal tube
blockage or displacementMechanical failure with the
ventilatorIncrease severity of underlying lung diseaseMassive
intraventricular haemorrhageAbdominal distentionPulmonary
haemorrhage
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ComplicationsAir leaksPulmonary hemorrhagePeriventricular
hemorrhagePatent ductus arteriosusChronic lung diseaseRetinopathy
of prematuritySubglottic stenosisThe Royal Womens Hospital,
Clinicians Handbook, 2005
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Meconium aspiration syndrome (MAS) Respiratory distress due to
aspiration of meconium by the fetus in utero or by the neonate
during labor and deliveryMSAF : 10-26% of all deliveries mostly in
term and postterm deliveriesmay represent fetal hypoxemiaAly H,
Pediatrics in Review 2004;25:201-208
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PathogenesisAspiration of meconiumAirway obstruction (ball and
valve)Chemical pneumonitis with activation of several inflammatory
mediatorsInactivation of lung surfactan
Aly H, Pediatrics in Review 2004;25:201-208
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pathogenesisAspiration of meconiumThin MSAF chemical
pneumonitisThick MSAF atelectasis, airway blockage, airleak
syndromAly H, Pediatrics in Review 2004;25:201-208
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Risk factorsPost-term pregnancyMaternal hypertensionAbnormal
fetal heart rateBiophysical profile 6Pre-eclampsiaMaternal diabetes
mellitusSGAChorioamnionitisAly H, Pediatrics in Review
2004;25:201-208
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Clinical presentationMeconium stain amniotic fluid before
birthMeconium staining of neonate after birthVarying degree of
respiratory distress; barrel chest; audible ralesPersistent
pulmonary hypertension of the newbornPneumotorax (10%-20% infants
with MAS)Aly H, Pediatrics in Review 2004;25:201-208
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Laboratory StudiesComplete blood countBlood gas analysisBlood
culture Aly H, Pediatrics in Review 2004;25:201-208
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Chest X-RayPatchy areas of atelectasis alternating with areas of
overinflation Hyperinflation of the lung and flattening of the
diaphragmAly H, Pediatrics in Review 2004;25:201-208
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Management
Prenatal managementIdentification of high-risk
pregnancyMonitoring of fetal heart rate during laborAly H,
Pediatrics in Review 2004;25:201-208
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managementDelivery room managementSuction infants mouth, pharinx
and nose as soon as complete deliveredPlaced under radiant warmer
suction the hypopharinx to clear any residual meconiumDepressed
infants (depressed respiration, HR < 100 beat / min, poor muscle
tone) tracheal visualization and suctioning should be performedAly
H, Pediatrics in Review 2004;25:201-208
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managementGeneral management
Empty the stomach contents to avoid further aspirationCorrection
of metabolic abnormalities e.g. hypoxia, acidosis, hypoglycemia,
hypocalcemia and hypothermiaSurveillance for end organ
hypoxic/ischemic damage (brain, kidney, heart and liver)Aly H,
Pediatrics in Review 2004;25:201-208
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managementRespiratory management
Frequent suction and chest vibrationPulmonary toilet to remove
residual meconium if intubatedAntibiotic coverage Ventilatory
supportECMOAly H, Pediatrics in Review 2004;25:201-208
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PrognosisMortality rate may be as high as 50%. Survivors may
suffer from bronchopulmonary dysplasia and neurologic sequelae.Aly
H, Pediatrics in Review 2004;25:201-208
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Air leak syndromes Spectrum of diseases with the same underlying
pathophysiology : Overdistension of alveolar space or terminal
airwaysDisruption of airway integrityDissection of air into
surrounding spacesAly H, Pediatrics in Review 2004;25:201-208
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IncidenceMost common in neonates with lung disease who are on
ventilatory support but can also occur spontaneouslyThe more severe
the lung disease, the higher the incidence of pulmonary air leakAly
H, Pediatrics in Review 2004;25:201-208
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Risk FactorsSpontaneous 0.5%Ventilatory support 15-20%CPAP 5%
Meconium staining / aspirationSurfactant therapyVigorous
resuscitation (bag ventilation)Aly H, Pediatrics in Review
2004;25:201-208
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Clinical manifestation
Respiratory distress Sudden deterioration of clinical course
with alteration of vital signs and worsening of blood
gasesAsymmetry of thorax is present in unilateral casesAly H,
Pediatrics in Review 2004;25:201-208
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InvestigationsThe definitive diagnosis of all air leak syndromes
is made radiographically by A-P and lateral chest X-ray. Aly H,
Pediatrics in Review 2004;25:201-208
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ManagementGeneralAvoid ventilatorsCareful use of manual bag
ventilation
SpecificDecompression of air leak according to the type.Do not
needle the chestAly H, Pediatrics in Review 2004;25:201-208
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Congenital and postnatal pneumoniaDeveloping countries pneumonia
> 50% cases of respiratory distressTerm and post term primary
pneumonia because of prenatal aspiration due to fetal hypoxia as a
result of placental disfunctionPreterm postnatal pneumonia as
consequence os septicemia, aspiration of feeds and ventilation for
respiratory failure Deorari, A. RD in a newborn baby. Teaching aids
on newborn care. NNF. India. 2005
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Clinical ManifestationTachipnea, respiratory distress with
subcostal retractions, expiratory grunt and cyanosisLethargy, poor
feeding, jaundice, apneic attacks, temperature instabilityCough
rare in newborn babyDeorari, A. RD in a newborn baby. Teaching aids
on newborn care. NNF. India. 2005
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ManagementSupportive treatment should be providedThermoneutral
environment NPO IV fluids given Oxygen given to relieve cyanosis
Antibiotics started
Deorari, A. RD in a newborn baby. Teaching aids on newborn care.
