my first grand seminar to whole college

1. APPROACH TO A CASE OF
RESPIRATORY DISTRESS IN THE
NEWBORN
DR JAGAN MOHAN VARAKALA

2. • Causes of significant morbidity and
mortality newborn
• Incidence 4 to 6% of live births
• Many are preventable
• Early recognition, timely referral,
appropriate treatment essential
2

3. OBJECTIVES
• TO IDENTIFY THE RESPIRATORY PROBLEMS IN
THE NEWBORN
• TO UNDERSTAND THE ETIOLOGY OF
RESPIRATORY PROBLEMS IN THE NEWBORN
• TO LEARN ABOUT THE MOST COMMON
RESPIRATORY PROBLEMS IN THE NEWBORN

4. APPROACH TO A CASE OF RDS
• WHY DO NEWBORNS DEVELOP HIGHER
INCIDENCE OF RESPIRATORY DISTRESS ?

5. APPROACH TO A CASE OF RDS
• MAINLY BECAUSE OF DIFFICULTIES IN
ADAPTING TO TRANSITION
• ASSSOCIATED DEVELOPMENTAL AND
PATHOLOGIC PROBLEMS
• DUE TO PREMATURE BIRTHS

6. FETUS TRANSITION NEWBORN
TRANSITIONAL CIRCULATION

7. UVDV  IVC  RA
 FO LA LV
SVC  RA RV
DA Des Ao
F
E
T
A
L

8. Fetus Birth Newborn
PulmonaryVascularResistance
 PaO2
 pH
 PaCO2
 Leukotrienes
 Endothelin
 PaO2
 pH
 PaCO2
 Nitric oxide
 Prostacyclin
CHANGES IN PULMONARY
VASCULAR RESISTENCEAT BIRTH

11. FIRST BREATH

12. NEONATE
WITH
RESPIRATORY
DISTRESS
LABORATORY
TESTS
DIFFERENTIAL
DIAGNOSIS
CARDIACPULMONARY MOTHER CAUSES
HISTORY
PRENATAL
INTRAPARTUM
PHYSICAL
EXAMNATION
FINAL DIAGNOSIS
MANGEMENT:
GENERAL AND SPECIFIC
APPROACH TO A CASE OF RDS

13. Determining Differential Diagnosis
What you need to know…
History•
•
•
Presentation/
X-rays
Lab values
clinical assessment
•
18

14. EVALUATION OF NEONATES
WITH RESPIRATORY DISTRESS
Ante History-obsterician friend
Premature delivery
Postmature delivery
Fetal distress
Meconium-stained
fluid
Maternal diabetes
Oligohydramnios/
polyhydramnios
Decreased fetal
movements
Traumatic
delivery
Drugs
Cesarean section
Vaginal bleeding

15. Antenatal Steroids

16. • Respiratory distress syndrome (RDS)
• Meconium aspiration syndrome (MAS)
• Transient tachypnoea of newborn (TTNB)
• Asphyxial lung disease
• Pneumonia-Congenital, aspiration, nosocomial
• Persistent pulmonary hypertension(PPHN)
9

17. • Tracheo-esophageal fistula
• Diaphragmatic hernia
• Pierre -Robin syndrome
• Choanal atresia
• Congenital lobar emphysema
10

18. Early progressive - Respiratory distress
syndrome or hyaline
membrane disease (HMD)
Early transient - Asphyxia, metabolic
causes, hypothermia
PneumoniaAnytime -
19

19. TTNB, polycythemia
MAS, asphyxia,
malformations
Cardiac
Early well looking
Early severe distress
-
-
Late sick with
hepatomegaly
-
Late sick
Anytime
with shock - Acidosis
Pneumonia-
20

20. • Obvious malformation
• Scaphoid abdomen
• Frothing
• History of aspiration
21

21. EVALUATION OF NEONATES
WITH RESPIRATORY DISTRESS
Major signs:
cyanosis, tachypnea
grunting, retraction,
flaring
Stridor, wheezes,
hoarseness, and
other
airway findings
Cardiovascularassessment
Blood pressure
Neurologic assessment
Temperature
Physical Exam

22. Downes score*
0 1 2
Resp. rate
Central
cyanosis
Retractions
Grunting
Air entry
<60
None
60-80
None with
40% FiO2
Mild
Minimal
Decreased
>80
Needs
>40% FiO2
Severe
Obvious
Very poor
1.
2.
None
None
Good
3.
4.
5.
* Score > 6 indicates severe distress
15
• Downes J,Vidyasagar D and Boggs T (1971)

23. 

24. Color—pink, dusky,
 Central Cyanosis
 Peripherally
Heart rate
Pulses
 Distal vsCentral
Perfusion
 Capillary RefillTime
 Blood Pressure
,pale,mottled
13

25. EVALUATION OF NEONATES
WITH RESPIRATORY DISTRESS
Laboratory Workup
Chest radiograph
Arterial blood gas
Blood glucose
Central hematocrit
White blood cell
and differential
If indicated:
Blood culture
Echocardiogram
Other diagnostic
imaging

26. TTN
TERM INFANT IN RESPIRATORY DISTRESS
A male infant weighing 3000g is born at 36 weeks'
gestation, with normal Apgar scores.Examination
the child is tachypneic, with subcostal retractions.
Lung sounds are clear and there is no heart
murmur.

