Department of Child Health Medical School University of Sumatera Utara Respiratory Distress Neonatology Division Department of Child Health Medical School University of Sumatera Utara

Alarming Signs for RD Cyanosis Severe apnea (coma?) Stridor Gasping efforts Severe respiratory retractions Poor perfusion (shock)

Evaluation of Respiratory Distress Using Down’s Score Audible with ear Audible by stethoscope No grunting Grunting No air entry Mild decrease in air entry Good bilateral air entry Air Entry Cyanosis on O2 Cyanosis relieved by O2 No cyanosis Cyanosis Severe retractions Mild retractions No retraction Retractions > 80/min 60 – 80/min < 60/min Respiratory Rate 2 1 Learning Objective 1

Evaluation 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

Be Prepared Resuscitation equipment and/or supplies Involve others (team approach) Have staff trained ABC Airway Breathing Circulation

Conditions Associated with Respiratory Distress

Investigations Chest X-ray Arterial blood gas CBC (anemia, polycythemia, sepsis) Glucose check (hypoglycemia) Blood culture (sepsis, pneumonia)

Treatment After stabilization, treat the cause of RD Use CPAP Avoid unnecessary exposure to oxygen Antibiotics until sepsis is ruled out

Common Causes of RD Transient tachypnea of the newborn (TTN) Hyaline membrane disease (HMD) Meconium aspiration syndrome (MAS) Air leak syndrome Pneumonia Congenital heart diseases

Transient Tachypnea of the Neonate (TTN) Definition A benign disease of near-term or term neonates who have respiratory distress shortly after delivery that resolves within 3-5 days. Learning Objective 3

Pathogenesis of TTN How is lung fluid formed? What is the function of lung fluids? What happens to lung fluids during labor? Does it matter the type of labor?

Transient Tachypnea of the Neonate (TTN) (cont) Module: Neonatal Respiratory Disorders - Session 1 Transient Tachypnea of the Neonate (TTN) (cont) Risk factors Cesarean section without labor Macrosomia Male sex Prolonged labor Excessive maternal sedation Low Apgar score (< 7 at 1 minute) Learning Objective 3

Transient Tachypnea of the Neonate (TTN) (cont) Clinical Presentation of TTN The neonate is usually near-term or term, and shortly after delivery has tachypnea (>80 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

Transient Tachypnea of the Neonate (TTN) (cont) Chest X-ray: Perihilar streaking, mild cardiomegaly, increased lung volume, fluid in the minor fissure, and perhaps fluid in the pleural space are common findings. Learning Objective 3

Transient Tachypnea of the Neonate (TTN) (cont) Management of TTN Judicious use of oxygen Fluid restriction Feeding as tachypnea improves Confirm the diagnosis by excluding other causes of tachypnea e.g. pneumonia, congenital heart disease, hyaline membrane disease, and cerebral hyperventilation. Learning Objective 3

Transient Tachypnea of the Neonate (TTN) (cont) Outcome and Prognosis of TTN The disease is self-limited and there is no risk of recurrence or further pulmonary dysfunction. Respiratory symptoms improve as intrapulmonary fluid is mobilized, and this is usually associated with diuresis. Learning Objective 3

Hyaline Membrane Disease (Respiratory Distress Syndrome) Definition Hyaline membrane disease (HMD) is also called respiratory distress syndrome (RDS). This condition usually occurs in a preterm neonate. Premature lungs are surfactant deficient. Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Respiratory difficulties exhibited include: Increasing tachypnea (> 60/min) Chest retractions Cyanosis on room air that persists or progresses over the first 24-48 hours of life. Decreased air entry Grunting Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Incidence HMD occurs in about 25% of neonates born at 32 weeks gestation. The incidence increases with increasing prematurity. Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Risk Factors of HMD Increased Risk Prematurity Male sex Neonate of diabetic mother Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Risk Factors of HMD Decreased Risk Chronic intrauterine stress Prolonged rupture of membranes Maternal hypertension Narcotic use Intrauterine Growth Retardation (IUGR) or Small for Gestational Age (SGA) Corticosteroids – Prenatal Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Investigations for HMD (RDS) Laboratory Studies: Blood gases: hypoxia, hypercarbia, acidosis. CBC and blood culture are required to rule out infection. Serum glucose levels are usually low. Chest X-ray Study: Reveals ground glass appearance with air bronchograms. Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Management of HMD (RDS) General Thermal regulation Parenteral fluid Antibiotics Continuous monitoring Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Continuous positive airway pressure (CPAP) is tried. If under CPAP PH < 7.2 Or PO2 < 40mmHg FiO2 > 60% Or PCO2 > 60mmH Base deficit > -10 Endotracheal intubation and mechanical ventilation. Consider surfactant therapy Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Caution: every 10 days on the ventilator is associated with 20% increased risk for cerebral palsy Learning Objective 4

Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont) Specific Treatment Surfactant replacement therapy if tracheal intubation is required Outcome RDS accounts for 20% of all neonatal deaths Chronic lung diseases occurs in 29% in VLBW infants Learning Objective 4

