An approach to Respiratory Distress in Newborn
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An approach to Respiratory Distress in Newborn
By Goh Kiam Seong
HTAR, Klang2011
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Plan• Introduction• Causes and
Classification• Respiratory Distress
Signs• Evaluation and
Investigation• General Management
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Introduction
Respiratory Distress in Newborn = Abnormal respiratory signs in neonates
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Causes and Classification
Respiratory Distress in Newborn
Causes
Respiratory
Extrapulmonary
Management
Medical
Surgical
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Causes
Respiratory
Extrapulmonary
Upper Airway Obstruction
Choanal Atresia
Pierre Robin Sequence
Laryngeal pathology
Lower Airway
TTN
RDS/HMD
MAS
Congenital Pneumonia
Air Leak Syndrome
Milk Aspiration
Rib cage anomalies
Congenital Diaphragmatic
Hernia
Neuromuscular diseases PPHN
Congenital Heart Diseases Shock Anaemia Polycythaemia
Hypoglycaemia Hypothermia Metabolic acidosis
Intracranial Birth Trauma/
Encephalopathy
Causes
Respiratory
Extrapulmonary
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ManagementMedical
• TTN• MAS• RDS/HMD• Pneumonia• Milk Aspiration• CHD• Shock• Anaemia• Polycythaemia• Hypoglycaemia• Hypothermia• Metabolic Acidosis
Surgical
• Choanal atresia• Pierre Robin Sequence• Air Leak Syndrome• Rib cage anomalies• Congenital Diaphragmatic
Hernia• Air Leak Syndrome• Intracranial Birth Trauma/
Encephalopathy
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Respiratory Distress in Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis
Respiratory Distress Signs
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Respiratory Rate:
< 1 week up to 2 months: 60 or more2 to 12 months: 50 or more12 months to 5 years: 40 or more
Respiratory Distress in Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis
Tachypnoea
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• Due to negative intrapleural pressure generated between the contraction of diaphragm, respiratory muscles and the mechanical properties of lung and chest wall– Suprasternal Retraction SSR– Intercostal Retraction ICR– Subcostal Retraction SCR
Respiratory Distress in Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis
TachypnoeaRetractions
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Suprasternal Retraction SSR
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Subcostal Retraction SCR
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Intercostal Retraction ICR
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• Expiration through partially closed vocal cords to increase airway pressure and lung volume resulting in improved ventilation-perfusion (V/P) ratio
• Low pitched expiratory sound.• Protective phenomenon to
prevent collapse of alveoli: PEEP
Respiratory Distress in Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis
Grunting
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Video – Baby Grunting
• Grunting Baby pt. 2.flv
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• Narrow nasal space contributes to total lung resistance
• Nasal flaring decreases the work of breathing
Respiratory Distress in Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis
Nasal Flaring
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• Clinical detection of cyanosis depends on total amount of desaturated HB in blood– Anaemic infants may have low
PaO2 that is missed clinically– Polycythaemic infants with
normal PaO2 can appear cyanotic
Respiratory Distress in Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis
Cyanosis
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Cyanotic Baby Pink Baby
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Central cyanosis, +ICR, +SCR, +NF
What respiratory distress signs you can see here in this child?
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Evaluation and Investigation
History Examination
Investigation
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Antenatal US Finding
Amniotic Fluid IndexRenal Agenesis
?Pulmonary Hypoplasia?RDS
LiquorOligohydramnio?Pulmonary Hypoplasia
Polyhydramnios?Cong Diaphr Hernia?Oesoph atresia/TEF
MSAF TMSL/MMSL/LMSL
?MAS ?PPHN
Gestation/DeliveryTerm LSCS
?TTNPreterm (no dexa)
?RDS
Postdate (IOL,MSAF)
?MAS
History Examination Investigation
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History Examination Investigation
Risk FactorsIDM
?HypoglycaemiaGBS+ Mother
?Sepsis/Congenital Pneumonia
Condition at birthDistress
?Met acidosisNot vigorous
?Asphyxial Lung DsRequire resus at birth?Air Leak Syndrome
Leaking Liquor>18hrs
?Presumed SepsisPPROM/PROM Maternal UTI
?Presumed Sepsis
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at birth
Respiratory Distress
later after a period of normal function
Term Baby
• TTN• MAS• Congenital
Pneumonia• Dev Anomalies
Preterm Baby
• RDS• Congenital
Pneumonia• TTN
Possible causes
• Acquired/Nosocomial Pneumonia
• Dev anomalies• CHD• IEM• Metabolic (Met
acidosis/ electrolytes)
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History Examination Investigation
• T – hypo/hyperthermic• RR – tachy/apnoea• HR – tach/bradycardia• SPO2 – desaturate?
