Respiratory Diseases of the Newborn

Beth Mogensen, RRT-NPS

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OBJECTIVES
1. Provide overview of respiratory system of the newborn 2. Identify non-respiratory causes of distress in the newborn 3. Review respiratory diseases/ anomalies of the newborn

Early Development

Fetal Lung Development

Week 4: the laryngotracheal groove forms on the floor foregut Week 5: the left and right lung buds push into the pericardioperitoneal canals (primordial of pleural cavity) Week 6: the descent of heart and lungs into the thorax. Pleuroperitoneal foramen closes
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Fetal Lung Development

Week 7: the lung buds divide into secondary and tertiary bronchi Week 24: the bronchi divide 14 more times and the respiratory bronchioles develop By birth, there will be an additional 7 divisions of bronchi
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Fetal Lung Histology

STAGE 1: Pseudoglandular Period (517 weeks) all the major elements of the lungs have formed except for those involved with gas exchange STAGE 2: Canalicular Period (16-25 weeks) bronchi and terminal bronchioles increase in lumen size and the lungs become vascularized
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Fetal Lung Histology

STAGE 3: Terminal Sac Period (24 weeks to birth) more terminal sacs develop and interface with capillaries lined with Type I alveolar cells or pneumocytes --Also have Type II pneumocytes which secrete surfactant thereby decreasing the surface tension forces and aids in expansion of the terminal sacs
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STAGE 4: Alveolar Period (late fetal period to 8 years) 95% of mature alveoli develop after birth. A newborn has only 1/6 to 1/8 of the adult number of alveoli and lungs appear denser on x-ray
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Respiratory Distress at Birth

Rule of 6: non respiratory causes of distress S&S
Hypothermia/ Hyperthermia Hypovolemia Hyoptension Hypoglycemia Anemia Polycythemia transfusion

Diagnosis
- check temperature - obtain prenatal history - measure blood pressure - blood glucose measurement - measure hematocrit - measure hematocrit

Management
- heat or cool as necessary - gingerly give volume - give volume and/or vasopressor - give glucose - transfuse with PRBC - partial exchange (lower Hct)
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Respiratory Distress in the Newborn

Transient Tachypnea of the Newborn (TTN) Surfactant Deficiency (HMD,RDS) Meconium Aspiration Syndrome (MAS) Pneumonia/ Sepsis Pneumothorax or other air leaks

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Respiratory Distress in the Newborn

Respiratory Causes Congenital Abnormalities of the Lung/Thorax

Congenital Heart Disease (CHD) Congenital Diaphragmatic Hernia (CDH) Congenital Cystic Adenomatiod Malformation (CCAM) Tracheal Abnormalities Esophageal Atresia Pulmonary Hypoplasia

Persistent Pulmonary Hypertension of the Newborn (PPHN)

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What do you need to know to Figure out the Cause

Maternal History

Any risk factors

Gestational age of Infant Amniotic fluid (color/odor/volume) Intrapartum history Clinical Presentation/ Assessment X-Rays Lab Evaluations
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Clinical Presentation
Respiratory Assessment

Respiratory rate Quality

Shallow Deep

Nasal Flaring Grunting Retractions Breath Sounds

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Clinical Presentation
Colorpink, dusky, pale, mottled

Central Peripherally

Heart rate Pulses

Distal vs Central Capillary Refill Time (CRT) Blood Pressure

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Perfusion

Clinical Presentation
Physical characteristics

Flat nasal bridge, Simian crease, recessed chin, low set ears Extra digits, gastroschesis, imperforate anus Hyoptonia vs Hypertonia Choanal Atresia, Osteogenesis Imperfecta Scaphoid abdomen, heart tones on Right side
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Deformities

Muscular

Skeleton

Other

X-Ray
Structures

Ribs Vertebra Liver Stomach/ intestine Lungs Heart Trachea Esophagus

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X-Ray
Lungs

Lung Volume Expansion Densities

Fluid/ collapse (atelectasis)>>white Free Air>>dark Mass

Heart shape and size

Boot shaped Egg or Oval shaped

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Lab Values
CBC with diff ABG/CBG/VBG Blood Cultures CRP Electrolytes Type and Cross PKU
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Respiratory Distress
Determining Differential Diagnosis

