21 Neonatal Respiratory Disorders

Neonatal Care Module: Neonatal Respiratory Disorders - Session 1

Slide 1

Neonatal Care Module:Neonatal Care Module:

Neonatal Respiratory Disorders


Module Overview Slide 2

Module Overview: Module Overview: PurposePurpose

The purpose of this session is to introduce participants to the knowledge, competencies, and skills required to evaluate respiratory distress and diagnose and manage various neonatal respiratory disorders.


Module Overview Slide 3

Module Overview: StoryModule Overview: StoryRespiratory problems are the most common form of disease in preterm neonates. Full term neonates also suffer from different forms of respiratory problems. Knowledge of the causes, risk factors, clinical presentations, and management of neonatal respiratory disorders is of primary importance in reducing neonatal morbidity and mortality.


Learning Objectives Slide 4

Learning ObjectivesLearning ObjectivesBy the end of this session, each participant By the end of this session, each participant

should should be able to:be able to:1. Evaluate the severity of respiratory distress

using the Down’s Score.2. Identify common neonatal respiratory disorders,

including:• Respiratory Distress Syndrome (RDS).Respiratory Distress Syndrome (RDS).• Transient Tachypnea of the Newborn Transient Tachypnea of the Newborn

(TTN).(TTN).• Meconium Aspiration Syndrome (MAS).Meconium Aspiration Syndrome (MAS).• Apnea.Apnea.• Air leak syndromes.Air leak syndromes.• Pneumonia.Pneumonia.



Learning Objectives Learning Objectives (cont.)(cont.)

3. Identify the incidence, risk factors, required laboratory and radiological investigations, and management of RDS.

4. Identify the risk factors, clinical presentation, required laboratory and radiological investigations, and management of TTN.

5. Identify the risk factors, clinical presentation, required laboratory and radiological investigations, management of MAS.



Learning Objectives Learning Objectives (cont.)(cont.)

6. Identify the incidence, risk factors, causes, required investigations, and management of apnea.

7. Identify the incidence, risk factors, clinical presentations, required radiological investigations, and management of air leak syndromes.

8. Identify the etiology, clinical presentation, required investigations, and management of pneumonia.


Introduction Slide 7

Introduction Introduction Respiratory problems are the most

common difficulties in preterm infants.

Birth initiates a dramatic change from the intrauterine state in which the placenta is the primary organ of respiration, to life outside the uterus in which the lung is the organ of gas exchange.


Introduction Slide 8

Introduction Introduction (cont.)(cont.)

Respiration involves a system that includes the lung and muscular structures of the diaphragm and chest, as well as complex neural, chemical, and sensory centers in the brain.

Neonatal respiratory diseases result from problems with any or all of these structures or neural pathways .


Slide 9

Table 1. Evaluation of Respiratory Table 1. Evaluation of Respiratory Distress Using Down’s ScoreDistress Using Down’s Score

TestTest Score Score

00 11 22RespiratRespiratory rateory rate

<60/min 60-80/min

>80/min

RetractioRetractionsns

No Mild Severe

CyanosisCyanosis No Cyanosis relieved

by Oxygen

Cyanosis on oxygen


Slide 10

Table 1. Evaluation of Respiratory Table 1. Evaluation of Respiratory Distress Using Down’s Score Distress Using Down’s Score

(cont.)(cont.)TestTest Score Score

00 11 22Air entryAir entry Good

bilateral air entry

Mild decrease

in air entry

No air entry

GruntingGrunting No grunt Audible by

stethoscope

Audible with ear


Evaluation of Respiratory Distress Using Down’s Score Slide 11

Evaluation of Respiratory Evaluation of Respiratory Distress Using Down’s Distress Using Down’s

ScoreScore

> 4 → No respiratory distressNo respiratory distress 4 - 7 → Respiratory distressRespiratory distress < 7 → Impending respiratoryImpending respiratory failure, failure, blood gases are blood gases are

required.required.


Common Neonatal Respiratory Disorders Slide 12

Common Neonatal Common Neonatal Respiratory DisordersRespiratory Disorders

Respiratory distress syndrome (RDS ). Transient tachypnea of the newborn

(TTN). Meconium aspiration syndrome (MAS). Apnea. Air leak syndrome. Pneumonia.


