Respiratory Assessment of Neonate Flashcards
Spontaneous Parameters of Neonate
RR: 40-60
Vt: 5-7
Vd/Vt: 0.3
FRC: 30
Resistance: 25-50
Compliance: 1-2
Neonate Respiratory Anatomy Compared to Adult
Anteroposterior transverse diameter ratio
Neonate: 1:1
Adult: 1:2
Neonate Respiratory Anatomy Compared to Adult
Angle of mainstream bronchi
Neonate: 10 degree to the right and 30 degrees to the left
Adult: 30 degrees to the right and 50 degrees to the left
Infant has a higher degree of curvature and are less prone to right lugnintubation also the trachea is shorter which is why they are so easy to extubate
Neonate Respiratory Anatomy Compared to Adult
Compliance of Trachea
Neonate: Compliant, fleixble
Adult: Noncompliant
Neonate Respiratory Anatomy Compared to Adult
Level of Trachea Bifurcation
Neonate: T3-4
Adult: T5
Neonate Respiratory Anatomy Compared to Adult
Shape and Location of Epiglottis
Neonate: Long/C1
Adult: Flat C4
large and floppy epiglottis (in infants we are using the miller blade to help move the large floppy epiglottis).
Neonate Respiratory Anatomy Compared to Adult
Narrowest Portion of Upper airway
Neonate: Cricoid Cartilage
Adult: Rima Glottidis
Cricoid cartilage is the narrowest part of the airway and is shaped in a funnel shape.
Neonate Respiratory Anatomy Compared to Adult
Laryngeal Shape
Neonate: Funnel Shape
Adult: Rectangular
Laryngeal soft tissue and lymph nodes which meakes them more susceptible to swelling and injury.
Neonate Respiratory Anatomy Compared to Adult
Tongue Size
Neonate: Large
Adult: Porportional
Largetongue with small mouth which makes it easy to cause an obstruction and is more difficult to navigate around it with a laryngoscope.
Neonate Respiratory Anatomy Compared to Adult
Head/Body Ratio
Neonate: 1:4
Adult: 1:8
Neonate Respiratory Anatomy Compared to Adult
Body Surface Area/Body Size Ratio
Neonate: 9 x adult
Large heart and belly- increase impedance for tidal volume as the heart is taking up more room
Adult: Normal
Neonate Respiratory Anatomy Compared to Adult
Location of Heart
Neonate: Center of chest midline
Adult: Lower portion of chest left of midline
Neonate Respiratory Anatomy Compared to Adult
Resting Poistion of Diaphragm
Neonate: Higher than adult
Adult: Normal
Neonate Respiratory Anatomy Compared to Adult
Thoracic Shape
Neonate: Bullet shaped
Adult: Conical shaped
Respiratory Anatomy and Sniffing Position
Large occipital which makes it harder to get the baby in sniffing position (best way is to put a small blanket under their shoulders or even just use your hand),
Sniffing position is very important becase the airway is easy to coallpse
Neonates Aspiration Risk
Airway and trachea more anterior and superior which puts them on a greater risk for aspiration and difficult intubation
Smaller trachea making it easier for stuff to get stuck in there
Obligated nose breathers so when they get an infection with a stuffy nose their nose will occlude quicker and will have to be stimulated to breath
Neonatal Compliance
Morecompliant chest wall because the cartilage under developed which will create high airway resistance in upper airway and more collapse in the lower airway (so when it comes out easier it will also collapse inwards easier
Accessory muscle are under developed so they are more susceptible to failure
Infant Trachea and Carina
Infant trachea is 4 mm wide; adult trachea is 16 mm wide
Carina is higher (3rdvertebrae), T4/5 by age 10
Infant airway is more funnel shaped, narrowest point is cricoid
Infant epiglottis is OMEGA Ω shaped, less flexible, more horizontal
Infants have poor neck flexion = higher obstruction risk
Infants have large tongue with posterior placements and larger amounts of lymph tissue = higher obstruction risk
Respiratory Failure
- CO2 production is higher than adults and, so if baby/child is working harder to breathe than normal, they will tire out faster than an adult
- Metabolic rate is twice as high as adults
- O2 consumption is much higher than in adults, so hypoxemia effects will be more profound
- Respiratory failure will occur much more quickly in an infant than in an adult
- If infant goes hypoxemic it will be very profound and very quick
- Infants tend to have smaller FRC’s than adults, so airway closure can occur more quickly creating shunting
Respiratory distress in the neonate
- Observed prior to birth via fetal monitoring strip, scalp pH, heart rate:
- Distress = profound bradycardia, late decelerations, variable decelerations, loss of normal heart rate variability, scalp pH less than 7.15
- Allows for preparation for resuscitation
- Observedafter delivery via rapid assessment:
- Assessment of the neonate commences as soon as baby presents…inspection!