What you need to know

History Presentation/ clinical assessment X-rays Lab values
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Transient Tachypnea of the Newborn (TTN)

Most common diagnosis of respiratory distress in the newborn Remember often term infants may be a little early Ineffective clearance of amniotic fluid from lungs with delivery Most often seen at birth or shortly after
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Transient Tachypnea of the Newborn

History

Common with C-Section delivery Maternal analgesia Maternal anesthesia during labor Maternal fluid administration Maternal asthma, diabetes, bleeding Perinatal asphyxia Prolapsed cord
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TTN presents:
Respiratory Assessment

Tachypnea 60-150 bpm Nasal flaring Grunting Retracting Fine Rales Cyanotic

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TTN
X-Ray findings

Prominent Perihilar streaking Hyperinflation Fluid in fissure CBC within normal limits ABG/CBG showing mild to moderate hypercapnia, hypoxemia with a respiratory acidosis
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Labs

TTN

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TTN
Have delayed reabsorption of fetal lung fluid which eventually will clear over several hours to days Treatment: Treat signs and symptoms. Support infant, may need O2, is probably too tachypneic to PO feed so start IV fluids Be patient!!
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Surfactant Deficiency (RDS, HMD)

One of the most common problems associated with a premature infant Decreased surfactant production in lungs of pre-term infants With decreased surfactant production, alveoli collapse, become atelectatic, yielding poor lung function and increasing signs of respiratory distress
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RDS
History

Gestational age < 38 weeks Prenatal care

Diabetes (controlled vs uncontrolled) Perinatal infection

Problems during pregnancy/delivery

Asphyxia Stress to fetus Hypothyroidism

Multiple births
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RDS presents:
Respiratory Assessment

Tachypnea > 60 bpm Nasal flaring Grunting Retracting Apnea/ irregular respiratory pattern Rales (crackles) Diminished breath sounds Cyanosis
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RDS
X-Ray

Loss of volume Reticulogranular pattern or ground glass appearance Air bronchograms Bell shaped thorax Air leak, PIE Loss of heart borders/ atelectasis White out
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RDS

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RDS

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RDS
Laboratory Results

ABG/CBG
Hypoxia Hypercarbia Acidosis

CBC with Differential/ HHP

Used to rule out other causes of respiratory distress

Always check electrolytes, especially glucose, potassium and calcium

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Treatment for RDS

Post-Exogenous Surfactant Therapy

Many on the market

Prophylactic Treatment

Administered in the delivery room Given after a definitive diagnosis of RDS

Rescue Treatment

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MECONIUM ASPIRATION SYNDROME

Most often found in post date infants > 40 weeks, but may occur in infants >34 weeks Infant passes meconium due to varying degrees of asphyxia in utero Obstruction of large and small airways with aspirated meconium Aspiration may occur:

in utero intrapartum postpartum period

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MAS
History Prenatal Care
Maternal diabetes Pregnancy Induced Hypertension (PIH) Pre-eclampsia

Problems during pregnancy/delivery Color of amniotic fluid

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MAS
Respiratory Assessment

Tachypnea Nasal flaring Grunting Retracting Apnea/ irregular respiratory pattern Decreased breath sounds/ wet/ rhonchi

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MAS
Clinical Assessment

Color
Pale/gray Cyanotic Stained skin

X-Ray

Increased AP diameter Hyperinflation Atelectasis Pneumothorax

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MAS

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MAS

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Pneumonia/ Sepsis
Occurs frequently in newborns 3 types

Congenital Pneumonia Intrapartum Pneumonia Postnatal Pneumonia

Most often seen with chorioamnionitis, prematurity and meconium aspiration Get thorough history
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Causes
Prematurity Prolonged rupture of membranes Maternal temp > 38C Foul smelling amniotic fluid Nonreassuring stress test Fetal tachycardia Meconium Maternal hx of STDs
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Respiratory Assessment
Tachypnea Apnea, irregular breathing pattern Grunting Retractions Nasal flaring Colorful secretions Rales, rhonchi Cyanosis
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Clinical Assessment
Gray, pale color Lethargy Temperature instability Skin rash-pettechia Tachycardia Glucose issues Hypoperfusion Oliguria
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X-Ray
Patchy infiltrates (aspiration) Bilateral diffuse granular pattern Streaky Loss of volume Densities

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Pneumonia/ Sepsis

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Pneumothorax and other Air Leaks

History

What happened in the delivery room? Was positive pressure given? Large amount of negative pressure generated with the 1st breath?