Respiratory Distress Syndrome Slide 13

Respiratory Distress Respiratory Distress Syndrome (RDS)Syndrome (RDS)

Definition Definition Respiratory distress syndrome (RDS), also

called Hyaline membrane disease (HMD), is a respiratory disease that primarily affects preterm infants.

It occurs in about one quarter of infants born at 32 weeks gestation and the incidence increases with shorter gestational periods.

The primary dysfunction is reduced surfactant synthesis .



Risk FactorsRisk Factors Increase Risk

• Prematurity. Prematurity.

• Male sex.Male sex.

• Familial predisposition.Familial predisposition.

• Cesarean section without labor.Cesarean section without labor.

• Perinatal asphyxia.Perinatal asphyxia.

• Chorionamnionitis. Chorionamnionitis.

• Infant of a diabetic mother Infant of a diabetic mother (IDM).(IDM).

• Hydrops.Hydrops.



Decrease Risk• Chronic intrauterine stress. Chronic intrauterine stress.

• Prolonged rupture of membranes.Prolonged rupture of membranes.

• Maternal hypertension.Maternal hypertension.

• Narcotic use.Narcotic use.

• IUGR or SGA.IUGR or SGA.

• Corticosteroids (prenatal).Corticosteroids (prenatal).

• Tocolytic agents.Tocolytic agents.

Risk FactorsRisk Factors (cont.)(cont.)



Clinical Presentation of Clinical Presentation of RDSRDS

RDS usually presents at birth but may appear up to 12 hours after birth.

It presents with worsening respiratory distress:

An increase in respiratory effort. Cyanosis in room air that persists or

progresses over the first 48 hours of life. Increasing tachypnea (> 60

breaths/minute), grunting on expiration, and retractions of the chest wall.



InvestigationsInvestigations Laboratory Studies

•Blood gases reveal hypoxia, Blood gases reveal hypoxia, hypercapnia, and acidosis. hypercapnia, and acidosis.

•Complete blood picture to rule out Complete blood picture to rule out infection.infection.

Chest X-ray

•Reveals bilateral reticulogranular Reveals bilateral reticulogranular density (ground glass appearance) density (ground glass appearance) and opaque lungs (air- bronchogram). and opaque lungs (air- bronchogram).



Management Management General General Basic support including thermal regulation,

parenteral fluid, and medications (antibiotics).

Oxygen administration: Preferably heated and humidified 30-40% O2 by head box.

Respiratory support is needed if the patient continues to deteriorate under FiO2 of more than 60% and/or if the PaO2 is less than 55-60 mmHg. Continuous positive airway pressure (CPAP) is then tried.



Management Management (cont.)(cont.)

IF under CPAP, two successive blood gas analyses 20 minutes apart reveal the following values: •PH > 7.2 PH > 7.2

•Or PaO2 > 55 mmHg Or PaO2 > 55 mmHg

•Or PaCO2 < 60 mmHgOr PaCO2 < 60 mmHg Proceed to endotracheal intubation

and mechanical ventilation.



Surfactant TherapySurfactant Therapy

IndicationsIndications Prophylactic treatment:

• For all infants < 32 weeks who For all infants < 32 weeks who require a ventilator.require a ventilator.

• For all infants > 29 weeks.For all infants > 29 weeks.

• For infants between 32 and 29 For infants between 32 and 29 weeks, the physician should use weeks, the physician should use his/her clinical judgment on a case his/her clinical judgment on a case by case basis.by case basis.



Surfactant Therapy Surfactant Therapy (cont.)(cont.)

Rescue treatment:

• For infants with moderate to For infants with moderate to severe RDS who require severe RDS who require mechanical ventilation.mechanical ventilation.

• If the infant remains ventilated If the infant remains ventilated at 12 hours after his/her first at 12 hours after his/her first dose of surfactant, a second dose of surfactant, a second dose of surfactant should be dose of surfactant should be considered. considered.



Dosage and administrationDosage and administration

Dose:Dose: Should be guided according to the type of surfactant used.

Timing:Timing: Usually within 1-2 hours of age, but without delaying resuscitation measures.




Administration:Administration: Check ET tube position. Insert 5F feeding tube with end-hole

into the ET tube – with its tip above the carina and below the ET tube end.

