Newborn Care: Respiratory distress and phototherapy


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Respiratory distress and phototherapy

  1. 1. 10 Respiratory distress and apnoea indicate that the infant has difficulty breathing. Objectives The 4 most important clinical signs of respiratory distress are: When you have completed this unit you 1. Tachypnoea. A respiratory (breathing) rate of 60 or more breaths per minute (normal should be able to: respiratory rate is less than 60). • Diagnose respiratory distress. 2. Central cyanosis. A blue tongue in room • Diagnose apnoea. air. • List the causes of respiratory distress and 3. Recession. The in-drawing of the ribs and apnoea. sternum during inspiration (also called • Diagnose the different causes of retractions). 4. Grunting. A snoring noise made in the respiratory distress and apnoea. throat during expiration. • Prevent respiratory distress and apnoea. • Manage an infant with respiratory If an infant has 2 or more of the above clinical signs, the infant is said to have respiratory distress or apnoea. distress. Most infants with respiratory distress have central cyanosis.RESPIRATORY DISTRESS An infant has respiratory distress if two or more of the important clinical signs of difficult10-1 What is respiratory distress? breathing are presentRespiratory distress in a newborn infant NOTE Respiratory distress is not a completepresents as a group of clinical signs which diagnosis as there are many different causes.
  2. 2. 184 NEWBORN CARE10-2 What are the important causes of increases the oxygen requirements. Thererespiratory distress? is no need to routinely suction the airways. 3. Provide energy, preferably by givingRespiratory distress in newborn infants has an infusion of maintenance fluidmany pulmonary (lung) as well as extra- (e.g. Neonatalyte).pulmonary (outside the lungs) causes. 4. Record the following importantThe most important pulmonary causes of observations every hour and note anyrespiratory distress are: deterioration: • Respiratory rate1. Hyaline membrane disease • Presence or absence of recession and2. Wet lung syndrome grunting3. Meconium aspiration • Presence or absence of cyanosis4. Pneumonia • Percentage of inspired oxygen (FiO2)The important extra-pulmonary causes of • Oxygen saturation (SaO2) by pulserespiratory distress are: oximeter1. Pneumothorax • Heart rate2. Heart failure • Both the abdominal skin (or axilla) and3. Hypothermia incubator temperatures4. Metabolic acidosis 5. Treat central cyanosis by giving oxygen by5. Anaemia head box, nasal cannula or nasal prongs.6. Polycythaemia An air/oxygen blender or venturi must be used. Monitor the percentage (fraction) of NOTE Less common pulmonary causes of inspired air (FiO2) and oxygen saturation respiratory distress include pulmonary (SaO2). If this is not possible, give just haemorrhage, hypoplastic lungs and chronic enough oxygen to keep the infant’s tongue lung disease while less common extra-pulmonary causes include diaphragmatic hernia and pink. persistent pulmonary hypertension. 6. Take a chest X-ray. 7. If possible measure the infant’s arterial blood gases (pH, oxygen and carbon There are many different causes of respiratory dioxide). distress 8. Consult the nearest level 2 or 3 hospital as the infant may need to be transferred.Always look for the cause if an infant has This is particularly important in hyalinerespiratory distress. Simply saying that an membrane disease.infant has respiratory distress is not enough. 9. The infant may need continuous positive airways pressure (CPAP) via nasal prongs if10-3 How should you manage an infant oxygen alone fails to keep the infant pink.with respiratory distress? 10. If the infant develops recurrent apnoea or if continuous positive airways pressure failsThe principles of general care are the same, to keep the infant pink, then intubationirrespective of the cause of the respiratory and ventilation are indicated.distress. Therefore, all infants with respiratorydistress should receive the following general In addition to the general management ofmanagement: respiratory distress, any specific treatment of the cause of the respiratory distress must1. Keep the infant warm, preferably in a be given, e.g. antibiotics for pneumonia or closed incubator or under an overhead surfactant for hyaline membrane disease. radiant heater. NOTE Spasm of the pulmonary arteries may be2. Handle the infant as little as possible, caused by excessive handling, hypothermia, because stimulating the infant often
  3. 3. RESPIRATOR Y DISTRESS AND APNOEA 185 acidosis or hypoxia. Pulmonary blood is then 10-5 Which infants do not have adequate shunted away from the lungs making the hypoxia surfactant? much worse. It is, therefore, essential to avoid these aggravating factors. Preterm infants often have immature lungs with inadequate surfactant. Therefore, the more preterm the infant, the greater is the riskHYALINE MEMBRANE of hyaline membrane disease.DISEASE Hyaline membrane disease is a major cause of death in preterm infants10-4 What is hyaline membrane disease(HMD)? 10-6 How can you tell whether an infantAt term the fetal alveoli are mature and ready has adequate amounts of surfactant?to be inflated with air after delivery. Thesemature alveoli secrete a substance called 1. The presence or absence of surfactant insurfactant that prevents them collapsing the fetal lung can be determined beforecompletely at the end of each expiration. This delivery by doing a bubbles test on aallows the infant to breathe air in and out with sample of amniotic fluid obtained byvery little physical effort. amniocentesis. 