Respiratory Diseases of the Newborn

Objectives Define various respiratory diseases that affect the newborn. Discuss risk factors associated with each disease. Explain the physiology of each disease. Discuss nursing considerations for each disease.

Transient Tachypnea of the Newborn

Occurrence Disease of near-term or term infants Delayed clearance of fetal lung fluid Wet Lung, Type II RDS or Retained Fetal Lung Fluid Symptoms similar to mild RDS Mild, self-limited condition

Risk Factors C section without labor Breech Delivery Birth asphyxia Small size Infant of Diabetic Mother Delayed cord clamping Maternal sedation Male sex Prolonged labor

Pathophysiology Fetal lung – fluid filled Delayed clearance Respiratory Changes Barrel chest Air trapping Ball-valve effect Expiratory grunt

Findings Respiratory Distress CXR Findings Tachypnea Mild retractions, grunting, & flaring Cyanosis CXR Findings Diffuse haziness and streakiness Fluid may be present in interlobar fissures May see mild hyperinflation Usually normal within 48-72 hours

Treatment Oxygen Pulse oximetry Thermoregulation Nutrition Antibiotics CPAP Pulse oximetry Thermoregulation Nutrition Antibiotics PPHN

Headhood

Pneumothorax

Occurrence Spontaneous Pulmonary Diseases Mechanical Ventilation ETT malposition Overeager PPV/suctioning PEEP Prolonged I time Elevated PIP

Risk Factors Respiratory Distress Syndrome Meconium Aspiration Syndrome Hypoplastic Lungs Congenital malformations Prematurity

Pathophysiology Spontaneous Underlying lung disease Overdistention Obstructive Poor lung compliance Overdistention

Findings Sudden deterioration Symptoms Decreased breath sounds on affected side Increased agitation Ineffective ventilation Hypotension Skin mottling Shift of mediastinum-detected by shift in PMI

Findings Obtain chest x-ray Transilluminator Will see a pocket of air See the outline of the collapsed lung Mediastinal shift indicates pneumo under tension and immediate intervention is indicated Transilluminator

Treatment Asymptomatic Nitrogen washout Needle aspiration Chest tube Head hood Partial pressure of nitrogen and oxygen Needle aspiration Supplies Procedure Chest tube

Chest Tube Supplies Pain control/comfort Procedure Daily care Removal Complications

Pulmonary Interstitial Emphysema Ruptured alveoli Pulmonary vascular circulation Treatment

Pneumonia

Occurrence Can occur perinatally or postnatally Prolonged hospitalization Bacterial Viral Fungal

Risk Factors Intrauterine infection Neonatal infection Passage of infecting agent by infection of fetal membranes Transplacental transmission Aspiration of meconium or infected amniotic fluid during delivery Neonatal infection Acquired during nursery stay Pathogens generally different from intrauterine Passage from other infants, equipment, caretakers

Pathophysiology Congenital pneumonia Neonatal pneumonia Preterm Widespread alveolar involvement Full term Localized or diffuse pattern

Findings Respiratory distress Cyanosis Lethargy Poor perfusion CXR findings Lab results

Treatment Nursing Interventions Management Medications Respiratory support Cardiac support Medications Antibiotics Antivirals

Respiratory Distress Syndrome

Occurrence Occurs most frequently in infants with premature lungs Increasing respiratory difficulty in first 3-6 hours, leading to hypoxia and hypoventilation Progressive atelectasis

Risk Factors Prematurity C-section without labor Maternal diabetes esp. less than 38 weeks Acute antepartum hemorrhage Second twin Greater risk of asphyxia First twin usually smaller, suggesting chronic stress leading to early lung maturity Asphyxia at birth Male/female ratio of 2:1

Lung Maturity Lecithin/Sphingomyelin (L/S) ratio In utero stress Has been used to assess fetal lung maturity Ratio greater than 2:1 is considered to indicate fetal lung maturity Lecithin is a major component of surfactant In utero stress Chronic fetal stress from maternal hypertension, retroplacental bleeding, maternal drug use, or smoking will tend to accelerate surfactant production This increases endogenous corticosteroids when then increases lung maturity Usually small for gest age and have more mature lungs

Pharmacologic Acceleration Antenatal steroids such as betamethasone help to prevent RDS They accelerate normal pattern of lung growth and increase the production of Type II cells Recommended for Maternal risk of preterm delivery between 24 – 34 weeks Tx at less than 24 hours PTD unless immediate delivery expected

Pathophysiology Surfactant Deficiency Serum proteins Surfactant produced by Type II cells in lungs Normal lung continuously produces surfactant Production is inadequate, resulting when the utilization of surfactant exceeds the rate of production Leads to diffuse alveolar atelectasis, edema, and cell injury Serum proteins Inhibit surfactant function, leak into the alveoli Leads to alveolar pulmonary edema

Findings Respiratory Changes Hypoxemia CXR Tachypnea Grunting Retractions Nasal flaring Hypoxemia CXR Shows granular pattern (ground glass), decreased lung volume and air bronchograms Air bronchograms are aerated bronchioles superimposed in the background of nonaerated alveoli

Treatment Surfactant replacement Respiratory support Reduces morbidity and mortality rates for RDS Improves lung compliance which reduces the pressure needed to inflate the lungs Dose 4 ml/kg four aliquots with repositioning of infant. Given by RT Suction before, try not to suction for at least 1 hour after administration Respiratory support Oxygen, CPAP, assisted ventilation Monitor blood gases Steroids-controversial

Treatment (cont.) Pulse oximetry Thermoregulation Nutrition Blood pressure volume replacement pressors Antibiotics

Complications Air leaks Barotrauma Oxygen toxicity Pulmonary edema Chronic Lung Disease

