Respiratory distress is a common problem in newborns that can have various causes. It requires early recognition and treatment to prevent morbidity and mortality. The document discusses the causes, clinical presentation, diagnostic evaluation and management of respiratory distress in newborns. Evaluation involves detailed history, physical exam including assessment of respiratory rate, retractions, grunting and cyanosis. Investigations may include chest x-ray, blood gas analysis and sepsis workup. Management is supportive with oxygen therapy, fluid resuscitation and respiratory support as needed. Specific treatments target the underlying condition.
A powerpoint presentation on the respiratory illness seen in newborns/neonates.
the diseases mentioned in this presentation are among the most commonly seen in the population.
A powerpoint presentation on the respiratory illness seen in newborns/neonates.
the diseases mentioned in this presentation are among the most commonly seen in the population.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
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Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
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Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
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Respiratory distress in newborn
1. Respiratory Distress in Newborn
Dr L S Deshmukh
DM ( Neonatology )
Professor and Head,
Dept. of Pediatrics
Govt. Medical College,
Aurangabad
2. Respiratory distress
• Cause of significant morbidity and
mortality
• Incidence 4 to 6% of live births
• Many are preventable
• Early recognition, timely referral,
appropriate treatment essential
3. Respiratory distress
• RR > 60/ min
• Retractions
• Grunt
• + Cyanosis
Note : RR should be recorded in a
quiet state for at least one minute.
4. RD IN NB - Causes
Pulmonary
- Parenchymal
- Extraparenchymal
Non Pulmonary
- Heart
- Metabolic
- Brain
- Blood
- Abdominal
10. Preterm - Possible etiology
Early progressive - Respiratory distress
syndrome or hyaline
membrane disease
(HMD)
Early transient - Asphyxia, metabolic
causes, hypothermia
Anytime - Pneumonia
11. Term – Possible etiology
Early well looking - TTNB, polycythemia
Early severe distress - MAS, asphyxia,
malformations
Late sick with - Cardiac
hepatomegaly
Late sick with shock - Acidosis
Anytime - Pneumonia
12. RR
(bpm
Aspiration cong. Pneumonia, sev. HMD CDH
cardiac malformation
Approx. 6 Hours of age
Normal
60
Course of Neonatal Tachypnoea : Etiologic possibilities
Source : Baurn DJ, Birth Risks, Nastle Nutrition Workshop, 1993
TTNB
HMD
13. Evaluation of RD in NB – Clinical History
Antenatal History Most likely association
* Prematurity, IDMs * HMD
* PROM, maternal fever, * Pneumonia
Unclean vaginal exams,
UTI, diarrhoea
* Asphyxia/MSAF * Aspiration
* Caesarean delivery * TTN
* Polyhydramnios * Pulm. Hypoplasia
* Oligohydramnios * TE fistula, CDH
* H/o receiving steroids * RDS less
* Traumatic/breech delivery * ICH / Phrenic nerve paralysis
14. Evaluation of RD in NB – Clinical History
When did the symptoms begin?
Best historical assistant
Stridor at birth – Cong. Anomaly
After increase feed volum. – GEF & aspiration
After intubation – tube block, air leak
After extubation – Trauma / atelectasis
15. Evaluation of RD in NB – Clinical History
Is the disorder new / chronic / recurrent?
Chronic disorder – BPD
Recurrent disorders
- Aspiration pneumonia
- Pulmonary hemorrhage
- Lobar atelectasis
16. Evaluation of RD in NB – Clinical History
Does the NB have spontaneous cough?
Spont. Cough, always abnormal in NB
Causes of cough in NB : CRADLE
C cystic fibrosis
R respiratory infection
A aspiration (reflux, TE fistula)
D dyskinesia of cilia
L lung, airway, vascular malformation
E edema (heart failure, BPD)
Fletcher MA, 1998, Physical diagnosis in neonatology
17. Approach to respiratory distress
Examination
• Severity of respiratory distress
• Neurological status
• Blood pressure, CFT
• Hepatomegaly
• Cyanosis
• Features of sepsis
• Look for malformations
18. Evaluation of RD in NB – Downes’ Score
0 1 2
Cyanosis None In room air In 40% FiO2
Retractions None Mild Severe
Grunting None Audible with
stetho.
Audible without
stetho.
Air entry C;ear Decreased Barely audible
RR Under 60 60-80 Over 80 or
apnea
Score : > 4 = Clinical respiratory distress; monitor ABG
> 8 = Impending respiratory failure
19.
