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Neonatology DivisionNeonatology DivisionDepartment of Child Health Medical School

U i it f S t UtVisual 1

University of Sumatera Utara

Alarming Signs for RD

CyanosisSevere apnea (coma?)Severe apnea (coma?)StridorG i ff tGasping effortsSevere respiratory retractionsPoor perfusion (shock)

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Evaluation of RespiratoryEvaluation of RespiratoryDistress Using Down’s Score

> 80/min60 – 80/min< 60/minRespiratory Rate

210

Severe retractionsMild retractionsNo retractionRetractions

80/min60 80/min 60/minRespiratory Rate

N i tMild d i i G d bil t l i Ai E t

Cyanosis on O2Cyanosis relieved by O2

No cyanosisCyanosis

Audible with earAudible by No gruntingGrunting

No air entryMild decrease in air entry

Good bilateral air entry

Air Entry

Learning Objective 1 Visual 3

stethoscope

Evaluation of RespiratoryEvaluation of Respiratory Distress Using Down’s Score

Score < 4 No respiratory distress

Score 4 -7 Respiratory distress

Score > 7 Impending respiratory failure (Blood gases should be obtained)

Learning Objective 1 Visual 4

Be Prepared

Resuscitation equipment and/or suppliesInvolve others (team approach)Involve others (team approach)Have staff trainedABCABC

Airway BreathingCirculation

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Conditions Associated with Respiratory Distress

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Investigations

Chest X-rayArterial blood gasArterial blood gasCBC (anemia, polycythemia, sepsis)Gl h k (h l i )Glucose check (hypoglycemia)Blood culture (sepsis, pneumonia)

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Treatment

After stabilization, treat the cause of RDUse CPAPUse CPAPAvoid unnecessary exposure to oxygenA tibi ti til i i l d tAntibiotics until sepsis is ruled out

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Common Causes of RDCommon Causes of RD

Transient tachypnea of the newborn (TTN)Hyaline membrane disease (HMD)Hyaline membrane disease (HMD)Meconium aspiration syndrome (MAS)Ai l k dAir leak syndromePneumoniaCongenital heart diseases

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Transient Tachypnea of theTransient Tachypnea of theTransient Tachypnea of the Transient Tachypnea of the Neonate (TTN)Neonate (TTN)

Definition

A benign disease of near-term or term neonates who have respiratory distress shortly after p y ydelivery that resolves within 3-5 days.

Learning Objective 3 Visual 11

Pathogenesis of TTNPathogenesis of TTN

How is lung fluid formed?What is the function of lung fluids?What is the function of lung fluids?What happens to lung fluids during labor?D it tt th t f l b ? Does it matter the type of labor?

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Transient Tachypnea of theTransient Tachypnea of theTransient Tachypnea of the Transient Tachypnea of the Neonate (TTN) (cont)Neonate (TTN) (cont)

Risk factors

Cesarean section without laborMacrosomiaMale sexProlonged laborgExcessive maternal sedation Low Apgar score (< 7 at 1 minute)

Learning Objective 3 Visual 13

o pga sco e ( at ute)

Transient Tachypnea of theTransient Tachypnea of theTransient Tachypnea of the Transient Tachypnea of the Neonate (TTN) (cont)Neonate (TTN) (cont)Clinical Presentation of TTN The neonate is usually near term or term and The neonate is usually near-term or term, and shortly after delivery has tachypnea (>80 b th / i t ) Th t l h breaths/minute). The neonate may also have grunting, nasal flaring, rib retractions, and cyanosis. The disease usually does not last longer than 72 hours.

Learning Objective 3 Visual 14

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Transient Tachypnea of theTransient Tachypnea of theTransient Tachypnea of the Transient Tachypnea of the Neonate (TTN) (cont)Neonate (TTN) (cont)

Chest X-ray: Perihilar streaking, mild cardiomegaly, increased lung volume, fluid in the minor fi d h fl id i th l l fissure, and perhaps fluid in the pleural space are common findings.

