Respiratory distress in newborn and niv support

1. Respiratory distress in
newborn and non invasive
respiratory support
Dr. Tareq Rahman,
Year 5, neonatology,
Bangabandhu sheikh mujib medical
university(BSMMU), Bangladesh.

2. Respiratory Distress in the Newborn
AND
Non-invasive Mechanical Ventilation

3. Respiratory Distress in the Newborn
• Definition: respiratory distress
is defined as a presence of one
of following signs and
symptoms irrespective of
etiology -
1. Tachypnea (Respiratory
rate>60/min)
2. Grunting
3. Nasal flaring
4. Chest retractions
5. Cyanosis
Pediatrics in Review, 2010 Dec; Vol.31(12) : 487-
495
Respiratory
Distress in
Newborn
Tachypnoea
Retractions
GruntingNasal Flaring
Cyanosis

4. Other symptoms
• Apnea
• Bradypnea (< 30/min)
• Irregular (see-saw) breathing
• Stridor (high-pitched, musical, monophonic
inspiratory breath sound that indicates
obstruction at the larynx, glottis, or subglottic
area )
• Hypoxia

5. • Tachypnea:
- Most common sign of respiratory distress in infants.
- First attempt at compensating for an increased production of
carbon dioxide (CO2) or a problem with gas exchange.
- Due to less expandibility of chest cavity and weaker intercostal
muscle infants have limited ability to increase tidal volume
compared to adult.
- Breathing at fast rates requires lots of energy and is a warning
sign that respiratory failure or decompensation may develop.

6. • Nasal flaring:
- compensatory mechanism in breathing
difficulty to increase the size of nares during
inspiration, making that passage larger and
decreasing airway resistance.

8. • Grunting:
- Low-pitched expiratory
noise, coming from deep in
the throat where the closed
glottis is located.
- Mechanism to maintain
lung volume.
- Represents the closure of,
and breathing against, the
glottis to provide PEEP and
maintain alveolar volume.

9. • Retractions:
- The increased muscle effort results
in a collapse of soft tissue, called
retractions.
- Increased respiratory muscle activity
to increase tidal volumes.
- various locations –
a) Suprasternal retractions
b) Intercostal retractions
c) Substernal or subcostal
retractions
d) Sternal retractions
* Suprasternal and sternal/substernal
retractions are most commonly found in
upper airway obstruction.

10. Mechanism
Normal lung Retraction

11. • Cyanosis:
- An advanced sign of
respiratory distress.
- Central cyanosis becomes
clinically apparent when at
least 5 g/dl of hemoglobin
becomes unsaturated.
- In anemia or those who
have larger amounts of fetal
hemoglobin, cyanosis may not
be detectable until the partial
pressure of arterial oxygen
(PaO2) is very low.

12. • Head Bobbing:
- Seen in progression of
respiratory distress and is
unique to infants.
- Baby becoming
lethergic, but is still using
significant amount of
accessory muscle to expand
the chest cavity, which
results in their head bobbng
up and down with each
breath.

13. Respiratory distress - Aetiology
• The most important factor determining the
etiology of respiratory distress is Gestational
age.
• In preterm infant RDS being the most common
cause(almost 90%) while in late preterm and
term infant TTN is the predominant
cause(68%).

14. • Preterm Newborns
-Respiratory distress syndrome (RDS)
-Delayed transition
-Hypo/ hyperthermia
• Term/ Near Term Newborns
- Transient Tachypnea of the Newborn
- PNA
- Meconium aspiration syndrome
- Persistent pulmonary hypertension of the newborn

15. • Irrespective of GA
-Congenital malformations
-Pneumonia, Sepsis
-Pneumothorax
-Congenital heart disease
-Hypoglycemia
-Acidosis, Inborn metabolic error,
hypo/hyperthermia, hypo/hypernatremia
-Meningitis, Seizure
-Anemia, Polycythaemia
-Maternal sedation, Narcotic withdrawal

16. Pediatrics in Review, 2014 oct ; 35 (10) : 417 – 429 .

17. Approach to a newborn with RD
• Quick initial assessment for life threatening
condition such as:
• Type equation here.Airway
obstruction
Insufficient
breathing
Circulatory
collapse
Poor oxygenation
-Gasping
-Stridor
-Apnea
-Poor respiratory
effort
-Bradycardia
-Hypotension
-Poor perfusion
-cyanosis

18. Relevant history in a newborn with RD
• Antenatal:
-Fever/ UTI
-DM
-Poly/ oligohydramnios
-APH
-Fetal assessment (USG, Biophysical profile)
-Rh iso-immunization
-Antenatal corticosteroids
-Drug
-H/O consanguinity

19. • Natal:
-PROM
-Chorioamnionitis/ fever
-Meconium stained fluid
-Birth trauma
-Detail of resuscitation

20. • Post natal:
-Gestational Age
-Postnatal age
-Onset and course of disease
-Chocking and coughing during feeding

21. Physical examination
• LOOK for-
-Signs of prematurity
-F/O IUGR
-Meconium staining
-Dysmorphic face
-Scaphoid abdomen
• Vital sign/ hemodynamic stability: Temperature,
Pulse, RR, BP, CRT
• Oxygen saturation: Both preductal and postductal.