Vitals
• Pallor • Plethoric• SGA/LGA• Macrosomic/hydroptic
General Condition
• Cleft palate• Excessive oral
secretion
Oral Cavity
• Pierre Robin • Potter face
Congenital
anomalies
Potter face: abnormal facies with a beak nose, receding chin, broad nasal bridge, epicanthal folds, and large low set ears
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History Examination Investigation
• Dextrocardi,murmurs• In-drawing sternum• Air entry
CVS/Lung
• Scaphoid abdomenAbdomen
• Meconium stainedUmbilical cord/ Nails
• Hypotonia• Poor sucking reflex• Incomplete Moro
Tone/ Reflexes
Meconium stained Cord
Meconium stained Nail
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Silverman Anderson Score for Premature Baby
Score Upper Chest Retraction
Lower Chest Retraction
Xiphoid Retraction
Nasal Flaring Grunting
0 Synchronous None None None None
1 Lag on Inspiration
Just visible Just visible Minimal Stethoscope
2 See-Saw Mark Mark Mark Naked ear
Downe’s Score for Term BabyScore Respiratory
RateCyanosis Air entry Retraction Grunting
0 <60 None Good None None
1 60-80 In air Decrease Minimal Stethoscope
2 >80/ apnoea In 40% O2 Barely audible
Moderate/ severe
Naked ear
Score > 6 = impending Respiratory Failure
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History Examination Investigation
SPO2 monitoring
VBG/ ABG FBC
DXT Blood C+S/LP
CXR Portable
Look for:• O2 Saturation• Metabolic/ respiratory
acidosis/ alkalosis• Blood counts
(Hb/TWC/Plt/Ht)• Glucose level• Sepsis causative agent• Collapse/Air
Leak/CDH/ Cardiomegaly
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General Management
Respiratory Support
Supportive Care
Definitive/Specific Therapy
• O2 Delivery• PEEP/ Mechanical ventilation
(CPAP/SiPAP)• Intubation and suction
• HR monitoring• Continuous SPO2
monitoring• Temp/DXT monitoring• I/O charting• Feeding (PO/TPN)• Cot/Incubator nursing
According to diagnosis
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Causes
Respiratory
Extrapulmonary
Upper Airway Obstruction
Choanal Atresia
Pierre Robin Sequence
Laryngeal pathology
Lower Airway
TTN
RDS/HMD
MAS
Congenital Pneumonia
Air Leak Syndrome
Milk Aspiration
Rib cage anomalies
Congenital Diaphragmatic
Hernia
Neuromuscular diseases PPHN
Congenital Heart Diseases Shock Anaemia Polycythaemia
Hypoglycaemia Hypothermia Metabolic acidosis
Intracranial Birth Trauma/
Encephalopathy
Our topics today
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Pierre Robin Sequence (PRS)
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Definition• PRS is a facial difference caused by
underdevelopment of the lower jaw • Characterised by:– Micro- and retrognathia– glossoptosis – respiratory obstruction – With or without cleft palate.
• Incidence = 1:8500-14000 birth• =
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PRS is a sequence not syndrome!
•Because underdeveloped lower jaw begins a sequence of events which leads to
abnormal position of tongue and cleft palate.
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Aetiology
• Unknown• Recently identify
may be caused by genetic anomalies at chromosomes 2, 11, or 17
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PRS is often part of an underlying disorder or syndrome
• Stickler syndrome• Velocardiofacial syndrome• Fetal Alcohol syndrome• Treacher Collins Syndrome
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PathophysiologyAt 12 -14/52 GA
Movement of the head causes the jaw to "pop out' of the
collar bones
Only from this time, jaw of the fetus
grows as it would normally
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9-11/52 GA
Tongue moves down and away from roof of the
mouth
Allow space for the side of palate
to shift to the midline to close
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In PRS
Small jaw keeps tongue positioned
higher and posteriorly in mouth than
normal
Interfering normal closure
of palate
U shaped cleft palate
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How to diagnose?
• Only by examining the patient at birth
Complication
• Difficulties in breathing and feeding.
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GERD more prevalent in children with Robin sequence. (Dudkiewicz, CPCJ Mar 2000)
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Our tactics
• Position: Keep in prone or lateral position
• Feeding: Tube feeding or Haberman feeder
• Nutrition: Increase daily calorie intake
• SPO2 monitoring
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Other considerations
• Endotracheal intubation/tracheostomy• Tongue lip adhesion• Ophthalmology follow up – if suspect Sticker
syndrome (possible retinal detachment)• Mandibular distraction (distraction
osteogenesis)• Cleft palate reparation (6.5 mo- 2 yo)
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Choanal Atresia• Choanal atresia is a congenital disorder where choana is
blocked by abnormal bony or soft tissue formed during fetal development
• Cause: unknown (thin tissue separating the nose and mouth area during fetal development remains after birth)
• Most common nasal abnormality in newborn (1 in 7,000 live births)
• : = 1 : 2• >50% associated with other congenital disorder• Diagnosed shortly after birth
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Types• Unilateral• Bilateral
• Membranous• Osseous
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Symptoms and Signs
Cyanosis during feeding
Pink while crying
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• Inability to nurse and breathe at same time• Inability to pass a catheter through each side
of the nose into the throat• Persistent one-sided nasal blockage or
discharge
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Associated conditions
• Coloboma • Heart defects• Retardation of growth or
mental development• Genital/urinary
abnormalities• Ear anomalies/deafness
IF associated with all these ~ CHARGE syndrome (defect in Chromosome 8 CHD7 gene)
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Tests that may be done include:
• CT scan• Endoscopy of the nose• Sinus x-ray
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Endoscopic view of choanal atresia.mt: middle turbinate; it: inferior turbinate; ns: nasal septum; a: atresia "plate".
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Management
• Secure the airway (laryngeal mask, intubation or tracheostomy may be needed)
• If infant can learn to mouth breathe, can delay the need for immediate surgery.
• Otherwise, surgery to remove the obstruction required (transnasal or transpalatal).