Respiratory Distress in Newborn

1. Respiratory Distress in Newborn Eko Sulistijono, Siti Lintang K Perinatology Division Pediatric Medical Faculty-Saiful Anwar Hospital

2. Respiratory Distress in Newborn • Normal infants/asphyxia with successful resuscitation – may have respiratory distress: • Infant’s respiratory rate more than 60 times/minute, may show one or more additional signs of respiratory problem • Infant’s respiratory rate less than 30 times/minute • Infant with central cyanosis (bluish at the tongue and lips) • Infant with apnea (breathing stops for more than 20 seconds)

3. Causes of Respiratory Distress • Pulmonary disorders: Pneumonia • Cardiologic disorders: Congenital Heart Disease, Myocardium dysfunction • Central nervous system disorders caused by: Asphyxia, Cerebral hemorrhage • Metabolic disorders: Hypoglycemia, Metabolic acidosis • Surgical diseases: Pneumothorax, Tracheo-esophageal fistula, Diaphragmatic hernia • Others: Meconeum Aspiration Syndrome, Transient Tachypnea of the Newborn, Hyaline Membrane Disease

4. Causes of Respiratory Distress Based on Gestational Age • In Preterm Infants: • Hyaline Membrane Disease • Pneumonia • Asphyxia • Congenital Anomaly or Malformation • In Aterm Infants: • Meconeum Aspiration Syndrome • Pneumonia • Transient Tachypnea of the Newborn • Acidosis • Congenital Anomaly or Malformation

5. Diagnosis of Respiratory Distress History taking: • The Time of Respiratory Distress’s Manifestation • Gestational Age • Antenatal Steroid Therapy • Predisposition Factors: PROM (Premature Rupture of the Membrane), Fever in mothers before delivery • History of Asphyxia and Delivery with Intervention • History of Aspiration

6. Diagnosis of Respiratory Distress (Cont’d) Clinical Features of Respiratory Distress • Clinical Syndrome consisting of these following symptoms: • Infant’s respiratory rate more than 60 times/minute or infant’s respiratory rate less than 30 times/minute and may show one or more additional signs of respiratory problem as such: • Infant with cyanosis (blueness at the tongue and lips) • Chest wall retraction • Grunting • Infant with apnea (breathing stops for more than 20 seconds)

7. Clinical Classification of Respiratory Distress Severe respiratory distress Moderate respiratory distress Mild respiratory distress

8. Table 1. Classification of respiratory distress

9. EVALUATION OF RESPIRATORY DISTRESS WITH DOWN SCORE Score < 4 : No respiratory distress Score 4 – 7 : Respiratory distress Score > 7 : Impending respiratory failure (Blood gas analysis must be taken)

10. Test Public health care is usually not provided with the facility to perform test, therefore: improving observation or clinical examination is the main concern • Laboratory testing: • Routine blood test and blood smear to diagnosis the possibility of infection or neonatal sepsis • Blood glucose level

11. General Management • Obtain intravenous line • If the infant is not dehydrated, administer Dextrose 5% IV • Monitor vital signs • Maintain airway patency • Give oxygen (2-3 liter/minute with nasal catheter) • If the infant has apnea: • Resuscitate according to the phase needed • Further evaluate • If seizure occurs, treat it • Immediately check blood glucose level (if the facility is available) • Administer adequate nutrition

12. Specific Or Advance Management • MODERATE RESPIRATORY DISTRESS: • Continue oxygenation 2-3 liter/minute with nasal catheter, if dyspnea persist give O2 4-5 liter/minute with mask • Do not give fluid to the infant • Administer antibiotic (ampicillin and gentamicin) to treat sepsis possibility: • Axillary temperature < 340C atau > 390C • Meconeal amniotic fluid • History of intrauterine infection, suspect severe infection if fever is present or premature rupture of the membrane (>18 hours)

13. If axillary temperature is 34 – 36,50C or 37,5 – 390C, treat the temperature abnormality and reevaluate after 2 hours • If the temperature is still unstable or respiratory distress is not improving, administer antibiotic to treat sepsis possibility • If the temperature is normal, continue to observe infant. If the temperature becomes unstable again, repeat the steps above

14. MILD RESPIRATORY DISTRESS: • Transient Tachypnea of the Newborn (TTN), • Especially after caesarian surgery, aterm infant • Usually this condition improves and is alleviated without treatment • Observe infant’s breathing every 2 hour for the next 6 hours • If during observation respiratory distress worsen or other sepsis symptoms appear, treat for sepsis possibility and manage the moderate respiratory distress and immediately refer to Referral Hospital • Give breast milk if infant could feed. If not, then give breast milk with one of the fluid administration alternatives

