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Respiratory Diseases of the Newborn. Beth Mogensen, RRT-NPS. OBJECTIVES. Provide overview of respiratory system of the newborn Identify non-respiratory causes of distress in the newborn Review respiratory diseases/ anomalies of the newborn. Early Development. Fetal Lung Development.

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objectives
OBJECTIVES
  • Provide overview of respiratory system of the newborn
  • Identify non-respiratory causes of distress in the newborn
  • Review respiratory diseases/ anomalies of the newborn
fetal lung development
Fetal Lung Development
  • Week 4: the laryngotracheal groove forms on the floor foregut
  • Week 5: the left and right lung buds push into the pericardioperitoneal canals (primordial of pleural cavity)
  • Week 6: the descent of heart and lungs into the thorax. Pleuroperitoneal foramen closes
fetal lung development7
Week 7: the lung buds divide into secondary and tertiary bronchi

Week 24: the bronchi divide 14 more times and the respiratory bronchioles develop

By birth, there will be an additional 7 divisions of bronchi

Fetal Lung Development
fetal lung histology
STAGE 1: Pseudoglandular Period (5-17 weeks) all the major elements of the lungs have formed except for those involved with gas exchange

STAGE 2: Canalicular Period (16-25 weeks) bronchi and terminal bronchioles increase in lumen size and the lungs become vascularized

Fetal Lung Histology
fetal lung histology9
Fetal Lung Histology
  • STAGE 3: Terminal Sac Period (24 weeks to birth) more terminal sacs develop and interface with capillaries lined with Type I alveolar cells or pneumocytes

--Also have Type II pneumocytes which secrete surfactant thereby decreasing the surface tension forces and aids in expansion of the terminal sacs

slide10
STAGE 4: Alveolar Period (late fetal period to 8 years) 95% of mature alveoli develop after birth. A newborn has only 1/6 to 1/8 of the adult number of alveoli and lungs appear denser on x-ray
respiratory distress at birth
Respiratory Distress at Birth

Rule of 6: non respiratory causes of distress

S & S Diagnosis Management

  • Hypothermia/ - check temperature - heat or cool as

Hyperthermia necessary

  • Hypovolemia - obtain prenatal history - gingerly give volume
  • Hyoptension - measure blood pressure - give volume and/or vasopressor
  • Hypoglycemia - blood glucose measurement - give glucose
  • Anemia - measure hematocrit - transfuse with PRBC
  • Polycythemia - measure hematocrit - partial exchange transfusion (lower Hct)
respiratory distress in the newborn
Respiratory Distress in the Newborn
  • Transient Tachypnea of the Newborn (TTN)
  • Surfactant Deficiency (HMD,RDS)
  • Meconium Aspiration Syndrome (MAS)
  • Pneumonia/ Sepsis
  • Pneumothorax or other air leaks
respiratory distress in the newborn13
Respiratory Distress in the Newborn

Respiratory Causes

  • Congenital Abnormalities of the Lung/Thorax
    • Congenital Heart Disease (CHD)
    • Congenital Diaphragmatic Hernia (CDH)
    • Congenital Cystic Adenomatiod Malformation (CCAM)
    • Tracheal Abnormalities
    • Esophageal Atresia
    • Pulmonary Hypoplasia
  • Persistent Pulmonary Hypertension of the Newborn (PPHN)
what do you need to know to figure out the cause
What do you need to knowto Figure out the Cause…
  • Maternal History
    • Any risk factors
  • Gestational age of Infant
  • Amniotic fluid (color/odor/volume)
  • Intrapartum history
  • Clinical Presentation/ Assessment
  • X-Rays
  • Lab Evaluations
clinical presentation
Clinical Presentation
  • Respiratory Assessment
    • Respiratory rate
    • Quality
      • Shallow
      • Deep
  • Nasal Flaring
  • Grunting
  • Retractions
  • Breath Sounds
clinical presentation16
Clinical Presentation
  • Color—pink, dusky, pale, mottled
    • Central
    • Peripherally
  • Heart rate
  • Pulses
    • Distal vs Central
  • Perfusion
    • Capillary Refill Time (CRT)
    • Blood Pressure
clinical presentation17
Clinical Presentation
  • Physical characteristics
    • Flat nasal bridge, Simian crease, recessed chin, low set ears
  • Deformities
    • Extra digits, gastroschesis, imperforate anus
  • Muscular
    • Hyoptonia vs Hypertonia
  • Skeleton
    • Choanal Atresia, Osteogenesis Imperfecta
  • Other
    • Scaphoid abdomen, heart tones on Right side
x ray
X-Ray
  • Structures
    • Ribs
    • Vertebra
    • Liver
    • Stomach/ intestine
    • Lungs
    • Heart
    • Trachea
    • Esophagus
x ray19
X-Ray
  • Lungs
    • Lung Volume
    • Expansion
    • Densities
      • Fluid/ collapse (atelectasis)>>white
      • Free Air>>dark
      • Mass
  • Heart shape and size
    • Boot shaped
    • Egg or Oval shaped
lab values
Lab Values
  • CBC with diff
  • ABG/CBG/VBG
  • Blood Cultures
  • CRP
  • Electrolytes
  • Type and Cross
  • PKU
respiratory distress
Respiratory Distress

