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Respiratory Diseases of the Newborn
Beth Mogensen, RRT-NPS1
OBJECTIVES1. Provide overview of respiratory system of the newborn 2. Identify non-respiratory causes of distress in the newborn 3. Review respiratory diseases/ anomalies of the newborn
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Early Development
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Fetal Lung DevelopmentWeek 4: the laryngotracheal groove forms on the floor foregut Week 5: the left and right lung buds push into the pericardioperitoneal canals (primordial of pleural cavity) Week 6: the descent of heart and lungs into the thorax. Pleuroperitoneal foramen closes5
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Fetal Lung DevelopmentWeek 7: the lung buds divide into secondary and tertiary bronchi Week 24: the bronchi divide 14 more times and the respiratory bronchioles develop By birth, there will be an additional 7 divisions of bronchi7
Fetal Lung HistologySTAGE 1: Pseudoglandular Period (517 weeks) all the major elements of the lungs have formed except for those involved with gas exchange STAGE 2: Canalicular Period (16-25 weeks) bronchi and terminal bronchioles increase in lumen size and the lungs become vascularized8
Fetal Lung HistologySTAGE 3: Terminal Sac Period (24 weeks to birth) more terminal sacs develop and interface with capillaries lined with Type I alveolar cells or pneumocytes --Also have Type II pneumocytes which secrete surfactant thereby decreasing the surface tension forces and aids in expansion of the terminal sacs9
STAGE 4: Alveolar Period (late fetal period to 8 years) 95% of mature alveoli develop after birth. A newborn has only 1/6 to 1/8 of the adult number of alveoli and lungs appear denser on x-ray10
Respiratory Distress at BirthRule of 6: non respiratory causes of distress S&S Hypothermia/ Hyperthermia Hypovolemia Hyoptension Hypoglycemia Anemia Polycythemia transfusion
Diagnosis- check temperature - obtain prenatal history - measure blood pressure - blood glucose measurement - measure hematocrit - measure hematocrit
Management- heat or cool as necessary - gingerly give volume - give volume and/or vasopressor - give glucose - transfuse with PRBC - partial exchange (lower Hct)11
Respiratory Distress in the NewbornTransient Tachypnea of the Newborn (TTN) Surfactant Deficiency (HMD,RDS) Meconium Aspiration Syndrome (MAS) Pneumonia/ Sepsis Pneumothorax or other air leaks
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Respiratory Distress in the NewbornRespiratory Causes Congenital Abnormalities of the Lung/Thorax
Congenital Heart Disease (CHD) Congenital Diaphragmatic Hernia (CDH) Congenital Cystic Adenomatiod Malformation (CCAM) Tracheal Abnormalities Esophageal Atresia Pulmonary Hypoplasia
Persistent Pulmonary Hypertension of the Newborn (PPHN)13
What do you need to know to Figure out the CauseMaternal History
Any risk factors
Gestational age of Infant Amniotic fluid (color/odor/volume) Intrapartum history Clinical Presentation/ Assessment X-Rays Lab Evaluations14
Clinical PresentationRespiratory Assessment
Respiratory rate QualityShallow Deep
Nasal Flaring Grunting Retractions Breath Sounds15
Clinical PresentationColorpink, dusky, pale, mottled
Central Peripherally
Heart rate Pulses
Distal vs Central Capillary Refill Time (CRT) Blood Pressure16
Perfusion
Clinical PresentationPhysical characteristics
Flat nasal bridge, Simian crease, recessed chin, low set ears Extra digits, gastroschesis, imperforate anus Hyoptonia vs Hypertonia Choanal Atresia, Osteogenesis Imperfecta Scaphoid abdomen, heart tones on Right side17
Deformities
Muscular
Skeleton
Other
X-RayStructures
Ribs Vertebra Liver Stomach/ intestine Lungs Heart Trachea Esophagus18
X-RayLungs
Lung Volume Expansion DensitiesFluid/ collapse (atelectasis)>>white Free Air>>dark Mass
Heart shape and size
Boot shaped Egg or Oval shaped
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Lab ValuesCBC with diff ABG/CBG/VBG Blood Cultures CRP Electrolytes Type and Cross PKU20
Respiratory DistressDetermining Differential Diagnosis
What you need to know History Presentation/ clinical assessment X-rays Lab values21
Transient Tachypnea of the Newborn (TTN)Most common diagnosis of respiratory distress in the newborn Remember often term infants may be a little early Ineffective clearance of amniotic fluid from lungs with delivery Most often seen at birth or shortly after22
