Respiratory Disorder IDAI 101207

Respiratory Disorders
in the Newborn
Perinatologi Division
Department of Child Health
Medical Faculty of Hasanuddin University
Introduction
Encountered frequently
Incidence 4 to 6 % of live births
Potentially life-threatening conditions
Early recognition, timely referral, appropriate
treatment
essential
Aly H, Pediatrics in Review 2004;25:201-208

Deorari, A. RD in a newborn baby. Teaching aids on newborn care. NNF. India. 2005
introduction
The key to succesful management :
Complete maternal and newborn history
Complete physical examination
Recognize the common respiratory disorder
Differentiate among various diagnostics entities
Identify those that are life-threatening

Definition
Characterized by one or more of the following :
Nasal flaring
Chest retractions
Tachipnea (RR > 60/min)
Grunting
definition
Advanced degree of respiratory distress :
Cyanosis
Gasping
Choking
Apnea
Stridor
Evaluation of Respiratory
Distress Using Downes Score
0
Respiratory Rate
< 60/min
60 80/min
> 80/min
Retractions
No retraction
Mild retractions
Cyanosis
Air Entry
Grunting
Severe
retractions
No cyanosis
Cyanosis relieved Cyanosis on O2
by O2
Good bilateral air Mild decrease in
No air entry
entry
air entry
No grunting
Audible by
Audible with ear
stethoscope
evaluation
Score < 4 Mild respiratory distress
Score 4 -7 Severe Respiratory distress
Score > 7 Impending respiratory failure
(Blood gases should be obtained)
Initial assesment
Conditions that require immediate support :
Obstructed airway (gasping, choking,stridor)
Insufficient breathing (apnea, poor respiratory

effort)
Circulatory collapse (bradycardia, hypotension,

poor perfusion)
Poor oxygenation (cyanosis)

initial assesment
Immediate oxygen support needed :
Possibly bag and mask ventilation
Even intubation and mechanical ventilation
initial assesment
Be prepared :
Resuscitation equipment and supplies
Senior physicians and other health care team

personnel
Resuscitation guideline should be followed in

stepwise manner
History
Maternal history
Drug abuse
Diabetes melitus
Infections
history
Obstetrical histories
Gestational age (if preterm steroid ?)
Results of fetal assesment and fetal monitoring

during labor & delivery
Complications at delivery birth trauma,

presence of meconium, perinatal depression,
premature rupture of membranes
history
Details of the presenting respiratory symptoms
Coughing and choking during feeding

functional and structural should be considered. If
symptoms follow the feeding & recurrent emesis
reflux with aspiration suspected
Gradually improving symptoms TTN

Gradual deterioration pneumonia / sepsis
Onset of distress
Preterm- Possible Etiology

Early progressive
Hyaline membrane disease
Early transient
Metabolic causes,
hypothermia
Anytime
Pneumonia
Term- Possible Etiology

Early well looking
TTN, polycythemia
Early severe distress
MAS, asphyxia, malformations
Late sick with

hepatomegaly
Cardiac
Late sick with shock
Acidosis
Anytime
Pneumonia
Physical examination
Inspection is the first and most important tool
Apnea, poor perfusions, retractions, cyanosis
Inspiratory stridor upper airway obstruction

Stridor (previous history of intubation)
subglottis stenosis
Asymmetric chest movement + severe distress

maybe tension pneumothorax
Scaphoid abdomen diaphragmatic hernia

physical examination
Auscultation
Symmetry and adequacy of air exchange
Abnormal breaths sound
The presence of heart murmur

