Presented By : Kamlah Olaimat 18\7\2010
Transient Tachpnea of the Definition:- newborn (TTN) TTN is a benign disease of near term or term infant who display respiratory distress shortly after delivery. Occur when the infant fails to clear his\her airway of lung fluid or mucus, or has excess fluid in the lung due to aspiration.
Risk factors Cesarean section Macrosomia Prolonged labor Male sex Excessive maternal sedation
Clinical presentation:- Tachpnea > 80 b\m Grunting Nasal flaring Rib retraction Cyanosis An important marker of TTN is the spontaneous improvement of the neonate.
Laboratory investigations Blood Gases Complete blood count ( CBC) Radiological studies :- Chest x-ray (perihilar streaking) Mild cardiomegaly Fluid in pleural space
Management of TTN General:- Oxygenation Fluid restriction Feeding at Tachpnea improves Confirm the diagnosis by excluding other causes of Tachpnea ( pneumonia )
Out come and prognosis :- Self limiting disease, no risk for further pulmonary dysfunction, respiratory symptoms improve as intrapulmonary fluid is mobilized by diuresis
Meconium aspiration syndrome Definition :- (MAS) Its caused by meconium aspiration by the fetus in utro or by the newborn during labor and delivery. The aspirated meconium can cause airway obstruction and an intense inflammatory reaction
Meconium aspiration syndrome (MAS) MAS is often a sign that the neonate has suffered asphyxia before or during birth Mortality rate as high as 50% Survival may suffer long term sequence include neurological damage
Risk factors Post term pregnancy Maternal hypertension Abnormal fetal heart rate Pre-eclampsia Maternal diabetes mellitus Small for gestation age Maternal respiratory disease
Clinical presentation Meconium staining of amniotic fluid before birth Meconium staining of amniotic fluid after birth Airway obstruction Respiratory distress leading to an increased anteropostereior diameter of the chest Meconium staining of amniotic fluid before birth
Laboratory investigation Blood gas analysis Radiological studies :- Chest x ray patchy infiltrates, coarse streaking of both lung fields Increased anteropostereior diameters Flattening of diaphragm
Management 1. Prenatal management :- - Identification of high risk pregnancy - Monitoring of fetal heart rate during labor 2. Delivery room management :- - Obstetric :- suctioning of oropharenx before delivery of shoulder - pediatric:- start resuscitation by medication
Management 3. Neonate unit care :- - General Emptying of stomach content to avoid further aspiration Correction of metabolic abnormalities Monitor organ had damage( heart, brain)
Management 3. Neonate unit care :- - Respiratory management Frequent suctioning Chest physiotherapy Antibiotic coverage ( ampicilline, gentamicin ) Oxygenation ( high saturation > 90 %) Mechanical ventilation Surfactant may be required
Management 3. Neonate unit care :- - Cardiovascular management :- Correct systemic hypotension Correct myocardial dysfunctional Treat pulmonary hypertension Maintain a PACO2 level <40 mmhg Maintain O2 saturation > 95%
apnea Definition :- Pathological apnea is a prolonged respiratory pause ( stop breathing ) for >= second,associated with bradycardia or color change ( cyanosis ). The respiratory pause maybe :- 1. Central with no respiratory effort, 2. obstructive usually to upper way obstruction 3. Mixed Note :short (<10 second ) episodes of central apnea ( stop breathing ) can be normal especially in premature babies.
Risk factors Hypothermia Hypovolemia Anemia Infection Cardiac disease Lung disease Neurological disorder Air way obstruction
Apnea Clinical presentation Apnea present as the cessation of respiration accompanied by bradycardia and \ or cyanosis for more than 20 seconds. Investigation : CBC, ABGs, serum glucose, electrolyte and calcium, Chest x-ray, ct for infant, signs of neurological involvement
Nursing role Monitoring : RR, HR, until free of apnea and bradycardia for one week. Prevent hypoxemic episode by providing a neutral thermal environment and support oxygenation status Set alarm for apnea if available ( apnea monitor) Observe for convulsions Mechanical ventilation if needed Give medication ( aminophylline ) as order
Air leak syndrome Definition : (pneumomed, pneumothorax, pulmonary, interstitial emphysema ) a disease with same underlying path physiology. Over distention of alveolar sacs or terminal airways lead to the disruption of airway integrity, resulting in the dissection of air into surrounding spaces.