Transient Tachypnea of the NewbornHistory
Common with C-Section delivery Maternal analgesia Maternal anesthesia during labor Maternal fluid administration Maternal asthma, diabetes, bleeding Perinatal asphyxia Prolapsed cord23
TTN presents:Respiratory Assessment
Tachypnea 60-150 bpm Nasal flaring Grunting Retracting Fine Rales Cyanotic24
TTNX-Ray findings
Prominent Perihilar streaking Hyperinflation Fluid in fissure CBC within normal limits ABG/CBG showing mild to moderate hypercapnia, hypoxemia with a respiratory acidosis25
Labs
TTN
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TTNHave delayed reabsorption of fetal lung fluid which eventually will clear over several hours to days Treatment: Treat signs and symptoms. Support infant, may need O2, is probably too tachypneic to PO feed so start IV fluids Be patient!!27
Surfactant Deficiency (RDS, HMD)One of the most common problems associated with a premature infant Decreased surfactant production in lungs of pre-term infants With decreased surfactant production, alveoli collapse, become atelectatic, yielding poor lung function and increasing signs of respiratory distress28
RDSHistory
Gestational age < 38 weeks Prenatal careDiabetes (controlled vs uncontrolled) Perinatal infection
Problems during pregnancy/deliveryAsphyxia Stress to fetus Hypothyroidism
Multiple births29
RDS presents:Respiratory Assessment
Tachypnea > 60 bpm Nasal flaring Grunting Retracting Apnea/ irregular respiratory pattern Rales (crackles) Diminished breath sounds Cyanosis30
RDSX-Ray
Loss of volume Reticulogranular pattern or ground glass appearance Air bronchograms Bell shaped thorax Air leak, PIE Loss of heart borders/ atelectasis White out31
RDS
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RDS
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RDSLaboratory Results
ABG/CBGHypoxia Hypercarbia Acidosis
CBC with Differential/ HHPUsed to rule out other causes of respiratory distress
Always check electrolytes, especially glucose, potassium and calcium35
Treatment for RDSPost-Exogenous Surfactant Therapy
Many on the marketProphylactic Treatment
Administered in the delivery room Given after a definitive diagnosis of RDS
Rescue Treatment
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MECONIUM ASPIRATION SYNDROMEMost often found in post date infants > 40 weeks, but may occur in infants >34 weeks Infant passes meconium due to varying degrees of asphyxia in utero Obstruction of large and small airways with aspirated meconium Aspiration may occur:
in utero intrapartum postpartum period37
MASHistory Prenatal CareMaternal diabetes Pregnancy Induced Hypertension (PIH) Pre-eclampsia
Problems during pregnancy/delivery Color of amniotic fluid
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MASRespiratory Assessment
Tachypnea Nasal flaring Grunting Retracting Apnea/ irregular respiratory pattern Decreased breath sounds/ wet/ rhonchi
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MASClinical Assessment
ColorPale/gray Cyanotic Stained skin
X-Ray
Increased AP diameter Hyperinflation Atelectasis Pneumothorax40
MAS
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MAS
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Pneumonia/ SepsisOccurs frequently in newborns 3 types
Congenital Pneumonia Intrapartum Pneumonia Postnatal Pneumonia
Most often seen with chorioamnionitis, prematurity and meconium aspiration Get thorough history43
CausesPrematurity Prolonged rupture of membranes Maternal temp > 38C Foul smelling amniotic fluid Nonreassuring stress test Fetal tachycardia Meconium Maternal hx of STDs44
Respiratory AssessmentTachypnea Apnea, irregular breathing pattern Grunting Retractions Nasal flaring Colorful secretions Rales, rhonchi Cyanosis45
Clinical AssessmentGray, pale color Lethargy Temperature instability Skin rash-pettechia Tachycardia Glucose issues Hypoperfusion Oliguria46
X-RayPatchy infiltrates (aspiration) Bilateral diffuse granular pattern Streaky Loss of volume Densities
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Pneumonia/ Sepsis
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Pneumothorax and other Air LeaksHistory
What happened in the delivery room? Was positive pressure given? Large amount of negative pressure generated with the 1st breath?