Determining Differential Diagnosis

What you need to know…

  • History
  • Presentation/ clinical assessment
  • X-rays
  • Lab values
transient tachypnea of the newborn ttn
Transient Tachypnea of the Newborn (TTN)
  • Most common diagnosis of respiratory distress in the newborn
  • Remember often “term infants” may be a little early
  • Ineffective clearance of amniotic fluid from lungs with delivery
  • Most often seen at birth or shortly after
transient tachypnea of the newborn
Transient Tachypnea of the Newborn
  • History
    • Common with C-Section delivery
    • Maternal analgesia
    • Maternal anesthesia during labor
    • Maternal fluid administration
    • Maternal asthma, diabetes, bleeding
    • Perinatal asphyxia
    • Prolapsed cord
ttn presents
TTN presents:
  • Respiratory Assessment
    • Tachypnea 60-150 bpm
    • Nasal flaring
    • Grunting
    • Retracting
    • Fine Rales
    • Cyanotic
slide25
TTN
  • X-Ray findings
    • Prominent Perihilar streaking
    • Hyperinflation
    • Fluid in fissure
  • Labs
    • CBC within normal limits
    • ABG/CBG showing mild to moderate hypercapnia, hypoxemia with a respiratory acidosis
slide27
TTN
  • Have delayed reabsorption of fetal lung fluid which eventually will clear over several hours to days
  • Treatment: Treat signs and symptoms. Support infant, may need O2, is probably too tachypneic to PO feed so start IV fluids
  • Be patient!!
surfactant deficiency rds hmd
Surfactant Deficiency (RDS, HMD)
  • One of the most common problems associated with a premature infant
  • Decreased surfactant production in lungs of pre-term infants
  • With decreased surfactant production, alveoli collapse, become atelectatic, yielding poor lung function and increasing signs of respiratory distress
slide29
RDS
  • History
    • Gestational age < 38 weeks
    • Prenatal care
      • Diabetes (controlled vs uncontrolled)
      • Perinatal infection
    • Problems during pregnancy/delivery
      • Asphyxia
      • Stress to fetus
      • Hypothyroidism
    • Multiple births
rds presents
RDS presents:
  • Respiratory Assessment
    • Tachypnea > 60 bpm
    • Nasal flaring
    • Grunting
    • Retracting
    • Apnea/ irregular respiratory pattern
    • Rales (crackles)
    • Diminished breath sounds
    • Cyanosis
slide31
RDS
  • X-Ray
    • Loss of volume
    • Reticulogranular pattern or “ground glass” appearance
    • Air bronchograms
    • Bell shaped thorax
    • Air leak, PIE
    • Loss of heart borders/ atelectasis
    • White out
slide35
RDS
  • Laboratory Results
    • ABG/CBG
      • Hypoxia
      • Hypercarbia
      • Acidosis
    • CBC with Differential/ HHP
      • Used to rule out other causes of respiratory distress
    • Always check electrolytes, especially glucose, potassium and calcium
treatment for rds
Treatment for RDS
  • Post-Exogenous Surfactant Therapy
    • Many on the market
      • Prophylactic Treatment
        • Administered in the delivery room
      • Rescue Treatment
        • Given after a definitive diagnosis of RDS
meconium aspiration syndrome
MECONIUM ASPIRATION SYNDROME
  • Most often found in post date infants > 40 weeks, but may occur in infants >34 weeks
  • Infant passes meconium due to varying degrees of asphyxia in utero
  • Obstruction of large and small airways with aspirated meconium
  • Aspiration may occur:
    • in utero
    • intrapartum
    • postpartum period
slide38
MAS
  • History
  • Prenatal Care
      • Maternal diabetes
      • Pregnancy Induced Hypertension (PIH)