Give each dose of surfactant with baby’s head turned 45°.

Between each dose baby is ventilated for at least 30 seconds.




During dosing monitor for:•Transient bradycardia.Transient bradycardia.

•Hypoxia.Hypoxia.

•Hypotension.Hypotension.

•ET blockage.ET blockage. After dosing:

•Do not suction ET tube for at least Do not suction ET tube for at least 1 hour. 1 hour.

Monitor ABGs and adjust ventilator setting.



Transient Tachypnea of The Newborn Slide 25

Transient Tachypnea ofTransient Tachypnea of The Newborn (TTN ) The Newborn (TTN )

DefinitionDefinition TTN is a benign disease of near-term

or term infants who display respiratory distress shortly after delivery.

It occurs when the infant fails to clear his/her airway of lung fluid or mucus, or has excess fluid in the lungs due to aspiration.



Risk FactorsRisk Factors

Cesarean section. Macrosomia. Prolonged labor. Male sex. Excessive maternal sedation.



Clinical PresentationClinical Presentation The infant is usually near-term or term,

and shortly after delivery exhibits tachypnea (> 80 breaths/min).

The infant may also display grunting, nasal flaring, rib retraction, and cyanosis.

An important marker of TTN is the spontaneous improvement of the neonate.



InvestigationsInvestigations Laboratory investigations

•Blood gases.Blood gases.

•Complete blood count (CBC) to Complete blood count (CBC) to rule out infection.rule out infection.

Radiological studies •Chest X-ray findings consistent with Chest X-ray findings consistent with

TTN include perihilar streaking, mild TTN include perihilar streaking, mild cardiomegaly, increased lung volume, cardiomegaly, increased lung volume, fluid in the minor fissure, and perhaps fluid in the minor fissure, and perhaps fluid in the pleural space. fluid in the pleural space.



ManagementManagementGeneral General Oxygenation. Fluid restriction. Feeding as tachypnea improves. Confirm the diagnosis by excluding

other causes of tachypnea, e.g., pneumonia, congenital heart disease, Respiratory distress syndrome (RDS), and cerebral hyperventilation.



Outcome and PrognosisOutcome and Prognosis

The disease is self-limiting and there is no risk of further pulmonary dysfunction.

Respiratory symptoms improve as intrapulmonary fluid is mobilized, usually occurring with diuresis.


Meconium Aspiration Syndrome Slide 31

Meconium Aspiration Meconium Aspiration Syndrome (MAS)Syndrome (MAS)

DefinitionDefinition This respiratory disorder is caused by

meconium aspiration by the fetus in-utero or by the newborn during labor and delivery.

The aspirated meconium can cause airway obstruction and an intense inflammatory reaction.



Meconium aspiration syndrome (MAS) is often a sign that the neonate has suffered asphyxia before or during birth.

The mortality rate can be as high as 50% and survivors may suffer long-term sequelae including bronchopulmonary dysplasia and neurological damage.

Meconium Aspiration Meconium Aspiration Syndrome Syndrome (cont.)(cont.)



Risk FactorsRisk Factors Post-term pregnancy. Maternal hypertension. Abnormal fetal heart rate. Pre-eclampsia. Maternal diabetes mellitus. Small for Gestational Age (SGA). Maternal respiratory or CVS

disease.



Clinical PresentationClinical Presentation Meconium staining of amniotic fluid

before birth. Meconium staining of neonate after

birth. Airway obstruction. Respiratory distress leading to an

increased anteroposterior diameter of the chest.



InvestigationsInvestigations Laboratory investigations

•Blood gas analysis.Blood gas analysis.

Radiological studies

•Chest X-ray will show patchy Chest X-ray will show patchy infiltrates, coarse streaking of both infiltrates, coarse streaking of both lung fields, an increased lung fields, an increased anteroposterior diameter, and anteroposterior diameter, and flattening of the diaphragm.flattening of the diaphragm.



ManagementManagement Prenatal management

• Identification of high-risk pregnancy. Identification of high-risk pregnancy.

•Monitoring of fetal heart rate during Monitoring of fetal heart rate during labor. labor.

