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    Respiratory - Distress (1) 2 PDF

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    Satya Prakash Tiwari
    This document discusses respiratory distress in newborns, including common causes, assessment, and management approaches. It covers: - Common causes of respiratory distress in preterm and term newborns, including respiratory distress syndrome, transient tachypnea of newborn, and meconium aspiration. - Methods for assessing severity of respiratory distress using the Silverman Anderson and Downe's scores. - General diagnostic workup and management approaches for newborns with mild, moderate or severe respiratory distress, including oxygen therapy, antibiotics, and monitoring. - Specific therapies are outlined depending on the suspected cause of respiratory distress and severity, such as CPAP, assisted ventilation, and antenatal cortic

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    Respiratory - Distress (1) 2 PDF

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    Satya Prakash Tiwari
    56 views8 pages
    This document discusses respiratory distress in newborns, including common causes, assessment, and management approaches. It covers: - Common causes of respiratory distress in preterm and term newborns, including respiratory distress syndrome, transient tachypnea of newborn, and meconium aspiration. - Methods for assessing severity of respiratory distress using the Silverman Anderson and Downe's scores. - General diagnostic workup and management approaches for newborns with mild, moderate or severe respiratory distress, including oxygen therapy, antibiotics, and monitoring. - Specific therapies are outlined depending on the suspected cause of respiratory distress and severity, such as CPAP, assisted ventilation, and antenatal cortic

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    This document discusses respiratory distress in newborns, including common causes, assessment, and management approaches. It covers: - Common causes of respiratory distress in preterm and term newborns, including respiratory distress syndrome, transient tachypnea of newborn, and meconium aspiration. - Methods for assessing severity of respiratory distress using the Silverman Anderson and Downe's scores. - General diagnostic workup and management approaches for newborns with mild, moderate or severe respiratory distress, including oxygen therapy, antibiotics, and monitoring. - Specific therapies are outlined depending on the suspected cause of respiratory distress and severity, such as CPAP, assisted ventilation, and antenatal cortic

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    © All Rights Reserved
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    Download as pdf or txt
    56 views8 pages

    Respiratory - Distress (1) 2 PDF

    Uploaded by

    Satya Prakash Tiwari
    This document discusses respiratory distress in newborns, including common causes, assessment, and management approaches. It covers: - Common causes of respiratory distress in preterm and term newborns, including respiratory distress syndrome, transient tachypnea of newborn, and meconium aspiration. - Methods for assessing severity of respiratory distress using the Silverman Anderson and Downe's scores. - General diagnostic workup and management approaches for newborns with mild, moderate or severe respiratory distress, including oxygen therapy, antibiotics, and monitoring. - Specific therapies are outlined depending on the suspected cause of respiratory distress and severity, such as CPAP, assisted ventilation, and antenatal cortic

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    Chapter 10

    RESPIRATORY DISTRESS IN NEWBORN


    Respiratory distress accounts for significant morbidity and mortality in neonates. It
    occurs in 4 to 6 percent of neonates. Many of the conditions causing respiratory distress
    are preventable. Early recognition and prompt management are required

    Learning objectives

    After completion of this module the participant should be able to-

    • Diagnose common causes of respiratory distress in Term and Preterm newborns


    • Identify babies with respiratory distress and assess severity of respiratory distress
    • Deliver oxygen and manage babies with respiratory distress
    • Monitor babies on oxygen therapy

    Common causes of respiratory distress

    Preterm baby

    • Respiratory distress syndrome


    • Congenital Pneumonia
    • Miscellaneous causes: hypothermia, hypoglycemia

    Term baby

    • Transient tachypnea of newborn (TTNB)


    • Meconium aspiration
    • Pneumonia,
    • Asphyxia

    Surgical causes

    • Diaphragmatic hernia
    • Tracheo-esophageal fistula
    • B/L choanal atresia

    Other causes

    • Cardiac
    • Metabolic

    NATIONAL NEONATOLOGY FORUM


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    Approach to respiratory distress

    History A detailed relevant antenatal and perinatal history should be taken based on the
    common causes:

    • Gestation
    • Onset of distress
    • Previous preterm babies with respiratory distress
    • Antenatal steroid prophylaxis if preterm delivery
    • Rupture of Membranes > 24 hours, Intrapartum fever, chorioamnionitis
    • Meconium stained amniotic fluid
    • Asphyxia
    • Maternal diabetes mellitus

