Respiratory Problems in the

Newborn

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

Common Respiratory Problems in the Newborn

TTN RDS MAS Infection (e.g.pneumonia, sepsis) PPHN

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

Respiratory Distress Syndrome

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)

Flow-Inflating Bag

Self- Inflating Bag

T-Piece Resuscitators

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

Pneumonia

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

Surgical Causes

Examination of the neck, nose, mouth and throat

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