2. Similarly the shake test on a sample ofIn contrast, infants with immature lungs do gastric aspirate obtained within 30 minutesnot have adequate amounts of surfactant after delivery will indicate whetherat birth. As a result their alveoli collapse adequate amounts of surfactant are presentwith expiration and the infant has difficulty in the lungs of a newborn infant.expanding them again during inspiration.Collapsed alveoli, due to the lack of surfactant, NOTE Fetal lung fluid is both swallowed and passedresult in respiratory distress. This condition out of the mouth into the amniotic fluid during pregnancy. A sample of amniotic fluid beforewith too little surfactant is known as hyaline delivery, or gastric aspirate immediately aftermembrane disease (HMD). delivery can, therefore, be used to test whether surfactant is being produced by the alveoli. Hyaline membrane disease is caused by the lack of enough surfactant in immature lungs 10-7 How do you diagnose hyaline membrane disease? NOTE The lungs of infants with hyaline membrane 1. The infant is almost always preterm. disease have 3 major problems: Only occasionally does a term infant • Generalised alveolar collapse due to develop hyaline membrane disease. inadequate amounts of surfactant Term infants with hyaline membrane • The collapsed alveoli fill with a protein-rich disease are usually born to women with fluid that forms hyaline membranes, giving the poorly controlled diabetes or after severe condition its name intrapartum hypoxia. • Spasm of the pulmonary arteries which results 2. The bubbles test on amniotic fluid or the in blood being shunted away from the lungs shake test on gastric aspirate is negative via the foramen ovale and ductus arteriosus indicating inadequate surfactant. These abnormalities all result in respiratory failure 3. The infant develops respiratory distress with poor oxygenation of the blood. at or soon after delivery. The signs of respiratory distress gradually become worse during the first 48 hours after birth if surfactant treatment is not given.
  4. 4. 186 NEWBORN CARE4. The infant is usually inactive and 10-9 How do you prevent hyaline commonly develops peripheral oedema. membrane disease?5. The chest X-ray is abnormal and shows 1. If possible, preterm delivery should be small lungs with granular lung fields. prevented. Unfortunately this is often not These findings are the result of alveolar possible. collapse. A typical chest X-ray is needed 2. If the patient is in preterm labour between to make a definite diagnosis of hyaline 26 and 34 weeks gestation, labour should membrane disease. be suppressed if there are no contra-6. Oxygenation improves dramatically if indications. Steroids (intramuscular surfactant treatment is given. betamethasone in 2 doses given 24 hours NOTE The typical X-ray findings of severe apart) should then be given to a mother to hyaline membrane disease include small lung accelerate maturation of the fetal lungs. If volume (best seen on the lateral view) with possible, delivery should be delayed for 48 air bronchograms extending beyond the hours to allow the full benefit of steroids. cardiothymic shadow, granular opacities extending out to the periphery of the lungs, poor distinction 3. Move the mother to a hospital where between the cardiothymic shadow and the lungs, there is a neonatal unit able to manage and usually a large thymus. The X-ray features of small infants. hyaline membrane disease may not be typical in 4. All preterm infants must be adequately the first few hours after birth and less marked in resuscitated. Avoid using high pressures infants with mild hyaline membrane disease.. during ventilation. 5. Prevent hypothermia, hypoglycaemia and10-8 What is the clinical course in hyaline hypoxia after birth as they can all decreasemembrane disease? the production of surfactant. 6. Giving steroids to the newborn infant doesThe degree of respiratory distress gets worse not prevent hyaline membrane disease.and the concentration of inspired oxygenneeded to keep the infant pink increasesfor the first 2 to 3 days after birth. During Maternal steroids during preterm labour canthis time some infants will die of hyaline prevent hyaline membrane disease in many infantsmembrane disease. Otherwise the respiratorydistress gradually improves after 48 to 72 hours NOTE In preterm labour, it is possible to assessand the oxygen can usually be stopped after whether the fetal lungs are mature by doing5 to 10 days of age. Once fully recovered the a bubbles test on a sample of amniotic fluidinfant’s lungs are usually normal, although obtained by amniocentesis. However, this isrepeated episodes of bronchiolitis during the usually no longer done.first year of life are common. This naturalcourse of hyaline membrane disease is changed 10-10 How do you manage an infant withand shortened with surfactant treatment. hyaline membrane disease? NOTE The clinical signs of respiratory distress get 1. Provide the general supportive worse after delivery as the alveolar surfactant management needed by all infants with is gradually used up. However, after 2 to 3 days respiratory distress. If the infant can be of breathing air the lungs start to produce kept alive for the first 72 hours, recovery surfactant again and the signs of respiratory distress, therefore, improve. usually occurs when spontaneous surfactant production increases. 2. It is important to diagnose hyaline Hyaline membrane disease gets worse before it membrane disease as soon as possible after gets better birth because these infants need urgent transfer to a level 2 or 3 hospital with a newborn intensive care unit. Whenever
