1. An approach to Respiratory Distress in Newborn By GohKiamSeong HTAR, Klang 2011

2. Plan • Introduction • Causes and Classification • Respiratory Distress Signs • Evaluation and Investigation • General Management

3. Introduction Respiratory Distress in Newborn = Abnormal respiratory signs in neonates

5. Causes and Classification

8. Respiratory Distress Signs

9. Tachypnoea Respiratory Rate: < 1 week up to 2 months: 60 or more 2 to 12 months: 50 or more 12 months to 5 years: 40 or more

10. Tachypnoea • Retractions • 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

11. Suprasternal Retraction SSR

12. Subcostal Retraction SCR

13. Intercostal Retraction ICR

15. 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 • Grunting

16. Video – Baby Grunting • Grunting Baby pt. 2.flv

17. Narrow nasal space contributes to total lung resistance • Nasal flaring decreases the work of breathing • Nasal Flaring

19. Cyanosis • 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

20. Cyanotic Baby • Pink Baby

21. What respiratory distress signs you can see here in this child? Central cyanosis, +ICR, +SCR, +NF

22. Evaluation and Investigation

26. Potter face: abnormal facies with a beak nose, receding chin, broad nasal bridge, epicanthal folds, and large low set ears

27. Meconium stained Nail Meconium stained Cord

28. Silverman Anderson Score for Premature Baby Score > 6 = impending Respiratory Failure Downe’s Score for Term Baby

29. Look for: • O2 Saturation • Metabolic/ respiratory acidosis/ alkalosis • Blood counts (Hb/TWC/Plt/Ht) • Glucose level • Sepsis causative agent • Collapse/Air Leak/CDH/ Cardiomegaly

30. General Management 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

31. Our topics today

32. Pierre Robin Sequence (PRS)

33. 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 • =

34. Because underdeveloped lower jaw begins a sequence of events which leads to abnormal position of tongue and cleft palate. PRS is a sequence not syndrome!

35. Aetiology • Unknown • Recently identify may be caused by genetic anomalies at chromosomes 2, 11, or 17

36. PRS is often part of an underlying disorder or syndrome • Stickler syndrome • Velocardiofacial syndrome • Fetal Alcohol syndrome • Treacher Collins Syndrome

37. Pathophysiology At 12 -14/52 GA

38. 9-11/52 GA

39. In PRS

40. How to diagnose? • Only by examining the patient at birth Complication • Difficulties in breathing and feeding.

41. GERD  more prevalent in children with Robin sequence. (Dudkiewicz, CPCJ Mar 2000)

42. Our tactics • Position: Keep in prone or lateral position • Feeding: Tube feeding or Haberman feeder • Nutrition: Increase daily calorie intake • SPO2 monitoring

43. 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)

44. ChoanalAtresia • Choanalatresia 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

45. Types • Unilateral • Bilateral • Membranous • Osseous

46. Symptoms and Signs Cyanosis during feeding Pink while crying

47. 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

48. 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)

50. Tests that may be done include: • CT scan • Endoscopy of the nose • Sinus x-ray