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Pneumothorax/ Air LeaksRespiratory Assessment
Tachypnea Nasal flaring Grunting Retractions BS absent or decreased
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Pneumothorax/ Air LeakClinical Assessment
Cyanotic Pale, gray Heart RateTachycardia Bradycardia PEA
PulsesNormal Poor absent51
Pneumothorax/ Air LeakPerfusion
Capillary Refill (CRT) Blood Pressure if monitoring Arterial Line, narrowing pulse pressure Asymmetry of chest
Deformities of Chest Wall
CHEST X-Ray speaks for itself!!52
Pneumothorax
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PneumothoraxRight lateral decubitus view of pneumothorax
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Pneumopericardium
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Congenital Abnormalities of the Lung and ThoraxCongenital Heart Disease (CHD) Congenital Diaphragmatic Hernia (CDH) Congenital Cystic Adenomatiod Malformation Tracheal Abnormalities Esophageal Atresia Pulmonary Hypoplasia56
Congenital Heart DiseaseDefect present at birth- often picked up on early ultrasound Increased risks:
Parents have CHD? Siblings have CHD? Maternal diabetes Exposure to German measles, toxoplasmosis, or if mother HIV+ Alcohol use during pregnancy Cocaine use during pregnancy57
CHDTwo types of CHD
Acyanotic-blood returning to Right side of heart passes thru lungsusually defect in heart wall, or obstructed valve or arteryPink baby Sats within normal limits
Cyanotic-have a mixing of oxygenated blood with venous bloodshunting ductus, PFO, ASD, VSDBlue baby Low sats58
CHDRespiratory Assessment
RespirationsNormal Tachypnea
Saturations depend upon defect.Acyanotic lesions sats are more normal Cyanotic lesions acceptable sats are low ~ 70% is acceptable; ideally on 21% FiO2
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CHDClinical Assessment
HRSlow, fast, variable murmur
BPCheck in all 4 extremities
Pulses in all extremities CRT in all 4 extremities ColorAcyanotic -pink Cyanotic-blue60
CHDLabs and Tests
ABGsdependent upon defect Lactic Acid Heart shape and size Pulmonary blood flow Best test to aid in diagnosis
Chest X-Ray
Echocardiogram
Cardiac Cath for possible intervention61
Congenital Diaphragmatic Hernia Congenital Cystic Adenomatoid MalformationIdeally diagnosed in utero Develops during pseudoglandular stage, but CCAM can form up to 35 weeks Normally compromised at delivery requiring immediate intubation CDH more commonly found on Left side62
CDH
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Congenital Diaphragmatic Hernia
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CDH/ CCAMRespiratory Assessment
Tachypneic Retractions Nasal flaring Grunting Breath SoundsDecreased on the affected side May hear bowel sounds in chest with CDH
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CDHClinical Assessment Clin
Scaphoid Abdomen- classic sign ColorCyanotic
Heart RateFast, slow or normal
PerfusionDepends upon the severity
X-RayBest diagnostic toolBowel, stomach, liver in chest
ABGsAcidosis, hypoxemia and hypercarbia
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Left Congenital Diaphragmatic Hernia
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CCAM
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Persistent Pulmonary Hypertension (PPHN)Pulmonary hypertension resulting in severe hypoxemia secondary to R>L shunt thru PFO and/or PDA Usually affecting term or near-term infants May be extremely difficult to manage If not responding to available therapy consider transporting to an ECMO center
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Fetal Circulation
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PPHNHistory
Meconium? Asphyxia? Stress? Pneumonia/ Sepsis Primary Pulmonary HypertensionDysfunction in pulmonary endothelial vasodilating mechanism
CDH/ CCAM71
PPHNRespiratory Assessment
Tachypnea Retractions Grunting Nasal flaring Breath SoundsDepend on cause
Pre and Post-ductal saturations to monitor shunting- best indicator if ECHO not available72
PPHNClinical Assessment
ColorBlue/ gray
X-RayDepends on cause Usually with decreased blood flow, minimal lung markings