  5. 5. RESPIRATOR Y DISTRESS AND APNOEA 187 possible, all infants at high risk of hyaline single dose is adequate. The dosing regime differs membrane disease should be delivered in a between the two products but their effectiveness level 2 or 3 hospital. is similar.3. Give oxygen correctly and safely to prevent hypoxia. 10-12 What are the complications of4. Provide continuous positive airways hyaline membrane disease? pressure (CPAP) via nasal prongs. This 1. All the other problems of the preterm has greatly improved the management of infant are common in these infants, infants with hyaline membrane disease and especially jaundice, apnoea of immaturity, should be started as soon as the diagnosis hypothermia and hypoglycaemia. is made. It is best started as soon as the 2. Hypoxic brain damage if the infant cannot infant has been resuscitated. be kept pink5. If nasal CPAP and oxygen fail to keep the 3. Secondary bacterial pneumonia if the infant pink, intubation and ventilation infant is intubated are needed. However, CPAP can usually 4. Intraventricular haemorrhage prevent the need for ventilation in most 5. Pneumothorax infants with hyaline membrane disease. 6. Patent ductus arteriosus6. The early use of artificial surfactant has 7. Chronic lung disease shortened the course and lessened the severity of hyaline membrane disease. It has also decreased the mortality. Fortunately artificial surfactant is less WET LUNG SYNDROME expensive than before. 10-13 What is the wet lung syndrome? The early use of continuous positive airways Before delivery the fetal lungs are not pressure and artificial surfactant has greatly collapsed but the alveoli and bronchi are filled improved the management and survival of with lung fluid. At vaginal delivery, most of infants with hyaline membrane disease this fluid is squeezed out of the lungs as the chest is compressed in the birth canal. After birth the remaining fluid is coughed up or is10-11 When and how is artificial surfactant absorbed into the capillaries and lymphatics ofgiven? the lung within a few minutes. In some infantsArtificial surfactant is usually given this rapid removal of fetal lung fluid does notwithin the first few hours to infants with take place resulting in the wet lung syndromehyaline membrane disease who cannot which presents as respiratory distress. Thebe adequately oxygenated with a FiO2 of wet lung syndrome (also called ‘wet lungs’ or0.4 using nasal prong CPAP alone. These transient tachypnoea of the newborn) is theinfants are intubated and the surfactant is commonest cause of respiratory distress. It isinstilled rapidly down the endotracheal tube. also important because during the first dayAfter a minute of gentle bag ventilation the of life it can easily be confused with hyalineendotracheal tube can be withdrawn and the membrane disease.infant is placed back on nasal prong CPAP.The use of artificial surfactant is usually The wet lung syndrome is the commonest causerestricted to level 2 and 3 units. It is important of respiratory distressthat staff receive special training beforeattempting to use this form of treatment. NOTE Survanta and Curosurf are two commonly used artificial surfactants in South Africa. Usually a
  6. 6. 188 NEWBORN CARE10-14 Which infants commonly develop the and clear peripheral lung fields. However, thewet lung syndrome? chest X-ray in the first few hours after delivery may be similar to that of hyaline membraneIn the following conditions the normal disease due to the presence of alveolar fluid. It is,clearance of lung fluid is often delayed for many therefore, best to wait a few hours before taking ahours resulting in the wet lung syndrome: chest X-ray if hyaline membrane disease and wet lung syndrome are to be differentiated.1. Caesarean section, especially if the mother has not been in labour and the membranes 10-16 What is the clinical course of the wet have not been ruptured before delivery lung syndrome? (elective caesarean section)2. Fetal hypoxia or severe neonatal asphyxia Respiratory distress caused by the wet lung (need for resuscitation after delivery) syndrome presents at or soon after birth and3. Maternal sedation can mimic hyaline membrane disease for4. Polyhydramnios the first few hours after delivery. However, infants with the wet lung syndrome graduallyIn some infants, however, the above risk improve during the first 24 hours, andfactors are not present and the cause of the wet oxygen is usually needed for 2 to 3 days only.lung syndrome is not known. Therefore the clinical course of the wet lung NOTE Excessive secretion of pulmonary fluid, poor syndrome is very different from that of hyaline respiratory efforts, damaged pulmonary capillaries membrane disease. and poor contraction of the left ventricle probable all can result in the wet lung syndrome. Wet lung syndrome steadily improves after delivery10-15 How can you diagnose the wet lungsyndrome? 