    Examination

    • Severity of respiratory distress


    • Neurological status
    • CFT
    • Hepatomegaly
    • Cyanosis
    • Features of sepsis
    • Look for malformations

    Assessment of severity of respiratory distress


    Table 10.1: Silverman Anderson Score and its interpretation

    Score Upper chest Lower chest Xiphoid Nasal Grunt


    retraction retraction retraction flaring
    0 Synchronised None None None None
    1 Lag during Just visible Just visible Minimal Audible with
    inspiration Stethoscope
    2 See-Saw Marked Marked Marked Audible with
    unaided ear

    Interpretation
    Score 0-3 = Mild respiratory distress – O2 by hood
    Score 4-6 = Moderate respiratory distress - CPAP
    Score > 6 = Impending respiratory failure
    Table 10.2 : Downe’s score and its interpretation

    NATIONAL NEONATOLOGY FORUM


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    Score Respiratory Cyanosis Air entry Grunt Retraction
    rate
    0 <60/min Nil Normal None Nil
    1 60-80/min In room air Mild Audible with Mild
    decrease Stethoscope
    2 >80/min In >40% Marked Audible with Moderate
    FiO2 decrease unaided ear

    Interpretation
    Score <6 = Respiratory distress
    Score > 6 = Impending respiratory failure

    Investigations

    The diagnosis is based on the x-ray findings and the sepsis screen.

    Chest X-ray

    To look for
    • Respiratory Distress Syndrome (RDS) - Air bronchogram, decreased lung volume
    and hazy lungs
    • Meconium Aspiration Syndrome (MAS) - Fluffy shadows involving both lungs
    with hyperinflation
    • Pneumonia - Infiltrates
    • Pulmonary hemorrhage, RDS - White out (Opaque lung)

    Sepsis screen : TLC, DLC, CRP, Micro ESR, IT Ratio, ANC

    Blood Culture: This may give a clue to the infectious etiology of the respiratory distress

    Management

    General management

    • Give oxygen with oxygen hood or nasal cannula to achieve appropriate oxygen
    saturation
    • Maintain normal body temperature (see section on hypothermia)
    • Give IV fluids if the baby does not accept feeds or has severe respiratory distress
    • Maintain blood glucose, if low treat hypoglycemia
    • If baby has apnea
    a. Stimulate to breathe by rubbing the back or flicking the sole
    b. If does not begin to breathe immediately provide positive-pressure
    ventilation with bag and mask
    c. Aminophylline if baby is preterm

    NATIONAL NEONATOLOGY FORUM


    63
    d. If recurrent apneic spells, treat for sepsis and organize transfer to a
    specialized centre for assisted ventilation.

    Specific management

    Moderate to Severe breathing difficulty


    • Monitor and record the baby’s respiratory rate, presence of chest indrawing or
    grunting on expiration, and episodes of apnoea every hour until the baby no longer
    requires oxygen and then for an additional 24 hours.
    • Monitor the baby’s response to oxygen by oxygen saturations.
    • Insert an oro-gastric tube to empty the stomach of air and secretions.
    • After taking a sepsis screen including blood culture start antibiotics.
    • When the baby begins to show signs of improvement:
    o Give expressed breast milk by oro-gastric tube
    o Allow the baby to begin breastfeeding as the respiratory distress settles. Baby can
    be put on to breast while on oxygen by nasal cannula with continuous monitoring.
    o If the baby cannot be breastfed, give expressed breast milk using a cup & spoon
    or paladai.

    TABLE 10.3: Methods for administering oxygen


    Method Nasal catheter Head box
    Flow • Low = 0.5 L per minute • Low = 3 L per minute
    • Moderate = 0.5 to 1 L per min • Moderate = 3 to 5 L per min

    • High = more than 1 L per min • High = more than 5 L per min

    Nasal Prongs :

    These are a useful means of delivering oxygen. Appropriate size prongs, which fit the
    neonate well, should be used. If a large size of the nasal cannula is used, it may cause
    blanching of the ala nasi and injure the nose.

    NATIONAL NEONATOLOGY FORUM


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    Nasal Catheter

    • Use a 6-8 french catheter.