Chest transilumination to detect pneumothorax
Suspect surgical cause
Obvious malformation
Scaphoid abdomen
Frothing
History of aspiration
Differential diagnosis of
respiratory distress
Pulmoner (Respiratory diseases)
Extra Pulmoner:
Cardiac diseases
Neurological disorder
Other Miscellaneous Diseases
RESPIRATORY DISEASES
A. Airway Obstructions
Nasal Stenosis
Pierre Robins
Sequence
Vocal Cord
paralysis
Vascular Rings
Choanal Atresia
Laryngeal
stenosis or
atresia
Hemagloma
Tracheobrochial
stenosis
B. Disorders of the Chest Wall and Diaphragm
Disorders of
the chest
wall
Congenital
diaphragmatic
hernia
C. Malformation of the Mediastinum

and Lung Parenchyma
Congenital cystic
adenomatoid
malformation
Congenital
pulmonary
cyst
Neoplasms (teratomas,
mediastinal,
neurablastoma
Congenital
lobar
emphysema
Pulmonary
arteriovenous
malformations
Bronchopulmonary
sequestrations
D. Air Leak Syndromes
Pulmonary interstitial
emphysema
Pneumomediastinum
Pneumopericardium
Pheumoperitoneum
Pneumothorax
Pulmonary Parenchymal and

Vascular Disease
Lung Parenchymal Disease:
Pneumonia
Pulmonary edema
Transcient tachypnea
of newborn
Meconium aspiration
syndrome
Hyaline membrane disease
Congenital alveolar proteinosis
Persistent pulmonary
hypertension of the
newborn
Cardiac Diseases
A. Cyanotic
Transposition of great arteries

Total anomalous pulmonary venous return
Pulmonic stenosis
Ebsteins anomaly
Tetralogy of Fallot
Tricuspidal atresia
Severe congestive heart failure
B. Acyanotic
Hypoplastic left heart syndrome

Interrupted aortic arch
Critical aortic coarctation
Patent ductus arteriousus
Neurological Disorder
Birth Trauma
Intravenricular hemorrhage
Meningitis
Primary seizure disorder
Obstructed hydrocephalus
Hypoxic ischemic encephalopathy
Infantile botulism
Spinal Cord injury
Muscular diseases (myasthenia gravis, poliomyelitis)
Other Miscellaneous Diseases
Sepsis
Anemia or polycythemia
Hypo or hyperthemia
Hypo or hypernatremia
Hypoglycemia
Inborn errors of metabolism
Maternal medication (magnesium sulfate or
opiates) or drug abuse
Medical causes of respiratory

distress
Transient tachypnea of the newborn (TTN)

Hyaline membrane disease (HMD)
Meconium aspiration syndrome (MAS)
Air leak syndrome
Pneumonia
Congenital heart diseases
Surgical causes of respiratory

distress
Tracheo-esophageal fistula
Diaphragmatic hernia
Lobar emphysema
Pierre-Robin syndrome
Choanal atresia
Investigations
Complete blood count (anemia, polycythemia,

sepsis)
Chest X-ray
Arterial blood gas
Glucose check (hypoglycemia)
Blood culture (sepsis, pneumonia)
Treatment
After stabilization, treat the cause of respiratory

distress
Avoid unnecessary exposure to oxygen
Antibiotics until sepsis is ruled out
Transient Tachypnea of the

Neonate (TTN)
Respiratory distress of near term or term

neonate
Transient pulmonary edema resulting from
delayed clearance of fetal lung fluids
Pathogenesis
Lung fluids produce in utero by chloride pump

water and chlor to alveolar space
2-3 d before delivery transformation process
pulmonary epithelium changes to Na-absorbing
lung fluid away from alveolar space
Low oncotic pressure favors fluid movement
from alveolar space into the interstitium
pathogenesis
Prostaglandin secretion lymphatic dilation

accelerates fluid clearance from interstitium
Lung expansion water to interstitium
gradually remove from lung by the lymphatic
system and pulmonary blood vessels
Risk factors
Cesarean section without labor

Macrosomia
Male sex
Prolonged labor
Excessive maternal sedation
Low Apgar score (< 7 at 1 minute)
Clinical presentation
Tachipnea shortly after birth

May have grunting, nasal flaring, rib retractions,
and cyanosis
Symptoms improve as lung fluid mobilized, and
usually associated with diuresis
Full recovery expected within 2 to 5 days
Chest X-Ray
Increased interstitial markings and occasionally

fluids in the interlobar fissure
Pleural effusion and signs of alveolar edema
may be seen
Management
Oxygen therapy some infants may need

