An approach to Respiratory Distress in Newborn

An approach to Respiratory Distress in Newborn

By Goh Kiam Seong

HTAR, Klang2011

Plan• Introduction• Causes and

Classification• Respiratory Distress

Signs• Evaluation and

Investigation• General Management

Introduction

Respiratory Distress in Newborn = Abnormal respiratory signs in neonates

Causes and Classification

Respiratory Distress in Newborn

Causes

Respiratory

Extrapulmonary

Management

Medical

Surgical

Causes

Respiratory

Extrapulmonary

Upper Airway Obstruction

Choanal Atresia

Pierre Robin Sequence

Laryngeal pathology

Lower Airway

TTN

RDS/HMD

MAS

Congenital Pneumonia

Air Leak Syndrome

Milk Aspiration

Rib cage anomalies

Congenital Diaphragmatic

Hernia

Neuromuscular diseases PPHN

Congenital Heart Diseases Shock Anaemia Polycythaemia

Hypoglycaemia Hypothermia Metabolic acidosis

Intracranial Birth Trauma/

Encephalopathy

Causes

Respiratory

Extrapulmonary

ManagementMedical

• TTN• MAS• RDS/HMD• Pneumonia• Milk Aspiration• CHD• Shock• Anaemia• Polycythaemia• Hypoglycaemia• Hypothermia• Metabolic Acidosis

Surgical

• Choanal atresia• Pierre Robin Sequence• Air Leak Syndrome• Rib cage anomalies• Congenital Diaphragmatic

Hernia• Air Leak Syndrome• Intracranial Birth Trauma/

Encephalopathy

Respiratory Distress in Newborn

Tachypnoea

Retractions

GruntingNasal Flaring

Cyanosis

Respiratory Distress Signs

Respiratory Rate:

< 1 week up to 2 months: 60 or more2 to 12 months: 50 or more12 months to 5 years: 40 or more

Respiratory Distress in Newborn

Tachypnoea

Retractions

GruntingNasal Flaring

Cyanosis

Tachypnoea

• Due to negative intrapleural pressure generated between the contraction of diaphragm, respiratory muscles and the mechanical properties of lung and chest wall– Suprasternal Retraction SSR– Intercostal Retraction ICR– Subcostal Retraction SCR

Respiratory Distress in Newborn

Tachypnoea

Retractions

GruntingNasal Flaring

Cyanosis

TachypnoeaRetractions

Suprasternal Retraction SSR

Subcostal Retraction SCR

Intercostal Retraction ICR

• Expiration through partially closed vocal cords to increase airway pressure and lung volume resulting in improved ventilation-perfusion (V/P) ratio

• Low pitched expiratory sound.• Protective phenomenon to

prevent collapse of alveoli: PEEP

Respiratory Distress in Newborn

Tachypnoea

Retractions

GruntingNasal Flaring

Cyanosis

Grunting

Video – Baby Grunting

• Grunting Baby pt. 2.flv

• Narrow nasal space contributes to total lung resistance

• Nasal flaring decreases the work of breathing

Respiratory Distress in Newborn

Tachypnoea

Retractions

GruntingNasal Flaring

Cyanosis

Nasal Flaring

• Clinical detection of cyanosis depends on total amount of desaturated HB in blood– Anaemic infants may have low

PaO2 that is missed clinically– Polycythaemic infants with

normal PaO2 can appear cyanotic

Respiratory Distress in Newborn

Tachypnoea

Retractions

GruntingNasal Flaring

Cyanosis

Cyanosis

Cyanotic Baby Pink Baby

Central cyanosis, +ICR, +SCR, +NF

What respiratory distress signs you can see here in this child?

Evaluation and Investigation

History Examination

Investigation

Antenatal US Finding

Amniotic Fluid IndexRenal Agenesis

?Pulmonary Hypoplasia?RDS

LiquorOligohydramnio?Pulmonary Hypoplasia

Polyhydramnios?Cong Diaphr Hernia?Oesoph atresia/TEF

MSAF TMSL/MMSL/LMSL

?MAS ?PPHN

Gestation/DeliveryTerm LSCS

?TTNPreterm (no dexa)

?RDS

Postdate (IOL,MSAF)

?MAS

History Examination Investigation

History Examination Investigation

Risk FactorsIDM

?HypoglycaemiaGBS+ Mother

?Sepsis/Congenital Pneumonia

Condition at birthDistress

?Met acidosisNot vigorous

?Asphyxial Lung DsRequire resus at birth?Air Leak Syndrome

Leaking Liquor>18hrs

?Presumed SepsisPPROM/PROM Maternal UTI

?Presumed Sepsis

at birth

Respiratory Distress

later after a period of normal function

Term Baby

• TTN• MAS• Congenital

Pneumonia• Dev Anomalies

Preterm Baby

• RDS• Congenital

Pneumonia• TTN

Possible causes

• Acquired/Nosocomial Pneumonia

• Dev anomalies• CHD• IEM• Metabolic (Met

acidosis/ electrolytes)

History Examination Investigation

• T – hypo/hyperthermic• RR – tachy/apnoea• HR – tach/bradycardia• SPO2 – desaturate?

