R

Neonatology Division
Department of Child Health Medical School
U i
University
it off S
Sumatera
t
Ut
Utara
Visual 1

Alarming Signs for RD

z
z
z
z
z
z

Cyanosis
Severe apnea (coma?)
Stridor
G i efforts
Gasping
ff t
Severe respiratory retractions
Poor perfusion (shock)
Visual 2

Evaluation of Respiratory
Distress Using Downs Score
0

Respiratory Rate

< 60/min

60 80/min

> 80/min

Retractions

No retraction

Mild retractions

Severe retractions

Cyanosis

No cyanosis

Cyanosis relieved by
O2

Cyanosis on O2

Ai E
Air
Entry
t

G d bil
Good
bilateral
t l airi
entry

Mild decrease
d
in
i airi
entry

N airi entry
No
t

Grunting

No grunting

Audible by
stethoscope

Audible with ear

Learning Objective 1

Visual 3

Evaluation of Respiratory
Distress Using Downs Score
Score < 4 No respiratory distress
Score 4 -7 Respiratory distress
Score > 7

Learning Objective 1

Impending respiratory failure

(Blood gases should be obtained)
Visual 4

Be Prepared
z
z
z
z

Resuscitation equipment and/or supplies

Involve others (team approach)
Have staff trained
ABC

Airway
Breathing
Circulation
Visual 5

Conditions Associated with

Respiratory Distress

Visual 6

Visual 7

Investigations
z
z
z
z
z

Chest X-ray
Arterial blood gas
CBC (anemia, polycythemia, sepsis)
Gl
Glucose
check
h k (hypoglycemia)
(h
l
i )
Blood culture (sepsis, pneumonia)

Visual 8

Treatment
z
z
z
z

After stabilization, treat the cause of RD

Use CPAP
Avoid unnecessary exposure to oxygen
A tibi ti until
Antibiotics
til sepsis
i is
i ruled
l d outt

Visual 9

Common Causes of RD
z
z
z
z
z
z

Transient tachypnea of the newborn (TTN)

Hyaline membrane disease (HMD)
Meconium aspiration syndrome (MAS)
Ai leak
Air
l k syndrome
d
Pneumonia
Congenital heart diseases
Visual 10

Transient Tachypnea of the

Neonate (TTN)
Definition
A benign disease of near-term or term neonates
p
y distress shortlyy after
who have respiratory
delivery that resolves within 3-5 days.

Learning Objective 3

Visual 11

Pathogenesis of TTN
z
z
z
z

How is lung fluid formed?

What is the function of lung fluids?
What happens to lung fluids during labor?
D
Does
it matter
tt th
the ttype off labor?
l b ?

Visual 12

Transient Tachypnea of the

Neonate (TTN) (cont)
Risk factors
z
z
z
z
z
z

Cesarean section without labor

Macrosomia
Male sex
Prolonged
g labor
Excessive maternal sedation
Low
o Apgar
pga sco
scoree ((< 7 at 1 minute)
ute)

Learning Objective 3

Visual 13

Transient Tachypnea of the

Neonate (TTN) (cont)
Clinical Presentation of TTN
The neonate is usually near-term
near term or term
term, and
shortly after delivery has tachypnea (>80
b th / i t ) Th
breaths/minute).
The neonate
t may also
l have
h
grunting, nasal flaring, rib retractions, and
cyanosis. The disease usually does not last
longer than 72 hours.
Learning Objective 3

Visual 14

Visual 15

Transient Tachypnea of the

Neonate (TTN) (cont)

Chest X-ray:
Perihilar streaking, mild cardiomegaly,
increased lung volume, fluid in the minor
fi
fissure,
and
d perhaps
h
fluid
fl id in
i the
th pleural
l
l space
are common findings.

Learning Objective 3

Visual 16

Transient Tachypnea of the

Neonate (TTN) (cont)
Management of TTN
z
z
z

Judicious use of oxygen

Fluid restriction
F di as ttachypnea
Feeding
h
improves
i

Confirm the diagnosis by excluding other causes of

tachypnea e.g. pneumonia, congenital heart disease,
hyaline membrane disease, and cerebral
hyperventilation.
Learning Objective 3

Visual 17

Transient Tachypnea of the

Neonate (TTN) (cont)
Outcome and Prognosis of TTN
The disease is self-limited and there is no risk
off recurrence or ffurther
th pulmonary
l
dysfunction. Respiratory symptoms improve as
i t
intrapulmonary
l
flfluid
id is
i mobilized,
bili d andd this
thi is
i
usually associated with diuresis.
Learning Objective 3

Visual 18

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
Definition
Hyaline membrane disease (HMD) is also called
respiratory distress syndrome (RDS). This condition
usually
ll occurs iin a preterm
t
neonate.
t P
Premature
t
lungs are surfactant deficient.