10-17 How should you manage infants with1. These infants may be born at or before term. the wet lung syndrome?2. They develop respiratory distress soon after delivery. The management of an infant with the wet3. They often have an overinflated chest and lung syndrome is the same as the general usually do not need more than 50% oxygen management of all infants with respiratory (FiO2 of 0.5) to correct the central cyanosis. distress. However, oxygen alone or continuous4. Their clinical signs gradually improve after positive airways pressure is usually all that is birth and usually disappear by 72 hours. needed to prevent cyanosis, and only rarely5. The shake test on the gastric aspirate is is there a need to transfer the infant to a level positive, which excludes hyaline membrane 2 or 3 unit as the condition can be expected disease. to steadily improve. Three hourly feeds by6. The chest X-ray in the wet lung syndrome nasogastric tube, rather than an intravenous shows hyperinflated (large) lungs, which infusion, can usually be given. is different from the small lungs seen in hyaline membrane disease. MECONIUM ASPIRATION The wet lung syndrome is important because it SYNDROME can be confused with hyaline membrane disease 10-18 What is the meconium aspiration NOTE After 6 hours of age the chest X-ray in the wet lung syndrome is typical with hyperexpanded syndrome? lungs (due to air trapping caused by oedematous If the fetus is hypoxic in utero it may pass small airways), increased parahilar vascular mark- meconium and make gasping movements ings (due to dilated lymphatics and capillaries)
  7. 7. RESPIRATOR Y DISTRESS AND APNOEA 189which suck the meconium-stained liquor into 10-20 What is the clinical course of thethe larynx and trachea. If the airways are not meconium aspiration syndrome?well suctioned after the head is delivered, the From birth the meconium-stained infant hasmeconium can be inhaled into the smaller respiratory distress which, in severe aspiration,airways and alveoli with the onset of breathing, gets progressively worse and may kill theresulting in the following lung damage: infant. Milder cases will gradually recover1. Meconium contains enzymes (from the over days or weeks. Infants who survive severe fetal pancreas) which damage the epithelial meconium aspiration often have damaged lining of the bronchi and bronchioles. lungs that may take months to recover.2. The enzymes in meconium also cause severe alveolar damage. 10-21 Can you prevent the meconium3. Meconium plugs partially or completely aspiration syndrome? block the airways resulting in some areas of collapsed lung and other areas of over- Yes, most cases of severe meconium aspiration expanded lung. syndrome can be prevented by carefully suctioning the upper airways of all meconium-Most meconium-stained infants have not stained infants before they start to breathegasped and inhaled meconium before delivery. at birth. Therefore, it is essential to clearTherefore they will not develop the meconium the airways before the infant’s shoulders areaspiration syndrome. delivered. NOTE Severe meconium aspiration causes a chemical pneumonitis and almost always results in pulmonary hypertension with shunting of blood Severe meconium aspiration can usually be away from the lungs via the foramen ovale and prevented by suctioning the upper airways ductus arteriosus. This causes severe hypoxaemia. immediately after the infant’s head has been delivered10-19 How do you diagnose the meconiumaspiration syndrome? Meconium may be passed into the amniotic1. The infant is usually born at term or fluid and then sucked into the large airways postterm but only rarely preterm. by a fetus who suffers hypoxia during labour.2. The amniotic fluid is meconium stained. Because the fetal alveoli are filled with lung The thicker the meconium the greater is fluid before delivery, very little meconium can the risk of severe meconium aspiration get into the small airways and alveoli until the syndrome. infant inhales air at delivery.3. Meconium may be suctioned from the If the infant requires active resuscitation after mouth and upper airways at birth and the delivery, suction the airway well once more infant is usually meconium stained. before starting bag and mask ventilation.4. Respiratory distress is present and the There is no need for further suctioning after chest usually appears hyperinflated (over- delivery if the infant cries well and does not expanded). need resuscitation.5. The chest X-ray shows hyperinflation with The most effective way to prevent meconium many white areas of collapsed lung. aspiration syndrome is to improve the care NOTE The contradictory combination of marked during labour to avoid fetal hypoxia. hyperinflation (due to partially blocked airways) together with diffuse patches of collapsed lung NOTE Reports from trials conducted in countries (due to completely blocked airways and chemical with high rates of caesarean section and low rates pneumonitis) is typical of the meconium of neonatal death due to meconium aspiration aspiration syndrome. syndrome suggest that early suctioning is not needed. These results must be accepted with
