21 Neonatal Respiratory Disorders

Neonatal Care Module: Neonatal Respiratory Disorders - Session 1
Neonatal Care Module:

Neonatal Respiratory Disorders
Slide 1
Module Overview: Purpose
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 2

Module Overview: Story

Respiratory 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.
Module Overview Slide 3

Learning Objectives
By the end of this session, each participant should
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).
• Transient Tachypnea of the Newborn (TTN).
• Meconium Aspiration Syndrome (MAS).
• Apnea.
• Air leak syndromes.
• Pneumonia.
Learning Objectives Slide 4
Learning Objectives (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 (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
 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 7
Introduction (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 .
Introduction Slide 8
Table 1. Evaluation of Respiratory Distress

Using Down’s Score
Test Score
0 1 2
Respiratory min/60< min/60-80 min/80>
rate
Retractions No Mild Severe
Cyanosis No Cyanosis Cyanosis on
relieved by oxygen
Oxygen
Slide 9
Table 1. Evaluation of Respiratory Distress

Using Down’s Score (cont.)
Test Score
0 1 2
Air entry Good Mild No air entry
bilateral air decrease in
entry air entry
Grunting No grunt Audible by Audible with
stethoscope ear
Slide 10
Evaluation of Respiratory
Distress Using Down’s Score
 < 4 → No respiratory distress

 4 - 7 → Respiratory distress
 > 7 → Impending respiratory
failure, blood gases are
required.
Evaluation of Respiratory Distress Using Down’s Score Slide 11
Common Neonatal Respiratory

Disorders
 Respiratory distress syndrome (RDS ).
 Transient tachypnea of the newborn (TTN).
 Meconium aspiration syndrome (MAS).
 Apnea.
 Air leak syndrome.
 Pneumonia.
Common Neonatal Respiratory Disorders Slide 12

Respiratory Distress Syndrome

(RDS)
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 .
Respiratory Distress Syndrome Slide 13

Risk Factors
 Increase Risk
• Prematurity.
• Male sex.
• Familial predisposition.
• Cesarean section without labor.
• Perinatal asphyxia.
• Chorionamnionitis.
• Infant of a diabetic mother (IDM).
• Hydrops.
Risk Factors (cont.)

 Decrease Risk
• Chronic intrauterine stress.
• Prolonged rupture of membranes.
• Maternal hypertension.
• Narcotic use.
• IUGR or SGA.
• Corticosteroids (prenatal).
• Tocolytic agents.

Clinical Presentation of RDS

 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.

Investigations
 Laboratory Studies
• Blood gases reveal hypoxia, hypercapnia, and
acidosis.
• Complete blood picture to rule out infection.
 Chest X-ray
• Reveals bilateral reticulogranular density
(ground glass appearance) and opaque lungs
(air- bronchogram).

Management
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 (cont.)
 IF under CPAP, two successive blood gas
analyses 20 minutes apart reveal the following
values:
• PH < 7.2
• Or PaO2 < 55 mmHg
• Or PaCO2 > 60 mmHg
 Proceed to endotracheal intubation and
mechanical ventilation.
Surfactant Therapy
Indications
 Prophylactic treatment:
• For all infants > 32 weeks who require a

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

Surfactant Therapy (cont.)

 Rescue treatment:
• For infants with moderate to severe RDS

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


Dosage and administration
 Dose: Should be guided according to the
type of surfactant used.
 Timing: Usually within 1-2 hours of age,

but without delaying resuscitation measures.


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.
• Hypoxia.
• Hypotension.
• ET blockage.
 After dosing:
• Do not suction ET tube for at least 1 hour.
 Monitor ABGs and adjust ventilator
setting.
Transient Tachypnea of
The Newborn (TTN )
Definition
 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.
Transient Tachypnea of The Newborn Slide 25

Risk Factors
 Cesarean section.
 Macrosomia.
 Prolonged labor.
 Male sex.
 Excessive maternal sedation.

Clinical 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.

Investigations
 Laboratory investigations
• Blood gases.
• Complete blood count (CBC) to rule out
infection.
 Radiological studies
• Chest X-ray findings consistent with TTN
include perihilar streaking, mild cardiomegaly,
increased lung volume, fluid in the minor
fissure, and perhaps fluid in the pleural space.
Management
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 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

(MAS)
Definition
 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 Slide 31
Meconium Aspiration Syndrome

(cont.)
 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.
Risk 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.
 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.

Investigations
 Laboratory investigations
• Blood gas analysis.
 Radiological studies
• Chest X-ray will show patchy infiltrates, coarse
streaking of both lung fields, an increased
anteroposterior diameter, and flattening of the
diaphragm.

Management
 Prenatal management
• Identification of high-risk pregnancy.
• Monitoring of fetal heart rate during labor.
 Delivery room management (if amniotic fluid
is meconium stained)
• Obstetrical: suctioning of the oropharynx by
obstetrician before delivery of the shoulders.

Management of The Newborn in

The Neonatal Unit
 General management
• Emptying of the stomach contents to avoid
further aspiration.
• Correction of metabolic abnormalities, e.g.,
hypoxia, acidosis, hypoglycemia,
hypocalcaemia, and hypothermia.
• Surveillance for end organ hypoxic/ischemic
damage (brain, kidney, heart, and liver).

