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Neonatal Respiratory Issues, Unfinished - Coggle Diagram
Neonatal Respiratory Issues
Respiratory Distress
Epidemiology
Common in newborns - 7% of term babies
Very common complication for preterm infants
Can easily escalate to repiratory failurea and cariopulmonary arrest
Signs of Respiratory Distress
Signs
Intercostal / subcostal recessions
Tracheal tug
Nasal Flaring
Grunting
Stridor
Pallor / cyanosis
Tachypnoea
Vitals
Hypercarbia
Hypoxaemia
Acidosis
Management
Initial resus and stabilisation
Detailed hx and exam
Imaging and lab investigations
DDx
Common
Transient tachypnoea of the newborn
Sepsis
Respiratory distress syndrome
Presistent pulmonary hypertension of the newborn
MEconium aspiration syndrome
Less Comon
• Haematological Disorders
• Pulmonary Hypoplasia
• Congenital Heart Disease
• Congenital Diaphragmatic Hernia
• Bilateral Choanal Atresia
• Pneumonia
• Pneumothorax
• Metabolic Disorders
Management
Oxygen
• Nasal cannula
• Incubator or head box oxygen
• Free Flow oxygen
Non-invasive VEntilation
• Humidified High Flow Nasal Canula
• Continuous positive pressure ventilation
• Patient Assist CPAP/BiPAP
Invasive Ventilation
Endotracheal tube ventilation
Normal Lung Development
Embryonic Stage 3-4 wks
Lungs buds begin to form
Trachea / bronchi differentiate
Pseudoglandular stage 7-17 wks
Formation of conducting airways and terminal bronchioles
Immature neural network
Appearance of type II pneumocytes
Canalicular stage 17-27 wks
Increased vacularisationo
Appreanace of type I penu
Saccular Stage 27-36
Surfactant production
Alveolar Stage 36 weeks
Aetiology Investigation
• Term or preterm?
• Antenatal steroids given?
• Abnormal scans? Renal or pulmonary anomalies?
• PROM or PPROM?
• Oligohydramnios/polyhydramnios?
• Maternal diabetes?
• Type of delivery?
• Vigorous or flat at delivery?
• Meconium at delivery?
• Risk factors for sepsis?
Transient Tachypnoea of the Newborn
Epi
Most common cause of resp distress in
term
infant
Risks
Elective CS
Precipitous delivery
Maternal diabetes
Pathology
Delayed reabsorption of lung fluid
Clinical features
Grunting
Tachypnoea
Increase work of breathing (WOB)
Investigation
CXR
Flat diaphragm and fluid in fissues
Diagnosis
Diagnosis of exlusion
Prognosis
Benign
Self-limiting
Usually resolves within 3-5 days
Management
Observation
Monitor O2, RR and WOB
Blood gas
Consider
IV fluis / NG is tachypnoeic
Supplemental O2/CPAP if required
Consider septic work up and IV abx if septic risk factors
Review
CXR
Assess other pathology
Respiratory Distress Syndrome RDS
Epi
Condition of premature infacnts
Higher incidence the more preterm
Pathology
Deficiency in surfactant
Alveolar collapse (atelectasis) and inadequate gas exchange
Clinical Features
Increased work of breathing
Tachypnoae
Hypoxia
Investigations
CXR
Diffuse fine granular infiltrates (ground glass)
Air bronchograms
Management
Mild-moderate
CPAP
Severe
Endogenous surfactant with NIV
Continued ventilation
Consider IV abx if not clinically improving / rf for sepsis
Prognosis
Typically improves at DOL3-4
Natural diuresis and endogenous surfactant production established
Risk of developing CLD/BPD
Prevention
Antenatal steroids - maturation of foetal lungs
Sufactant
Fx
Lowers alveolar surface tension and prevents collapse
Prevents collapse
Immune function within the lung
RF for Surfactant Deficiency
Prematurity
Infants of diabetic mothers
Endogenous surfactant
Produced by Type 2 pneumocytes from 24 wks gestation
Phospholipids and proteins
Exogenous surfactatn
Admin endotracheally to preterm infants with RDS
Consiferably reduces respiratory complications
Continuous Positive Airway Pressure
Fx
Prevents alveolar collapse
...
Bronchopulmonary Dysplasia
Epi
30% of VLBW babies will have
AKA
Chronic lung disease
Risk factors
Prematurity
Prolonged mechanical ventilation
Postnatal infection
Management
Gentle ventilation
Diuresis
Nutrition
Home O2
Palivizumab
Prognosis
Few require home O2
First 2 yrs of life - increased risk of readmission with viral RTI, cough and wheeze
Most outgrow and have normal exercise tolerance in childhood
Meconium aspiration syndrome
Epi
Meconium stained liqou occurs in 10% of births
Risk Factors
Perinatal stress
Post-term delivery
Causes
Inflammation
Obstruction
Pneymonitis
Surfactant dysfunction / depletion
Complications
PPHN
Pneumothorax
Pognosis
30% require ventilation
Management
Ventilation
Vasodilation
Surfactant
Broad spectrum abx
Consider ECMO if not repsonding
Extra corporeal membranous oxygenation
Persistent Pulmonary Hypertension of the Newborn PPHN
Pathology
Failure to transition from in utero to ex utero pulmonary circulation
High pulmonary pressure
Impaired pulmonary blood flow
Right to left shunting of blood via foramen ovale and ductus arteriosus
Respiratory distress, hypoxia and cyanosis
Secondary PPHN
Congenital diaphragmatic hernia MAS
Investigations
CXR
May show pulmonary oligaemia
Management
Aim to reduce pulmonary pressures by encouraging vasodilation
Mechanical ventilation and invasive circulatory support
Urgent ECHO diagnosis to ruleout congenital heart disease
Vasodilation
O2
Inhaled nitric oxide
IV Milrinone or sildenafil
Consider HFOV or EXMO if persistent hypoxia
Bacterial Pneumonia
Risk Factors
Preterm
Congenital
Nosocomial
Aspiration
VAP
Management
Broad spectrum abx
Respiratoary support
Pneumothorax
Epi
1% of health term infants
Usually asymptomatic
Risk Factors
Preterm
Surfactant deficiency
Pulmonary hypoplasia
MAS
Management
Conservative
Needle aspirate
Chest drain instertion
Straigh or pigtail
Congenital Heart Disease
Clinical Features
Delivery and discharge exam can be normal
Poor feeding
Fatigue or diaphoresis with feeding
Poor weight gain
Tachypnoae
Respiratory distress
Cyanosis
Murmur on exam
Reduced or bounding pulses
Focused hx is essential
Congeital Diaphragmatic Hernia
Often diagnosed antenatally
Ideally deliver in tertiary level centre
Clinical Features
Severe respiratory distress
Scaphoid abdomen
Chest assymmetry
Management
Intubation at delivery
Manage pulmonary hypertension
Transfer to surgical NICU/PICU
May require HFOV/ECMO
Surgery when stable
Prognosis
Depends on acute mangement and degreee of pulmonary hypoplasia
Tracheo-Oesophageal Fistula
Pathology
Antenatally - polyhydramnios
Foetus unable to swallow aminiotics fluid
Unfinished