22. Respiratory system examination
• Inspection:
-RR
-Asymmetry of chest shape/ movement
-F/O respiratory distress
• Auscultation:
-Air entry
-Breath sound,
-Added sounds such as crepitation
• Transillumination test: When there is suspicion of
pneumothorax.

23. • Precordium should also be examined to
document any murmur and/ or cardiac
disease.

24. Score > 4 Clinical respiratory distress
Score >7 Impending respiratory failure
Silverman score

25. Feature Score 0 Score 1 Score 2
Cyanosis None In room air In 40% FiO2
Retractions None Mild Severe
Grunting None Audible with
stetho.
Audible
without stetho.
Air entry Normal Decreased Barely audible
RR < 60 60-80 > 80 or apnea
Score > 4 = Clinical respiratory distress
Score> 7= Impending respiratory failure
Downe’s score

26. Laboratory Evaluation:
• Guided by history and examination findings.
-Chest radiography
-Arterial blood gas
-Blood glucose
-Complete blood count with differentials
-Blood culture
-Lumber puncture
-Echocardiography and CT of thorax

27. Treatment
• Basic principles of treatment are:
A. Supportive care
B. Respiratory care
C. Specific therapy
D. Monitoring for and
E. Management of complications

28. A. Supportive care:
• Thermal care
• Management of fluid, electrolyte and
nutrition
• Maintenance of adequate haemoglobin
• Monitoring Vital signs &
• Scoring the severity of respiratory distress

29. B. Respiratory support:
• The objective is to ensure adequate oxygenation&
ventilation& thereby decrease work of breathing.
• Respiratory support can be provided through:
-Supplemental O2
-Mechanical ventilation
- Invasive
- Non-invasive (CPAP)

30. C. Specific therapy:
• According to underlying cause-
- RDS: Surfactant replacement therapy
-EONS/ Pneumonia: Parenteral antibiotics
-Lung malformation: Surgical resection
(All dyspneic newborn babies, should have
appropriate blood C/S taken and be treated with
antibiotic from the earliest sign of respiratory
illness)

31. D. Monitoring for & Mx of
complications
• Worsening of distress and impending
respiratory failure
• Hemodynamic instability
• Hypoxia related complications like AKI,
convulsions etc.
• F/O PPHN
• Complications of mechanical ventilation

32. Common causes of RD in neonate
Condition Risk factors Clinical course Radiological
features
RDS • Prematurity
(usually ˂34
weeks)
• Lack of antenatal
steroids
• Infant of diabetic
mother
• Birth asphyxia
• Rh
isoimmunization
• Onset at or soon
after birth
• Progress till 48
hours, static for
48 hours&
improves later.
• FiO₂
requirement
often >40%
• Surfactant
modifies the
typical course
• Low volume
lungs
• Fine reticuo-
granular pattern
• Ground glass
appearance
• Air
bronchograms
• White-out lungs
TTN • Predominantly
late PT & Term
infants
• Onset at or soon
after birth
• Hyperinflated
lungs

33. Condition Risk factors Clinical course Radiological
features
TTN • Born by C/S
• Maternal
diabetes
• Maximum
severity at
birth& improves
gradually
• FiO₂
requirement
seldom >40%
• Perihilar
streaking
• Fluid in minor
fissure
• Pleural effusion
• Mild
cardiomegaly
EOS/ Pneumonia • Risk factors such
as PROM,
chorioamnionitis
, maternal fever,
unclean vaginal
examinations
• Onset at birth or
delayed
• May fail to
improve with
oxygen/ CPAP
• Homogenous/
Non
homogenous
opacities B/L in
CXR

34. Condition Risk factors Clinical course Radiological
features
Meconium
aspiration
syndrome (MAS)
• Meconium
stained amniotic
fluid
• Onset may be at
birth or delayed
• Meconium
staining of cord/
skin
• Hyperinflated
chest
• F/O PPHN
• Hyperinflated
lungs
• Coarse nodular
opacities
• Patchy
atelactasis
• Areas of
overinflation

35. Non-invasive Mechanical Ventilation

36. Definition
• Noninvasive ventilation (NIV) can be defined
as a ventilation modality that supports
breathing by delivering mechanically assisted
breaths without the need for intubation
or surgical airway