Learning Objective 3 Visual 16

Transient Tachypnea of theTransient Tachypnea of theTransient Tachypnea of the Transient Tachypnea of the Neonate (TTN) (cont)Neonate (TTN) (cont)

Management of TTN

Judicious use of oxygenFluid restriction F di t h iFeeding as tachypnea improves

Confirm the diagnosis by excluding other causes of Confirm the diagnosis by excluding other causes of tachypnea e.g. pneumonia, congenital heart disease, hyaline membrane disease, and cerebral hyperventilation.

Learning Objective 3 Visual 17

hyperventilation.

Transient Tachypnea of theTransient Tachypnea of theTransient Tachypnea of the Transient Tachypnea of the Neonate (TTN) (cont)Neonate (TTN) (cont)

Outcome and Prognosis of TTN

The disease is self-limited and there is no risk f f th l of recurrence or further pulmonary

dysfunction. Respiratory symptoms improve as i t l fl id i bili d d thi i intrapulmonary fluid is mobilized, and this is usually associated with diuresis.

Learning Objective 3 Visual 18

Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome)(Respiratory Distress Syndrome)

DefinitionHyaline membrane disease (HMD) is also called respiratory distress syndrome (RDS). This condition

ll i t t P t usually occurs in a preterm neonate. Premature lungs are surfactant deficient.

Learning Objective 4 Visual 19

Hyaline Membrane Disease Hyaline Membrane Disease yy(Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)(cont)(cont)Respiratory difficulties exhibited include:

Increasing tachypnea (> 60/min)Chest retractionsChest retractionsCyanosis on room air that persists or progresses over the first 24-48 hours of lifeprogresses over the first 24-48 hours of life.Decreased air entryGrunting

Learning Objective 4 Visual 20

Grunting

Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)(cont)(cont)

Incidence

HMD occurs in about 25% of neonates born at 32 k t ti Th i id i 32 weeks gestation. The incidence increases with increasing prematurity.

Learning Objective 4 Visual 21

Hyaline Membrane DiseaseHyaline Membrane Disease (Respiratory Distress Syndrome) (cont)(cont)

Risk Factors of HMDIncreased Risk

P t itPrematurityMale sexNeonate of diabetic Neonate of diabetic mother

Learning Objective 4 Visual 22

Hyaline Membrane DiseaseHyaline Membrane Disease (Respiratory Distress Syndrome) (cont)(cont)Risk Factors of HMD

Decreased RiskDecreased RiskChronic intrauterine stress

Prolonged rupture of membranes o o ged uptu e o e b a esMaternal hypertensionNarcotic useIntrauterine Growth Retardation (IUGR) or Small for Intrauterine Growth Retardation (IUGR) or Small for Gestational Age (SGA)

Corticosteroids – Prenatal

Learning Objective 4 Visual 23

Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)(cont)(cont)

Investigations for HMD (RDS)g ( )Laboratory Studies:

Blood gases: hypoxia hypercarbia acidosisBlood gases: hypoxia, hypercarbia, acidosis.CBC and blood culture are required to rule out infection.Serum glucose levels are usually lowSerum glucose levels are usually low.

Chest X-ray Study:Reveals ground glass appearance with air bronchograms

Learning Objective 4 Visual 24

Reveals ground glass appearance with air bronchograms.

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Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)( )( )

Management of HMD (RDS)G lGeneral

Thermal regulation Parenteral fluid AntibioticsContinuous monitoring

Learning Objective 4 Visual 26

Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)(cont)(cont)

Continuous positive airway pressure (CPAP) is triedtried.If under CPAP

PH < 7 2PH < 7.2Or PO2 < 40mmHg FiO2 > 60%Or PCO2 > 60mmH⎢Base deficit > -10

Endotracheal intubation and mechanical ventilation.C id f t t thLearning Objective 4 Visual 27

Consider surfactant therapy

Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)(cont)(cont)

