Dr. (Kate) Katherine Miller GUELPH ON 121 RESPIRATORY DISTRESS IN THE NEWBORN

Transcription

1 Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12-14, 2018 Dr. (Kate) Katherine Miller GUELPH ON 121 RESPIRATORY DISTRESS IN THE NEWBORN Tachypnea is the most common problem encountered in the first hours of life. This case-based session will review the most common causes of respiratory distress in newborns and help equip rural physicians to diagnose and manage these babies. 1. Assess the neonate demonstrating respiratory distress with a view to determining cause and severity 2. Interpret common investigations (CBC, CRP, CXR) ordered for neonates with respiratory distress 3. More confidently manage the most common causes of respiratory distress in neonates.

2 Approach to the Tachypneic Newborn Dr Kate Miller Rural and Remote Medicine St John s, 2018 Objectives To develop an approach to the neonate demonstrating respiratory distress To review cases and Xrays for the most common causes of respiratory distress in the newborn 1

3 How to participate in the polls Case #1 G1P0, increased BP on Labetolol Induced at 37 4/7 based on first trimester US GBS positive 3 doses Pen G in labour BW 2858g. Apgars 7,9,10. resus with stim, no PPV 30 min age noted to be grunty, RR50, good tone, no indrawing, occ. flaring, sats 94% on RA 90 min age first attempt to breastfeed, becomes floppy, pale, and poor resp effort, you are called 2

4 Assessing the tachypneic baby Assess the degree of distress Think about the risks Watch the progression Remember, watch for hypoglycemia, don t feed if moderate to severe distress Assess the degree of distress 3

5 Degree of Distress Poll Quantifying the degree of distress Score Resp Rate 40-60/minute 60-80/minute >80/minute O2 required None <50% >50% Retractions None Mild-moderate Severe Grunting None With stimulation Continuous at rest Breath Sounds Easily heard throughout Decreased Barely heard Prematurity >34 weeks weeks <30 weeks <5 = mild resp distress 5-8 = moderate >8 = severe ACORN respiratory score, Acute Care of at-risk Newborns Textbook, Based on: Downes et al. Respiratory distress syndrome of newborn infants. I. New clinial scoring systme with acid-base and blood-gas correlations. Clin. Pediatr 1970; 9(6);

6 Is that baby actually grunting? Noise Description Causes Stertor Stridor Wheeze Grunting Sonorous snoring sound, mid pitched, monophonic, may transmit throughout airways, heard loudest with stethoscope near mouth and nose Musical, monophonic, audible breath sound. Typically high pitched. High pitched, whistling sound, typically expiratory, polyphonic, loudest in chest Low or mid pitched, expiratory sound caused by sudden closure of the glottis during expiration in an attempt to maintain FRC Nasopharyngeal obstruction nasal or airway secretions, congestion, choanal stenosis, enlarged or redundant upper airway tissue or tongue Laryngeal obstruction laryngomalacia, vocal cord paralysis, subglottic stenosis, vascular ring, papillomatosis, foreign body Lower airway obstruction MAS, bronchiolitis, pneumonia Compensatory symptom for poor pulmonary compliance TTN, RDS, pneumonia, atelectasis, congenital lung malformation or hypoplasia, pleural effusion, pneumothorax What do you hear 1 A) Stertor B) Stridor C) Wheeze D) Grunting 5

7 What do you hear 2 A) Stertor B) Stridor C) Wheeze D) Grunting What do you hear 3 A) Stertor B) Stridor C) Wheeze D) Grunting 6

8 Non respiratory causes Respiratory causes of Respiratory Distress Transient Tachypnea of the Newborn Prematurity/Surfactant Deficiency/RDS Pneumonia/Sepsis Meconium Aspiration Pneumothorax Congenital Malformations Persistent Pulmonary Hypertension 7

9 Case continued Grunty, flaring, indrawing, pink, good tone RR60, T 37.0, HR 140, BP 65/43, Sat 100% with blowby 02 Chest clear, Normal HS, good femoral pulses CXR, CBC, and cultures ordered Mom s chart reviewed by certain LMP is only 35 4/7. Early US agrees with LMP but dictation error made on EDD. 8