  8. 8. 190 NEWBORN CARE caution in countries with inadequate obstetric present and result in respiratory distress even if services where severe meconium aspiration is good suctioning prevents meconium aspiration. common. Other studies suggest that amniotic fluid washout before delivery may reduce the risk of meconium aspiration. PNEUMONIA10-22 How should you manage an infantwith the meconium aspiration syndrome? 10-24 What is the cause of pneumonia in1. Management consists of the supportive newborn infants? care needed by any infant with respiratory 1. An infant may be born with bacterial distress. pneumonia (congenital pneumonia) as a2. Unfortunately there is no specific treatment complication of chorioamnionitis. for the infant with respiratory distress 2. Infants may develop pneumonia in the days caused by meconium aspiration. The value or weeks after birth (acquired pneumonia) of steroids, to decrease the inflammation, due to the spread of bacteria by the hands of and prophylactic antibiotics remains staff or parents (nosocomial infection). unproved and, therefore, they are usually 3. Congenital syphilis may also cause not given. pneumonia if mothers are not routinely3. Continuous positive airways pressure or screened for syphilis during pregnancy. mechanical ventilation may be needed to correct hypoxaemia. 10-25 How is pneumonia diagnosed and4. A stomach washout with 2% sodium treated in newborn infants? bicarbonate or half normal saline helps to prevent gastritis caused by meconium. The diagnosis of congenital pneumonia The phagocytes in colostrum feeds also resulting from chorioamnionitis is suggested by help in the removal of meconium from seeing pus cells and bacteria in a Gram stain of the stomach. the gastric aspirate after delivery. These infants5. Look for complications. are often preterm and develop respiratory distress soon after birth. Usually their mothers have no clinical symptoms or signs of infection. It is far better to prevent than have to treat meconium aspiration syndrome In contrast, infants with acquired pneumonia usually only become ill 2 or 3 days after delivery. Acquired pneumonia is common10-23 What are the complications of in infants receiving ventilation. Every effortmeconium aspiration? must be made to prevent pneumonia in newborn nurseries by practising good aseptic1. Pneumothorax and pneumomediastinum techniques (clean hands). are common due to rupture of areas of over-expanded lung. The clinical diagnosis of pneumonia can be2. Hypoxic damage to other organs, such as confirmed by a chest X-ray which usually the brain, due to the intrapartum hypoxia shows areas of collapsed or consolidated that caused the fetus to pass meconium. lung. Treatment of pneumonia is supportive3. Meconium gastritis which presents with care plus parenteral antibiotics, e.g. penicillin repeated vomiting of meconium-stained and gentamicin, or ceftriaxone. Infants with mucus. congenital syphilis are treated with penicillin. NOTE Persistent pulmonary hypertension (damage and spasm of the pulmonary arteries) often Clean hands can prevent many cases of complicates meconium aspiration syndrome and pneumonia in a newborn care unit causes severe hypoxia. This condition may be
  9. 9. RESPIRATOR Y DISTRESS AND APNOEA 191PNEUMOTHORAX 2. A chest X-ray which will show air in the pleural space.10-26 What is a pneumothorax? 10-29 How do you treat a pneumothorax?A pneumothorax (pneumo=air; thorax=chest) 1. If the infant has mild respiratory distressis a collection of air in the pleural cavity with a small pneumothorax and is notsurrounding the lung. It is caused by the cyanosed in headbox oxygen, the infantrupture of one or more alveoli which allows air can be closely observed. Many smallto escape from the lung. The pneumothorax pneumothoraces will reabsorb withoutcompresses the lung and prevents normal drainage. However, infants requiringlung expansion during inspiration. Usually a oxygen should be transferred to a level 2pneumothorax occurs on one side only but it or 3 hospital where a chest drain can bemay be bilateral (pneumothoraces). inserted, if necessary. 2. If the infant develops severe respiratory10-27 Who is at risk of pneumothorax? distress due to a pneumothorax, is receiving continuous positive airways1. All infants with respiratory distress, pressure or is on a ventilator, a chest drain whatever the cause must be inserted immediately.2. Infants with meconium aspiration 3. If a chest drain cannot be inserted due3. Infants that need ventilation at resuscitation to lack of equipment or a trained person,4. Infants that are intubated and are ventilated the pleural space can be aspirated with in the nursery a needle and syringe as an emergency procedure. This is a first aid measure only10-28 How do you diagnose a and must be followed as soon as possiblepneumothorax? with a chest drain.The clinical diagnosis of pneumothorax in thenewborn is often very difficult as the classical HEART FAILURE ANDsigns may not be present. The following signsare helpful however: PATENT DUCTUS1. Sudden unexpected collapse ARTERIOSUS2. Rapidly increasing oxygen needs in respiratory distress3. Poor breath sounds with little movement 10-30 What are the common causes of on one side of the chest heart failure in the newborn infant?4. An easily palpable liver in a right-sided There are many different causes of heart failure. pneumothorax The common causes in the newborn infant are:5. Poor heart sounds or heart sounds best heard on the right of the sternum in a left- 1. Patent ductus arteriosus sided pneumothorax (the heart is pushed 2. Congenital malformation of the heart to the right) 3. Infusion of excessive amounts of intravenous fluidThe suspected clinical diagnosis can be 4. Hypoxiaconfirmed by: 5. Anaemia1. Transillumination of the chest. The chest Heart failure in many of these conditions wall on the side of the pneumothorax presents as respiratory distress due to transilluminates well while the chest wall pulmonary oedema. on the normal side does not.