NCPAP
Feeding as tachypnea improves
Prognosis
Self-limited disease
There is no risk of recurrence or further
pulmonary dysfunction
Hyaline membrane disease=

Respiratory Distress Syndrome
Also called respiratory distress syndrome (RDS)

Usually occurs in a preterm neonate
Surfactant deficiency
Incidence
About 25% of neonates born at 32 weeks

gestation
The incidence increases with increasing
prematurity
Predisposing factors
Prematurity
Male sex
Neonate of diabetic mother
Asphyxia
Protective Factors
Chronic intrauterine stress
Prolonged rupture of membranes
Maternal hypertension
Narcotic use
Intrauterine Growth Retardation (IUGR) or

Small for Gestational Age (SGA)
Corticosteroids Prenatal
Clinical Manifestation
Increasing tachypnea (> 60/min)

Chest retractions
Cyanosis on room air that persists or progresses
over the first 24-48 hours of life.
Decreased air entry
Grunting
Investigations
Laboratory studies:
Blood gases: hypoxia, hypercarbia, acidosis

CBC and blood culture are required to rule out
infection
Serum glucose levels are usually low
Chest X-ray study:
Reveals ground glass appearance with air

bronchograms
Management
Resuscitation by experienced pediatric staff :
Prompt gentle stimulation and inflation to

produce and maintain the FRC by CPAP and
PPV
Give surfactant as soon as possible
Minimize heat loss

The Royal Womens Hospital, Clinicians Handbook, 2007
Surfactant therapy
Should be used only if facilities for ventilation

available
Cost
Prophylactic Vs Rescue
surfactant therapy
Prophylactic therapy
Extremely preterm
< 28 wks
< 1000 gm
Rescue therapy
Any neonate diagnosed to have RDS
Dose 100 mg / kg phospoholipid intra tracheal
Radiologic appearance
before and after surfactant
therapy
Transportation to NICU
After resuscitation transferred to NICU

without any deterioration
Keep warm and avoid hypoxemia by giving O2,
CPAP or IPPV as needed
Use pulse oximeter for adequacy of O2
Neonatal Respiratory Disorders 2nd ed, 2003, 247-71
transportation to NICU
If longer transport is needed
Neonatal transport team
Assisted ventilation preferred than CPAP
Adequate cardiorespiratory monitoring
Surfactant given before transportation
Stabilization needed after surfactant treatment

Stabilization on the NICU
Under radiant warmer not longer than 1-2

hours to place IV and arterial lines, and to do
CXR and abdominal X ray
After stabilization the infants should be placed in
humidified incubator
stabilization on the NICU

In the first hour organize :
A thermoneutral environment
Clear airway
Oxygen saturation 88-92% (not too high)
Maintain lung volume if recession CPAP or

PPV as necessary
Maintain adequate breathing or ventilation

Blood tests: arterial gases, full blood

examination, cultures, cross match
Chest X-ray
IV 10% dextrose to prevent hypoglycemia
Minimal handling
Dont feed

Respiratory support :
Head box (heated and humidified) if minimal
recession and FiO2 <30%
CPAP if recessing and FiO2 >30%

Consider PPV if FiO2 >60% and/or high and
rising PaCO2

Indications for insertion an arterial catheter :
O requirement >30%
2
Likely to require several blood gases

Blood pressure monitoring

Metabolic acidosis :
pH 7.25 and BE > - 8 with normal PaCO2
Treat underlying cause before bicarbonate,
eg hypoxia, hypotension, hypovolemia,
septicemia
Improve when the baby is ventilated