Learning Objective 4

Visual 19

Hyaline
y
Membrane Disease
(Respiratory Distress Syndrome)
(cont)
Respiratory difficulties exhibited include:
z
z
z

z
z

Increasing tachypnea (> 60/min)

Chest retractions
Cyanosis on room air that persists or
progresses over the first 24-48 hours of life.
life
Decreased air entry
Grunting

Learning Objective 4

Visual 20

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
Incidence
HMD occurs in about 25% of neonates born at
32 weeks
k gestation.
t ti Th
The iincidence
id
iincreases
with increasing prematurity.

Learning Objective 4

Visual 21

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
Risk Factors of HMD
z

Increased Risk

Prematurity
P
t it
Male sex
Neonate of diabetic
mother

Learning Objective 4

Visual 22

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
Risk Factors of HMD
z

Decreased Risk
Chronic intrauterine stress

Prolonged
o o ged rupture
uptu e o
of membranes
e b a es
Maternal hypertension
Narcotic use
Intrauterine Growth Retardation (IUGR) or Small for
Gestational Age (SGA)

Corticosteroids Prenatal

Learning Objective 4

Visual 23

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
Investigations
g
for HMD (RDS)
(
)
z

Laboratory Studies:

Blood gases: hypoxia,

hypoxia hypercarbia,
hypercarbia acidosis.
acidosis

CBC and blood culture are required to rule out infection.

Serum glucose levels are usually low.

low

Chest X-ray Study:

Reveals ground glass appearance with air bronchograms.

bronchograms

Learning Objective 4

Visual 24

Visual 25

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
(
)
Management of HMD (RDS)
z General
G
l

Thermal regulation
Parenteral fluid
Antibiotics
Continuous monitoring

Learning Objective 4

Visual 26

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)

Continuous positive airway pressure (CPAP) is

tried.
tried
If under CPAP

PH < 7.2
72
Or PO2 < 40mmHg
Or PCO2 > 60mmH
Base deficit > -10

FiO2 > 60%

Endotracheal intubation and mechanical ventilation.

C id surfactant
Consider
f t t therapy
th
Learning Objective 4

Visual 27

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)

Caution: every 10 days on the ventilator is

associated
i t d with
ith 20% increased
i
d risk
i k for
f
cerebral palsy

Learning Objective 4

Visual 28

Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
z

Specific
p
Treatment

Surfactant replacement therapy if tracheal

intubation is required
q

Outcome

RDS accounts for 20% of all neonatal deaths

Chronic lung diseases occurs in 29% in VLBW
infants

Learning Objective 4

Visual 29

Visual 30

Meconium Aspiration Syndrome

(MAS)
Definition
The respiratory distress secondary to
meconium aspiration by the fetus in utero or
by the neonate during labor and delivery.

Learning Objective 5

Visual 31

Meconium Aspiration Syndrome

(MAS) (cont)
Pathogenesis: aspiration of meconium can
cause:
z
z
z
z

Airway obstruction (ball and valve)

Severe inflammation
Pulmonary hypertension
Platelet activation

Learning Objective 5

Visual 32

Meconium Aspiration Syndrome

(MAS) (cont)
Risk Factors of MAS
z
z
z
z

Post-term pregnancy
Maternal hypertension
yp
Abnormal fetal heart rate
Biophysical profile 6

Learning Objective 5

z
z
z
z

Pre-eclampsia
Maternal diabetes mellitus
SGA
Chorioamnionitis

Visual 33

Meconium Aspiration Syndrome

(MAS) (cont)
Clinical presentation of MAS
z
z
z

Meconium staining of amniotic fluid before birth.

Meconium staining of neonate after birth.
Respiratory distress leading to increased
anteroposterior diameter of the chest.
Persistent pulmonary hypertension of the newborn
(PPHN).

Learning Objective 5

Visual 34

Meconium Aspiration Syndrome

(MAS) (cont)
Investigations for MAS
z

Laboratory studies

Blood ggas analysis

y
Blood culture and CBC

Learning Objective 5

Visual 35

Meconium Aspiration Syndrome

(MAS) (cont)
Investigations for MAS
z

Radiologic studies

Chest X-ray: findings include patchy infiltrates,

coarse streaking of both lung fields, hyperinflation of
the lung and flattening of the diaphragm.

Learning Objective 5

Visual 36

Visual 37

Meconium Aspiration Syndrome

(MAS) (cont)
Management of MAS
Prenatal management:
z
z
z

Identification of high-risk pregnancy.

Monitoring of fetal heart rate during labor.
Amnioinfusion (?)
( )

Learning Objective 5

Visual 38

Meconium Aspiration Syndrome

(MAS) cont)
Management of MAS
Delivery
D
li
room management:t (if amniotic
i ti flfluid
id is
i
meconium stained)
z

Obstetrical:
Ob
t ti l S
Suction
ti off th
the oropharynx
h
bby obstetrician
b t ti i
before delivery of shoulders.
Pediatric: Visualization of vocal cords and tracheal
suction if infant is not breathing.