Delivery room management (if amniotic fluid is meconium stained)

•Obstetrical: suctioning of the Obstetrical: suctioning of the oropharynx by obstetrician before oropharynx by obstetrician before delivery of the shoulders.delivery of the shoulders.



Management of The Management of The Newborn in The Neonatal Newborn in The Neonatal

UnitUnit General management

• Emptying of the stomach contents to Emptying of the stomach contents to avoid further aspiration. avoid further aspiration.

• Correction of metabolic abnormalities, Correction of metabolic abnormalities, e.g., hypoxia, acidosis, hypoglycemia, e.g., hypoxia, acidosis, hypoglycemia, hypocalcaemia, and hypothermia. hypocalcaemia, and hypothermia.

• Surveillance for end organ Surveillance for end organ hypoxic/ischemic damage (brain, hypoxic/ischemic damage (brain, kidney, heart, and liver).kidney, heart, and liver).



Respiratory management • Frequent suctioning and chest physiotherapy. Frequent suctioning and chest physiotherapy.

• Pulmonary toilet to remove residual Pulmonary toilet to remove residual meconium if intubated. meconium if intubated.

• Antibiotic coverage (ampicillin and Antibiotic coverage (ampicillin and gentamicin). gentamicin).

• Oxygenation (maintain a high saturation < Oxygenation (maintain a high saturation < 95%). 95%).

• Mechanical ventilation (to avoid hypercarbia Mechanical ventilation (to avoid hypercarbia and respiratory acidosis). and respiratory acidosis).


UnitUnit (cont.)(cont.)



Surfactant may be required if clinical condition continues to deteriorate.

Cardiovascular management• Correct systemic hypotension Correct systemic hypotension

(hypovolemia and myocardial (hypovolemia and myocardial dysfunction). dysfunction).

• Treat persistent pulmonary hypertension.Treat persistent pulmonary hypertension.

• Maintain a PaCO2 level > 40mmHg, and Maintain a PaCO2 level > 40mmHg, and ensure an O2 saturation of < 95%.ensure an O2 saturation of < 95%.


UnitUnit (cont.)(cont.)


Apnea Slide 40

ApneaApneaDefinitionDefinition Apnea is the cessation of respiration

accompanied by bradycardia and/or cyanosis for more than 20 seconds.

Fifty to sixty percent of preterm infants show evidence of apnea (35% with central apnea, 5-10% with obstruction apnea, and 15-20% with mixed apnea).


Apnea Slide 41

Definition Definition (cont.)(cont.)

The incidence of apnea increases as the gestational age decreases.

Apnea within 24 hours of delivery is usually pathological in origin, whereas apnea developing after the first three days of life and not associated with other pathologies may be classified as apnea of prematurity.

In most cases, apnea resolves without long-term sequelae.


Apnea Slide 42


• Hypothermia.Hypothermia.

• Hypoglycemia.Hypoglycemia.

• Anemia.Anemia.

• Hypovolemia.Hypovolemia.

• Aspiration.Aspiration.

• NEC/distensionNEC/distension

• Cardiac disease.Cardiac disease.

• Lung disease.Lung disease.


Apnea Slide 43

Risk FactorsRisk Factors (cont.)(cont.)

•Gastroesophageal reflux.Gastroesophageal reflux.

•Airway obstruction.Airway obstruction.

•Infection (e.g., meningitis).Infection (e.g., meningitis).

•Neurological disordersNeurological disorders


Apnea Slide 44

Clinical PresentationClinical Presentation

Apnea presents as the cessation of respiration accompanied by bradycardia and/or cyanosis for more than 20 seconds.


Apnea Slide 45

ManagementManagement Monitor at-risk neonates of less than 32

weeks gestational age. Evaluate for a possible underlying cause. Laboratory studies should include a CBC,

blood gases analysis, serum glucose, and electrolyte and calcium levels.

Radiological studies should include a chest X-ray, abdominal X-ray, cranial sonar, and a computerized tomography (CT) for infants with definite signs of neurological involvement.


Apnea Slide 46


General therapy

• Begin with tactile stimulation. Begin with tactile stimulation.

• If the infant does not respond to If the infant does not respond to tactile stimulation, bag and mask tactile stimulation, bag and mask ventilation should be used during ventilation should be used during the spell. the spell.