Use bicarbonate if other treatment dont work
and severe acidosis

Low blood pressure :
Not due to blood loss give 10-20 mL/kg of

normal saline over 30 min
If this does not work use dopamine
Blood loss is corrected by a similar volume

blood transfusion
Fluid management
Peripheral vein or umbilical vein

10% dextrose and calcium 60 mL/kg/day
Adjust fluid intake by assessing sodium and
glucose level
Keep blood glucose above 2.0 mmol/L
TPN on day 2 or 3 if respiratory distress persist
No oral feeds until minimal respiratory distress
fluid management
Radiant warmer and phototherapy IWL

PDA indication for fluid restriction
Diuretics are not recommended
Kavvadia V, et al, J Perinat Med 1998;26:469-74
Ventilatory support
CPAP and PPV reduce mortality in neonates

with RDS
CPAP should be used for baby with vigorous
spontaneous respiration (initial pressure 5-6 cm
H2O, sometimes higher pressure of 7-8 cm H2O
needed)
ventilatory support
IPPV should start at high rates (60-80/min), peak

pressure 20 cm H2O or less, inspiration time 0,3-0,4
seconds, PEEP levels 3 cm H2O (increased if RDS is
severe). Inspiratory time and ventilator rates should
be manipulated to have synchrony
Infants requiring mechanical ventilation may need
sedation with morphine
Suction is rarely needed early in the course of RDS
Halliday HL, Croatian Medical Journal 1998;39:165-70
ventilatory support
After surfactant therapy ventilator setting must

be adjusted downward
The lowest ventilator setting should be used to
reduce BPD
HFOV is not recommended as starting treatment
for infants with RDS
Adequate humidification of inspired gases is very
important
Handerson-Smart DJ, et al, The Cochrane Library, Issue 1, 2003
Nasal CPAP
Sudden deterioration in
ventilated infant
Pneumothorax
Endotracheal tube blockage or displacement
Mechanical failure with the ventilator
Increase severity of underlying lung disease
Massive intraventricular haemorrhage
Abdominal distention
Pulmonary haemorrhage
Complications
Air leaks
Pulmonary hemorrhage
Periventricular hemorrhage
Patent ductus arteriosus
Chronic lung disease
Retinopathy of prematurity
Subglottic stenosis
Meconium aspiration syndrome

(MAS)
Respiratory distress due to aspiration of meconium
by the fetus in utero or by the neonate during
labor and delivery
MSAF :
10-26% of all deliveries
mostly in term and postterm deliveries
may represent fetal hypoxemia
Pathogenesis
Aspiration of meconium
Airway obstruction (ball and valve)
Chemical pneumonitis with activation of several
inflammatory mediators
Inactivation of lung surfactan
pathogenesis
Aspiration of meconium
Thin MSAF chemical pneumonitis

Thick MSAF atelectasis, airway blockage, airleak
syndrom
Risk factors
Post-term pregnancy
Maternal hypertension
Abnormal fetal heart rate
Biophysical profile 6
Pre-eclampsia
Maternal diabetes mellitus
SGA
Chorioamnionitis
Clinical presentation
Meconium stain amniotic fluid before birth

Meconium staining of neonate after birth
Varying degree of respiratory distress; barrel
chest; audible rales
Persistent pulmonary hypertension of the
newborn
Pneumotorax (10%-20% infants with MAS)
Laboratory Studies
Complete blood count

Blood gas analysis
Blood culture
Chest X-Ray
Patchy areas of atelectasis alternating with

areas of overinflation
Hyperinflation of the lung and flattening of the
diaphragm
Management
Prenatal management
Identification of high-risk pregnancy
Monitoring of fetal heart rate during labor
management
Delivery room management
Suction infants mouth, pharinx and nose as

soon as complete delivered
Placed under radiant warmer suction the

hypopharinx to clear any residual meconium
Depressed infants (depressed respiration, HR <
100 beat / min, poor muscle tone) tracheal
visualization and suctioning should be performed
management
General management
Empty the stomach contents to avoid further

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

Pulmonary toilet to remove residual meconium if
intubated
Antibiotic coverage
Ventilatory support
ECMO
Prognosis
Mortality rate may be as high as 50%.

