1. Assessment of the Neonate Fred Hill, MA, RRT

2. Reduction in Pulmonary Reserve Thorax is more flexible Thorax is more flexible Heart is larger in proportion to thorax Heart is larger in proportion to thorax Abdominal contents are larger in proportion to thorax Abdominal contents are larger in proportion to thorax

3. Breathing and Coughing Newborns are “obligate nose breathers” Newborns are “obligate nose breathers” Neonates lack a cough reflex Neonates lack a cough reflex Smaller airways, but epithelial cells are similar in size Smaller airways, but epithelial cells are similar in size Breathing rate = 30-50 vs 12-20; premature = 40-60 Breathing rate = 30-50 vs 12-20; premature = 40-60 Heart Rate = 100-140 vs 60-80 Heart Rate = 100-140 vs 60-80

4. Upper Airway Anatomy Tongue is larger in proportion to oropharynx. More lymphoid tissues in pharynx. Tongue is larger in proportion to oropharynx. More lymphoid tissues in pharynx. Larynx is more anterior and higher. Larynx is more anterior and higher. Epiglottis is larger and stiffer in proportion, lies more horizontal, omega shaped Epiglottis is larger and stiffer in proportion, lies more horizontal, omega shaped Cricoid cartilage is narrowest portion of upper airway (~7 years changes to glottic area) Cricoid cartilage is narrowest portion of upper airway (~7 years changes to glottic area) Carina is only 4 cm below vocal cords Carina is only 4 cm below vocal cords Tracheal diameter: 4 mm vs 16 mm Tracheal diameter: 4 mm vs 16 mm

5. Other Considerations Ribs are more horizontal (not bucket handle). Rely primarily on diaphragmatic breathing. Ribs are more horizontal (not bucket handle). Rely primarily on diaphragmatic breathing. Breath sounds transmit well due to thin thoracic wall, but harder to localize sounds. Breath sounds transmit well due to thin thoracic wall, but harder to localize sounds.

6. Newborn X Ray

7. Infant X Ray

8. Other Aspects of Newborn Higher metabolic rate: 100 cal/kg vs 40- 50 cal/kg Higher metabolic rate: 100 cal/kg vs 40- 50 cal/kg Reactions to medicines not predictable Reactions to medicines not predictable –High metabolic rate –Immature liver and kidneys High surface area to body weight ratio High surface area to body weight ratio

9. Gestational Age Assessment Dubowitz Gestational Age Assessment Dubowitz Gestational Age Assessment –11 physical signs –10 neurologic signs –Useful in the first 5 days of life Ballard Gestational Age Assessment Ballard Gestational Age Assessment –6 neurologic signs –6 physical signs –Before 42 hours of life (ideal 30 to 42 hours)

10. Ballard Gestational Age Assessment

11. Physical Signs Skin Skin Lanugo Lanugo Plantar surface Plantar surface Ear recoil Ear recoil Breast tissue Breast tissue Genitalia Genitalia

12. Size for Gestational Age Two reasons for low-birth-weight infant Two reasons for low-birth-weight infant – Prematurity – Growth retardation Size for gestational age Size for gestational age – Appropriate for gestational age (AGA) – Large for gestational age (LGA) – Small for gestational age (SGA)

13. Weight vs Gestational Age: Boys

14. Weight vs Gestational Age: Girls

15. Signs of Respiratory Distress Synchrony of chest/abdomen movements Synchrony of chest/abdomen movements Retractions Retractions –Lower chest (lateral ribs) –Xiphoid (substernal) Nasal flaring Nasal flaring Expiratory grunting Expiratory grunting Cyanosis Cyanosis Tachypnea Tachypnea

16. Respiratory Care Procedures Fred Hill, MA, RRT

17. Endotracheal Tube Suctioning Two people Two people –One to perform suctioning –One to monitor and provide support as needed Depth of catheter insertion determined by length of ET tube; only to tip Depth of catheter insertion determined by length of ET tube; only to tip Size of suction catheter as per ETT size Size of suction catheter as per ETT size Suction pressure: -50 to -80 mm Hg Suction pressure: -50 to -80 mm Hg

18. Suction Catheter Size Endotracheal Tube Suction Catheter 2.5 5, 6 3.06-8 3.58-10 4.08-10

19. Suction Catheter Size Nonintubated Suction Catheter Preemie 5, 6 Term6-8 Newborn to 6 months 8-10

20. Oxygen Hazards Hazards –Retinopathy of prematurity –Bronchopulmonary dysplasia Oxygen Hood (Oxyhood) Oxygen Hood (Oxyhood) –High flow device –Usually <0.6 FiO2 –Flows >7 lpm –Appropriate temperature of gas Cannulas: always humidified with newborns, 1/8 to 1 lpm typical flows or 0.2 to 1 lpm Cannulas: always humidified with newborns, 1/8 to 1 lpm typical flows or 0.2 to 1 lpm

21. Oxyhood