Respiratory Distress in the Neonate

1. Respiratory Distress in the Neonate Early Stabilization and Management Kathey Voelker, NNP-BC

2. Tachypnea • RR > 80 • Most common sign of illness in the neonate • Can occur with or without distress

3. Respiratory Distress • Retractions • Grunting • Nasal flaring

4. Tachypnea with Distress • Decreased lung volume • HMD • TTN • Pneumonia • Air leaks • Diaphragmatic hernia • Meconium aspiration

5. Tachypnea Without Distress • Acidosis (metabolic) • Congenital heart defect/disease • Hypothermia • Hypoglycemia • Sepsis

6. Hyaline Membrane Disease • Surfactant deficiency leads to alveolar collapse, decreased volume, microatelectasis

7. General Physiology • Lung Development • < 22 weeks • 22 - 24 weeks • 24 - 34 weeks • 34 - 36 weeks

8. Conditions that Interfere with Surfactant Metabolism • Acidemia • Hypoxia • Shock • Pulmonary edema • Over inflation • Under inflation • Mechanical ventilation • Hypercapnea

9. Conditions That Delay Surfactant Metabolism • Infant of diabetic mother • Erythroblastosis fetalis • Smaller of twins

10. Conditions that Accelerate Surfactant Production • Infant of diabetic mothers - • classes D, F, and R • Heroin addicted mother • PROM > 48 hrs • Infant of hypertensive mother • Maternal infection • Placental insufficiency • Maternal administration of steroids • Abruptio placentae

13. Treatment • Antenatal steroids • Exogenous surfactant • Distending airway pressure (CPAP/PEEP) • Nasal CPAP • Recruitment of alveoli (PIP) • Can be with intubation or nasal prongs (RAM) Goal is to not damage lungs while waiting for surfactant production

15. Ventilation Options • Nasal CPAP • Nasal IMV • Conventional ventilation (SIMV) • High frequency jet ventilator • High frequency oscillating ventilator • *controversal: iNO in VLBW*

16. Transient Tachypnea of the Newborn • Retained lung fluid remains in alveoli and pulmonary tree • Minimal distress

17. Transient Tachypnea

18. Treatment of TTN • Supportive care • Primarily CPAP • High flow nasal canula • Surfactant of little use • Can take 72 hrs to resolve • Can develop into PPHN if not treated

19. Air Leaks • Pneumothorax • Pneumomediastinum • Pneumopericardium • Pulmonary interstitial emphysema

20. Clinical Signs • Sign depends on size and location of the air leak. Can be sudden deterioration, can be insidious. • +/- shift of midline structures • Positive transillumination

24. Treatment of pneumothorax • Needle aspiration • Chest tube or “quick-cath” to either suction or one-way valve • “Gentle ventilation” with HFOV or jet • Time and love

25. Treatment of Pneumothorax • Aspiration kits • 23 or 25 g butterfly or IV catheter • Three-way stopcock • 30 – 60 cc syringe

27. Pulmonary Interstitial Emphysema

28. Worsening PIE

29. Treatment of PIE • Minimize further alveolar trauma with • HFOV • Jet ventilator

30. Meconium Aspiration Syndrome • Fetal passage of meconium • Fetal response to hypoxia • Management in the delivery room • Meconium aspiration

31. MAS Clinical findings • Early, progressively worsening distress • Pneumothorax not uncommon • Fluffy xray with areas of hyperinflation and areas of atelectasis

32. MAS

34. MAS with Pleural Effusion

35. Management of MAS • Pulmonary toilet • Generous oxygenation to avoid PPHN • Antibiotic coverage • HFOV or Jet vent for “gentle ventilation” • Monitor closely for hyperinflation/air leaks

36. Diaphragmatic Hernia • Defect in the diaphragm allowing abdominal structures to enter thoracic space. • Large defects can be identified on prenatal ultrasound • Early distress

37. Diaphragmatic Hernia • Notice the midline shift of the structures as bowel fills left chest. Note position of OG tube.

38. Diaphragmatic Hernia Management • Immediate intubation • BVM ventilation contraindicated • Gastric decompression • Jet ventilation • +/- ECMO • Surgical correction of the defect

39. V/Q mismatch • Pulmonary hypertension • From hypoxia or hypercapnea • From GBS • Shock • Perinatal blood loss • Sepsis • Extreme prematurity

40. Blood Pressure • Systolic/Diastolic • Mean Arterial Pressure • Pulse Pressure • Perfusion

41. Pneumonia • GBS • Aspiration • Formula • Blood • Amniotic fluid

44. Time to worry? • If the FIO2 requirement exceeds 40% • If there is respiratory acidosis • If there is also poor perfusion , low blood pressure, or tachcardia • If there is a history to suspect sepsis • If breath sounds are diminished on one or both sides • If the blood sugar drops below 50

45. Time to worry? • If the hemoglobin is <10 or >20 • If the respiratory distress has lasted over 2 hours in a preterm infant or 4 hours in a term infant • If the respiratory distress is worsening rather than improving • If the infant is hypothermic • If a term infant has apnea/gasping

46. Oxygen delivery devices • Nasal canula on a blender • High flow • Low flow • Oxygen hood • Blow-by (least preferred method)

47. Oxygen Delivery Devices • Nasal CPAP • Nasal IMV • ETT ventilation • Conventional • HFOV • Jet

48. Management on Oxygen • Maintain pulse oximeter – Adjust oxygen to keep saturations >90% in the full term infant, >88% in the premature infant • Follow blood gases, particularly if the oxygen requirement exceeds 40% • Treat underlying cause!

49. In Review • Monitor closely for signs of respiratory distress • Monitor FIO2 and changes or trends • Keep a close eye on vital signs, blood pressure/perfusion and blood sugar • Match treatment with the disease