Air leak syndrome Risk factors :- 1. Following vigorous resuscitation at birth 2. Meconium aspiration 3. Surfactant therapy 4. Ventilator support Clinical presentation :- Respiration distress and sudden deterioration in vital signs
Air leak syndrome Investigation :- o Arterial blood gases o Chest x- ray with lateral films Nursing role :- o Depend in cause o Monitor V\S o Usual care of infant receiving oxygen therapy o Close attention to infant in ventilator support o Monitor of ABGs o Give medication as order
pneumonia Definition:- Congenital pneumonia is an aspiration of bacteria in amniotic fluid, or acquiring the bacterial infection systemically prior to delivery (fetal distress ) at delivery Risk factors :- Premature Prolonged rupture of membrane>18 h before delivery Maternal infection Intrapartum maternal fever
Clinical presentation Temperature instability Lethargy Irritability Metabolic acidosis Hypo or hyperglycemia Apnea Cyanosis Respiratory distress Increase RR, grunting, retraction
investigation CBC BGs Blood cultures Tracheal aspiration Chest x ray Nursing role:- Monitor infant for any respiratory distress Close observation of vital signs Support respiration Give antibiotic as prescribed
THE HISTORY 1774 J. Priestly produced O 2 Dephlogisticated Air 1776 A. L. Lavoisier termed this vital air OXYGEN Late 1800 Bonnaire gave O 2 to preterm Blue Baby with success. 1907 A. Lane invented NASAL CATHETER 1919 L. Hill developed O 2 TENT. 1920 - O 2 therapy became routine for SICK NEW BORN
ASSESSMENT OF NEED OF O 2 THERAPY DURING AND JUST AFTER RESUSCITATION IN NEWBORN Only clinical Cyanosis Heart rate i.e bradycardia Resp effort Muscle tone Response to stimuli LATER PART OF THE NEW BORN LIFE Clinical Cyanosis Heart rate Pattern of breathing i.e. apnea/periodic breathing Monitoring - ABG PaO 2 < 50 mm.hg. Pulse oximetry - SpO 2 < 85 %
O 2 THERAPY IN NEONATE VS OLDER CHILDREN In Neonate O 2 reserve less O 2 requirement / kg. higher. large change in Pa O 2 Unrestricted O 2 therapy produce pulmonary / extra pulmonary hazards. MORE CAUTION REQUIRED IN NEONATAL O 2 THERAPY
MODES OF OXYGEN DELIVERY SOURCE O 2 cylinder O 2 concentrator - max 5 8 lit / min. of 90 92% O 2 Pipeline - Cheapest
MODES OF OXYGEN DELIVERY DELIVERY DEVICE LOW FLOW DEVICE Nasal Canula Max flow 2 3 lts./min. in new born. Nasopharyngeal Catheter Insert a length Alae nasai to Tragus Check for blockage with mucus plug Better if changed 24 hrly. Not more than 3 lit. / min. O 2 in new born
MODES OF OXYGEN DELIVERY HIGH FLOW DEVICE Mask mask with 5 lit / min O 2 can give 40 60% O 2 require a minimum O 2 flow to prevent rebreathing of CO 2 Enclosure system O 2 hood - > 7 lit./ min of 100% O 2 required initially to wash out CO 2 O 2 given < 4 lit. min. can be managed without humidifier.
WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY A. Clinical Monitoring: No cyanosis No apnea or periodic breathing Stable heart rate B. Non Invasive Monitoring: Pulse Oximetry Alarm set 85 96% SpO 2 Target range 88 95% SpO 2 Except PPHN SpO 2 >97% Unable to detect hyperoxia reliably Plenty of other limitation
WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY.. Trans centaneous O 2 monitoring Not accurate in term babies with thick skin Not used in prematures < 27 wks. Heat related problems skin heated to 44 o c C. Invasive monitoring ABG Gold standard 8 12 hourly may be required PaO 2 50 80 mm Hg. PaO 2 100 120 mm Hg acceptable in PPHN
MARKERS OF O2 MONITORING PiO 2 = (760 47) x 0.21 = 150 mmhg. FiO 2 = 0.21 PAO 2 = 100 mmhg PaO 2 = 90 mmhg SaO 2 O 2 saturation derived from arterialised cap. Blood. SpO 2 O 2 saturation by puls. ox THUMB RULE: FiO 2 x 5 = PaO 2
UNWANTED EFFECTS OF O 2 THERAPY IMMEDIATE Some neonate on hypoxic drive going to apnea. LATE - ROP Persistent PaO 2 - main contributary factor Free radical damage due to O 2 therapy. HOME O 2 DEPENDANCE AND REHOSPITALISATION NOSOCOMIAL INFECTION
EFFECTS OF NOT ENOUGH OXYGEN Pulm Vasc. Resistance Airway Resistance? Limitation in Growth? Sleep Disorder
New born Resus KEY POINTS If O 2 not available Room Air may be enough in 90% cases. To save life Short term PaO 2 acceptable. Beyond EMERGENCY period Strict monitoring of PaO 2 necessary. To Detect ROP Eye exam from 4-6 weeks & 2 4 weekly in<32 wk. < 1250 gm. Max O 2 flow through nasal catheter - do not exceed 3 lit./ min. O 2 hood initial flow of 7 lit./ min. required.
KEY POINTS. Keep PaO 2 50 80 mm. Hg., SpO 2 88-95 % O 2 is a DRUG only should be used Documented hypoxia Resp. Distress Cynosis When prescribing O 2 specify - Dose Device Duration Monitoring Take care of devices judiciously to prevent NOS. INFECTION
Birth 30sec Term gestation Amniotic fluid clear Breathing or crying Good muscles tone yes Routine care. Provide warmth Clear airway Dry Assess Provide warmth Position, Clear airway Dry, stimulate, reposition breathing, HR>100 &pink Evaluate respiration, heart rate and color Observational care breathing, HR>100,cyanotic Give supplementary oxygen pink
Evaluate respiration, heart rate and color Apneic or HR<100 30sec Give O2 persistent cyanosis HR<60 Provide positive pressure ventilation HR>60 effective ventilation HR>100 &pink Post resuscitation care t HR<60 Provide positive pressure ventilation Chest compression Administer epinephrine or valume 30sec Endotracheal intubations
Nasal continuous positive airway pressure (CPAP) (CPAP) is the application of positive pressure to the airway of spontaneously breathing clients throughout respiratory cycles Neonates are nose breathers which easily facilitate the application of nasal (CPAP) The device provides a heated and humidified continuous gas source
Nasal continuous positive airway pressure (CPAP) Mechanical ventilator designed for neonates. This pressure result in an increase in functional residual capacity, and improvement in static lung compliance and decrease airway resistance in infant with unstable lung mechanics Its reduce O2 requirement and prevent collapse and obstruction of lung
Weaning from CPAP If infant breath comfortably on CPAP, it should to give a trail off from CPAP During weaning the infant should assess :- - Tachpnea - Retraction - Apnea - O2 saturation If any of these signs are observed the infant should restart on CPAP immediately at least for one day before another trail