Questions at the Time of Delivery
- Expected gestational age
- Clear amniotic fluid
- Singleton or…?
- Other risk factors
Rapid Assessment at Delivery
Inspection
- Color
- Tone / movement (active, flexed extremities vs flaccid, extended extremities)
- WOB/ respiratory distress (gasping vs vigorous cry)
- Presence of Meconium
- RR [absent, too fast, too slow, depth]
Rapid Assessment at Delivery
Routine
Infants who meet the following four criteria generally will not require resuscitation and can be quickly dried, placed on the mother’s abdomen, and covered with dry, warm linen to maintain temperature
–Infants born at full-term gestation
–Amniotic fluid clear with no evidence of infection
–Crying or normal breathing
–Good muscle tone
APGAR Scores
- Used to assess infants at
- 1 and 5 minutes…
- Will continue to be done q 5 minsuntil the baby is 7 or greater
- Best use: reflective indication of fetal well being at time of delivery and the efficiency of interventions
- Does not guide the resuscitation, rather it is a means of gauging the effectiveness of the resuscitation
APGAR Scores Limintations
–Only gives snapshot of that particular instant
–Does not always reflect the clinical situation
–No substitute for clinical history – high risk etc.
–Will notdictate survival of the infant
APGAR Scoring
Heart Rate
- Absent (Score 0)
- <100 bpm (Score 1)
- >100 bpm (Score 2)
Respiratory Effort
- Absent (Score 0)
- Gasping, irregular (Score 1)
- Good (Score 2)
Muscle Tone
- Limp (Score 0)
- Some Flexion (Score 1)
- Active Motion (Score 2)
Reflex Irritability
- No Response (Score 0)
- Grimance (Score 1)
- Cry (Score 2)
Color
- body pale or blue, extremities blue (Score 0)
- Body pink and extremities blue (Score 1)
- Completely pink (Score 2)
Determine Gestational Age
- Neonatologists post stabilization in order to confirm gestational age if uncertain
- 2 common scales used criteria measuring from 26 to 42 week:
- Dubowitz: 11 score
- Ballard: 6 neuromuscular & 6 physical maturity scores able 12 s (a revision of the Dubowitz)
- Both use a system of neuromuscular assessments and physiological observations relating to gestational age
- Most reliable in assessing babes earlier than 26 weeks gestation if done ASAP (before 12 hours of age)
Signs & Symptoms of Respiratory Distress in the Neonate
- Retractions
- Intercostal, suprasternal, substernal (xiphoid)
- Grunting
- Nasal flaring
- Increasing oxygen requirements
- Cyanosis
- Tachypnea
- RR > 60 bpm
Silverman Index
The Silverman Index is a good method of evaluating respiratory distress in the neonate.
Rooting Reflex
Stroke the lip and corner of the cheek with a finger and the infant will turn in that direction and open his mouth
Blink Reflex
Blink: Tap gently on the forehead and the eyes will blink
Head Lag Reflex
Head Lag: Lift the babe by the arms and observe head position for head control
Startle Reflex
Startle: Loud noise and observe response – babe should startle
Grasping Reflex
Grasp: babe should grab a finger with full hand
Cranial Nerve Reflex
Cranial Nerves:Reaction of the pupils and the ability of the infant to follow objects with its eyes
Movement Reflex
Movement: Spontaneous movement of limbs, trunk, face, and neck should be observed. Tremors are normal but clonic movements are associated with seizures
Moro Reflex
Moro: if babe “feels” it is falling
- Spread arms (abduction)
- Unspreadarms (adduction)
- cry
Neurological Expectations of a Newborn
•Gestational age 28 weeks:
–Can be awoken from sleep and can stay awake for a few minutes
–Flicker eye movement in response to light
–Active
Neurological Expectations of a Newborn
•Gestational age 38 weeks:
–Can self-wake and can stay awake and alert for long periods
–Responds to stimulation like light and sound
–Can smile
–Active with good gross motor function
–Cries for food, mommy, snuggles, sleep, diaper issues, discomfort
–Can express pain
