1. Respiratory Diseases of the Newborn

2. 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.

3. Transient Tachypnea of the Newborn

4. 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

5. 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

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

7. 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 hours

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

9. Headhood

10. Pneumothorax

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

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

13. Pathophysiology Spontaneous Underlying lung disease Overdistention
Obstructive
Poor lung compliance
Overdistention

14. 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

15. 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

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

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

18. Pulmonary Interstitial Emphysema
Ruptured alveoli
Pulmonary vascular circulation
Treatment

19. Pneumonia

20. Occurrence Can occur perinatally or postnatally
Prolonged hospitalization
Bacterial
Viral
Fungal

21. 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

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

23. Findings Respiratory distress Cyanosis Lethargy Poor perfusion
CXR findings
Lab results

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

25. Respiratory Distress Syndrome

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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

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

34. Complications Air leaks Barotrauma Oxygen toxicity Pulmonary edema
Chronic Lung Disease

35. Chronic Lung Disease

36. 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

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

38. 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

39. 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

40. 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

41. 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

42. Fetal Circulation

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

46. Persistent Pulmonary Hypertension of the Newborn

47. 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

48. 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

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

50. PPHN

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

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

53. PPHN

54. Meconium Aspiration Syndrome

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

56. 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

57. Prevention Labor Delivery Amnioinfusion Suction nasopharynx
Visualization of cords

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

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

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

62. Complications
PPHN
Air Leak Syndrome
Barotrauma
PIE

63. Pulmonary Hypoplasia

64. 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

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

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

67. 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

68. Congenital Diaphragmatic Hernia

69. 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

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

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

72. 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)

73. Surgical Treatment
Timing
Transabdominal Approach
Gortex patch
Hernia

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