Caution: every 10 days on the ventilator is i t d ith 20% i d i k f associated with 20% increased risk for

cerebral palsy

Learning Objective 4 Visual 28

Hyaline Membrane DiseaseHyaline Membrane DiseaseHyaline Membrane Disease Hyaline Membrane Disease (Respiratory Distress Syndrome) (Respiratory Distress Syndrome) (cont)(cont)(cont)(cont)

Specific TreatmentpSurfactant replacement therapy if tracheal intubation is requiredq

OutcomeRDS accounts for 20% of all neonatal deathsRDS accounts for 20% of all neonatal deathsChronic lung diseases occurs in 29% in VLBW infants

Learning Objective 4 Visual 29

infants

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Meconium Aspiration SyndromeMeconium Aspiration SyndromeMeconium Aspiration Syndrome Meconium Aspiration Syndrome (MAS)(MAS)Definition

The respiratory distress secondary to meconium aspiration by the fetus in utero or by the neonate during labor and delivery.

Learning Objective 5 Visual 31

Meconium Aspiration SyndromeMeconium Aspiration SyndromeMeconium Aspiration Syndrome Meconium Aspiration Syndrome (MAS) (cont)(MAS) (cont)Pathogenesis: aspiration of meconium can

cause:

Airway obstruction (ball and valve)Severe inflammationPulmonary hypertensionPlatelet activation

Learning Objective 5 Visual 32

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)Risk Factors of MAS

Post-term pregnancyMaternal hypertension

Pre-eclampsiaMaternal diabetes mellitusyp

Abnormal fetal heart rateBiophysical profile ≤ 6

SGAChorioamnionitisBiophysical profile ≤ 6

Learning Objective 5 Visual 33

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)Clinical presentation of MAS

Meconium staining of amniotic fluid before birth.Meconium staining of neonate after birth.Respiratory distress leading to increased anteroposterior diameter of the chest.Persistent pulmonary hypertension of the newborn (PPHN).

Learning Objective 5 Visual 34

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)

Investigations for MAS

Laboratory studiesBlood gas analysisg yBlood culture and CBC

Learning Objective 5 Visual 35

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)Investigations for MAS

Radiologic studiesChest X-ray: findings include patchy infiltrates, coarse streaking of both lung fields, hyperinflation of the lung and flattening of the diaphragm.

Learning Objective 5 Visual 36

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Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)

Management of MASPrenatal management:

Identification of high-risk pregnancy.Monitoring of fetal heart rate during labor.Amnioinfusion (?)( )

Learning Objective 5 Visual 38

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) cont)Management of MAS

D li t (if i ti fl id i Delivery room management: (if amniotic fluid is meconium stained)

Ob t t i l S ti f th h b b t t i i Obstetrical: Suction of the oropharynx by obstetrician before delivery of shoulders.Pediatric: Visualization of vocal cords and tracheal Pediatric: Visualization of vocal cords and tracheal suction if infant is not breathing.

Learning Objective 5 Visual 39

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)

General Management of Neonate with MASEmpty the stomach contents to avoid further Empty the stomach contents to avoid further aspiration.Correction of metabolic abnormalities e g hypoxia Correction of metabolic abnormalities e.g. hypoxia, acidosis, hypoglycemia, hypocalcemia and hypothermia.ypSurveillance for end organ hypoxic/ischemic damage (brain, kidney, heart and liver).

Learning Objective 5 Visual 40

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)

Respiratory Management of Neonate with MASFrequent suction and chest vibrationFrequent suction and chest vibration.Pulmonary toilet to remove residual meconium if

intubatedintubated.Antibiotic coverage (ampicillin and gentamicin).Use CPAPUse CPAP.

Learning Objective 5 Visual 41

Meconium Aspiration SyndromeMeconium Aspiration Syndrome (MAS) (cont)Outcome and Prognosis (MAS)

Mortality rate may be as high as 50% Mortality rate may be as high as 50%. Survivors may suffer from bronchopulmonary d l i d l i ldysplasia and neurologic sequelae.

