By Goh Kiam Seong HTAR Klang 2011 Plan Introduction Causes and Classification Respiratory Distress Signs Evaluation and Investigation General Management Introduction Respiratory Distress in Newborn ID: 707867
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Slide1
An approach to Respiratory Distress in Newborn
By Goh Kiam SeongHTAR, Klang2011Slide2
Plan
IntroductionCauses and ClassificationRespiratory Distress SignsEvaluation and Investigation
General ManagementSlide3
Introduction
Respiratory Distress in Newborn = Abnormal respiratory signs in neonatesSlide4Slide5
Causes and ClassificationSlide6Slide7Slide8
Respiratory Distress SignsSlide9
Respiratory Rate:
< 1 week up to 2 months: 60 or more2 to 12 months: 50 or more12 months to 5 years: 40 or more
TachypnoeaSlide10
Due to negative intrapleural
pressure generated between the contraction of diaphragm, respiratory muscles and the mechanical properties of lung and chest wallSuprasternal Retraction SSRIntercostal Retraction ICRSubcostal Retraction SCR
Tachypnoea
RetractionsSlide11
Suprasternal
Retraction SSRSlide12
Subcostal
Retraction SCRSlide13
Intercostal
Retraction ICRSlide14Slide15
Expiration through partially closed vocal cords to increase airway pressure and lung volume resulting in improved ventilation-perfusion (V/P) ratio
Low pitched expiratory sound.Protective phenomenon to prevent collapse of alveoli: PEEP
GruntingSlide16
Video – Baby Grunting
Grunting Baby pt. 2.flvSlide17
Narrow nasal space contributes to total lung resistanceNasal flaring decreases the work of breathing
Nasal FlaringSlide18Slide19
Clinical detection of cyanosis depends on total amount of desaturated
HB in bloodAnaemic infants may have low PaO2 that is missed clinicallyPolycythaemic infants with normal PaO2 can appear cyanotic
CyanosisSlide20
Cyanotic Baby
Pink BabySlide21
Central cyanosis, +ICR, +SCR, +NF
What respiratory distress signs you can see here in this child?Slide22
Evaluation and InvestigationSlide23Slide24Slide25Slide26
Potter face:
abnormal
facies
with a beak nose, receding chin, broad nasal bridge,
epicanthal
folds, and large low set earsSlide27
Meconium
stained Cord
Meconium
stained NailSlide28
Silverman Anderson Score for Premature Baby
ScoreUpper Chest RetractionLower Chest RetractionXiphoid RetractionNasal FlaringGrunting0
Synchronous
None
None
None
None
1
Lag on
Inspiration
Just visible
Just visible
Minimal
Stethoscope
2
See-Saw
Mark
Mark
Mark
Naked ear
Downe’s
Score for Term Baby
Score
Respiratory Rate
Cyanosis
Air entry
Retraction
Grunting
0
<60
None
Good
None
None
1
60-80
In airDecrease
MinimalStethoscope2
>80/ apnoeaIn 40% O2
Barely audible
Moderate/ severe
Naked ear
Score > 6 = impending Respiratory FailureSlide29
Look for:
O2 SaturationMetabolic/ respiratory acidosis/ alkalosisBlood counts (Hb/TWC/Plt
/Ht)
Glucose level
Sepsis causative agent
Collapse/Air Leak/CDH/
CardiomegalySlide30
General Management
O2 DeliveryPEEP/ Mechanical ventilation (CPAP/SiPAP)Intubation and suction
HR monitoring
Continuous
SPO
2
monitoring
Temp/DXT monitoring
I/O charting
Feeding (PO/TPN)
Cot/Incubator nursing
According to diagnosisSlide31
Our topics todaySlide32
Pierre Robin Sequence (PRS)Slide33
Definition
PRS is a facial difference caused by underdevelopment of the lower jaw Characterised by:Micro- and retrognathiaglossoptosis respiratory obstruction With or without cleft palate.Incidence = 1:8500-14000 birth=Slide34
PRS is a sequence not syndrome!Because underdeveloped lower jaw begins a sequence of events which leads to abnormal position of tongue and cleft palate.Slide35
Aetiology
UnknownRecently identify may be caused by genetic anomalies at chromosomes 2, 11, or 17Slide36
PRS is often part of an underlying disorder or syndrome
Stickler syndromeVelocardiofacial syndromeFetal Alcohol syndromeTreacher Collins SyndromeSlide37
Pathophysiology
At 12 -14/52 GASlide38
9-11/52 GASlide39
In PRSSlide40
How to diagnose?
Only by examining the patient at birthComplication
Difficulties in breathing and feeding.Slide41
GERD more prevalent in children with Robin sequence. (
Dudkiewicz, CPCJ Mar 2000)Slide42
Our tactics
Position: Keep in prone or lateral positionFeeding: Tube feeding or Haberman feederNutrition: Increase daily calorie intakeSPO2 monitoringSlide43
Other considerations
Endotracheal intubation/tracheostomyTongue lip adhesionOphthalmology follow up – if suspect Sticker syndrome (possible retinal detachment)Mandibular distraction (distraction osteogenesis)Cleft palate reparation (6.5 mo- 2 yo)Slide44
Choanal Atresia
Choanal atresia is a congenital disorder where choana is blocked by abnormal bony or soft tissue formed during fetal developmentCause: unknown (thin tissue separating the nose and mouth area during fetal development remains after birth)Most common nasal abnormality in newborn (1 in 7,000 live births) : = 1 : 2>50% associated with other congenital disorderDiagnosed shortly after birthSlide45
Types
UnilateralBilateral MembranousOsseousSlide46
Symptoms and Signs
Cyanosis during feedingPink while cryingSlide47
Inability to nurse and breathe at same timeInability to pass a catheter through each side of the nose into the throat
Persistent one-sided nasal blockage or dischargeSlide48
Associated conditions
Coloboma Heart defectsRetardation of growth or mental developmentGenital/urinary abnormalitiesEar anomalies/deafnessIF associated with all these ~ CHARGE syndrome (defect in Chromosome 8 CHD7 gene)Slide49Slide50
Tests that may be done include:
CT scanEndoscopy of the noseSinus x-raySlide51
Endoscopic view of
choanal atresia.mt: middle turbinate; it: inferior turbinate; ns: nasal septum; a: atresia "plate".Slide52
Management
Secure the airway (laryngeal mask, intubation or tracheostomy may be needed)If infant can learn to mouth breathe, can delay the need for immediate surgery.Otherwise, surgery to remove the obstruction required (transnasal or transpalatal).