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Pneumothorax/ Air Leaks

Respiratory Assessment

Tachypnea Nasal flaring Grunting Retractions BS absent or decreased

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Pneumothorax/ Air Leak

Clinical Assessment

Cyanotic Pale, gray Heart Rate

Tachycardia Bradycardia PEA

Pulses
Normal Poor absent
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Pneumothorax/ Air Leak

Perfusion

Capillary Refill (CRT) Blood Pressure if monitoring Arterial Line, narrowing pulse pressure Asymmetry of chest

Deformities of Chest Wall

CHEST X-Ray speaks for itself!!

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Pneumothorax

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Pneumothorax
Right lateral decubitus view of pneumothorax

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Pneumopericardium

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Congenital Abnormalities of the Lung and Thorax

Congenital Heart Disease (CHD) Congenital Diaphragmatic Hernia (CDH) Congenital Cystic Adenomatiod Malformation Tracheal Abnormalities Esophageal Atresia Pulmonary Hypoplasia
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Congenital Heart Disease

Defect present at birth- often picked up on early ultrasound Increased risks:

Parents have CHD? Siblings have CHD? Maternal diabetes Exposure to German measles, toxoplasmosis, or if mother HIV+ Alcohol use during pregnancy Cocaine use during pregnancy
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CHD
Two types of CHD

Acyanotic-blood returning to Right side of heart passes thru lungsusually defect in heart wall, or obstructed valve or artery
Pink baby Sats within normal limits

Cyanotic-have a mixing of oxygenated blood with venous bloodshunting ductus, PFO, ASD, VSD
Blue baby Low sats
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CHD
Respiratory Assessment

Respirations
Normal Tachypnea

Saturations depend upon defect.

Acyanotic lesions sats are more normal Cyanotic lesions acceptable sats are low ~ 70% is acceptable; ideally on 21% FiO2

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CHD
Clinical Assessment

HR
Slow, fast, variable murmur

BP
Check in all 4 extremities

Pulses in all extremities CRT in all 4 extremities Color

Acyanotic -pink Cyanotic-blue
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CHD
Labs and Tests

ABGsdependent upon defect Lactic Acid Heart shape and size Pulmonary blood flow Best test to aid in diagnosis

Chest X-Ray

Echocardiogram

Cardiac Cath for possible intervention

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Congenital Diaphragmatic Hernia Congenital Cystic Adenomatoid Malformation

Ideally diagnosed in utero Develops during pseudoglandular stage, but CCAM can form up to 35 weeks Normally compromised at delivery requiring immediate intubation CDH more commonly found on Left side
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CDH

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Congenital Diaphragmatic Hernia

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CDH/ CCAM
Respiratory Assessment

Tachypneic Retractions Nasal flaring Grunting Breath Sounds

Decreased on the affected side May hear bowel sounds in chest with CDH

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CDH
Clinical Assessment Clin

Scaphoid Abdomen- classic sign Color

Cyanotic

Heart Rate
Fast, slow or normal

Perfusion
Depends upon the severity

X-RayBest diagnostic tool

Bowel, stomach, liver in chest

ABGs
Acidosis, hypoxemia and hypercarbia

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Left Congenital Diaphragmatic Hernia

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CCAM

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Persistent Pulmonary Hypertension (PPHN)

Pulmonary hypertension resulting in severe hypoxemia secondary to R>L shunt thru PFO and/or PDA Usually affecting term or near-term infants May be extremely difficult to manage If not responding to available therapy consider transporting to an ECMO center

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Fetal Circulation

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PPHN
History

Meconium? Asphyxia? Stress? Pneumonia/ Sepsis Primary Pulmonary Hypertension

Dysfunction in pulmonary endothelial vasodilating mechanism

CDH/ CCAM
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PPHN
Respiratory Assessment