  10. 10. 192 NEWBORN CARE10-31 What is a patent ductus arteriosus In most cases further treatment is not needed(PDA)? and the ductus closes spontaneously when term is reached.The ductus arteriosus is a large artery thatjoins the aorta and pulmonary artery in the However, if the infant has signs of respiratoryfetus. Because the lungs do not function before distress:birth, blood from the pulmonary artery by- 1. The infant must be referred to a level 2 orpasses the fetal lungs via the ductus arteriosus 3 the aorta. After delivery the ductus 2. Restrict fluid intake to 120 ml/kg/day.arteriosus normally closes and blood then 3. Furosemide (Lasix) 1 mg/kg must be givenpasses from the pulmonary artery to the lungs. orally or by intramuscular or intravenousIn preterm infants the ductus often does not injection.close normally but remains open (patent) for a 4. Transfuse very slowly with packed cellsfew weeks. As a result, blood flows backwards (10 ml/kg) if the PCV is below 30% (Hbfrom the aorta into the pulmonary artery, below 10 g/dl).flooding the lungs with blood and causingheart failure. This usually presents 3 or more If the infant fails to respond to this managementdays after delivery and may be precipitated then the infant must be transferred to a level 3by increasing a preterm infant’s feeds to more hospital for ultrasound examination to confirmthan 150 ml/kg/day. If the ductus is large then the clinical diagnosis. Oral or intravenousit will cause pulmonary oedema and present treatment with indomethacin (Indocid) orwith signs of respiratory distress. ibuprofen (Brufen) is used to close the patent ductus arteriosus. Rarely surgical closure may10-32 How is a patent ductus arteriosus be needed.diagnosed? NOTE Indomethicinan or ibuprofen blocks the synthesis of prostaglandins which keep theThe clinical diagnosis of a patent (open) ductus arteriosus patent. Both drugs have sideductus arteriosus can be made by observing effects, however, including renal failure.the following signs:1. A heart murmur 10-34 How can you differentiate between2. Collapsing pulses (the pulses are very easy the common causes of respiratory distress? to feel) Factors in the history, physical examination3. In severe cases the infant will also have and investigations may suggest a particular signs of respiratory distress. cause for the respiratory distress.The clinical diagnosis is easily confirmed by History:ultrasonography. NOTE The heart murmur is typically pansystolic 1. Hyaline membrane disease in a preterm and heard best under the left clavicle or to the infant or an infant of a diabetic mother left of the sternum. Usually the heart beat can 2. Wet lung syndrome in an infant born by also be easily felt by placing your hand over the elective caesarean section infant’s lower sternum. On chest X-ray the lungs 3. Meconium aspiration if the infant is appear congested. meconium stained 4. Congenital pneumonia if there has been10-33 How should you treat a patient with maternal pyrexia or offensive liquora patent ductus arteriosus? 5. Patent ductus arteriosus in a preterm infant who is a few days or weeks oldIf the infant has no signs of heart failure, thenthe feeds should not exceed 150 ml/kg/day Examination:and the infant should be carefully observed. 1. Preterm infant in hyaline membrane disease
  11. 11. RESPIRATOR Y DISTRESS AND APNOEA 1932. Hyperexpanded chest in the wet lung Periodic breathing does not cause bradycardia or syndrome cyanosis3. Meconium staining in the meconium aspiration syndrome4. Offensive smell at birth in congenital 10-36 How should you diagnose apnoea? pneumonia5. Asymmetrical chest movement and breath 1. The diagnosis of apnoea is usually made sounds in pneumothorax by observing the breathing pattern, colour6. Murmur and full pulses in an infant with a and heart rate of an infant. patent ductus arteriosus 2. Apnoea can also be diagnosed with the aid of an apnoea monitor which is usually setInvestigations: to trigger if the infant does not breathe for1. No surfactant on shake test in hyaline 20 seconds. A solid sensor pad is placed membrane disease under the infant, or electrodes are attached2. Pus cells and bacteria in the gastric aspirate to the infant’s chest. The sensor pad or in congenital pneumonia electrodes are attached via a connecting3. Typical chest X-ray in hyaline membrane lead to the monitor unit. disease, wet lung syndrome, meconium 3. A cardiorespiratory monitor, that measures aspiration syndrome, pneumonia and and displays both the respiratory and heart pneumothorax rate, can also be used to detect apnoea.4. Transillumination in pneumothorax 4. A pulse oximeter will indicate a fall in5. Ultrasonography to diagnose patent ductus oxygen saturation when the infant has arteriosus apnoea. NOTE Obstruction of the airways can similarlyAPNOEA present with bradycardia and cyanosis even though respiratory efforts are still being made. However, there is no movement of air in and out of the lungs (obstructional apnoea).10-35 What is apnoea?Apnoea is the arrest (stopping) of respiration for 10-37 What are the causes of apnoea?long enough to cause bradycardia together with Apnoea is a clinical sign that has many causes:cyanosis or pallor. The oxygen saturation fallswith apnoea. Usually apnoea for 20 seconds or 1. The commonest cause is apnoea oflonger is needed to produce these clinical signs. immaturity.The infant may have a single apnoeic attack but 2. Respiratory distress of any cause may resultusually the episodes of apnoea are repeated. in apnoea. 3. Infection, especially pneumonia, septi- caemia and meningitis may cause apnoea. Infants with apnoea stop breathing for long 4. Hypoxia, hypothermia or hypoglycaemia. enough to result in bradycardia and cyanosis 5. Hyperthermia due to overheating in an incubator or overhead radiant heater is anApnoea should not be confused with periodic important and easily correctable cause ofbreathing, which is a normal pattern of apnoea.breathing in preterm and some term infants. 6. Intraventricular haemorrhage.These infants have frequent short pauses in 7. A large feed, vomit or gastro-oesophagealtheir respiration (less than 20 seconds each). reflux.With periodic breathing, the arrest of breathing 8. Convulsions may present with recurrentmovements does not last long enough to cause apnoea only.bradycardia, cyanosis or pallor.