      • Pre-eclampsia
  • Problems during pregnancy/delivery
  • Color of amniotic fluid
slide39
MAS
  • Respiratory Assessment
    • Tachypnea
    • Nasal flaring
    • Grunting
    • Retracting
    • Apnea/ irregular respiratory pattern
    • Decreased breath sounds/ wet/ rhonchi
slide40
MAS
  • Clinical Assessment
    • Color
      • Pale/gray
      • Cyanotic
      • Stained skin
  • X-Ray
    • Increased AP diameter
    • Hyperinflation
    • Atelectasis
    • Pneumothorax
pneumonia sepsis
Pneumonia/ Sepsis
  • Occurs frequently in newborns
  • 3 types
    • Congenital Pneumonia
    • Intrapartum Pneumonia
    • Postnatal Pneumonia
  • Most often seen with chorioamnionitis, prematurity and meconium aspiration
  • Get thorough history
causes
Causes
  • Prematurity
  • Prolonged rupture of membranes
  • Maternal temp > 38C
  • Foul smelling amniotic fluid
  • Nonreassuring stress test
  • Fetal tachycardia
  • Meconium
  • Maternal hx of STDs
respiratory assessment
Respiratory Assessment
  • Tachypnea
  • Apnea, irregular breathing pattern
  • Grunting
  • Retractions
  • Nasal flaring
  • Colorful secretions
  • Rales, rhonchi
  • Cyanosis
clinical assessment
Clinical Assessment
  • Gray, pale color
  • Lethargy
  • Temperature instability
  • Skin rash-pettechia
  • Tachycardia
  • Glucose issues
  • Hypoperfusion
  • Oliguria
x ray47
X-Ray
  • Patchy infiltrates (aspiration)
  • Bilateral diffuse granular pattern
  • Streaky
  • Loss of volume
  • Densities
pneumothorax and other air leaks
Pneumothorax and otherAir Leaks
  • History
    • What happened in the delivery room?
    • Was positive pressure given?
    • Large amount of negative pressure generated with the 1st breath?
pneumothorax air leaks
Pneumothorax/ Air Leaks
  • Respiratory Assessment
    • Tachypnea
    • Nasal flaring
    • Grunting
    • Retractions
    • BS absent or decreased
pneumothorax air leak
Pneumothorax/ Air Leak
  • Clinical Assessment
    • Cyanotic
    • Pale, gray
    • Heart Rate
      • Tachycardia
      • Bradycardia
      • PEA
    • Pulses
      • Normal
      • Poor
      • absent
pneumothorax air leak52
Pneumothorax/ Air Leak
  • Perfusion
    • Capillary Refill (CRT)
    • Blood Pressure if monitoring Arterial Line, narrowing pulse pressure
  • Deformities of Chest Wall
    • Asymmetry of chest
  • CHEST X-Ray speaks for itself!!
pneumothorax54
Pneumothorax
  • Right lateral decubitus view of pneumothorax
congenital abnormalities of the lung and thorax
Congenital Abnormalities of the Lung and Thorax
  • Congenital Heart Disease (CHD)
  • Congenital Diaphragmatic Hernia (CDH)
  • Congenital Cystic Adenomatiod Malformation
  • Tracheal Abnormalities
  • Esophageal Atresia
  • Pulmonary Hypoplasia
congenital heart disease
Congenital Heart Disease
  • Defect present at birth- often picked up on early ultrasound
  • Increased risks:
    • Parents have CHD?
    • Siblings have CHD?
    • Maternal diabetes
    • Exposure to German measles, toxoplasmosis, or if mother HIV+
    • Alcohol use during pregnancy
    • Cocaine use during pregnancy
slide58
CHD
  • Two types of CHD
    • Acyanotic-blood returning to Right side of heart passes thru lungs—usually defect in heart wall, or obstructed valve or artery
      • Pink baby
      • Sats within normal limits
    • Cyanotic-have a mixing of oxygenated blood with venous blood—shunting ductus, PFO, ASD, VSD
      • Blue baby
      • Low sats
slide59
CHD
  • Respiratory Assessment
    • Respirations
      • Normal
      • Tachypnea