20.
21. Evaluation of RD in NB – RR
Affected by various conditions
Low rates – Decreased MV
High rates – Wasted ventilation
Rapid & shallow – Stiff lungs (RDS)
Slow & Deep – Increased resistance (MAS)
Isolated tachypnoea – Acidosis, sepsis, CCF
22. Evaluation of RD in NB – Grunting
Classical in HMD, may be seen in
pneumonia, pulmonary edema & others.
Expiration through partially closed glottis.
Intermittent / continuous (Severity)
Generates CDP of 2-3 cms H2O
Maintains FRC
23. Evaluation of RD in NB – Cyanosis
Total desat. Hb > 3.5 gm/dl
Central cyanosis – always abnormal
Acrocyanosis – May be normal
Hyperoxia test – Pulm. Vs Cardiac
Anemia / Polycythemia - Falacious
24. Hyperoxia test
test Method result diagnosis
Hyperoxia 100 % fio2 5-10
min
Pao2 increases
to > 100 torr
Pao2 increases
by < 20 torr
Parenchymal
lung disease
PPHN / CCHD
Hyperoxia-
hypervetilation
MV 100 % fio2
& VR 100-150 /
min
Pao2 increases
to > 100 torr
w HV
Pao2 increases
at critical Pco2
No increase in
Pao2 with HV
Parenchymal
lung disease
PPHN
CCHD
25. Evaluation of RD in NB – Physical Exam.
Look for :
- Shrill cry / abn. tone (CNS disorder)
- Persistent frothing at mouth (TE fistula)
- Cyanosis, relieved on crying (choanal atresia)
- Seaphoid abd. (CDH)
- Single umbilical astery (CHD)
- Meconium staining of skin, nails or cord (MAS)
26. Evaluation of RD in NB – Retractions
Site of
retraction
Probable
region affected
Likely clinical association
Intercostal Pulmonary
parenchyma or
distal airway
Conditions of decreased
parenchymal compliance
MHD, TTN, Pneumonia
Subcostal Insertion of
diaphragm
Mild degree of retraction
are normal in neonates;
Airway obstruction or
parenchymal disease; in
the absence of intercostal
retractions, indicates
proximal airway obstruction
27. Evaluation of RD in NB – Retractions
Site of
retraction
Probable region
affected
Likely clinical association
Unilateral
subcostal
Decreased
movement of
opposite diaphragm
Isolated phrenic nerve weakness
Brachial palsy
Massive pleural effusion
Tension pneumothorax,
CDH
Suprasternal Obstruction in
upper airway
Choanal atresia or stenosis
Laryngeal stenosis or malacia
Obstruction of upper airway due
to secretions, edema
Sternal Sternal compliance
greater than pulm.
compliance
Proximal airway obstruction
28. Clinical Examination
Color—pink, dusky, pale, mottled
– Central
– Peripherally
Heart rate
Pulses
– Distal vs Central
Perfusion
– Capillary Refill Time (CRT)
– Blood Pressure
29. Clinical Examination
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, hepatomegaly, situs inversus
30. Suspect surgical cause
• Obvious malformation
• Scaphoid abdomen
• Frothing
• History of aspiration
31. Evaluation of RD in NB – Chest Exam.
Increased A-P diameter of chest
- Pneumothorax, emphysema or CDH
Asymmetric chest movement
- Tension pneumothorax, pleural effusion, CDH,
Diaphragmatic paralysis, PIE.
Auscultation
- Breath sounds ,
- Early, coarse crackles – Pneumonia & HMD
- Late crackles - PIE
Wheezing – BPD, GER, Vascular rings, bronchomalacia
Auscultatory percussion – Lobar atelectasis, effusion.
Transillumination of the chest
34. Pulse oximetry
• Effective non invasive monitoring of
oxygen therapy
• Ideally must for all sick neonates and
those requiring oxygen therapy
• Maintain SaO2 between 90 – 93 %
35.
36.
