Copy of Respiratory Disorder IDAI 101207

Respiratory Disorders in the Newborn

Perinatologi DivisionDepartment of Child HealthMedical Faculty of Hasanuddin University

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

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

definitionAdvanced degree of respiratory distress :CyanosisGaspingChokingApneaStridorAly H, Pediatrics in Review 2004;25:201-208

Evaluation of RespiratoryDistress Using Downes Score

evaluationScore < 4Mild respiratory distress

Score 4 -7Severe Respiratory distress

Score > 7 Impending respiratory failure (Blood gases should be obtained)

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

initial assesmentImmediate oxygen support needed :Possibly bag and mask ventilationEven intubation and mechanical ventilation


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

HistoryMaternal historyDrug abuseDiabetes melitusInfectionsAly H, Pediatrics in Review 2004;25:201-208

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

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

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

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

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

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

physical examinationSuspect surgical causeObvious malformationScaphoid abdomenFrothingHistory of aspiration

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005

Differential diagnosis of respiratory distress Pulmoner (Respiratory diseases)Extra Pulmoner:Cardiac diseasesNeurological disorderOther Miscellaneous DiseasesAly H, Pediatrics in Review 2004;25:201-208

A. Airway ObstructionsNasal StenosisPierre RobinsSequenceVocal Cord paralysisVascular RingsChoanal AtresiaLaryngeal stenosis or atresiaHemaglomaTracheobrochial stenosisRESPIRATORY DISEASES

B. Disorders of the Chest Wall and DiaphragmDisorders of the chest wallCongenital diaphragmatic hernia

C. Malformation of the Mediastinum and Lung Parenchyma Congenital cystic adenomatoid malformation Congenital pulmonary cystNeoplasms (teratomas, mediastinal, neurablastoma Congenital lobar emphysemaPulmonary arteriovenous malformationsBronchopulmonary sequestrations

D. Air Leak SyndromesPulmonary interstitial emphysemaPheumoperitoneumPneumothoraxPneumomediastinum Pneumopericardium

Pulmonary Parenchymal and Vascular DiseaseLung Parenchymal Disease:Persistent pulmonary hypertension of the newbornPneumoniaPulmonary edemaTranscient tachypnea of newbornMeconium aspiration syndromeHyaline membrane diseaseCongenital alveolar proteinosis

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

Neurological DisorderBirth TraumaIntravenricular hemorrhageMeningitisPrimary seizure disorderObstructed hydrocephalusHypoxic ischemic encephalopathyInfantile botulismSpinal Cord injuryMuscular diseases (myasthenia gravis, poliomyelitis)

Other Miscellaneous DiseasesSepsisAnemia or polycythemiaHypo or hyperthemiaHypo or hypernatremiaHypoglycemiaInborn errors of metabolismMaternal medication (magnesium sulfate or opiates) or drug abuse

Medical causes of respiratory distress Transient tachypnea of the newborn (TTN)Hyaline membrane disease (HMD)Meconium aspiration syndrome (MAS)Air leak syndromePneumoniaCongenital heart diseases


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

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

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

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

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

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

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

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

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

ManagementAly H, Pediatrics in Review 2004;25:201-208Oxygen therapy some infants may need NCPAP Feeding as tachypnea improves

PrognosisAly H, Pediatrics in Review 2004;25:201-208Self-limited disease There is no risk of recurrence or further pulmonary dysfunction

Hyaline membrane disease= Respiratory Distress Syndrome

Also called respiratory distress syndrome (RDS) Usually occurs in a preterm neonateSurfactant deficiency

Incidence About 25% of neonates born at 32 weeks gestationThe incidence increases with increasing prematurityAly H, Pediatrics in Review 2004;25:201-208

Predisposing factors

PrematurityMale sexNeonate of diabetic motherAsphyxiaAly H, Pediatrics in Review 2004;25:201-208

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

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

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

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

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

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

Radiologic appearance before and after surfactant therapy

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

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

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

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

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

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

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

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

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

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

fluid managementRadiant warmer and phototherapy IWLPDA indication for fluid restrictionDiuretics are not recommended

Kavvadia V, et al, J Perinat Med 1998;26:469-74

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

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

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

Nasal CPAP

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

ComplicationsAir leaksPulmonary hemorrhagePeriventricular hemorrhagePatent ductus arteriosusChronic lung diseaseRetinopathy of prematuritySubglottic stenosisThe Royal Womens Hospital, Clinicians Handbook, 2005

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

PathogenesisAspiration of meconiumAirway obstruction (ball and valve)Chemical pneumonitis with activation of several inflammatory mediatorsInactivation of lung surfactan


pathogenesisAspiration of meconiumThin MSAF chemical pneumonitisThick MSAF atelectasis, airway blockage, airleak syndromAly H, Pediatrics in Review 2004;25:201-208

Risk factorsPost-term pregnancyMaternal hypertensionAbnormal fetal heart rateBiophysical profile 6Pre-eclampsiaMaternal diabetes mellitusSGAChorioamnionitisAly H, Pediatrics in Review 2004;25:201-208

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

Laboratory StudiesComplete blood countBlood gas analysisBlood culture Aly H, Pediatrics in Review 2004;25:201-208

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

Management

Prenatal managementIdentification of high-risk pregnancyMonitoring of fetal heart rate during laborAly H, Pediatrics in Review 2004;25:201-208

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

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

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

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

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

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

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

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

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

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

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

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

ManagementSupportive treatment should be providedThermoneutral environment NPO IV fluids given Oxygen given to relieve cyanosis Antibiotics started


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


Congenital pneumonia

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

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

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

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

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

Respiratory distress needing referralRDS (HMD)MASSurgical or cardiac causePPHNSevere or worsening distressAly H, Pediatrics in Review 2004;25:201-208

Apnea Cessation of respiration for more than 20 seconds or less than 20 seconds accompanied by bradycardia and / or cyanosis


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

Risk factorsPathological apneaHypothermiaHypoglycemiaAnemiaHypovolemiaAspirationNEC / DistensionCardiac diseaseLung diseaseGastro intestinal refluxAirway obstructionInfection, meningitisNeurological disordersAly H, Pediatrics in Review 2004;25:201-208

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

Management

General management : Tactile stimulationPharmacological therapy (caffeine or theophylline)CPAP in recurrent and prolonged apneaAly H, Pediatrics in Review 2004;25:201-208

managementSpecific therapyTreatment of the underlying diseases, eg sepsis, hypoglycemia, anemia, and electrolyte abnormalitiesAly H, Pediatrics in Review 2004;25:201-208

Prognosis

In most neonates apnea resolves without the occurrence of long-term deficiencies


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

summary3. Identify the risk factors, clinical presentation, required laboratory and radiological investigations, and management of TTN, RDS, MAS, Air Leak Syndromes, Pneumonia, Apnea

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Management of HMD (RDS)GeneralThermal regulation Parenteral fluid AntibioticsContinuous monitoring

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

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Caution: every 10 days on the ventilator is associated with 20% increased risk for cerebral palsy

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

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)

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

Conditions Associated with Respiratory Distress

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*

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Copy of Respiratory Disorder IDAI 101207