Respiratory distress in the newborn
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- David Cain
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1 Respiratory distress in the newborn Respiratory distress is encountered frequently in newborns. respiratory distress in the newborn may be a potentially lifethreatening condition,. The key to successful management includes a complete maternal and newborn history, perform a thorough physical examination, recognize the common respiratory disorders, differentiate among various diagnostic entities, and identify those that are life-threatening. Respiratory distress in the newborn is characterized by one or more of the following: nasal flaring, chest retractions, tachypnea, grunting An infant who has an advanced degree of respiratory distress may exhibit additional signs, cyanosis, gasping, choking, apnea, stridor. Initial assessment The aim of the initial assessment of the infant in respiratory distress is to identify life-threatening conditions that require prompt support, Alarming" Signs of Life-threatening Conditions Obstructive Airway Gasping Choking Stridor Insufficient Breathing Apnea Poor respiratory effort Circulatory Collapse
2 Bradycardia Hypotension Poor perfusion Poor Oxygenation Cyanosis HISTORY Results of fetal assessment during pregnancy (triple screen, ultrasonography, biophysical profile) Fetal monitoring during labor and delivery (fetal heart rate, beat-tobeat variability, presence of decelerations) Complications at delivery (eg, birth trauma, presence of meconium, perinatal depression) Maternal and obstetric conditions associated with respiratory distress in neonates Details of the presenting respiratory symptoms A history of coughing and choking in relation to feeding A maternal history of polyhydramnios Choking after feeding History of recurrent emesis. Gradually improving symptoms Gradual deterioration Inspection Cyanosis Physical examination
3 Respiratory rate Retractions Apnea Inspiratory stridor Asymmetric chest movement A scaphoid abdomen Auscultation Symmetry and adequacy of air exchange Abnormal breath sounds Heart murmur Transillumination Differential Diagnosis Parenchymal lung diseases, Pneumonia, Surfactant deficiency, Meconium aspiration, Congenital heart diseases Neurologic disorder Seizures, asphyxia, and meningitis Metabolic causes Hypoglycemia and acidosis Hypothermia, sepsis, acidosis, polycythemia, or anemia. Airway and chest wall deformities as well as abnormalities of the diaphragm and mediastinal structures Transient Tachypnoea of Newborn TTN represents transient pulmonary edema resulting from delayed clearance of fetal lung liquid. It can occur in both term and preterm neonates. Seen in babies delivered by C-Section Clinical Presentation Grunting nasal flaring immediately after birth Chest Xray increased interstitial markings and occasionally fluid in the interlobar fissures Arterial blood gases reveal respiratory acidosis and mild-tomoderate hypoxemia
4 TTN is generally a benign, self-limited disease responds well to oxygen therapy. Mechanical ventilation seldom is needed. Full recovery is expected within 2 to 5 days. Meconium Aspiration Syndrome Meconium staining of amniotic fluid occurs in approximately 10% to 26% of all deliveries Seen almost exclusively in term and postterm deliveries. Passage of meconium in utero may represent fetal hypoxemia. Meconium can be aspirated before, during, or after delivery. Once aspirated, meconium can cause obstruction of the air passages, chemical pneumonitis with activation of several inflammatory mediators, and inactivation of lung surfactant. Presentation Varying degrees of respiratory distress A "barrel chest" Audible rales or rhonchi on auscultation The chest radiograph usually shows patchy areas of atelectasis alternating with areas of overinflation Pneumothorax is seen in 10% to 20% of infants who have MAS.
5 Hyaline Membrane disease Common condition in preterm infants. The cause is insufficient pulmonary surfactant, produced by type II pneumocytes. It reduces the surface tension inside the alveoli, preventing them from collapsing. The blood gas typically reveals hypoxemia and respiratory acidosis. Chest XRay lungs demonstrate the typical "ground glass" appearance and "air bronchograms" Prevention of HMD to continue gestation or treatment with antenatal steroids Affected infants often are managed with mechanical ventilation and endotracheal surfactant replacement therapy The use of continuous positive airway pressure is a less invasive alternative. PNEUMONIA The most common infection in neonates, Can be due to different antenatal, perinatal, or postnatal causes. Pneumonia can present with a diversity of signs in infancy, including any form of respiratory distress, lethargy, poor feeding, jaundice, or apnea. Temperature instability.
6 Chest Xray Bilateral consolidation Patchy involvement TREATMENT Treat respiratory distress with antibiotics until pneumonia is ruled out Congenital Heart Diseases Important to differentiate from pneumonia The two can co-exist Presence of murmer doesn t exclude pneumonia Meconium staining of amniotic fluid doesn t rule out CHD : Signs that generally are consistent with CHD Visibly hyperactive precordial impulse, gallop rhythm, poor capillary refill, weak pulses, decreased or delayed pulses in lower extremities, hepatomegaly, Differentiation of CHD from Pulmonary diseases CHD History previous sibling Prenatal Echo Findings Cyanosis Gallop sound Split second sound Large liver Mild respiratory distress
7 Chest Radiograph Increased heart size Decreased pulmonary vascularity Dec.PO2 N-Dec PCO2 Arterial Blood Gases Dec.PO2 Inc.PCO2 PO2<150 Hyperoxia test Echocardiography Abnormal heart and vessels Pulmonary diseases Maternal fever Meconium-staining Preterm delivery Severe retraction Single second heart Fever Cyanosis Chest Radiograph Normal heart size Abnormal parenchyma Dec.PO2 Inc.PCO2 Arterial Blood Gases
8 Hyperoxia test PO2>150 Echocardiography Normal heart and vessels Thank you
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