Chronic Lung Disease

Occurrence Definition Incidence Oxygen requirements after 28 days of age or at 36 weeks postconceptional age Decreased alveolarization Incidence Varies – difference in diagnostic criteria Overall seems to be increasing, but population of neonates on assisted ventilation has changed Less than 700 gm 85% affected, greater than 1500 gm 5% affected

Risk Factors Oxygen, intubation, and assisted ventilation Gestational age Nutritional deficiencies Underlying lung disease Air leaks

Pathophysiology All levels of tracheobronchial tree are involved Constant and recurring lung injury and ongoing repair and healing Oxygen toxicity Assisted Ventilation PDA Excessive fluid intake Gestational age

Findings Inability to wean from ventilator Hypoxia, Hypercapnia, Respiratory acidosis Audible rales, rhonchi, wheezes Retractions Increased secretions Bronchospasm CXR Multiple areas of fibrosis Cystic changes Fluid intolerance

Treatment Respiratory support Diuretics Bronchodilators Will need long term oxygen once extubated May enhance overall growth of infant Diuretics Bronchodilators Fluid restriction Nutrition May need 150 – 200 kcal/kg per day Growth failure is common Tracheostomy

Complications Intermittent bronchospasms Inability to wean from ventilator Recurrent infections Congestive heart failure from cor pulmonale (Right ventricular hypertrophy) BPD “spells” Gastroesophageal reflux Developmental delays Sudden death

Fetal Circulation

Review Fetal Shunts Systemic Vascular Resistance ductus arteriosus foramen ovale Systemic Vascular Resistance Pulmonary Vascular Resistance Oxygenation

Persistent Pulmonary Hypertension of the Newborn

Occurrence Near term and term Infants Increased pulmonary muscularization Intrauterine or Perinatal Asphyxia Pulmonary Disease Meconium Aspiration Syndrome Pneumonia Myocardial Dysfunction Right ventricular failure Myocarditis

Risk Factors Fetal Distress Pulmonary Hypoplasia Hypoxia and Acidosis Intrauterine Perinatal Pulmonary Hypoplasia Congenital Diaphragmatic Hernis Oligohydramnios Hypoxia and Acidosis Sepsis/Pneumonia Meconium Aspiration Syndrome Myocardial Dysfunction

Pathophysiology Transition from fetal circulation Cyanosis Right to Left Shunting Patent ductus arteriosus Patent foramen ovale Myocardial Dysfunction Pulmonary Vasoconstriction Increased Pulmonary Vascular Resistance

PPHN

Findings Respiratory Changes CXR Findings Cardiac ECHO Mild Severe CXR Findings Cardiac ECHO Differential oximetry

Treatment Management Nursing Interventions Medications Maintain oxygenation Minimal stimulation/cluster care Medications Volume expanders Pressor support Sedation/paralysis

PPHN

Meconium Aspiration Syndrome

Occurrence Meconium Incidence Development Content Meconium-Stained Amniotic Fluid Meconium Aspiration

Risk Factors Term and Post Term Infants Reduced Placental or Uterine Blood Flow Toxemia Elevated Blood Pressure Smoking IDM Maternal Hypoxia or Anemia Cord Accidents Complicated Deliveries

Prevention Labor Delivery Amnioinfusion Suction nasopharynx Visualization of cords

Pathophysiology Intrauterine Asphyxia Airway Occlusion Pneumonitis Peripheral Proximal Pneumonitis Hypoxemia/Acidosis PPHN

Findings Respiratory Distress CXR Diffuse fluffy or streaky densities Air trappings Hyperaeration, pulmonary air leak

Treatment Nursing Interventions Pulmonary care Medications PPHN care Antibiotics Sedation PPHN care

Complications PPHN Air Leak Syndrome Barotrauma PIE

Pulmonary Hypoplasia

Occurrence Defective or inhibited growth of the lungs Can be unilateral or bilateral Developmental disorder that results in decreased numbers of alveoli, bronchioles, and arterioles

Risk Factors Compression of lung growth Oligohydramnios Congenital Diaphragmatic Hernia Oligohydramnios Renal disorders Amniotic fluid leakage Congenital malformations Renal dysgenesis Chromosomal anomalies

Pathophysiology Respiratory Distress Pneumothorax Hypercapnea CXR PPHN Will usually show decreased volume of the thorax Bell shaped chest-rib cage PPHN

Treatment Supportive Treatment of PPHN iNO (nitric oxide) ECMO Treatment is supportive and directed at respiratory failure Assisted ventilation/HFOV Degree of hypoplasia determines outcome Treatment of PPHN iNO (nitric oxide) ECMO

Congenital Diaphragmatic Hernia

Occurrence Incidence Definition Survival Rates 1 out of 3000 live births 85% occur on left side Definition Herniation of Abdominal Contents Lung Development Pulmonary Hypoplasia Survival Rates

Pathophysiology Prenatal Diagnosis Herniation Lung Development Respiratory Distress/PPHN Abdominal Malrotation

Findings Respiratory Distress Scaphoid Abdomen Breath Sounds/Bowel Sounds CXR Findings Cardiac ECHO

Medical Treatment At Delivery Arterial line-preductal (right radial) Gastric decompression Intubation Arterial line-preductal (right radial) Ventilation Strategies Preductal saturations >85% No metabolic acidosis High frequency oscillatory ventilator (HFOV) Inhalational Nitric Oxide (iNO) Medications Fluid bolus Pressors Sedation Extracorporeal Membrane Oxygenation (ECMO)

Surgical Treatment Timing Transabdominal Approach Gortex patch Hernia

Complications Recurrent Diaphragmatic Hernia Gastroesophageal Reflux Neurodevelopmental Delay Chronic Lung Disease Fetal Surgery