    • Saturations depend upon defect.
      • Acyanotic lesions sats are more normal
      • Cyanotic lesions acceptable sats are low
      • ~ 70% is acceptable; ideally on 21% FiO2
slide60
CHD
  • Clinical Assessment
    • HR
      • Slow, fast, variable
      • murmur
    • BP
      • Check in all 4 extremities
    • Pulses in all extremities
    • CRT in all 4 extremities
    • Color
      • Acyanotic -pink
      • Cyanotic-blue
slide61
CHD
  • Labs and Tests
    • ABGs—dependent upon defect
    • Lactic Acid
  • Chest X-Ray
    • Heart shape and size
    • Pulmonary blood flow
  • Echocardiogram
    • Best test to aid in diagnosis
  • Cardiac Cath for possible intervention
congenital diaphragmatic hernia congenital cystic adenomatoid malformation
Congenital Diaphragmatic HerniaCongenital Cystic Adenomatoid Malformation
  • Ideally diagnosed in utero
  • Develops during pseudoglandular stage, but CCAM can form up to 35 weeks
  • Normally compromised at delivery requiring immediate intubation
  • CDH more commonly found on Left side
cdh ccam
CDH/ CCAM
  • Respiratory Assessment
    • Tachypneic
    • Retractions
    • Nasal flaring
    • Grunting
    • Breath Sounds
      • Decreased on the affected side
      • May hear bowel sounds in chest with CDH
slide66
CDH
  • Clinical Assessment
    • Scaphoid Abdomen- classic sign
    • Color
      • Cyanotic
    • Heart Rate
      • Fast, slow or normal
    • Perfusion
      • Depends upon the severity
    • X-Ray—Best diagnostic tool
      • Bowel, stomach, liver in chest
    • ABGs
      • Acidosis, hypoxemia and hypercarbia
persistent pulmonary hypertension pphn
Persistent PulmonaryHypertension (PPHN)
  • Pulmonary hypertension resulting in severe hypoxemia secondary to R>L shunt thru PFO and/or PDA
  • Usually affecting term or near-term infants
  • May be extremely difficult to manage
  • If not responding to available therapy consider transporting to an ECMO center
slide71
PPHN
  • History
    • Meconium?
    • Asphyxia?
    • Stress?
    • Pneumonia/ Sepsis
    • Primary Pulmonary Hypertension
      • Dysfunction in pulmonary endothelial vasodilating mechanism
    • CDH/ CCAM
slide72
PPHN
  • Respiratory Assessment
    • Tachypnea
    • Retractions
    • Grunting
    • Nasal flaring
    • Breath Sounds
      • Depend on cause
    • Pre and Post-ductal saturations to monitor shunting- best indicator if ECHO not available
slide73
PPHN
  • Clinical Assessment
    • Color
      • Blue/ gray
    • X-Ray
      • Depends on cause
      • Usually with decreased blood flow, minimal lung markings
    • Lab
      • Dependent on cause
      • Many present with abnormal Platelets/ PT/ Fibrinogen
    • ABG
      • Respiratory and metabolic acidosis
airway abnormalities
Airway Abnormalities
  • Occur less frequently than pulmonary parenchymal diseases
  • Presentation is often quite dramatic with significant respiratory distress
  • Stridor may be an important key to diagnosing the abnormality
airway abnormalities75
Airway Abnormalities
  • Supraglottic
    • Nose-Choanal Atresia
    • Craniofacial-Pierre Robin
    • Macroglossia-Down’s
    • Tumors-Hemangioma
  • Glottic
    • Vocal Cord Paralysis
    • Tumors and Cysts
      • Hemangioma, Cystic Hygroma, Teratoma
      • Tracheal Esophageal Fistula/ Atresia
      • Webs
      • Trauma
airway abnormalities78
Airway Abnormalities
  • Subglottic
    • Stenosis—congenital or acquired
    • Webs
    • Atresia
    • Tumors
  • Trachea
    • Tracheomalacia
    • Stenosis