LabDependent on cause Many present with abnormal Platelets/ PT/ Fibrinogen
ABGRespiratory and metabolic acidosis73
Airway AbnormalitiesOccur less frequently than pulmonary parenchymal diseases Presentation is often quite dramatic with significant respiratory distress Stridor may be an important key to diagnosing the abnormality
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Airway AbnormalitiesSupraglottic
Nose-Choanal Atresia Craniofacial-Pierre Robin Macroglossia-Downs Tumors-Hemangioma Vocal Cord Paralysis Tumors and CystsHemangioma, Cystic Hygroma, Teratoma Tracheal Esophageal Fistula/ Atresia Webs Trauma75
Glottic
Cystic Hygroma
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Tracheal Esophageal Fistula/ Esophageal Atresia
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Airway AbnormalitiesSubglottic
Stenosiscongenital or acquired Webs Atresia Tumors Tracheomalacia Stenosis Cyst Atresia Vascular Ring Mediastinal Mass
Trachea
Extrinsic
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History/ Presentation PCircumstances surrounding onset of symptoms Speed of progression of symptoms Position of comfort and how change affects symptoms Presence of feeding abnormalities Nature of cry Previous infection History of previous intubation or trauma Presence of associated cardiopulmonary abnormalities79
Airway AbnormalitiesRespiratory Assessment
Tachypnea Retractions Work of Breathing Stridor is the MOST important physical sign created by airway turbulence and indicates obstructionInspiratoryimplies supraglottic or glottic Expiratoryimplies intrathoracic airway Mixedimplies subglottic
Breath Sounds
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Airway AbnormalitiesClinical Assessment
Heart RateTachycardia Bradycardia when obstructed
ColorCyanotic
Lethargy Irritability Feeding Difficulty81
Airway AbnormalitiesBronchoscopy used for evaluating abnormality Tools for Treatment:
Dependent upon DiagnosisProne patient Oral Airway N-P Tube Steroids Meds for reflux OG, NG, NJ or G-Tube feedings82
Airway Abnormalities
Possible Surgical InterventionsCricoid Split Tracheostomy Excise Hygroma Place stents
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ScenarioBaby Boy S
No prenatal care. Uneventful delivery vaginal delivery. APGARS 8 and 9 at 1 and 5 minutes, respectively. Infant taken to newborn nursery and given routine care. Eyes and thighs done, bath completed. VSS. Looking good and smelling nice. Infant went out to mother to breast feed and you have been summoned to check on baby. 84
ScenarioUpon arriving in the mothers room, you begin assessing infant. Babys color is rather blue. TachypneicRR 70s to 80s Bulb sx and get a little bit of colostrum. Retractions and Grunting present Babys temp is 35.9 What will you do?85
Scenario1. Take infant back to nursery for observation and monitoring. 2. Place infant on O2 if sat < 90-92 depending upon your policy. 3. Place infant under radiant warmer. 4. Obtain a full set of vital signs.1. 2. 3. 4.
RR 80sRetracting, nasal flaring, grunting HR 180with murmur BP 42/30 with MAP 36 SaO2 on 100% blow by 88%86
Scenario
5. 6. 7.
Colordusky CRT 4 seconds Poor peripheral pulses
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ScenarioCALL MD if you havent already Continually reassess infant. With your next assessment: VS have not changed much. Infant continues to grunt, retract and have nasal flaring. Sats 86.
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ScenarioWhen auscultating, you notice that the heart tones are now more midline than on left. You also notice that when auscultating the left lung that you thought you heard gas bubbles What do you want to do? What do you suspect this infant has?
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ScenarioSTAT CXR Intubate infant and ventilate Place large bore Anderson/ Replogle tube to continuous low suction Give fluid bolus (and more if needed) Probably start pressors Do what needs to be done to stabilize this infant and call for transport90
Take AwayDont be afraid to think out of the box We continually see funky things Do no harm this is someones baby
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