Download MBBS Final Year Pediatrics Respiratory Distress in Newborn Notes

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RESPIRATORY DISTRESS IN NEWBORN

FEATURES

• Tachypnea – respiratory rate > 60/min
• Chest retractions

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• Grunting
• Flaring of ala nasi
• Cyanosis

CAUSES

MEDICAL

Pulmonary

• Respiratory distress syndrome
• Meconium aspiration syndrome

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• Pneumonia
• Transient tachypnea of newborn
• Persistent pulmonary hypertension
• Pneumothorax

NON PULMONARY CAUSES

Cardiac

congenital heart disease, congestive heart failure

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Metabolic

Hypothermia, hypoglycaemia, metabolic acidosis

CNS

Asphyxia, cerebral oedema, haemorrhage

Chest wall

Asphyxiating thoracic dystrophy, Werdning-Hoffman disease

SURGICAL

• Tracheo-oesophageal fistula
• Diaphragmatic hernia

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• Lobar emphysema
• Choanal atresia

APPROACH TO RESPIRATORY DISTRESS

HISTORY

• Onset of distress
• Gestation
• Antenatal steroids

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• Predisposing factors – PROM, fever
• Meconium stained amniotic fluid
• Asphyxia

EXAMINATION

• Severity of respiratory distress
• Neurological status

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• Blood pressure
• Hepatomegaly
• Cyanosis
• Features of sepsis
• Malformations

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CHEST EXAMINATION

• Air entry
• Mediastinal shift
• Adventitious sounds
• Hyperinflation
• Heart sounds

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ASSESSMENT OF RESPIRATORY DISTRESS

Assessment of respiratory distress

* Score > 6 indicates severe distress

PRE-TERM POSSIBLE ETIOLOGY

TERM - POSSIBLE ETIOLOGY

SUSPECT SURGICAL CAUSE

• Scaphoid abdomen
• Frothing
• History of aspiration

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INVESTIGATION

• Chest X-ray
• Polymorph count
• Gastric aspirate
• Sepsis screen
• Blood gas analysis

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MANAGEMENT

• Monitoring
• Supportive
  • IV fluids
  • Maintain vital signs
  • Oxygen therapy
  • Respiratory support

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• Specific

RESPIRATORY DISTRESS SYNDROME \ HYALINE MEMBRANE DISEASE

RISK FACTORS

• PREMATURITY
  • Common in preterm babies less than 34 weeks of gestation
  • 80% neonates < 28 weeks

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• Maternal diabetes
• Asphyxia
• Acidosis

ETIOPATHOGENESIS

• Decreased or abnormal surfactant
• Alveolar collapse

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• Impaired gas exchange
• Respiratory failure

CLINICAL FEATURES

• Usually within minutes of birth
• Tachypnea
• Retractions

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• Grunting
• Cyanosis
• Breath sounds normal or diminished

DIAGNOSIS

CHEST X-RAY

• Reticogranular pattern
• Ground-glass opacity

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• Low lung volume
• Air bronchogram
• White out lung in severe disease

MANAGEMENT

• Cared in NICU with IV fluids and oxygen.
• Continuous positive airway pressure (CPAP).

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• Mechanical ventilation.
• Exogenous surfactant – intratracheal. DOSE: 100mg/kg

CPAP

It is non invasive modality where continuous distending pressure (5-7 cm of water) applied at nostril level to keep the alveoli open in a spontaneously breathing baby

Minimises lung injury, air leak and sepsis.

PREVENTION- ANTENATAL STEROIDS

To mother in preterm labour (<35 weeks).

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DOSE: Inj. Betamethasone 12mg IM every 24hrs- 2 doses OR Dexamethasone 6mg IM every 12 hrs.- 4 doses.

MECONIUM ASPIRATION SYNDROME

• Meconium staining of amniotic fluid(MSAF) occur in 10-14%pregnancies
• Meconium staining on cord, nails, skin
• Onset within 4-6 hrs.
• Hyper inflated chest

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THICK : Atelectasis, air blockage, air leak syndrome

THIN : Chemical pneumonitis

Chest X-ray

Bilateral heterogeneous opacities, areas of hyper expansion and atelectasis and air leak

MANAGEMENT

• Good supportive care – body temperature, blood glucose and calcium levels ensuring analgesia and avoiding unnecessary fiddling.
• Oxygenation and ventilation.

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TRANSIENT TACHYPNEA OF NEWBORN

It is a benign self liming disease usually in term neonates and is due to clearance of lung fluid

These babies have tachypnea with minimal or nonrespiratory distress.

Chest X-ray - hyperxpanded lung fields, prominent vascular marking and prominent interlobar fissure

Treatment - oxygen treatment is adequate.

PNEUMONIA

Caused by bacteria – E.coli, S.aureus, K.pneumonia, occasionally due to fungal and viral infections

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PREDISPOSING FACTORS

PROM> 24 hrs., peripartal fever, unclean or multiple per vaginal delivery, foul smelling liquor

Chest X-ray shows pneumonia, blood counts are raised, blood culture may be positive

TREATMENT -

Supportive care and antibiotic therapy (ampicillin or cloxacillin with gentamycin)

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ASPHYXIA

• Myocardial dysfunction
• Cerebral oedema
• Asphyxia lung injury
• Metabolic acidosis
• Persistent pulmonary hypertension

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PNEUMOTHORAX

ETIOLOGY

Spontaneous, MAS, positive pressure ventilation

CLINICAL FEATURES

Sudden distress, indistinct heart sounds

MANAGEMENT

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Needle aspiration, chest tube

PERSISTANT PULMONARY HYPERTENSION

• Neonates present with severe respiratory distress and cyanosis.
• CAUSES
  • Primary
  • Secondary : MAS, asphyxia, sepsis

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• MANAGEMENT

  Ventilatory support , pulmonary vasodilators like Nitric oxide

SURGICAL PROBLEMS

TRACHEOESOPHAGAL FISTULA should be suspected in case of excessive frothing.

Plain X-ray with a red rubber catheter inserted in stomach : the catheter generally stops at tenth thoracic vertebrae in presence of oesophageal attrition. Presence of gastric bubble suggest TEF.

• Diaphragmatic hernia suspected in neonates was respiratory distress and has scaphoid abdomen. Chest X-ray shows bowel loops in the thoracic cavity. This can detected during antenatal USG scanning.

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