37. Shake test
• Take a test tube
• Mix 0.5 ml gastric aspirate +
0.5 ml absolute alcohol
• Shake for 15 seconds
• Allow to stand 15 minutes for
interpretation of result
38. RD in Newborn – Differential Diagnosis
Condition Gestation History Clinical signs
RDS PT>FT APH/IDM asphyxia Retractions, grunt
Pneumoni
a
Any PROM, smelly
liquor, fever in
mother
Hypo/hyperthermia
leukocytosis or
neutropenia
MAS FT NSAF, asphysia
MA
Distended chest
Meconium staining
TTNB FT>PT C section Tachypnoea ++
PPHH Usually
FT
Asphyxia Profound cyanosis
CVS normal
41. Roentgen Finding in RD in the Neonate
Pulmonary infiltrates Aeration e/o PAL
Distributio
n
Characteristis
Hyaline
membrane
disease
Diffuse Fine reticulogranula
pattern with air
bronchograms
Hypoaeration Present usually
as a complication
of respirator
therapy
Transient
tachypnoea
Diffuse Symmetrical stringy
perihilar infiltration
Hypoaeration Uncommon
Meconium
aspiration
syndrome
Usually
diffuse
Bilat patchy, course
infiltrate & atelectasis
alternating with areas
of alveolar
emphysema
Hypoaeration Often seen in the
absence of
respiratory
therapy
Neonatal
pneumonia
Variable but
usually
asymmetrica
l & localized
Variable pattern
ranges from localized
to diffuse alveolar or
interstitial disease
Mild
hyperaeration
Uncommon
60. Respiratory distress - Management
• Monitoring
• Supportive
- IV fluid
- Maintain vital signs
- Oxygen therapy
- Respiratory support
• Specific
61. Oxygen therapy*
Indications
• All babies with distress
• Cyanosis
• Pulse oximetry SaO2 < 90%
Method
• Flow rate 2-5 L/ min
• Humidified oxygen by hood or nasal prongs
* Cautious administration in pre-term
62. Antenatal corticosteroid
- Simple therapy that saves neonatal lives
• Preterm labor 24-34 weeks of gestation
irrespective of PROM, hypertension and
diabetes
• Dose:
Inj Betamethasone 12mg IM every 24 hrs X
2 doses; or Inj Dexamethasone 6 mg IM
every 12 hrs X 4 doses
• Multiple doses not beneficial
63. Surfactant therapy - Issues
• Should be used only if facilities for
ventilation available
• Cost
• Prophylactic Vs rescue
64. Prophylactic therapy
Extremely preterm <28 wks
<1000 gm
Not routine in India
Rescue therapy
Any neonate diagnosed to have RDS
Surfactant therapy - Issues
Dose 100mg/kg phospholipid Intra tracheal
65. 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
65
67. 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
67
68. 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!!
68
69. Congenital pneumonia
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)
70. Nosocomial pneumonia
Risk Factor : Ventilated neonates
: Preterm neonates
Prevention : Handwash
: Use of disposables
: Infection control
measures
Antibiotics : Usually require higher
antibiotics
71. Respiratory distress in a neonate with
asphyxia
• Myocardial dysfunction
• Cerebral edema
• Asphyxial lung injury
• Metabolic acidosis
• Persistent pulmonary hypertension
74. Pneumothorax and other
Air Leaks
History
– What happened in the delivery room?
– Was positive pressure given?
– Large amount of negative pressure generated
with the 1st breath?
74
76. Pneumothorax/ Air Leak
Clinical Assessment
– Cyanotic
– Pale, gray
– Heart Rate
Tachycardia
Bradycardia
PEA
– Pulses
Normal
Poor
absent
76
77. 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!!
77
78. Congenital Diaphragmatic Hernia
Congenital 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
78
84. 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
84
85.
86. Evaluation of RD in NB
History and physical examination
Dawnes’ or RDS score (clinical)
Arterial blood gases
Pulse oximetry – SaO2
Chest x-ray
Serum glucose and calcium; central
hematocrit, WBC and differential; platelet
count.
Maternal vaginal culture
Newborn surface (e.g. earcanal, gastric
aspirate) smears, cultures (?), blood culture,
urine culture (?). CSF culture (?)
87. Respiratory distress syndrome (RDS)
• Pre-term baby
• Early onset within 6 hours
• Supportive evidence: Negative shake test
• Radiological evidence
88. Pathogenesis of RDS
• Decreased or abnormal surfactant
• Alveolar collapse
• Impaired gas exchange
• Respiratory failure
96. Meconium aspiration syndrome
• Post term/SFD
• Meconium staining – cord, nails, skin
• Onset within 4 to 6 hours
• Hyperinflated chest
97. MAS - Prevention
• Oropharyngeal suction before delivery of
shoulder for all neonates born through
MSAF
• Endotracheal suction for non vigorous*
neonates born through MSAF
*Avoid bag & mask ventilation till trachea is
cleared