    • Cyst
    • Atresia
  • Extrinsic
    • Vascular Ring
    • Mediastinal Mass
history p resentation
History/ Presentation
  • Circumstances surrounding onset of symptoms
  • Speed of progression of symptoms
  • Position of comfort and how change affects symptoms
  • Presence of feeding abnormalities
  • Nature of cry
  • Previous infection
  • History of previous intubation or trauma
  • Presence of associated cardiopulmonary abnormalities
airway abnormalities80
Airway Abnormalities
  • Respiratory Assessment
    • Tachypnea
    • Retractions
    • Work of Breathing
  • Breath Sounds
    • Stridor is the MOST important physical sign created by airway turbulence and indicates obstruction
      • Inspiratory—implies supraglottic or glottic
      • Expiratory—implies intrathoracic airway
      • Mixed—implies subglottic
airway abnormalities81
Airway Abnormalities
  • Clinical Assessment
    • Heart Rate
      • Tachycardia
      • Bradycardia when obstructed
    • Color
      • Cyanotic
    • Lethargy
    • Irritability
    • Feeding Difficulty
airway abnormalities82
Airway Abnormalities
  • Bronchoscopy used for evaluating abnormality
  • “Tools” for Treatment:
    • Dependent upon Diagnosis
      • Prone patient
      • Oral Airway
      • N-P Tube
      • Steroids
      • Meds for reflux
      • OG, NG, NJ or G-Tube feedings
airway abnormalities83
Airway Abnormalities
  • Possible Surgical Interventions
    • Cricoid Split
    • Tracheostomy
    • Excise Hygroma
    • Place stents
scenario
Scenario
  • Baby Boy S
    • No prenatal care. Uneventful delivery vaginal delivery. APGARS 8 and 9 at 1 and 5 minutes, respectively.
    • Infant taken to newborn nursery and given routine care. Eyes and thighs done, bath completed. VSS. Looking good and smelling nice.
    • Infant went out to mother to breast feed and you have been summoned to “check on baby”.
scenario85
Scenario
  • Upon arriving in the mother’s room, you begin assessing infant.
  • Baby’s color is rather blue.
  • Tachypneic—RR 70s to 80s
  • Bulb sx and get a little bit of colostrum.
  • Retractions and Grunting present
  • Baby’s temp is 35.9
  • What will you do?
scenario86
Scenario
  • Take infant back to nursery for observation and monitoring.
  • Place infant on O2 if sat < 90-92 depending upon your policy.
  • Place infant under radiant warmer.
  • Obtain a full set of vital signs.
    • RR 80s—Retracting, nasal flaring, grunting
    • HR 180—with murmur
    • BP 42/30 with MAP 36
    • SaO2 on 100% blow by 88%
scenario87
Scenario
  • 5. Color—dusky
  • 6. CRT 4 seconds
  • 7. Poor peripheral pulses
scenario88
Scenario

CALL MD if you haven’t already…

Continually reassess infant.

With your next assessment: VS have not

changed much. Infant continues to grunt, retract and have nasal flaring. Sats 86.

scenario89
Scenario
  • When auscultating, you notice that the heart tones are now more midline than on left. You also notice that when auscultating the left lung that you thought you heard gas bubbles…
  • What do you want to do?
  • What do you suspect this infant has?
scenario90
Scenario
  • STAT CXR
  • Intubate infant and ventilate
  • Place large bore Anderson/ Replogle tube to continuous low suction
  • Give fluid bolus (and more if needed)
  • Probably start pressors
  • Do what needs to be done to stabilize this infant and call for transport…
take away
Take Away…
  • Don’t be afraid to “think out of the box”
  • We continually see “funky” things
  • Do no harm… this is someone’s baby