    • Determine the distance the tube should be passed by measuring the distance from the
    nostril to the inner margin of the eyebrow.

    • Gently insert the catheter into the nostril.

    • Ensure that the catheter is correctly positioned.

    - Look into the baby’s mouth;


    - The catheter should not be visible at the back of the mouth;
    - If the catheter is visible at the back of the mouth, pull the catheter out slowly until it
    is no longer visible.

    • Adjust the flow of oxygen to achieve the desired oxygen saturation.

    • Change the nasal catheter twice daily. Give oxygen using a face mask while changing
    the catheter if necessary.

    Head Box

    • Place a head box over the baby’s head.

    • Ensure that the baby’s head stays within the head box, even when the baby moves.

    • Adjust the flow of oxygen to achieve the desired oxygen saturation.


    If the baby’s breathing difficulty worsens or the baby is desaturating or has central
    cyanosis:

    • Give oxygen at a high flow rate


    • If breathing difficulty is so severe that the baby has central cyanosis even in 100%
    oxygen, organize transfer and urgently refer the baby to a tertiary hospital or
    specialized centre capable of assisted ventilation.

    If investigations reveal evidence of sepsis, stop antibiotics after 7 – 10 day and observe
    the baby for 24 hours after discontinuing antibiotics.

    If the baby’s oxygen saturation on pulse oximetry are acceptable, gradually wean from
    oxygen. If he baby has no difficulty breathing and is feeding well, discharge the baby.

    Pulse oximetry : Maintain a saturation of 88 – 92% in preterm and 90-93 % in term


    neonates

    NATIONAL NEONATOLOGY FORUM


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    Mild breathing difficulty
    • Monitor for respiratory distress and oxygen saturation. Give oxygen if needed.
    • Give expressed breast milk by gastric tube
    • When oxygen is no longer needed, allow the baby to begin breastfeeding. If the baby
    cannot be breastfed, continue giving expressed breast milk using an alternative
    feeding method.
    • If the breathing difficulty worsens at any time during the observation period: treat for
    moderate breathing difficulty
    • All babies with mild and transient respiratory distress, do not need antibiotics.
    However, if the respiratory distress persists for more than 6 hour or there are risk
    factors, start antibiotics after taking a sepsis screen. Once respiratory distress settles
    and the sepsis screen is negative – STOP ANTIBIOTICS.

    Antenatal corticosteroids for prevention of RDS

    • Antenatal corticosteroid therapy is a simple and effective therapy that


    prevents RDS.
    • Optimal effect of antenatal steroids is seen if delivery occurs after 24 hrs of
    starting therapy.
    • Recommended Dose is Inj Betamethasone 12 mg IM every 24 hrs X 2 doses or
    Inj. Dexamethasone 6 mg IM every 12 hrs X 4 doses.
    • Give to mothers with preterm labour or APH before 34 wks of gestation.

    NATIONAL NEONATOLOGY FORUM


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    VIDEO DEMONSTRATION OF DIFFICULTY IN BREATHING

    This video demonstrates a neonate with fast breathing, chest retractions, nasal flaring and
    grunting.

    NATIONAL NEONATOLOGY FORUM


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    EVALUATION
    A 7 day old baby born at term with a birth weight of 2.8 kg is brought with complaints of
    difficulty in breathing and inability to feed at the breast. The present weight is 2.65 kg,
    temperature is 36oC, and respiratory rate is 96 / min with moderate retraction with
    grunting and central cyanosis.

    1. What is your assessment about the respiratory status of this baby and what is the likely
    diagnosis?
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________

    2. What supportive management would you do for this baby?


    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________

    3. What are the ways of giving oxygen to the baby and how will you monitor efficacy of
    oxygen delivery.
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________

    4. A baby is born prematurely at 32 weeks of gestation and develops respiratory distress


    soon after birth with grunting and chest retractions. What is the likely diagnosis.
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________

    5. What are the principles of management of severe breathing difficulty?


    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________

    6. How will you manage a baby who is brought with breathing difficulty and develops
    apneic spells.
    _____________________________________________________________________
    _____________________________________________________________________
    _____________________________________________________________________
    ____________________________________________________________________

    NATIONAL NEONATOLOGY FORUM


    68

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