• Use CPAP or IPPV in recurrent and Use CPAP or IPPV in recurrent and prolonged apnea. prolonged apnea.


Apnea Slide 47

• In apnea of prematurity In apnea of prematurity pharmacological therapy should pharmacological therapy should be administered: be administered:

• Theophylline; Start with a loading Theophylline; Start with a loading dose of 5 mg/kg/IV, followed 8 dose of 5 mg/kg/IV, followed 8 hours later by a maintenance hours later by a maintenance dose of 2 mg/kg every 8 hours. dose of 2 mg/kg every 8 hours.

• Monitor theophylline level.Monitor theophylline level.



Apnea Slide 48

Specific therapy

•Treat the cause if identified, e.g., Treat the cause if identified, e.g.,

sepsis, hypoglycemia, anemia, or sepsis, hypoglycemia, anemia, or

electrolyte abnormalities.electrolyte abnormalities.



Air Leak Syndrome Slide 49

Air Leak SyndromeAir Leak SyndromeDefinitionDefinition The air leak syndromes

(pneumomediastinum, pneumothorax, pulmonary, interstitial emphysema, and pneumopericardium) comprise a spectrum of disease with the same underlying pathophysiology.

Over distension of alveolar sacs or terminal airways leads to the disruption of airway integrity, resulting in the dissection of air into surrounding spaces.



Definition Definition (cont.)(cont.)

These air leak syndromes are most commonly seen in infants with lung disease who are on ventilatory support, and can occur spontaneously.

The more severe the lung disease, the higher the incidence of pulmonary air leak.




• Ventilatory support.Ventilatory support.

• Meconium Meconium staining/aspiration.staining/aspiration.

• Surfactant therapy.Surfactant therapy.

• Vigorous resuscitationVigorous resuscitation



Clinical PresentationClinical Presentation The infant presents with respiratory distress

or a sudden deterioration in status with an alteration in vital signs and worsening blood gas levels. Asymmetry of the thorax is sometimes present in unilateral cases.

The definitive diagnosis of all air leak syndromes is made radiographically by A-P and lateral chest X-ray films. Chest transillumination can help in the diagnosis of pneumathorax.



ManagementManagement Prevention

•Judicious use of ventilatory support,Judicious use of ventilatory support,

• Close attention to distending Close attention to distending pressure (PEEP), inspiratory time,pressure (PEEP), inspiratory time,

•Appropriate weaning of ventilatory Appropriate weaning of ventilatory support as the clinical condition support as the clinical condition improves. improves.

General •OxygenationOxygenation



Specific •Decompression of air leak according to Decompression of air leak according to

the type. the type.

• In cases of tension pneumathorax, In cases of tension pneumathorax, urgent needle aspiration from the urgent needle aspiration from the second intercostal space in the second intercostal space in the midclavicular line is done, followed by midclavicular line is done, followed by insertion of a chest tube with an insertion of a chest tube with an underwater seal in the fourth underwater seal in the fourth intercostal space in the anterior intercostal space in the anterior axillary line.axillary line.



Pneumonia Slide 55

PneumoniaPneumonia

Definition Definition Aspiration of bacteria in amniotic fluid leads to congenital pneumonia or a systemic bacterial infection with the manifestation becoming apparent prior to delivery (fetal distress and/or tachycardia), at delivery (perinatal asphyxia), or after a latent period of a few hours (respiratory distress and/or shock).


Pneumonia Slide 56

Clinical PresentationClinical Presentation

Onset occurs 1-2 days after delivery.

Moderate to severe respiratory distress in the presence of one or more risk factors for infection.


Pneumonia Slide 57

InvestigationsInvestigations

Chest X-Ray

•Finding may be identical to other Finding may be identical to other causes of respiratory distress. causes of respiratory distress.

Bacterial cultures

•Some cases of pneumonia may be Some cases of pneumonia may be culture negative. culture negative.


Pneumonia Slide 58

Management of Management of PneumoniaPneumonia

Respiratory support.

If the culture is negative for pneumonia, treatment consists of parenteral ampicillin and gentamicin for 10 days.

If the culture is positive for pneumonia, treatment consists of the appropriate antibiotic according to culture result.

21 Neonatal Respiratory Disorders

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