37. MASK
ARGYLE PRONGS
FISCHER PAYKEL
HUDSON
VYGON NP PRONGS
CANNULAIDE ( for preventing trauma)

38. Benefits over endotracheal
intubation
• Decrease upper airway trauma
• No vocal cord dysfunction
• Less Chronic Lung Disease
• Less sedation needed
• No need for paralytics
• Less risk of aspiration
• Fewer Infections
• If successful, fewer oxygen days leading to less oxygen
toxic side effects (ROP)
• Less stress for babies, families, and staff
• Lower cost

39. Subdivision
1. Negative-pressure ventilation (NPV)
2. Noninvasive positive-pressure ventilation

40. Negative-pressure ventilation (NPV)
• Lower the pressure surrounding
the chest wall during inspiration
and reversing the pressure to
atmospheric level during
expiration. These devices
augment the tidal volume by
generating negative extrathoracic
pressure.
• Method of ventilation for
patient with progressive
neuromuscular disease, severe
chest deformities & broncho-
pulmonary dysplasia.

41. Noninvasive positive-pressure ventilation

42. Figure 1. Types of non-invasive ventilatory support given to neonates. Abbreviations: CPAP; continuous positive airway pressure,
HFNC; high-flow nasal cannula, nBiPAP; nasal bilevel positive airway pressure, nIPPV; nasal intermittent positive airway pressure,
nSIPPV; synchronized nasal intermittent positive airway pressure, nHFV; nasal high-frequency ventilation.
R.A. Mahmoud et al. , Paediatric Respiratory Reviews 12 (2011) 196–205

43. Physiologic Effect
Effects Mechanism
Decreased intrapulmonary shunting Recruits additional alveoli, decreases
pulmonary vascular resistance
Increased compliance and functional
residual capacity and prevention of
atelectasis
Recruits additional alveoli and splints the
airways
Improved oxygenation Decreases pulmonary vascular resistance
Decreased thoracoabdominal asynchrony Splints the airways and diaphragm,
stabilizes chest wall
Decreased obstructive and mixed apnea Splints the airways and diaphragm,
stabilizes chest wall; regularizes and slows
respiratory rate
Conservation of surfactant Recruits
alveoli,
Improved lung growth
Recruits alveoli, improves pulmonary
blood flow, improves oxygenation,
Stretches lung tissue

44. Indications
• Post-extubation respiratory support
• Preventing collapse of the lung
• Need for respiratory support, with good
respiratory drive

45. Contraindications
• Unstable cardiorespiratory status
• Inability to protect airway
• congenital malformations of the airway
• Trauma or burns involving the face
• Facial, esophageal, or gastric surgery
• Poor respiratory drive
• Reduced consciousness
• Air leak syndrome

46. Complications of NIV
• Nasal septal irritation and necrosis
• Gastric distension
• Pneumothorax
• Increased intracranial pressure
• Difficulty keeping prongs in place
• Overdistension of the lungs (inadvertent PEEP)
• Mucous obstruction of the airway

47. CPAP
• Continuous positive airway
pressure (CPAP) is a form of
noninvasive ventilation where
a positive pressure is applied
to the airway of a
spontaneously breathing
infant through out the
respiratory cycle, thereby
preventing the collapse of
alveoli & terminal airways
during expiration.

48. How Does It Work?
CPAP predominantly helps by preventing collapse of the alveoli
with marginal stability
Recruitment of more alveoli
Increase the functional residual capacity (FRC)

50. Bubble CPAP

51. Indication of CPAP
• Respiratory distress syndrome
• Apnea of prematurity
• Delivery room respiratory support and prophylactic CPAP (<28
weeks GA)
• Post-extubation respiratory support
• Postoperative respiratory support
• Heart failure due to PDA
• Pneumonia, MAS, TTN, tracheo/bronchomalacia, pulmonar
edema, pulomonary haemorrhage.

52. Contraindications
1. Progressive respiratory failure with pH<7.25 and PaCO2
>60 mmHg and/or inabitity to maintain oxygenation
(PaO2<50 mmHg)
2. Certain congenital malformations of the airway
- Choanal atresia
- Cleft palate
-Tracheo-esophageal fistula
-Congenital diaphragmatic hernia
3. Conditions with imminant ventilatory support
- Severe cardio-vascular instability
-Poor respiratory drive

53. Assess respiratory status by scoring systems
• Pressure(PEEP): Start at 5 cm H2O
• FiO2: 0.5
• Flow: 5 L/min
How to Initiate CPAP?

54. Pressure(PEEP):Increase in steps of 1-2cm H2O to reach
a maximum of 8 cm H2O
FiO2:Increase in steps of 0.05 (if oxygenation is still
compromised) up to a maximum of 0.6
Flow: Usually constant
 Always increase pressure before FiO2 for better
oxygenation
How to proceed?