Survivors may suffer from bronchopulmonary
dysplasia and neurologic sequelae.
Air leak syndromes

Spectrum of diseases with the same underlying
pathophysiology :
Overdistension of alveolar space or terminal
airways
Disruption of airway integrity
Dissection of air into surrounding spaces
Incidence
Most common in neonates with lung disease

who are on ventilatory support but can also
occur spontaneously
The more severe the lung disease, the higher
the incidence of pulmonary air leak
Risk Factors
Spontaneous 0.5%
Ventilatory support 15-20%
CPAP 5%
Meconium staining / aspiration
Surfactant therapy
Vigorous resuscitation (bag ventilation)
Clinical manifestation
Respiratory distress
Sudden deterioration of clinical course with

alteration of vital signs and worsening of blood
gases
Asymmetry of thorax is present in unilateral

cases
Investigations
The definitive diagnosis of all air leak syndromes

is made radiographically by A-P and lateral
chest X-ray.
Management
General
Avoid ventilators
Careful use of manual bag ventilation

Specific
Decompression of air leak according to the type.
Do not needle the chest

Congenital and postnatal

pneumonia
Developing countries pneumonia > 50% cases
of respiratory distress
Term and post term primary pneumonia
because of prenatal aspiration due to fetal
hypoxia as a result of placental disfunction
Preterm postnatal pneumonia as consequence
os septicemia, aspiration of feeds and ventilation
for respiratory failure
Clinical Manifestation
Tachipnea, respiratory distress with subcostal

retractions, expiratory grunt and cyanosis
Lethargy, poor feeding, jaundice, apneic attacks,
temperature instability
Cough rare in newborn baby
Management
Supportive treatment should be provided
Thermoneutral environment
NPO IV fluids given
Oxygen given to relieve cyanosis
Antibiotics started
Congenital pneumonia
PROM > 24 hours, foul smelling liquor, peripartal

fever, prolonged / difficult delivery, single or
multiple unclean vaginal examination
Respiratory distress soon after birth / during
first 24 hours
Auscultation non spesific
Congenital pneumonia
Nosocomial pneumonia
Risk factor
Prevention
Antibiotics
: Ventilated neonates
: Preterm neonates
: Hand wash
: Use of disposables
: Infection control measures
: Usually require higher
antibiotics
Congenital heart disease
May present with cyanosis and heart failure

CHD and pulmonary disease can coexist
Differentiation between heart and lung disease
are cumulative
Clinical manifestation
Visible hyperactive precordial impulse

Gallop rhythm
Poor capillary refill
Weak pulse
Decreased / delayed pulse in lower extremities
Hepatomegaly
Abnormal vascularity or cardiomegaly on CXR
clinical manifestation
Single second heart sound

No hypercapnia unless associated with lung
disease
Tachypnea is common; no chest retraction
Decreased oxygen saturation
Hyperoxygenation test no significant increase
in PaO2 in most infants with cyanotic CHD
Cyanotic Heart Disease

History
Physical
findings
Arterial Blood
Gases
Pulmonary Disease
Previous sibling who has CHD Maternal fever

Diagnosis of CHD by prenatal
Meconium stained amniotic
ultrasonography
fluid
Preterm delivery
Cyanosis
Gallop rhythm
Single second heart sound
Large liver
Mild respiratory distress
Cyanosis
Severe retraction
Split second heart sound
Fever
Normal or decreased PCO2
Decreased PO2
Increased PCO2
Decreased PO2
Cyanotic Heart Disease Pulmonary Disease

Chest
Radiograph
Hyperoxyge
nation test
Echocardio
graphy
Increased heart size

Decreased pulmonary
vascularity (except in
transposition of the great
vessels and total anomalous
pulmonary venous return)
PaO2 < 150 mm Hg
Abnormal heart or vessels
Normal heart size

