Review of Neonatal Respiratory Problems

Review of Neonatal Respiratory Problems

Respiratory Distress Occurs in about 7% of infants Clinical presentation includes: Apnea Cyanosis Grunting Inspiratory stridor Nasal flaring Poor feeding Tachypnea (RR > 60) Retractions (intercostal, subcostal, supracostal)

Clinical Scenario You are called to the nursery to evaluate a term infant born 1 hour ago via repeat C section after a pregnancy complicated by maternal asthma and gestational diabetes who is having trouble breathing. You arrive to find an LGA male infant who is breathing at 80 per minute with subcostal and intercostal retractions. Pulse ox is 82% on room air. Breath sounds are coarse bilaterally and cardiac exam is normal.

Clinical Scenario After giving supplemental oxygen the child s O2 sat improves to 92% but he is still tachypneic. CBC is normal.

Your Diagnosis Transient Tachypnea of the Newborn

Transient Tachypnea of the Newborn Most common cause of term neonatal respiratory distress (>40% of cases) Residual pulmonary fluid remains in fetal lung tissue after delivery Risk factors Maternal asthma Male sex Macrosomia Gestational diabetes C/S

Transient Tachypnea of the Newborn Benign, self-limited condition Diagnosis of exclusion Presents with tachypnea immediately after birth or within two hours with other signs of respiratory distress Symptoms can last from a few hours (>90% resolve in 2 hours) to two days CXR shows diffuse parenchymal infiltrates, a wet silhouette around the heart, or intralobar fluid

Transient Tachypnea of the Newborn Treatment Maintain temperature O2 via hood or NC Rarely requires > 40% FiO2 CPAP for more severe cases Nutrition OG tube or IVF if remain tachypneic or increased work of breathing If persists > 24 hours or initial CBC abnormal, consider blood culture and empiric antibiotics Ampicillin and gentamicin

Clinical Scenario You are paged to respond for the infant just born to a gestational diabetic mother with little to no prenatal care who underwent an emergent C/S for HELLP syndrome at 30 weeks after presenting to triage with a severe headache, RUQ pain, hypertension, and edema. The child is delivered to the warmer tachypneic, cyanotic, and grunting.

Clinical Scenario You correctly start chest compressions while the RT steals your intubation. After 2 minutes of chest compressions and PPV via ET tube, the pulse is now 120 and the child is no longer cyanotic. You transfer the patient to the NICU and an umbilical artery catheter is placed. Cardiac exam is normal. A chest x-ray displays the following:

Your diagnosis Respiratory Distress Syndrome

Respiratory Distress Syndrome Most common cause of respiratory distress in premature infants Most common in infants < 28 weeks 1/3 of infants between 28-34 weeks < 5% of infants > 34 weeks More common in boys and in infants whose mothers have diabetes

Respiratory Distress Syndrome Immature type II alveolar cells produce less surfactant Increases alveolar surface tension Decreases compliance Resultant atelectasis causes Pulmonary vascular constriction Hypoperfusion Lung tissue ischemia Hyaline membranes form through Sloughed epithelium Protein Edema

Respiratory Distress Syndrome Persistent respiratory distress syndrome leads to bronchopulmonary dysplasia Associated with recurrent wheezing Higher risk of hospital admission for asthma Diagnosis suspected when Respiratory distress occurs in a premature infant immediately after birth CXR shows homogenous opaque ground glass infiltrates and air bronchograms

Respiratory Distress Syndrome General treatment measures Surfactant CPAP is preferred over mechanical ventilation if active and breathing spontaneously Less incidence of air leaks and bronchopulmonary dysplasia Steroids generally not indicated due to higher risk of abnormal neurodevelomental outcomes

Clinical Scenario You are called to attend to the newborn during delivery for a primigravida induced at 41 3/7. Thick particulate meconium was noted after AROM earlier in labor. An amnioinfusion was not started. At delivery the child is DeLee suctioned on the perineum (what do guidelines recommend about this?) The child is delivered and is obviously meconium stained, hypotonic with depressed respirations and cyanotic.

Clinical Scenario You perform direct laryngoscopy and suction meconium from the hypopharynx and beyond the vocal cords and then intubate the child. You obtain the following chest x-ray after transferring the patient to the NICU

Your Diagnosis Meconium Aspiration Syndrome

Meconium Aspiration Syndrome Occurs in about 10-15% of all deliveries involving meconium Postdate pregnancy SGA infants Meconium is sterile but locally irritative, obstructive, and a medium for bacterial culture Causes significant respiratory distress and hypoxia immediately after delivery because aspiration takes place in utero

Meconium Aspiration Syndrome CXR shows patchy atelectasis or consolidation Complications include air leaks (pneumothorax) and persistent pulmonary hypertension Amnioinfusion has typically not proven to be effective except in cases of concurrent variable decelerations Intrapartum suctioning is not recommended Empiric antibioitcs until culture results negative Supportive therapy with adequate oxygenation, ventilation, perfusion

Case Scenario A 35 yo multiparous female at 39 2/7 presents to triage and delivers a viable male infant precipitously. You notice the mother has a documented temperature of 101 on admission and her uterus is tender to palpation. She admits that her water broke over 18 hours ago and she has been laboring at home. Upon review of her prenatal record you see that she tested positive for GBS at 38 weeks. You treat the mother presumptively for endometritis. The infant initially appears well but at 12 hours has developed respiratory distress and a fever up to 101.2.

Clinical Scenario CBC shows leukocytosis with a left shift, UA and LP are both negative, blood cultures are drawn and CXR reveals the following

Your Diagnosis Congenital Pneumonia (likely GBS) Your antibiotics of choice for treatment? Ampicillin and Gentamicin

Clinical Scenario You are called to see a term newborn with respiratory distress just delivered to a 28 yo primigravida with no prenatal care. Upon arriving you find the infant is tachypneic and grunting with a barrel chest and scaphoid abdomen. You resuscitate him appropriately and obtain the following chest xray

Your Diagnosis Congenital Diaphragmatic Hernia Your next step of action? Stabilization and transfer to tertiary care center for repair

Diaphragmatic Hernia 1/2000-3000 live births Several types Morgagni Bochdalek Hiatal Variable degree of pulmonary hypoplasia Presents with respiratory distress and cyanosis within a few minutes to hours after birth

Clinical Scenario You are called to the room of a mother with a newborn who is having persistent difficulty in feeding. You ask the mother to feed the child while you observe and notice the infant turn diaphoretic and cyanotic when on the bottle. When the bottle is removed and the patient cries the cyanosis resolves. The child is tachycardic and you have a hard time telling if there is a murmur or not

Your Diagnosis Choanal atresia

Choanal Atresia Obstruction of one or more of the nasal passages Complete obstruction associated with respiratory distress with nasal breathing that is relieved with crying and mouth breathing Insert an oral airway for bilateral neonatal choanal atresia with referral for surgical repair

Key Points Remember your NRP algorithms CXR, ABG, CBC and blood culture at a minimum Amp and Gent for delayed transitioning, progressive respiratory distress or sepsis risk factors