Learning Objective 5 Visual 42

Air Leak SyndromesDefinitionDefinitionThe air leaks syndromes (pneumomediastinum, pneumothorax pulmonary interstitial emphysema pneumothorax, pulmonary interstitial emphysema and pneumopericardium) comprise a spectrum of diseases with the same underlying diseases with the same underlying pathophysiology. Overdistension of alveolar sacs or terminal airways leads to disruption of airway or terminal airways leads to disruption of airway integrity, resulting in dissection of air into surrounding spacesLearning Objective 6 Visual 43

surrounding spaces.

Air Leak Syndromes (cont)

IncidenceMost commonly seen in neonates with lung Most commonly seen in neonates with lung disease who are on ventilatory support but can also occur spontaneously The more severe the also occur spontaneously. The more severe the lung disease, the higher the incidence of pulmonary air leakpulmonary air leak.

Learning Objective 6 Visual 44

Air Leak Syndromes (cont)

Risk Factors for Air Leak Syndromes

Spontaneous 0.5%Ventilatory support 15-20%CPAP 5% Meconium staining / aspirationg pSurfactant therapyVigorous resuscitation (bag ventilation)

Learning Objective 6 Visual 45

Vigorous resuscitation (bag ventilation)

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Air Leak Syndromes (cont)

Clinical Presentation of Neonates with Air Leak SyndromesSyndromes

Respiratory distress or sudden deterioration of clinical course with alteration of vital signs and worsening of course with alteration of vital signs and worsening of blood gases.Asymmetry of thorax is present in unilateral casesAsymmetry of thorax is present in unilateral cases.

Learning Objective 6 Visual 48

Air Leak Syndromes (cont)

Investigations for Air Leak Syndromes

The definitive diagnosis of all air leak syndromes is made radiographically by an A-P chest X-ray film and a made radiographically by an A P chest X ray film and a lateral film.

Learning Objective 6 Visual 49

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Air Leak Syndromes (cont)M t f Ai L k S dManagement of Air Leak Syndromes

GeneralAvoid ventilatorsCareful use of manual bag ventilation

SpecificDecompression of air leak according to the type.Do not needle the chest

Learning Objective 6 Visual 51

AApneaDefinitionDefinition

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

IncidenceIncidence50-60% of preterm neonates have evidence of apnea (35% with central apnea, 5-10% with apnea (35% with central apnea, 5 10% with obstructive apnea, and 15-20% with mixed apnea).

Learning Objective 7 Visual 52

p )

A ( t)Apnea (cont)Risk Factors of Neonatal ApneaRisk Factors of Neonatal Apnea

Pathological apneaHypothermiaHypoglycemia

Cardiac diseaseLung disease

AnemiaHypovolemia

Gastro intestinal refluxAirway obstruction

AspirationNEC / Distension

Infection, meningitisNeurological disorders

Learning Objective 7 Visual 53

Apnea (cont)I ti tiInvestigations

Monitoring at-risk neonates less than 32 weeks t ti l gestational age.

Evaluate for a possible underlying cause.Laboratory studies should include a CBC, blood gas analysis, serum glucose, electrolyte, and

l i l lcalcium levels.Radiologic studies if chest disease is suspected

Learning Objective 7 Visual 54

Apnea (cont)Apnea (cont)Management of Apnea

General Therapy General Therapy Perform tactile stimulation.CPAP i t d l d CPAP in recurrent and prolonged apnea. Pharmacological therapy (caffeine or theophylline) may be requiredmay be required.

Monitor levels.

Learning Objective 7 Visual 55

Apnea (cont)

Management of ApneaSpecific TherapySpecific Therapy

Treatment of the cause, if identified, eg. treatment of sepsis hypoglycemia anemia and electrolyte sepsis, hypoglycemia, anemia, and electrolyte abnormalities.

Learning Objective 7 Visual 56

Apnea (cont)

Outcome and Prognosis

I t t l ith t th In most neonates apnea resolves without the occurrence of long-term deficiencies.

Learning Objective 7 Visual 57

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