NNF. India. 2005
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Congenital pneumoniaPROM > 24 hours, foul smelling liquor,
peripartal fever, prolonged / difficult delivery, single or
multiple unclean vaginal examinationRespiratory distress soon after
birth / during first 24 hoursAuscultation non spesific
Deorari, A. RD in a newborn baby. Teaching aids on newborn care.
NNF. India. 2005
-
Congenital pneumonia
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Nosocomial pneumoniaRisk factor: Ventilated neonates: Preterm
neonatesPrevention: Hand wash: Use of disposables: Infection
control measuresAntibiotics: Usually require higher antibiotics
Deorari, A. RD in a newborn baby. Teaching aids on newborn care.
NNF. India. 2005
-
Congenital heart diseaseMay present with cyanosis and heart
failureCHD and pulmonary disease can coexistDifferentiation between
heart and lung disease are cumulative Aly H, Pediatrics in Review
2004;25:201-208
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Clinical manifestationVisible hyperactive precordial
impulseGallop rhythm Poor capillary refillWeak pulseDecreased /
delayed pulse in lower extremitiesHepatomegalyAbnormal vascularity
or cardiomegaly on CXRAly H, Pediatrics in Review
2004;25:201-208
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clinical manifestationSingle second heart soundNo hypercapnia
unless associated with lung diseaseTachypnea is common; no chest
retraction Decreased oxygen saturation Hyperoxygenation test no
significant increase in PaO2 in most infants with cyanotic CHDAly
H, Pediatrics in Review 2004;25:201-208
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Cyanotic Heart DiseasePulmonary DiseaseHistoryPrevious sibling
who has CHDDiagnosis of CHD by prenatal ultrasonographyMaternal
feverMeconium stained amniotic fluidPreterm deliveryPhysical
findingsCyanosisGallop rhythmSingle second heart soundLarge
liverMild respiratory distressCyanosisSevere retractionSplit second
heart soundFeverArterial Blood GasesNormal or decreased
PCO2Decreased PO2Increased PCO2Decreased PO2
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Cyanotic Heart DiseasePulmonary DiseaseChest RadiographIncreased
heart sizeDecreased pulmonary vascularity (except in transposition
of the great vessels and total anomalous pulmonary venous
return)Normal heart sizeAbnormal pulmonary parenchyma, such as
:Total whiteout or patches of consolidation in pneumoniaFluid in
the fissures in TTNGround glass appearance in HMDHyperoxygenation
test EchocardiographyPaO2 < 150 mm Hg
Abnormal heart or vesselsPaO2 > 150 mm Hg (except in severe
PPHN)Normal heart and vessels
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Respiratory distress needing referralRDS (HMD)MASSurgical or
cardiac causePPHNSevere or worsening distressAly H, Pediatrics in
Review 2004;25:201-208
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Apnea Cessation of respiration for more than 20 seconds or less
than 20 seconds accompanied by bradycardia and / or cyanosis
Aly H, Pediatrics in Review 2004;25:201-208
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Incidence50-60% of preterm neonates have evidence of apnea (35%
with central apnea, 5-10% with obstructive apnea, and 15-20% with
mixed apnea)Aly H, Pediatrics in Review 2004;25:201-208
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Risk factorsPathological
apneaHypothermiaHypoglycemiaAnemiaHypovolemiaAspirationNEC /
DistensionCardiac diseaseLung diseaseGastro intestinal refluxAirway
obstructionInfection, meningitisNeurological disordersAly H,
Pediatrics in Review 2004;25:201-208
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InvestigationsMonitoring at-risk neonates less than 32 weeks
gestational ageEvaluate for a possible underlying causeLaboratory
studies should include a CBC, blood gas analysis, serum glucose,
electrolyte, and calcium levelsRadiologic studies if lung disease
is suspectedAly H, Pediatrics in Review 2004;25:201-208
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Management
General management : Tactile stimulationPharmacological therapy
(caffeine or theophylline)CPAP in recurrent and prolonged apneaAly
H, Pediatrics in Review 2004;25:201-208
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managementSpecific therapyTreatment of the underlying diseases,
eg sepsis, hypoglycemia, anemia, and electrolyte abnormalitiesAly
H, Pediatrics in Review 2004;25:201-208
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Prognosis
In most neonates apnea resolves without the occurrence of
long-term deficiencies
Aly H, Pediatrics in Review 2004;25:201-208
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Summary1. Evaluate the severity of respiratory distress using
the Downe's Score2. Identify common neonatal respiratory disorders,
including:Transient Tachypnea of the Newborn (TTN)Respiratory