Learning Objective 5

Visual 39

Meconium Aspiration Syndrome

(MAS) (cont)
z

General Management of Neonate with MAS

Empty the stomach contents to avoid further

aspiration.
Correction of metabolic abnormalities e.g.
e g hypoxia
hypoxia,
acidosis, hypoglycemia, hypocalcemia and
hypothermia.
yp
Surveillance for end organ hypoxic/ischemic damage
(brain, kidney, heart and liver).

Learning Objective 5

Visual 40

Meconium Aspiration Syndrome

(MAS) (cont)
z

Respiratory Management of Neonate with MAS

Frequent suction and chest vibration.

vibration
Pulmonary toilet to remove residual meconium if
intubated.
intubated
Antibiotic coverage (ampicillin and gentamicin).
Use CPAP.
CPAP

Learning Objective 5

Visual 41

Meconium Aspiration Syndrome

(MAS) (cont)
Outcome and Prognosis (MAS)
z
z

Mortality rate may be as high as 50%.

50%
Survivors may suffer from bronchopulmonary
d l i andd neurologic
dysplasia
l i sequelae.
l

Learning Objective 5

Visual 42

Air Leak Syndromes

Definition
The air leaks syndromes (pneumomediastinum,
pneumothorax pulmonary interstitial emphysema
pneumothorax,
and pneumopericardium) comprise a spectrum of
diseases with the same underlying
pathophysiology. Overdistension of alveolar sacs
or terminal airways leads to disruption of airway
integrity, resulting in dissection of air into
surrounding spaces.
spaces
Learning Objective 6

Visual 43

Air Leak Syndromes (cont)

Incidence
Most commonly seen in neonates with lung
disease who are on ventilatory support but can
also occur spontaneously.
spontaneously The more severe the
lung disease, the higher the incidence of
pulmonary air leak.
leak

Learning Objective 6

Visual 44

Air Leak Syndromes (cont)

Risk Factors for Air Leak Syndromes
z
z
z
z
z
z

Spontaneous 0.5%
Ventilatory support 15-20%
CPAP 5%
Meconium stainingg / aspiration
p
Surfactant therapy
Vigorous resuscitation (bag ventilation)

Learning Objective 6

Visual 45

Visual 46

Visual 47

Air Leak Syndromes (cont)

Clinical Presentation of Neonates with Air Leak
Syndromes
z

Respiratory distress or sudden deterioration of clinical

course with alteration of vital signs and worsening of
blood gases.
Asymmetry of thorax is present in unilateral cases.
cases

Learning Objective 6

Visual 48

Air Leak Syndromes (cont)

Investigations for Air Leak Syndromes
z

The definitive diagnosis of all air leak syndromes is

made radiographically by an A
A-P
P chest X
X-ray
ray film and a
lateral film.

Learning Objective 6

Visual 49

Visual 50

Air Leak Syndromes (cont)

Managementt off Air
M
Ai Leak
L k Syndromes
S d
z General

Avoid ventilators
Careful use of manual bag ventilation

Specific

Decompression of air leak according to the type.

Do not needle the chest

Learning Objective 6

Visual 51

Apnea
Definition
z Cessation of respiration accompanied by
bradycardia and/or cyanosis for more than 20
seconds.
Incidence
z 50-60% of preterm neonates have evidence of
apnea (35% with central apnea, 55-10%
10% with
obstructive apnea, and 15-20% with mixed
p )
apnea).
Learning Objective 7

Visual 52

A
Apnea
((cont)
t)
Risk Factors of Neonatal Apnea
z

Pathological apnea

Hypothermia

Cardiac disease

Hypoglycemia

Lung disease

Anemia

Gastro intestinal reflux

Hypovolemia

Airway obstruction

Aspiration

Infection, meningitis

NEC / Distension

Neurological disorders

Learning Objective 7

Visual 53

Apnea (cont)
I
Investigations
ti ti
z

z
z

Monitoring at-risk neonates less than 32 weeks

gestational
t ti l age.
Evaluate for a possible underlying cause.
Laboratory studies should include a CBC, blood
gas analysis, serum glucose, electrolyte, and
calcium
l i llevels.
l
Radiologic studies if chest disease is suspected

Learning Objective 7

Visual 54

Apnea (cont)
Management of Apnea
z General Therapy

Perform tactile stimulation.

CPAP in
i recurrentt andd prolonged
l
d apnea.
Pharmacological therapy (caffeine or theophylline)
may be required.
required

Monitor levels.

Learning Objective 7

Visual 55

Apnea (cont)
Management of Apnea
z

Specific Therapy

Treatment of the cause, if identified, eg. treatment of

sepsis hypoglycemia
sepsis,
hypoglycemia, anemia
anemia, and electrolyte
abnormalities.

Learning Objective 7

Visual 56

Apnea (cont)
Outcome and Prognosis
z

IIn mostt neonates

t apnea resolves
l
without
ith t the
th
occurrence of long-term deficiencies.

Learning Objective 7

Visual 57

Visual 58