  12. 12. 194 NEWBORN CARE9. Maternal analgesia or sedation during 9. In more severe apnoea, resuscitation with labour, e.g. pethidine, morphine or bag and mask ventilation is needed. If diazepam (Valium). oxygen is used, the concentration must be10. Anaemia, especially if the infant also has a reduced to 25% or less as soon as breathing patent ductus arteriosus. is established and the cyanosis corrected. These infants may need intubation and10-38 What is apnoea of immaturity? ventilation to prevent further apnoea. 10. Apnoea needing ventilation usually is notIn some preterm infants the respiratory centre due to immaturity but is caused by somein the brain stem is immature and this results other more serious repeated attacks of apnoea. These infants areusually under 34 weeks of gestation. The morepreterm the infant, the greater is the risk of Apnoea of immaturity can be prevented by oralapnoea of immaturity. Apnoeic attacks usually theophyllinestart after 48 hours of age, and occur especiallyafter a feed. 10-40 How is theophylline administered?10-39 How should you manage apnoea? Theophylline is usually given via a nasogastric1. Always look for a cause of the apnoea and tube, e.g. as Nuelin liquid. With oral treat the cause if possible. theophylline, a loading dose of 5 mg/kg2. Apnoea of immaturity can be prevented is given, followed by a maintenance dose and treated with the use of oral of 2.5 mg/kg every 12 hours. Prophylactic theophylline or caffeine. theophylline is given routinely to all infants3. Nursing newborn infants slightly head up born below 35 weeks of gestation. It can on their abdomen (the prone position) usually be stopped at 35 weeks or when a decreases the incidence of apnoea. weight of 1600 g is reached. Monitor the However, older infants should be nursed on infant for apnoea for 48 hours after stopping their backs to prevent sudden infant death. theophylline. An overdose of theophylline can4. Keeping the infant’s abdominal skin cause tachycardia, vomiting or convulsions. temperature strictly between 36 and Oral caffeine is very effective but has to be 36.5 °C helps to prevent apnoea. made up by the hospital pharmacy. An oral5. Monitor infants for apnoea, or infants with loading dose of 10 mg/kg is followed by a daily a high risk of apnoea, using an apnoea dose of 2.5 mg/kg. monitor, cardiorespiratory monitor or NOTE Theophylline can also be given intravenously pulse oximeter. at the same dose as oral theophylline. The serum6. During an attack of apnoea, breathing concentration of theophylline can be measured can be restarted in most cases by simply to determine whether the correct dose is being stimulating the infant. Touching the feet is given. The correct range to prevent apnoea of usually adequate to restart breathing. immaturity is 5–10 μg/ml.7. Headbox or nasal cannula oxygen, at a concentration not higher than 25% (FiO2 0.25), may prevent repeated apnoea. CASE STUDY 1 Giving a higher concentration of oxygen to prevent apnoea is extremely dangerous as A male infant is born at 32 weeks gestation it can cause retinopathy of prematurity. in a level 1 hospital. Soon after delivery his8. Continuous positive airways pressure via respiratory rate is 80 breaths per minute with nasal prongs is used to prevent repeated recession and expiratory grunting. The infant’s apnoea if theophylline fails. It can usually tongue is blue in room air. The gastric aspirate be given without oxygen.
