1. Respiratory Problems in the Newborn

2. Objectives
Understand pathophysiology of common respiratory conditions in the newborn
Management of these conditions
Update on resuscitation devices
Discuss case scenarios

3. Respiratory Problems in the Newborn
Challenging problem
Requires early recognition and prompt therapy
Associated with significant morbidity and mortality

4. Introduction Most newborn babies are vigorous after birth
About 10% require some assistance
Only 1% need resuscitative measures (intubation, chest compressions, and/or medications) to survive
NRP 2006

5. Signs of a Compromised Newborn
Poor muscle tone
Depressed respiratory drive
Low HR
Low BP
Tachypnea
Cyanosis, nasal flaring, grunting, SCR and ICR
NRP 2006

6. Fetal Physiology In the fetus Alveoli filled with lung fluid
Lungs expand with air after birth
NRP 2006

7. Tachypnea vs Respiratory Distress
Normal respiratory rate: per minute
Tachypnea: RR>60 in a quiet resting baby
Distress: RR>or <60 with retractions, grunting, central cyanosis, lethargy and poor feeding

8. Common Respiratory Problems in the Newborn
TTN
RDS
MAS
Infection (e.g.pneumonia, sepsis)
PPHN

9. Nonpulmonary Conditions with RD
Anemia
Asphyxia
Heart Disease
Malformations
Metabolic conditions
Maternal drug abuse
Pneumothorax

10. History Gestation: Term or Preterm
Consistency of the amniotic fluid: Clear or meconium stained
Risk factors for infection: PPROM, chorioamnionitis, HSV lesions

11. Physical Examination
Respiratory Rate –intermittent apnea and tachypnea and with distress
Cyanosis – place pulse ox
Retractions, Flaring, Grunting, Stridor
Auscultation - decreased aeration (RDS), distant heart sounds (Pneumothorax)

12. Physical Examination
Cleft palate and micrognathia – aspiration, upper airway obstruction
Scaphoid abdomen and worsening with bag mask ventilation - CDH
Excessive frothing/secretions - TEF
Worsening condition at rest and improves with crying - Choanal atresia

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16. Common causes of RD in Preterms
Most common cause : Respiratory Distress Syndrome (RDS)
Asphyxia
Pneumonia
Hypoglycemia
Hypothermia
NRP 2006

17. Respiratory Distress Syndrome
Classic presentation:
-grunting
-retractions
-flaring
-cyanosis
-tachypnea
CXR: mild granularity to ground-glass appearance

18. Respiratory Distress Syndrome

19. Initial Management Check laryngoscope and ET tubes
Suction and CO2 detector
Pre-warmed radiant warmer, (Polyethlene bag/Saran wrap)
Suction mouth and nose
Perform tactile stimulation
Attach pulse oximeter to right upper extremity (preductal saturations)

20. T-Piece Resuscitators
Flow-Inflating Bag
T-Piece Resuscitators
Self- Inflating Bag

21. Positive Pressure Support
CPAP (4-5 cm H20),
FiO2 (sats 85-93% in preterm and 90-98% in term infants)
HR<100, apnea/gasping or with cyanosis, give breaths per minute
Adequate chest movement (start PIP at 20 cm H20 then increase to achieve chest rise)

22. Apnea Commonly seen in preterm infants
Due to immature control of breathing
Other causes: hypoglycemia, anemia, infection, hypoxemia
Consider load with caffeine
May need CPAP or HFNC
Rarely need intubation and mechanical ventilation

23. Diagnostic Work-up Chest X-ray Sepsis work-up - CBC/blood culture
Consider lumbar puncture as clinically indicated
Begin antibiotics

24. Management Respiratory therapy -PPV/oxyhood/HFNC/NCPAP/intubation
Transfer to a higher center when necessary
Monitor all babies - HR/RR/perfusion/BP/Urine output/hydration
NPO with OG to gravity
IV fluids; D10W 60ml/kg/d for term infants and 80ml/kg/d for preterm infants

25. Case # 1
35yo mother, good prenatal care, serologies appropriate, admitted in labor, clear fluid
39w, male infant, 3.8kg
Tachypneic with mild SCR, intermittent grunting
Saturation: 88-92% on RA
CXR, ABG,CBC, Blood culture sent, antibiotics started
What is the diagnosis?

26. Transient Tachypnea of the Newborn
Delayed clearance of lung fluid
CXR: perihilar linear densities
Monitor respiratory status closely
Most do not require any respiratory support
May need HFNC or CPAP

28. Case #2 You are asked to attend a delivery
32yo, G5P4, 38w, good prenatal care, serologies appropriate, admitted in labor, ROM with meconium stained fluid
Baby born SVD, floppy, pale
What do you do?
After above steps, infant noted to have spontaneous breathing with SCR, ICR, grunting

29. Case # 2 continued Place pulse ox: sats 81%
Increased WOB with decreasing saturations
What is the cause?

30. Meconium Aspiration Syndrome
Meconium causes mechanical obstruction
Non vigorous: intubate and suction
Supportive respiratory therapy: CPAP/HFNC
UAC/UVC placement
NPO
Antibiotics
Sedation as indicated
Monitor closely

32. Case #3 17y mother, presents in labor, G1P0, 40w Good prenatal care
Serologies appropriate
GBS negative
Present with fever 101, mild abdominal tenderness
Infant born apneic, responds to resuscitation
SCR, ICR, flaring and grunting
What could be the likely cause?

33. Infection/Neonatal Pneumonia
Prolonged rupture of membranes, chorioamnionitis
May present with RD, lethargy, poor feeding
CXR, CBC, blood culture, LP
CXR: similar to RDS with haziness all over
Antibiotics – Ampicillin and gentamicin as per neofax

34. Pneumonia

35. Case # 4 27yo mother, presented to OB clinic with spotting
Admitted to hospital, NRFHT
Crash C-section under GA
41w, G1P0, O negative mother, GBS negative
Born floppy, responds to inititial resus
Admitted to term nursery
Respiratory distress with SCR, desaturations
Hypotensive, acidotic

36. PPHN Severe cyanosis, respiratory distress
Preductal>postductal saturations
Respiratory support with FIO2 as needed to maintain saturation above 95%
May be primary or associated with other causes: MAS, pneumonia
Echocardiogram: elevated RV pressure
Begin antibiotics

38. Surgical Causes
Examination of the neck, nose, mouth and throat

39. Pneumothorax Can occur spontaneously
Presentation: respiratory distress
Decreased breath sounds on affected side
Small, less symptomatic, clinically stable-conservative management –follow CXR
May conider 100% oxygen for nitrogen wash-out
More sick: may need emergent needling or chest tube placement

41. Needle Thoracentesis
22 gauge angiocatheter, or 23 gauge butterfly needle, 3-way stopcock, ml syringe
Rapid improvement in respiratory distress and saturations and overall clinical appearance

42. Congenital Diaphragmatic Hernia
Herniation of abdominal contents into the chest
AVOID bag and mask ventilation/CPAP
Intubate in delivery room and inform surgery immediately
Arrange transport to a tertiary center