Abnormal pulmonary
parenchyma, such as :
Total whiteout or patches of

consolidation in pneumonia
Fluid in the fissures in TTN
Ground glass appearance in HMD
PaO2 > 150 mm Hg (except in

severe PPHN)
Normal heart and vessels
Respiratory distress needing

referral
RDS (HMD)
MAS
Surgical or cardiac cause
PPHN
Severe or worsening distress
Apnea
Cessation of respiration for more than 20

seconds or less than 20 seconds accompanied
by bradycardia and / or cyanosis
Incidence
50-60% of preterm neonates have evidence of

apnea (35% with central apnea, 5-10% with
obstructive apnea, and 15-20% with mixed
apnea)
Risk factors
Pathological apnea
Hypothermia
Hypoglycemia
Anemia
Hypovolemia
Aspiration
NEC / Distension
Cardiac disease
Lung disease
Gastro intestinal reflux
Airway obstruction
Infection, meningitis
Neurological disorders
Investigations
Monitoring at-risk neonates less than 32 weeks

gestational age
Evaluate for a possible underlying cause
Laboratory studies should include a CBC, blood
gas analysis, serum glucose, electrolyte, and
calcium levels
Radiologic studies if lung disease is suspected
Management
General management :
Tactile stimulation
Pharmacological therapy (caffeine or

theophylline)
CPAP in recurrent and prolonged apnea
management
Specific therapy
Treatment of the underlying diseases, eg sepsis,
hypoglycemia, anemia, and electrolyte
abnormalities
Prognosis
In most neonates apnea resolves without the

occurrence of long-term deficiencies
Summary
1. Evaluate the severity of respiratory distress using
the Downe's Score
2. Identify common neonatal respiratory disorders,
including:
Transient Tachypnea of the Newborn (TTN)

Respiratory Distress Syndrome (RDS)
Meconium Aspiration Syndrome (MAS)
Air leak syndromes
Apnea
Pneumonia
summary
3. Identify the risk factors, clinical presentation,
required laboratory and radiological
investigations, and management of TTN, RDS,
MAS, Air Leak Syndromes, Pneumonia, Apnea
Hyaline Membrane Disease

(Respiratory Distress Syndrome)
(cont)
Management of HMD (RDS)
General
Thermal regulation
Parenteral fluid
Antibiotics
Continuous monitoring

(cont)
Continuous positive airway pressure (CPAP) is
tried.
If under CPAP
PH < 7.2
Or PO2 < 40mmHg
Or PCO2 > 60mmH
Base deficit > -10
FiO2 > 60%
Endotracheal intubation and mechanical ventilation.

Consider surfactant therapy

(cont)
Caution: every 10 days on the ventilator is

associated with 20% increased risk for
cerebral palsy

(cont)
Specific Treatment
Surfactant replacement therapy if tracheal

intubation is required
Outcome
RDS accounts for 20% of all neonatal deaths

Chronic lung diseases occurs in 29% in VLBW
infants
Causes of Respiratory Distress

- Medical
Respiratory distress syndrome (RDS)

Meconium aspiration syndrome (MAS)
Transient tachypnoea of newborn (TTN)
Asphyxial lung disease
Pneumonia-congenital, aspiration, nosocomial
Persistent pulmonary hypertension (PPHN)
Guidelines for early management

of RDS (Advances in Perinatal Medicine, 1997, 360-70)
Gestational Age (Weeks)
< 28
Especially if no
antenatal
steroids, known
lung immaturity,
male sex and
need for
intubation in
resuscitation
Consider if no
antenatal
steroids, lung
immaturity,
male sex, and
need for
intubation in
resuscitation
Prophylaxis
28 - 31
32
When needing
IPPV and > 3040% oxygen
Rescue
MANAGEMENT
Delivery room management

Surfactant treatment
Ventilatory support
General supportive care
Prophylactic surfactant
Surfactant is given within 10-15 minutes of birth

Recommended only for infants of less than 2728 weeks of gestation
Egberts J, et al, Pediatrics 1983;102:912-7
Early rescue surfactant
Infants > 32 weeks gestation, early rescue is

recommended if endotracheal intubation needed
At GA between 28-31 weeks CPAP is
recommended with surfactant given as soon as
intubation is needed
In resuscitating infants 23-31weeks of gestation,
surfactant must be available in delivery room
Surfactant to those under 27-28 weeks GA