The Neonatal Unit (cont.)
 Respiratory management
• Frequent suctioning and chest physiotherapy.
• Pulmonary toilet to remove residual meconium if
intubated.
• Antibiotic coverage (ampicillin and gentamicin).
• Oxygenation (maintain a high saturation > 95%).
• Mechanical ventilation (to avoid hypercarbia and
respiratory acidosis).

The Neonatal Unit (cont.)
 Surfactant may be required if clinical
condition continues to deteriorate.
 Cardiovascular management
• Correct systemic hypotension (hypovolemia and
myocardial dysfunction).
• Treat persistent pulmonary hypertension.
• Maintain a PaCO2 level < 40mmHg, and ensure
an O2 saturation of > 95%.
Apnea
Definition
 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 40
Definition (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 41
Risk Factors
• Hypothermia.
• Hypoglycemia.
• Anemia.
• Hypovolemia.
• Aspiration.
• NEC/distension
• Cardiac disease.
• Lung disease.
Apnea Slide 42
Risk Factors (cont.)
• Gastroesophageal reflux.
• Airway obstruction.
• Infection (e.g., meningitis).
• Neurological disorders
Apnea Slide 43
Apnea presents as the cessation of

respiration accompanied by bradycardia
and/or cyanosis for more than 20 seconds.
Apnea Slide 44
Management
 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 45
Management (cont.)
 General therapy
• Begin with tactile stimulation.
• If the infant does not respond to tactile
stimulation, bag and mask ventilation should
be used during the spell.
• Use CPAP or IPPV in recurrent and
prolonged apnea.
Apnea Slide 46
Management (cont.)
• In apnea of prematurity pharmacological
therapy should be administered:
• Theophylline; Start with a loading dose of 5
mg/kg/IV, followed 8 hours later by a
maintenance dose of 2 mg/kg every 8 hours.
• Monitor theophylline level.
Apnea Slide 47
Management (cont.)
 Specific therapy
• Treat the cause if identified, e.g., sepsis,
hypoglycemia, anemia, or electrolyte
abnormalities.
Apnea Slide 48
Air Leak Syndrome

Definition
 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.
Air Leak Syndrome Slide 49

Definition (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.

Risk Factors
• Ventilatory support.
• Meconium staining/aspiration.
• Surfactant therapy.
• Vigorous resuscitation

 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.

Management
 Prevention
• Judicious use of ventilatory support,
• Close attention to distending pressure (PEEP),
inspiratory time,
• Appropriate weaning of ventilatory support as
the clinical condition improves.
 General
• Oxygenation
Management (cont.)
 Specific
• Decompression of air leak according to the
type.
• In cases of tension pneumathorax, urgent
needle aspiration from the second intercostal
space in the midclavicular line is done, followed
by insertion of a chest tube with an underwater
seal in the fourth intercostal space in the
anterior axillary line.
Pneumonia
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 55
 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 56
Investigations
 Chest X-Ray
• Finding may be identical to other causes of
respiratory distress.
 Bacterial cultures
• Some cases of pneumonia may be culture
negative.
Pneumonia Slide 57
Management of Pneumonia
 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.
Pneumonia Slide 58

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21 Neonatal Respiratory Disorders

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Neonatal Care Module: Neonatal Respiratory Disorders - Session 1

Neonatal Care Module:

Module Overview: Purpose

The purpose of this session is to introduce

Module Overview Slide 2

Module Overview: Story

Module Overview Slide 3

Learning Objectives (cont.)

Learning Objectives Slide 5

Learning Objectives (cont.)

Learning Objectives Slide 6

Table 1. Evaluation of Respiratory Distress

Table 1. Evaluation of Respiratory Distress

 < 4 → No respiratory distress

Common Neonatal Respiratory

Common Neonatal Respiratory Disorders Slide 12

Respiratory Distress Syndrome

Respiratory Distress Syndrome Slide 13

Risk Factors (cont.)

Respiratory Distress Syndrome Slide 15

Clinical Presentation of RDS

Respiratory Distress Syndrome Slide 16

Respiratory Distress Syndrome Slide 17

• For all infants > 32 weeks who require a

Respiratory Distress Syndrome Slide 20

Surfactant Therapy (cont.)

• For infants with moderate to severe RDS

Respiratory Distress Syndrome Slide 21

Surfactant Therapy (cont.)

 Timing: Usually within 1-2 hours of age,

Respiratory Distress Syndrome Slide 22

Surfactant Therapy (cont.)

Surfactant Therapy (cont.)

Transient Tachypnea of The Newborn Slide 25

Transient Tachypnea of The Newborn Slide 26

Transient Tachypnea of The Newborn Slide 27

Transient Tachypnea of The Newborn Slide 29

Outcome and Prognosis

 The disease is self-limiting and there is no

Transient Tachypnea of The Newborn Slide 30

Meconium Aspiration Syndrome

Meconium Aspiration Syndrome

Meconium Aspiration Syndrome Slide 34

Meconium Aspiration Syndrome Slide 35

Meconium Aspiration Syndrome Slide 36

Management of The Newborn in

Management of The Newborn in

Management of The Newborn in

Risk Factors (cont.)

Apnea presents as the cessation of

• Monitor theophylline level.

Air Leak Syndrome

Air Leak Syndrome Slide 49

Air Leak Syndrome Slide 50

Air Leak Syndrome Slide 51

Air Leak Syndrome Slide 52

 Onset occurs 1-2 days after delivery.

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