Respiratory Distress in the Neonate

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Respiratory Distress in the Neonate. Early Stabilization and Management Kathey Voelker, NNP-BC. Tachypnea. RR > 80 Most common sign of illness in the neonate Can occur with or without distress. Respiratory Distress. Retractions Grunting Nasal flaring. Tachypnea with Distress.
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Respiratory Distress in the Neonate Early Stabilization and Management Kathey Voelker, NNP-BC Tachypnea
  • RR > 80
  • Most common sign of illness in the neonate
  • Can occur with or without distress
  • Respiratory Distress
  • Retractions
  • Grunting
  • Nasal flaring
  • Tachypnea with Distress
  • Decreased lung volume
  • HMD
  • TTN
  • Pneumonia
  • Air leaks
  • Diaphragmatic hernia
  • Meconium aspiration
  • Tachypnea Without Distress
  • Acidosis (metabolic)
  • Congenital heart defect/disease
  • Hypothermia
  • Hypoglycemia
  • Sepsis
  • Hyaline Membrane Disease
  • Surfactant deficiency leads to alveolar collapse, decreased volume, microatelectasis
  • General Physiology
  • Lung Development
  • < 22 weeks
  • 22 - 24 weeks
  • 24 - 34 weeks
  • 34 - 36 weeks
  • Conditions that Interfere with Surfactant Metabolism
  • Acidemia
  • Hypoxia
  • Shock
  • Pulmonary edema
  • Over inflation
  • Under inflation
  • Mechanical ventilation
  • Hypercapnea
  • Conditions That Delay Surfactant Metabolism
  • Infant of diabetic mother
  • Erythroblastosis fetalis
  • Smaller of twins
  • 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
  • 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
  • Ventilation Options
  • Nasal CPAP
  • Nasal IMV
  • Conventional ventilation (SIMV)
  • High frequency jet ventilator
  • High frequency oscillating ventilator
  • *controversal: iNO in VLBW*
  • Transient Tachypnea of the Newborn
  • Retained lung fluid remains in alveoli and pulmonary tree
  • Minimal distress
  • Transient Tachypnea 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
  • Air Leaks
  • Pneumothorax
  • Pneumomediastinum
  • Pneumopericardium
  • Pulmonary interstitial emphysema
  • 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
  • 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
  • Treatment of Pneumothorax
  • Aspiration kits
  • 23 or 25 g butterfly or IV catheter
  • Three-way stopcock
  • 30 – 60 cc syringe
  • Pulmonary Interstitial Emphysema Worsening PIE Treatment of PIE
  • Minimize further alveolar trauma with
  • HFOV
  • Jet ventilator
  • Meconium Aspiration Syndrome
  • Fetal passage of meconium
  • Fetal response to hypoxia
  • Management in the delivery room
  • Meconium aspiration
  • MAS Clinical findings
  • Early, progressively worsening distress
  • Pneumothorax not uncommon
  • Fluffy xray with areas of hyperinflation and areas of atelectasis
  • MAS MAS with Pleural Effusion 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
  • Diaphragmatic Hernia
  • Defect in the diaphragm allowing abdominal structures to enter thoracic space.
  • Large defects can be identified on prenatal ultrasound
  • Early distress
  • Diaphragmatic Hernia
  • Notice the midline shift of the structures as bowel fills left chest. Note position of OG tube.
  • Diaphragmatic Hernia Management
  • Immediate intubation
  • BVM ventilation contraindicated
  • Gastric decompression
  • Jet ventilation
  • +/- ECMO
  • Surgical correction of the defect
  • V/Q mismatch
  • Pulmonary hypertension
  • From hypoxia or hypercapnea
  • From GBS
  • Shock
  • Perinatal blood loss
  • Sepsis
  • Extreme prematurity
  • Blood Pressure
  • Systolic/Diastolic
  • Mean Arterial Pressure
  • Pulse Pressure
  • Perfusion
  • Pneumonia
  • GBS
  • Aspiration
  • Formula
  • Blood
  • Amniotic fluid
  • 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
  • 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
  • Oxygen delivery devices
  • Nasal canula on a blender
  • High flow
  • Low flow
  • Oxygen hood
  • Blow-by (least preferred method)
  • Oxygen Delivery Devices
  • Nasal CPAP
  • Nasal IMV
  • ETT ventilation
  • Conventional
  • HFOV
  • Jet
  • 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!
  • 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
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