55. Weaning
When to wean ?
- Apnea free for 24 to 48 hours
- Optimum corrected gestational age and weight:
32 to 33 weeks and 1600 gm (Amatya et al 2015 )
How to wean ?
- wean pressure before weaning FiO2.
- FiO2>50% and pressure >5 cm, wean FiO2 till 50% and then wean
pressure.
- pressure 4 cm with a FiO2 <30% with normal saturation and minimal
retraction, CPAP may be removed.
 Infants clinical condition will guide the speed of weaning

56. CPAP failure
• Inability to maintain SpO2 >90% or PaO2>50
mmHg with FiO2 >60% and pressure >7cm of
water and PaCO2 >60 mmHg on CPAP are
indication for mechanical ventilation.

57. Complications Associated With CPAP
Nasal irritation, septal erosion or necrosis
• -Keep prongs away from the septum
Nasal obstruction
• - Remove secretions and check for proper
positioning of the prongs
Sepsis
Feeding intolerance
Gastric distension/CPAP belly syndrome
Pneumothorax

58. Heated humidified high flow nasal
cannula
• ‘High flow’ nasal cannula
refers to the administration
of blended oxygen and air to
newborn infants via nasal
cannulae at higher flow rates
than with low flow nasal
cannulae (greater than 1
L/min). ( Cochrane 2011 )

59. Mechanism
• Washes out nasopharyngeal dead space.
• Provides flow adequate to support inspiration
there by reducing inspiration work of
breathing.
• Improves lung and airway mechanics by
eliminating the effects of drying/cooling.
• Provide end distending pressure, thus it
maintain adequate functional residual
capacity.

60. Indication
• In post-extubation settings<28 weeks of
gestation.
• Weaning from nasal CPAP.
• Respiratory distress as primary mode.

61. Contraindication
• Congenital anomalies of nose like choanal
atresia.
• Significant respiratory pathology.
• Hemodynamically unstability.

62. Protocol for initiating equipment set up
• Initial flow rate setting –
1 to 2 kg = 3 lpm
2 to 3 kg = 4 lpm
>3 kg = 5 lpm
• Increase flow rate 1 lpm increments if -
- FiO2 increases >10% above starting FiO2
- PCO2 increases >10 mmHg above baseline
- increased distress or retraction
- Decreased lung expansion on CXR

63. Weaning
• Clinically stable and apnea free for 3 days and
maintaining SpO2 90 – 94%, weaning is done
gradually by decreasing flow rate of 0.5 – 1
and monitoring clinically to maintain target
saturation.

64. Side Effect
• Gastric distension
• Nasal trauma ( incidence less as compared to
CPAP)
• Air leak syndrome

65. Facts of HHHFNC
• HHHFNC is not true CPAP
• Pressure is inconsistent, unreliable and
unpredictable
• Easier to use
• Less adverse effects such as local trauma
• Post-extubation support or to transition from
nCPAP
Clinical perinatlogy,2016; 43: 693-705

66. HHHFNC vs CPAP
• Heated Humidified High Flow Nasal Cannula versus Nasal
Continuous Positive Airway Pressure as Primary Mode of
Respiratory Support for Respiratory Distress in Preterm Infants
Indian Pediatrics VOLUME 53 , FEBRUARY 15, 2016
-HHHFNC appeared to have similar efficacy and safety to
NCPAP when applied as a primary mode of respiratory
support to preterm infants between 28 and 34 weeks of
gestation with mild to moderate respiratory distress , with
lesser incidence of nasal trauma.

67. NIPPV
• Nasal intermittent positive pressure ventilation (NIPPV)
superimposes an intermittent peak pressure on CPAP and is
delivered to the infant with a ventilator and nasal prongs /
nasal mask.
• It reduces the rate of extubation failure in preterm infants. (
Cochrane 2017 )
• Among preterm infants with respiratory distress syndrome,
NIPPV decreases the need for invasive ventilation within the
first 72 hours of life compared with NCPAP. (Jucille et al 2012)

68. NAVA
• Nasal neurally adjusted ventilatory assist is newer form of
noninvasive respiratory support that uses the eletrical activity
of the diaphragm ( EAdi) to assess the timing and magnitude
of inspiratory pressure delivered during spontaneous
breathing.
• The EAdi signal is obtained by an indwelling 5.5French feeding
tube placed in the oesophagus fitted 10 electrodes so that the
electrodes are at the level of the diaphragm.
• NAVA requires good spontaneous breathing efforts.
• Premature neonates who are apneic may not be good
candidates for nasal NAVA.

69. Conclusion
• Noninvasive ventilation ( NIV ) is not a new therapy but has
received new attention in the interest of preventing lung
injury.
• Numerous research studies and meta-analyses have
demonstrated the benefits of NIV for the treatment of RDS
and the reduction in the need for intubation and mechanical
ventilation.
• Success of NIV therapy increases with increasing experience
of the clinicians administering the therapy.
• Further research is required to enhance our understanding of
the optimal application of NIV therapies.