Distress Syndrome (RDS)Meconium Aspiration Syndrome (MAS)Air leak
syndromesApneaPneumonia
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summary3. Identify the risk factors, clinical presentation,
required laboratory and radiological investigations, and management
of TTN, RDS, MAS, Air Leak Syndromes, Pneumonia, Apnea
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Hyaline Membrane Disease (Respiratory Distress Syndrome)
(cont)Management of HMD (RDS)GeneralThermal regulation Parenteral
fluid AntibioticsContinuous monitoring
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Hyaline Membrane Disease (Respiratory Distress Syndrome)
(cont)Continuous positive airway pressure (CPAP) is tried.If under
CPAPPH < 7.2Or PO2 < 40mmHg FiO2 > 60%Or PCO2 >
60mmHBase deficit > -10 Endotracheal intubation and mechanical
ventilation.Consider surfactant therapy
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Hyaline Membrane Disease (Respiratory Distress Syndrome)
(cont)Caution: every 10 days on the ventilator is associated with
20% increased risk for cerebral palsy
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Hyaline Membrane Disease (Respiratory Distress Syndrome)
(cont)Specific TreatmentSurfactant replacement therapy if tracheal
intubation is requiredOutcomeRDS accounts for 20% of all neonatal
deathsChronic lung diseases occurs in 29% in VLBW infants
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Causes of Respiratory Distress - MedicalRespiratory distress
syndrome (RDS)Meconium aspiration syndrome (MAS)Transient
tachypnoea of newborn (TTN)Asphyxial lung
diseasePneumonia-congenital, aspiration, nosocomialPersistent
pulmonary hypertension (PPHN)Deorari, A. RD in a newborn baby.
Teaching aids on newborn care. NNF. India. 2005
-
< 2828 - 3132ProphylaxisRescueConsider if no antenatal
steroids, lung immaturity, male sex, and need for intubation in
resuscitationWhen needing IPPV and > 30-40% oxygenEspecially if
no antenatal steroids, known lung immaturity, male sex and need for
intubation in resuscitationGestational Age (Weeks)Guidelines for
early management of RDS (Advances in Perinatal Medicine, 1997,
360-70)
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MANAGEMENTDelivery room managementSurfactant
treatmentVentilatory supportGeneral supportive careNeonatal
Respiratory Disorders 2nd ed, 2003, 247-71
-
Prophylactic surfactantSurfactant is given within 10-15 minutes
of birthRecommended only for infants of less than 27-28 weeks of
gestation Egberts J, et al, Pediatrics 1983;102:912-7
-
Early rescue surfactantInfants > 32 weeks gestation, early
rescue is recommended if endotracheal intubation neededAt GA
between 28-31 weeks CPAP is recommended with surfactant given as
soon as intubation is neededIn resuscitating infants 23-31weeks of
gestation, surfactant must be available in delivery roomSurfactant
to those under 27-28 weeks GAIn reserve for those who need
intubation Neonatal Respiratory Disorders 2nd ed, 2003, 247-71
-
Rescue surfactantSurfactant given based on severity of RDS
assessed by clinical signs, blood gas result and CXRSurfactant
given earlier rather than later improves outcome and extubation to
CPAP will add advantagesNatural surfactants are preferred2nd and
3rd doses are indicated if relapseVerder H, et al, Pediatrics
1999;103:E24
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Conditions Associated with Respiratory Distress
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IntroductionRespiratory distressencountered frequently the most
frequent indication for re-evaluationPotentially life-threatening
conditionsEarly recognition, timely referral, appropriate treatment
essentialAly H, Pediatrics in Review 2004;25:201-208Deorari, A. RD
in a newborn baby. Teaching aids on newborn care. NNF. India.
2005
-
physical examinationChest examination Air entryMediastinal
shiftHyperinflationHearts soundsDeorari, A. RD in a newborn baby.
Teaching aids on newborn care. NNF. India. 2005
-
stabilization on the NICUAntibiotics :Start with IV antibiotics
soon after birth in every baby with respiratory distress because we
cant tell whether there is pneumonia / septicemiaThe Royal Womens
Hospital, Clinicians Handbook, 2007
-
Respiratory distress in a neonate with asphyxiaMyocardial
dysfunctionCerebral edemaAsphyxial lung injuryMetabolic
acidosisPersistent pulmonary hypertensionDeorari, A. RD in a
newborn baby. Teaching aids on newborn care. NNF. India. 2005
-
Persistent pulmonary hypertension of the
newbornCausesPrimarySecondary: MAS, asphyxia,
sepsisManagementSevere respiratory distress needing ventilatory
support, pulmonary vasodilatorsPoor prognosisDeorari, A. RD in a
newborn baby. Teaching aids on newborn care. NNF. India. 2005
Module: Neonatal Respiratory Disorders - Session 1*Module:
Neonatal Respiratory Disorders - Session 1*Module: Neonatal
Respiratory Disorders - Session 1*