Vitals

• Pallor • Plethoric• SGA/LGA• Macrosomic/hydroptic

General Condition

• Cleft palate• Excessive oral

secretion

Oral Cavity

• Pierre Robin • Potter face

Congenital

anomalies

Potter face: abnormal facies with a beak nose, receding chin, broad nasal bridge, epicanthal folds, and large low set ears

History Examination Investigation

• Dextrocardi,murmurs• In-drawing sternum• Air entry

CVS/Lung

• Scaphoid abdomenAbdomen

• Meconium stainedUmbilical cord/ Nails

• Hypotonia• Poor sucking reflex• Incomplete Moro

Tone/ Reflexes

Meconium stained Cord

Meconium stained Nail

Silverman Anderson Score for Premature Baby

Score Upper Chest Retraction

Lower Chest Retraction

Xiphoid Retraction

Nasal Flaring Grunting

0 Synchronous None None None None

1 Lag on Inspiration

Just visible Just visible Minimal Stethoscope

2 See-Saw Mark Mark Mark Naked ear

Downe’s Score for Term BabyScore Respiratory

RateCyanosis Air entry Retraction Grunting

0 <60 None Good None None

1 60-80 In air Decrease Minimal Stethoscope

2 >80/ apnoea In 40% O2 Barely audible

Moderate/ severe

Naked ear

Score > 6 = impending Respiratory Failure

History Examination Investigation

SPO2 monitoring

VBG/ ABG FBC

DXT Blood C+S/LP

CXR Portable

Look for:• O2 Saturation• Metabolic/ respiratory

acidosis/ alkalosis• Blood counts

(Hb/TWC/Plt/Ht)• Glucose level• Sepsis causative agent• Collapse/Air

Leak/CDH/ Cardiomegaly

General Management

Respiratory Support

Supportive Care

Definitive/Specific Therapy

• O2 Delivery• PEEP/ Mechanical ventilation

(CPAP/SiPAP)• Intubation and suction

• HR monitoring• Continuous SPO2

monitoring• Temp/DXT monitoring• I/O charting• Feeding (PO/TPN)• Cot/Incubator nursing

According to diagnosis

Causes

Respiratory

Extrapulmonary

Upper Airway Obstruction

Choanal Atresia

Pierre Robin Sequence

Laryngeal pathology

Lower Airway

TTN

RDS/HMD

MAS

Congenital Pneumonia

Air Leak Syndrome

Milk Aspiration

Rib cage anomalies

Congenital Diaphragmatic

Hernia

Neuromuscular diseases PPHN

Congenital Heart Diseases Shock Anaemia Polycythaemia

Hypoglycaemia Hypothermia Metabolic acidosis

Intracranial Birth Trauma/

Encephalopathy

Our topics today

Pierre Robin Sequence (PRS)

Definition• PRS is a facial difference caused by

underdevelopment of the lower jaw • Characterised by:– Micro- and retrognathia– glossoptosis – respiratory obstruction – With or without cleft palate.

• Incidence = 1:8500-14000 birth• =

PRS is a sequence not syndrome!

•Because underdeveloped lower jaw begins a sequence of events which leads to

abnormal position of tongue and cleft palate.

Aetiology

• Unknown• Recently identify

may be caused by genetic anomalies at chromosomes 2, 11, or 17

PRS is often part of an underlying disorder or syndrome

• Stickler syndrome• Velocardiofacial syndrome• Fetal Alcohol syndrome• Treacher Collins Syndrome

PathophysiologyAt 12 -14/52 GA

Movement of the head causes the jaw to "pop out' of the

collar bones

Only from this time, jaw of the fetus

grows as it would normally

9-11/52 GA

Tongue moves down and away from roof of the

mouth

Allow space for the side of palate

to shift to the midline to close

In PRS

Small jaw keeps tongue positioned

higher and posteriorly in mouth than

normal

Interfering normal closure

of palate

U shaped cleft palate

How to diagnose?

• Only by examining the patient at birth

Complication

• Difficulties in breathing and feeding.

GERD more prevalent in children with Robin sequence. (Dudkiewicz, CPCJ Mar 2000)

Our tactics

• Position: Keep in prone or lateral position

• Feeding: Tube feeding or Haberman feeder

• Nutrition: Increase daily calorie intake

• SPO2 monitoring

Other considerations

• Endotracheal intubation/tracheostomy• Tongue lip adhesion• Ophthalmology follow up – if suspect Sticker

syndrome (possible retinal detachment)• Mandibular distraction (distraction

osteogenesis)• Cleft palate reparation (6.5 mo- 2 yo)

Choanal Atresia• Choanal atresia is a congenital disorder where choana is

blocked by abnormal bony or soft tissue formed during fetal development

• Cause: unknown (thin tissue separating the nose and mouth area during fetal development remains after birth)

• Most common nasal abnormality in newborn (1 in 7,000 live births)

• : = 1 : 2• >50% associated with other congenital disorder• Diagnosed shortly after birth

Types• Unilateral• Bilateral

• Membranous• Osseous

Symptoms and Signs

Cyanosis during feeding

Pink while crying

• Inability to nurse and breathe at same time• Inability to pass a catheter through each side

of the nose into the throat• Persistent one-sided nasal blockage or

discharge

Associated conditions

• Coloboma • Heart defects• Retardation of growth or

mental development• Genital/urinary

abnormalities• Ear anomalies/deafness

IF associated with all these ~ CHARGE syndrome (defect in Chromosome 8 CHD7 gene)

Tests that may be done include:

• CT scan• Endoscopy of the nose• Sinus x-ray

Endoscopic view of choanal atresia.mt: middle turbinate; it: inferior turbinate; ns: nasal septum; a: atresia "plate".

Management

• Secure the airway (laryngeal mask, intubation or tracheostomy may be needed)

• If infant can learn to mouth breathe, can delay the need for immediate surgery.

• Otherwise, surgery to remove the obstruction required (transnasal or transpalatal).