  13. 13. RESPIRATOR Y DISTRESS AND APNOEA 195collected 10 minutes after delivery contains 6. How is hyaline membrane diseaseno pus cells or bacteria on Gram stain but the treated in a neonatal intensive care unit?shake test is negative. The use of artificial surfactant and continuous positive airways pressure (CPAP) via nasal1. What are the infant’s clinical signs which prongs has greatly improved the managementindicate that he has respiratory distress? on infants with respiratory distress due toTachypnoea, recession, grunting and central hyaline membrane disease. Ventilation via ancyanosis in room air. endotracheal tube may be needed.2. What is the probable cause of the respira- 7. What is the best way to determinetory distress? Give reasons for your answer. whether this infant is receiving the correct amount of oxygen?The infant probably has hyaline membranedisease due to immature lungs. This is common By measuring his oxygen saturation with ain infants born preterm. The diagnosis is pulse oximeter.supported by the negative shake test. Thenormal Gram stain suggests that the infantdoes not have congenital pneumonia as a CASE STUDY 2complication of chorioamnionitis. A preterm infant with mild hyaline membrane3. Should this infant remain at the level 1 disease is treated with nasal cannula oxygen inhospital? the intensive care unit of a level 2 hospital. On day 5 the respiratory distress becomes muchNo, he should be moved as soon as possible to worse and the amount of oxygen (FiO2) has toa level 2 or 3 hospital with staff and facilities be care for sick infants. Hyaline membranedisease deteriorates for 2 to 3 days beforeimproving. Therefore, this infant will need 1. Give 3 important conditions that maymore intensive care during the next 72 hours. complicate hyaline membrane disease on day 5.4. What would you expect to see on a chest Pneumonia, pneumothorax and a patentX-ray of this infant? ductus arteriosus.The lungs will appear small and granular dueto collapsed alveoli. 2. How would you diagnose a pneumo- thorax?5. How would you manage this infant The chest may move poorly with decreasedbefore transfer to a larger hospital? breath sounds on the side of the pneumothorax. An easily palpable liver suggests a right-sidedKeep the infant warm and give just enough pneumothorax while poorly heard heartoxygen via a head box or nasal cannula to keep sounds suggest a left-sided pneumothorax.the tongue pink. Handle the infant as little as However, the clinical diagnosis is difficult andpossible after starting an intravenous infusion transilluminating the chest is the quickest wayof maintenance fluid (e.g. Neonatalyte). to diagnose a pneumothorax. A chest X-ray willCarefully observe his respiration rate and also confirm the diagnosis.pattern, colour, heart rate and temperature. 3. How is a pneumothorax treated? Usually a chest drain must be inserted for a few days. In an emergency, the air in the
  14. 14. 196 NEWBORN CAREpleural space can be aspirated with a syringe 4. Why is a patent ductus arteriosusand needle while waiting for staff and unlikely to be the cause of the respiratoryequipment to insert a chest drain. distress in this infant? Because a patent ductus arteriosus rarely causes4. What clinical signs would suggest a respiratory distress in a term infant and usuallypatent ductus arteriosus? does not present the first few days of life.A heart murmur and collapsing pulses (i.e.very easy to feel). 5. Should this infant be transferred to hospital?5. What investigation can confirm a patent Yes. As the wet lung syndrome usuallyductus arteriosus? resolves in 48 hours, this infant need onlyUltrasonography. be transferred to a level 1 hospital, provided that there are adequate facilities to give6. What drug can be used to close a patent and monitor oxygen via a headbox or nasalductus arteriosus? cannulas. Careful observations are essential. The infant must be transferred to a level 2 orIndomethicin or ibrufen. 3 hospital if the signs of respiratory distress become worse as this would suggest that the cause is not wet lung syndrome.CASE STUDY 3A 2900 g infant is delivered in a clinic CASE STUDY 4and appears normal at birth. However, at30 minutes of age the infant has tachypnoea and An infant with a gestational age of 30 weeksmild central cyanosis. There is no meconium has 3 apnoeic attacks on day 3. Clinicallystaining. The infant improves markedly in the infant is well with no signs of respiratoryoxygen and is transferred to a level 1 hospital. distress or infection. The infant is nursed in a closed incubator and fed by nasogastric tube.1. Does this infant have enough clinicalsigns to diagnose respiratory distress? 1. What are the likely causes of the apnoea?Yes, as the infant has 2 of the 4 important signs Apnoea of immaturity, big volume feeds, orof respiratory distress, i.e. tachypnoea and the incubator temperature being too high.central cyanosis in room air. 2. What is apnoea of immaturity?2. What is the probable cause of therespiratory distress? Apnoea which is common in healthy preterm infants, due to immaturity of the respiratoryWet lung syndrome. The birth weight suggests centre.that the infant is not preterm while the lackof meconium staining makes meconium 3. How do you differentiate apnoea fromaspiration unlikely. Congenital pneumonia periodic breathing?cannot be excluded. In periodic breathing the infant stops3. What test on the gastric aspirate after breathing for less than 20 seconds and doesbirth would help to diagnose congenital not develop bradycardia, cyanosis or pallor.pneumonia? The oxygen saturation does not drop.A Gram stain showing pus cells and bacteria.
  15. 15. RESPIRATOR Y DISTRESS AND APNOEA 1974. How would you treat this infant? 5. Should this infant be given oxygen?Give the infant oral theophylline (e.g. Nuelin Infants with apnoea but no respiratoryliquid) 5 mg/kg as a loading dose via a naso- distress usually do not need oxygen. If oxygengastric tube, then 2.5 mg/kg every 12 hours. The is used for apnoea alone, the FiO2 must not betheophylline can usually be stopped when the higher than 0.25. If possible a pulse oximeterinfant reaches 1800 g or 35 weeks. If available. should be used to make sure too much oxygenOral caffeine could also be used. Observe the is not given.infant carefully with an apnoea monitor.