27. X-Ray findings
 Prominent Perihilar
 Hyperinflation
 Fluid in fissure
streaking
28

28. X-ray
Fluid in the
fissure

29. What Next ?

30. Most common diagnosis of respiratory
distress in the newborn
Ineffective clearance of amniotic fluid
from lungs with delivery
Most often seen at birth or shortly after birth
25

36. 68

37. Predisposing factors
PROM >24 hours, foul smelling liquor,
Peripartal fever, unclean or multiple per
vaginal
Treatment
Thermoneutral environment, NPO, IV
fluids, Oxygen, antibiotics-
(Amp+Gentamicin)
69

38. 70

39. • Myocardial dysfunction
• Cerebral edema
• Asphyxial lung injury
• Metabolic
• Persistent
acidosis
pulmonary hypertension
72

40. CASE HISTORY
• A 3kg female infant is delivered via caesarean section
at 41 weeks’ gestational age because of MSAF. She is
limp and cyanotic at birth with minimal respiratory
effort. Apgar scores are 2 and 7 at 1 and 5 minutes,
respectively. Temp:is 99°F (37.2°C), HR: 177/ minute,
and RR: 80/minute.
• Physical examination findings include marked
increased work of breathing with nasal flaring,
subcostal and suprasternal retractions.
• Barrel-shaped chest, and coarse rhonchi in bilateral
lung fields.
• Chest X Ray findings…

41. 61
 IncreasedAP
diameter
 Hyperinflation
 Atelectasis

42. Note meconium staining of skin Increase AP
diameter of chest and the convexity of the sternum

43. MAS:PATHOPHYSIOLOGY
Vidysagar D. PEDIATRICS 1975

44. PREVENTION OF MECONIUM ASPIRATION
SYNDROME(MAS)
• Because of potential morbidity and
mortality from MAS,
prevention would clearly be beneficial.
• This has led to a number of antenatal,
intrapartum and postnatal preventative
therapies with a varying degree of
success.

45. IS MENONIUM PRESENT
YESNO
IS THE BABY VIGOROUS?
Intubate and
tracheal suction.
CONTINUE WITH RESUSCITATION
 CLEAR MOUTH AND NOSE FROM
SECRETIONS
 DRY,STIMULATE AND REPOSITION
 GIVE OXYGEN AS NECESSARY
NOYES
Bag and masking is contraindicated

48. Small right pneumothorax

49. Pneumomediastinum

50. Pneumopericardium

51. Etiology
Spontaneous, MAS, Positive pressure
ventilation (PPV)
73

52.  RespiratoryAssessment
 Tachypnea
 Nasal flaring
 Grunting
 Retractions
 BS absent or decreased
74

53.  ClinicalAssessment
 Cyanotic
 Pale, gray
 Heart Rate
▪
▪
▪
Tachycardia
Bradycardia
PEA
 Pulses
▪
▪
▪
Normal
Poor
absent
75

54.  Perfusion
 Capillary Refill (CRT)
 Blood Pressure if monitoringArterial
narrowing pulse pressure
 Deformities ofChestWall
 Asymmetry of chest
Line,
 CHESTX-Ray speaksfor itself!!
76

55. Pneumothorax/Airleaks
• Management
• Needle aspiration, chest tube

58. TERM INFANT IN RESPIRATORY DISTRESS

60. Left diaphragmatic hernia

64.  Defect present at birth
 Increased risks:
 Parents haveCHD?
 Siblings haveCHD?
 Maternal diabetes
often picked up on usg
 Exposure toGerman
mother HIV+
measles, toxoplasmosis, or if
 Alcohol use during pregnancy
 Cocaine use during pregnancy
86

65.  RespiratoryAssessment
 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
87

66.  ClinicalAssessment
 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
88

67. Hyperoxia Test
• Obtain ABG–> Then place the patient on 100%
O2 for 10 minutes then repeat ABG , If the
cyanosis is pulmonary , the PaO2 should be
increased by 30 mm of Hg. If the cause is
cardiac , there will be minimal improvement in
PaO2.
 Echocardiogram
 Best test to aid in diagnosis
 CardiacCath for possible intervention

68. PRETEM INFANT WITH RESPIRATORY
DISTRESS

70. 44

71. Respiratory Distress Syndrome
• Also called as hyaline membrane disease
• Most common cause of respiratory distress in
premature infants, correlating with structural
& functional lung immaturity.
• 1/3 infants born between 28 to 34 weeks, but
less than 5% of those born after 34 weeks.