Tachypnea Retractions Grunting Nasal flaring Breath Sounds

Depend on cause

Pre and Post-ductal saturations to monitor shunting- best indicator if ECHO not available
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PPHN
Clinical Assessment

Color
Blue/ gray

X-Ray
Depends on cause Usually with decreased blood flow, minimal lung markings

Lab
Dependent on cause Many present with abnormal Platelets/ PT/ Fibrinogen

ABG
Respiratory and metabolic acidosis
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Airway Abnormalities
Occur less frequently than pulmonary parenchymal diseases Presentation is often quite dramatic with significant respiratory distress Stridor may be an important key to diagnosing the abnormality

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Airway Abnormalities
Supraglottic

Nose-Choanal Atresia Craniofacial-Pierre Robin Macroglossia-Downs Tumors-Hemangioma Vocal Cord Paralysis Tumors and Cysts
Hemangioma, Cystic Hygroma, Teratoma Tracheal Esophageal Fistula/ Atresia Webs Trauma
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Glottic

Cystic Hygroma

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Tracheal Esophageal Fistula/ Esophageal Atresia

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Airway Abnormalities
Subglottic

Stenosiscongenital or acquired Webs Atresia Tumors Tracheomalacia Stenosis Cyst Atresia Vascular Ring Mediastinal Mass

Trachea

Extrinsic

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History/ Presentation P
Circumstances surrounding onset of symptoms Speed of progression of symptoms Position of comfort and how change affects symptoms Presence of feeding abnormalities Nature of cry Previous infection History of previous intubation or trauma Presence of associated cardiopulmonary abnormalities
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Airway Abnormalities
Respiratory Assessment

Tachypnea Retractions Work of Breathing Stridor is the MOST important physical sign created by airway turbulence and indicates obstruction
Inspiratoryimplies supraglottic or glottic Expiratoryimplies intrathoracic airway Mixedimplies subglottic

Breath Sounds

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Airway Abnormalities
Clinical Assessment

Heart Rate
Tachycardia Bradycardia when obstructed

Color
Cyanotic

Lethargy Irritability Feeding Difficulty

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Airway Abnormalities
Bronchoscopy used for evaluating abnormality Tools for Treatment:

Dependent upon Diagnosis

Prone patient Oral Airway N-P Tube Steroids Meds for reflux OG, NG, NJ or G-Tube feedings
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Airway Abnormalities

Possible Surgical Interventions

Cricoid Split Tracheostomy Excise Hygroma Place stents

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Scenario
Baby Boy S

No prenatal care. Uneventful delivery vaginal delivery. APGARS 8 and 9 at 1 and 5 minutes, respectively. Infant taken to newborn nursery and given routine care. Eyes and thighs done, bath completed. VSS. Looking good and smelling nice. Infant went out to mother to breast feed and you have been summoned to check on baby. 84

Scenario
Upon arriving in the mothers room, you begin assessing infant. Babys color is rather blue. TachypneicRR 70s to 80s Bulb sx and get a little bit of colostrum. Retractions and Grunting present Babys temp is 35.9 What will you do?
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Scenario
1. Take infant back to nursery for observation and monitoring. 2. Place infant on O2 if sat < 90-92 depending upon your policy. 3. Place infant under radiant warmer. 4. Obtain a full set of vital signs.
1. 2. 3. 4.

RR 80sRetracting, nasal flaring, grunting HR 180with murmur BP 42/30 with MAP 36 SaO2 on 100% blow by 88%
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Scenario

5. 6. 7.

Colordusky CRT 4 seconds Poor peripheral pulses

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Scenario
CALL MD if you havent already Continually reassess infant. With your next assessment: VS have not changed much. Infant continues to grunt, retract and have nasal flaring. Sats 86.

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Scenario
When auscultating, you notice that the heart tones are now more midline than on left. You also notice that when auscultating the left lung that you thought you heard gas bubbles What do you want to do? What do you suspect this infant has?

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Scenario
STAT CXR Intubate infant and ventilate Place large bore Anderson/ Replogle tube to continuous low suction Give fluid bolus (and more if needed) Probably start pressors Do what needs to be done to stabilize this infant and call for transport
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Take Away
Dont be afraid to think out of the box We continually see funky things Do no harm this is someones baby

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