10 Case conclusion Babe moved to nursery. Initially requiring O2 at 28%. Glucometer 3.2 Hb 191, WBC 19.6, Neuts 11.2, Lymph 7.7 O2 slowly weaned over 6 hours RR settled to normal by 8 hours What is your diagnosis? Transient Tachypnea of the Newborn 9

11 Case #2 Infant male born vaginally at 38 1/7 weeks, 3238g, Apgars 9 and 9. At 7 minutes of age begins to experience labored breathing SaO2 94% in RA with RR of 50. HR , afebrile. Sats drop however with crying or repositioning Breath sounds seem diminished bilaterally CBC, CRP, and CXR ordered 10

12 Pneumothorax What is your diagnosis? 11

13 Needle Aspiration Transillumination 12

14 Needle Aspiration Case 2 Conclusion 25g ¾ butterfly needle attached to 3 way stopcock and 20cc syringe obtained. Skin cleansed with Betadine, needle inserted in 4 th interspace, anterior axillary line Advancement stopped when air aspirated. 40cc of air evacuated from left hemithorax, HR immediately dropped to

15 Case 2a before and after Case 2b Before and after 14

16 Case # 3 G4P1 at 37 6/7 GBS negative but given cefuroxime in labour EFM started in late 1 st stage for baseline 108. Uncomplicated but persistent variable decels Vigorous babe, no resus, Apgars 9, 9 10 min age grunty, no indrawing, no flaring, good tone, pink 1 hour attempt breastfeed, no success. Still grunty, now flaring. Moved to nursery. Case # 3 T 35.6, HR 130, RR 50, Sat 88% on RA, 51/36, cap refill 3 sec Started on 26% O2, sats now 97% Chest wet on right, grunty, flaring, indrawing HS normal, femoral pulses equal, 4 limb BPs congruent 15

17 What are you ordering? A) CBC and CXR B) CBC, CRP and CXR C) CRP and CXR D) CBC, CXR and blood cultures E) CBC, CRP, CXR and Blood cultures F) nothing, observation will be good enough 16

18 Case # 3 Hb 220, WBC 22.5, neuts 13.3, lymph 5.9 CRP 1.2 NG placed RA at 6 hours of age resps 70 80, in 39% O2 to keep sats of 91 92%, temp 37.2 Occ spells without grunting and indrawing, and chest no longer sounds wet Repeat CXR done 17

19 Pneumonia What is your diagnosis? Case Conclusion Diagnosis pneumonia made Decision to transfer and IV Abx started Cultures ultimately negative but treated with 10 days of IV Abx 18

20 What about that CBC? Can a CRP help then? 19

21 And the Blood Culture? Case # 4 G3P0 at 41 weeks, spontaneous labour GBS negative ARM at 7 cm pea soup meconium, followed by complicated variable decels (deep and long), improved with repositioning Baby boy heavy meconium staining Spont cry, mouth and nose suctioned for copious meconium Grunty, poor resp effort, poor tone Suctioned below cords x 3 Sats 88%, RR 20, HR 128, PPV x 60 seconds significant improvement 20

22 Case #4 Babe stable by 10 minutes of age, left with Mom and close nursing supervision 40 minutes of age grunty and flaring but improving, RR40, 02 sat 93% on RA, HR 175 Attempt to BF desat to 70% Moved to isolette, 28% O2, Sats now 95%, T36.4, HR 166, BP 54/26 HS normal, femoral pulses equal, chest bilat crackles CBC, CXR and cultures ordered 21

23 Case Conclusion WBC 24.4, neuts 10.2, lymph 6.8 Decision to transfer Increased O2 need, intubated by team prior to transport Antibiotics given Cultures ultimately negative Required respiratory support (CPAP) 2 days What Meconium is your diagnosis? Aspiration Syndrome 22

24 Effects of meconium Occlusion Chemical irritation and inflammation Infection Surfactant PPHN Changing approach to meconium 23

25 Questions? Comments? 24