72. INCREASED RISK FACTORS
• Infants of diabetic mothers
• Delivery before 37 wk gestation
• Multifetal pregnancies
• Cesarean section delivery
• Precipitous delivery
• Asphyxia
• Cold stress
• History of previously affected infants

73. DECREASED RISK FACTORS
• Chronic or pregnancy-associated
hypertension
• Maternal opiate addiction
• Prolonged rupture of membranes
• Antenatal corticosteroid use

74. PATHOPHYSIOLOGY

75. PATHOPHYSIOLOGY
• Surfactant deficiency - decreased
production and secretion
• Present in amn.fluid:28-30wks, mature
levels after 35 wks
• Surfactant reduce surface tension and
prevent the collapse alveoli
• Alveolar atelectasis, hyaline membrane
formation, and interstitial edema make the
lungs less compliant, so greater pressure is
required to expand the small alveoli and
airways

76. PATHOPHYSIOLOGY (CONTD…)
• Decreased lung compliance- insufficient
alveolar ventilation – result in hypercapnia
• Combination of hypercapnia, hypoxia, and
acidosis → pulmonary arterial vasoconstriction
→ increased R → L shunting through the
foramen ovale and ductus arteriosus →
Pulmonary blood flow is reduced → ischemic
injury cap endothelium & alveolar epithelium
→ leak of plasma (proteinaceous material) into
the alveolar spaces

77. PATHOPHYSIOLOGY (CONTD…)
• leak of plasma (proteinaceous
material) into the alveolar spaces
→combine with fibrin & necrotic
alveolar pneumocytes & form
hyaline membrane
• Hyaline membranes: coagulum of
sloughed cells and exudate,
plastered against epithelial
basement membrane

78.  Primary Hyaline membrane
disease(HMD):e.g Prematurity
 Secondary HMD e.g Meconium aspiration
syndrome, asphyxial lung injury, pulmonary
haemorrage

79. 42

80. PREVENTION
• Prevention of prematurity
• Lecithin:sphingomyelin ratio in amniotic
fluid: >2 means mature lungs <1.5 means
HMD
• Betamethasone to women 48hr before the
delivery - between 24 and 34 wk of
gestation- 6mg IM for 4 doses 12 hrs apart
or 12 mg IM for 2 doses 12 hrs apart

81. PREVENTION (CONTD…)
• First dose of surfactant into the
trachea of symptomatic premature
baby immediately after birth
(prophylactic) or during the first few
hours of life (early rescue)

82. • Monitoring
Supportive
22
• Avoid hypothermia
• IV Calories and fluids
• Warm humidified oxygen
• CPAP : prevents collapse of surfactant-
deficient alveoli
• Assisted ventilation
• High-frequency ventilation (HFV )

83. Indications
• All babies with distress
• Cyanosis
• Pulse oximetrySaO2 < 90%
Method
• Flow rate 2-5 L/ min
• Humidified oxygen by hood ,nasal prongs ,orCPAP
*Cautious administration in pre-term
23

84. DEFINITIVE TREATEMENT

85. SURFACTANT THERAPY : DEFINITIVE
TREATEMENT
• Multidose endotracheal instillation :
4ml/kg
• Treatment (rescue) is initiated as soon as
possible in the 1st 24hr of life
• Dose repeated - via the ET tube 6–12hrly
for a total of 2-4 doses
• Appropriate monitoring equipment must
also be available - radiology, blood gas
laboratory, and pulse oximetry

88. INDICATIONS FOR MECHANICAL
VENTILATION
• Clinical: Absolute: Apnea (intractable),
gasping, cyanosis not responsive to O2
RDS SCORE: >4-6 ,Increased Fio2,Work of
breathing
• Laboratory (while on CPAP or FiO2 > 0.5):
pH < 7.25 with increasing PCO2 > 50 mm Hg
(or) PO2 < 60 and / or SpO2 < 85 %
• Other: Surgical procedures, compromised
airway

89. Neonate with
respiratory
distress Abnormal
Chest X-Ray
?
Common Uncommon
Yes Look for
abnormalities
of:
No
Resp Distress Synd
Transient Tachypnea
Aspiration Syndromes
Pneumonia
Air leaks
Effusion
Pulmonary Edema
Diaphrag. Hernia
Trach-Esoph fistula
Cysts, tumors
Hypoplasia
Hemorrhage
Cong. Lobar Emph.
Lymphangiectasia
Sequestration
AV fistulae
Perfusion,
BP, HCT
Upper or lower
airway
Cardiac problems
Neuro-
muscular
Diaphragm or
Chest wall
AbdomenOther or
Mixed findings
IN SUMMARY

91. TAKE HOME MESSAGES
• Obtain good Prenatal and Perinatal history
• Identify at risk pregnancies
• Establish communication between
OB/PED/NEONATAL services prior to delivery
• Early diagnosis of infant in Respiratory Distress,
using:
• Clinical and Diagnostic work up :RDS score, pulse
oximetry, X-ray ,CBC.
• EARLY AND SAFE TRANSFER TO LEVEL II AND III
NICU WILL SAVE MANY BABIES

93. Thank You …

94. Thank You …