In reserve for those who need intubation
Rescue surfactant
Surfactant given based on severity of RDS

assessed by clinical signs, blood gas result and
CXR
Surfactant given earlier rather than later
improves outcome and extubation to CPAP will
add advantages
Natural surfactants are preferred
2nd and 3rd doses are indicated if relapse
Verder H, et al, Pediatrics 1999;103:E24
Conditions Associated with

Respiratory Distress
Introduction
Respiratory distress
encountered frequently
the most frequent indication for re-evaluation

Potentially life-threatening conditions
Early recognition, timely referral, appropriate
treatment essential
Chest examination
Air entry
Mediastinal shift
Hyperinflation
Hearts sounds

Antibiotics :
Start with IV antibiotics soon after birth in every
baby with respiratory distress because we cant
tell whether there is pneumonia / septicemia
Respiratory distress in a neonate

with asphyxia
Myocardial dysfunction
Cerebral edema
Asphyxial lung injury
Metabolic acidosis
Persistent pulmonary hypertension
Persistent pulmonary
hypertension of the newborn
Causes
Primary
Secondary: MAS, asphyxia, sepsis

Management
Severe respiratory distress needing

ventilatory support, pulmonary vasodilators
Poor prognosis

Respiratory Disorder IDAI 101207

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Respiratory Disorders

Aly H, Pediatrics in Review 2004;25:201-208

Complete maternal and newborn history

Complete physical examination

Recognize the common respiratory disorder

Differentiate among various diagnostics entities

Identify those that are life-threatening

Tachipnea (RR > 60/min)

Aly H, Pediatrics in Review 2004;25:201-208

Obstructed airway (gasping, choking,stridor)

Insufficient breathing (apnea, poor respiratory

Circulatory collapse (bradycardia, hypotension,

Poor oxygenation (cyanosis)

Possibly bag and mask ventilation

Even intubation and mechanical ventilation

Aly H, Pediatrics in Review 2004;25:201-208

Resuscitation equipment and supplies

Senior physicians and other health care team

Resuscitation guideline should be followed in

Aly H, Pediatrics in Review 2004;25:201-208

Aly H, Pediatrics in Review 2004;25:201-208

Gestational age (if preterm steroid ?)

Results of fetal assesment and fetal monitoring

Complications at delivery birth trauma,

Coughing and choking during feeding

Gradually improving symptoms TTN

Preterm- Possible Etiology

Hyaline membrane disease

Term- Possible Etiology

Early severe distress

MAS, asphyxia, malformations

Late sick with

Late sick with shock

Apnea, poor perfusions, retractions, cyanosis

Inspiratory stridor upper airway obstruction

Asymmetric chest movement + severe distress

Scaphoid abdomen diaphragmatic hernia

Symmetry and adequacy of air exchange

Abnormal breaths sound

The presence of heart murmur

Aly H, Pediatrics in Review 2004;25:201-208

B. Disorders of the Chest Wall and Diaphragm

C. Malformation of the Mediastinum

D. Air Leak Syndromes

Pulmonary Parenchymal and

Transposition of great arteries

Hypoplastic left heart syndrome

Other Miscellaneous Diseases

Medical causes of respiratory

Transient tachypnea of the newborn (TTN)

Surgical causes of respiratory

Complete blood count (anemia, polycythemia,

After stabilization, treat the cause of respiratory

Aly H, Pediatrics in Review 2004;25:201-208

Transient Tachypnea of the

Respiratory distress of near term or term

Aly H, Pediatrics in Review 2004;25:201-208

Lung fluids produce in utero by chloride pump

Prostaglandin secretion lymphatic dilation

Aly H, Pediatrics in Review 2004;25:201-208

Cesarean section without labor

Tachipnea shortly after birth

Increased interstitial markings and occasionally