15. Reduce oxygenation periodically when respiratory distress improves. Stop oxygenation when respiratory rate is between 30 – 60 times/minute • Observe infant for the next 24 hours, when respiratory rate is stable between 30 – 60 times/minute, no sign of sepsis, and no other problem needing treatment, infant could be discharged

16. SEVERE RESPIRATORY DISTRESS: • Prepare to refer to Referral Hospital • Stabilize before referring • Refer with resuscitation-skilled personnel • Maintain airway and oxygenation during transportation

17. NEONATAL PNEUMONIA

18. Introduction Pneumonia • is an important cause of neonatal infection • Accounts morbidity and mortality aspecialy in developing country

19. Pathogenesis Routes of acquisition: Varies in part with the time of onset of pneumonia • Early – onset pneumonia • Late - onset pneumonia

20. Early – onset pneumonia • Generally within three days of birth • Aquired from the mother by one of three routes • Intra uteri aspiration of infected amniotic fluid • Transplacental tranmision of organisms from the mother to the fetus • Aspiration during or after birth of infected amniotic fluid or vaginal organisms

21. Late - onset pneumonia • Occures during hospitalization or after discharge • Nosocomial acquired from • Infected individuals • Contaminated equipment • Microorganisms can invide through • injury tracheal • bronchoia mucosa • bloodstream

22. Mechanisms of injury in GBS pneumonia • In GBS pneumonia, • the level of beta – hemolysin expression correlate directly with the abilility of the organism to injure of epithelial cell • Hemolysin act as pore forming cytolysis  alveolar edema and hemorrhage • Surfactant phospholipid inhibits beta- hemolysis- associated lung epithelial cell injury  premature infants more severelly affected

23. Pathology (The patologic changes very with type of organisms) Bacteria : • Inflammation of pleura • infiltration / distruction of brochopulmonary tissue • leukocyte and fibrious exudate within alveoli and bronchi/ bronchioles • Bacteria are seen within interstitial spaces, alveoli,bronci/bronchioles

24. Virus • Cause an interstitial pneumonia • Infiltration of mononuclear cell and lympocytes  hyalin membrane formation - interstitial fibrosis and scarring

25. Microbiology Cause : • Bacterial • Viral • Spirochetal • Protozoan • Fungal pathogens

26. Early- onset pneumonia • Bacterial infections • Escherichia coli • Group B streptococcus • Kleibsiella spp • Staphylococcus aureus • Streptococcus pneumonia • Mycobacterium tuberculosis transplacentally • Listeria monocytogenes

27. Viral infections • Herpes simplex virus ( HSV) • Adenovirus • Enteroviruses • Mumps • Rubella • Cytomegalovirus • Fungal infections • Candida sp • Other patogens • Toxoplasma • Syphilis

28. Late – onset pneumonia • Bacterial infections • Staphylococcus • Kleibsiella • Escheichia coli • Enterobacter cloacae • Streptococcus pneumoniae • Pseuodomonas aeroginosa • Serratia marcescens

29. Viral infections • Adenovirus • Parainfluenza virus • Rhinovirus • Enteroviruses • Influenza • RSV • Fungal infections • Candida sp

30. Risk factors • Early – onset pneumonia • PRM > 18 hours • Maternal amnionitis • Premature delevery • Fetal tachycardia • Maternal intrapartum fever • Late – onset pneumonia • Assisted ventilation

31. Other factors • Anomaly of the airway (choanal atresia, tracheoesophageal fistule) • Severe underlying disease • Prolonge hospitalization • Neurologic empairment  aspiration gastroentestinal contents • Poor hand washing • Overcrowding

32. Clinical manifestation Early- onset pneumonia • Respiratory distress beginning at / soon after birth • May have associated • Lethagy • Apnea • Tachycardia • Poor perfusion • Septic • Shock • Other sign • Temperature instability • Metabolic acidosis • Abdominal distentions

33. Late – onset pneumonia • Respiratory distress • Apnea • Tachypnea • Tachycardia • Poor feeding • Abdominal distention • Jaundice • Emesis • Circulatory collapse

34. Diagnosis • Sudden onset of respiratory distress or other sign of illness should be evaluated for pneumonia / sepsis • culture: Blood,cerebrospinal fluid, pleural fluid • Chest radiography Bilaterall alveolar densities + air bronchograms Irregular patchy infiltrates Normal pattern

35. Treatment • Early- onset pneumonia • Ampicillin + gentamycin • Cephalosphorin • Late - onset pneumonia • Vancomycin + aminoglycoside • viral infection • Acylovir

36. Outcome • Predicted • Severity disease • Gestational age • Underlying medical conditions • Infecting organism • Increased mortality : • preterm birth • chronic lung disease • immune deficiencies