Respiratory Problems in the Newborn

Objectives Understand pathophysiology of common respiratory conditions in the newborn Management of these conditions Update on resuscitation devices 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

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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)

T-Piece Resuscitators Flow-Inflating Bag T-Piece Resuscitators Self- Inflating Bag

Positive Pressure Support CPAP (4-5 cm H20), FiO2 (sats 85-93% in preterm and 90-98% in term infants) HR<100, apnea/gasping or with cyanosis, give 40-60 breaths per minute 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