Meconium Aspiration Syndrome (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

Meconium Aspiration Syndrome (MAS) (cont) Pathogenesis: aspiration of meconium can cause: Airway obstruction (ball and valve) Severe inflammation Pulmonary hypertension Platelet activation Learning Objective 5

Meconium Aspiration Syndrome (MAS) (cont) Risk Factors of MAS Post-term pregnancy Maternal hypertension Abnormal fetal heart rate Biophysical profile  6 Pre-eclampsia Maternal diabetes mellitus SGA Chorioamnionitis Learning Objective 5

Meconium 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

Meconium Aspiration Syndrome (MAS) (cont) Investigations for MAS Laboratory studies Blood gas analysis Blood culture and CBC Learning Objective 5

Meconium Aspiration Syndrome (MAS) (cont) Investigations for MAS Radiologic studies Chest X-ray: findings include patchy infiltrates, coarse streaking of both lung fields, hyperinflation of the lung and flattening of the diaphragm. Learning Objective 5

Meconium Aspiration Syndrome (MAS) (cont) Management of MAS Prenatal management: Identification of high-risk pregnancy. Monitoring of fetal heart rate during labor. Amnioinfusion (?) Learning Objective 5

Meconium Aspiration Syndrome (MAS) cont) Management of MAS Delivery room management: (if amniotic fluid is meconium stained) Obstetrical: Suction of the oropharynx by obstetrician before delivery of shoulders. Pediatric: Visualization of vocal cords and tracheal suction if infant is not breathing. Learning Objective 5

Meconium Aspiration Syndrome (MAS) (cont) General Management of Neonate with MAS Empty the stomach contents to avoid further aspiration. Correction of metabolic abnormalities e.g. hypoxia, acidosis, hypoglycemia, hypocalcemia and hypothermia. Surveillance for end organ hypoxic/ischemic damage (brain, kidney, heart and liver). Learning Objective 5

Meconium Aspiration Syndrome (MAS) (cont) Respiratory Management of Neonate with MAS Frequent suction and chest vibration. Pulmonary toilet to remove residual meconium if intubated. Antibiotic coverage (ampicillin and gentamicin). Use CPAP. Learning Objective 5

Meconium Aspiration Syndrome (MAS) (cont) Outcome and Prognosis (MAS) Mortality rate may be as high as 50%. Survivors may suffer from bronchopulmonary dysplasia and neurologic sequelae. Learning Objective 5

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

Air Leak Syndromes (cont) Incidence Most commonly seen in neonates with lung disease who are on ventilatory support but can also occur spontaneously. The more severe the lung disease, the higher the incidence of pulmonary air leak. Learning Objective 6

Air Leak Syndromes (cont) Risk Factors for Air Leak Syndromes Spontaneous 0.5% Ventilatory support 15-20% CPAP 5% Meconium staining / aspiration Surfactant therapy Vigorous resuscitation (bag ventilation) Learning Objective 6

Air Leak Syndromes (cont) Clinical Presentation of Neonates with Air Leak Syndromes Respiratory distress or sudden deterioration of clinical course with alteration of vital signs and worsening of blood gases. Asymmetry of thorax is present in unilateral cases. Learning Objective 6

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 lateral film. Learning Objective 6

Air Leak Syndromes (cont) Management of Air Leak Syndromes General Avoid ventilators Careful use of manual bag ventilation Specific Decompression of air leak according to the type. Do not needle the chest Learning Objective 6

Apnea Definition Cessation of respiration accompanied by bradycardia and/or cyanosis for more than 20 seconds. Incidence 50-60% of preterm neonates have evidence of apnea (35% with central apnea, 5-10% with obstructive apnea, and 15-20% with mixed apnea). Learning Objective 7

Apnea (cont) Risk Factors of Neonatal Apnea Pathological apnea Hypothermia Hypoglycemia Anemia Hypovolemia Aspiration NEC / Distension Cardiac disease Lung disease Gastro intestinal reflux Airway obstruction Infection, meningitis Neurological disorders Learning Objective 7

Apnea (cont) Investigations Monitoring at-risk neonates less than 32 weeks gestational age. Evaluate for a possible underlying cause. Laboratory studies should include a CBC, blood gas analysis, serum glucose, electrolyte, and calcium levels. Radiologic studies if chest disease is suspected Learning Objective 7

Apnea (cont) Management of Apnea General Therapy Perform tactile stimulation. CPAP in recurrent and prolonged apnea. Pharmacological therapy (caffeine or theophylline) may be required. Monitor levels. Learning Objective 7

Apnea (cont) Management of Apnea Specific Therapy Treatment of the cause, if identified, eg. treatment of sepsis, hypoglycemia, anemia, and electrolyte abnormalities. Learning Objective 7

Apnea (cont) Outcome and Prognosis In most neonates apnea resolves without the occurrence of long-term deficiencies. Learning Objective 7

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