Respiratory Disorders of the Neonate Flashcards by Bianca Munteanu

What are the Major Categories of Neonatal Adaptation?

Respiratory Transition
Cardiovascular Transition
Thermal & Metabolic Transition

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What are the normal vital signs for a term newborn?

Heart Rate - 100-160 bpm
Respiratory rate - 30-60 breaths per min
Temperature - 36.5-37.5 C
Length - 49-53 cm
Head circumference - 32-38 cm

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What is the normal transition?

First period reactivity (0-30mins post birth)
Decreased Responsiveness (30mins-3hrs)
Second period of reactivity (2-8hrs)

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What happens in the First period reactivity?

increased heart rate, irregular reps, fine crackles on auscultation of breath sounds

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What happens in decreased responsiveness?

decrease heart rate, shallow rapid reps, decreased muscle activity & sleep myoclonus

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What happens in the second period reactivity?

Exaggerated responsiveness; labile; HR, tone, colour; Gagging/vomiting

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What residual symptoms of transition may persist for up to 24 hours?

Crackles (auscultation of breath sounds)
Soft cardiac murmur
Acrocyanosis (24hr max.)
Tachypnoea
Tachycardia

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What are major respiratory disorders of the neonate?

TTN
RDS
MAS
PH
PPHN
BPD
Pulmonary Air Leaks
SUPC?

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What are the 4 stages of lung development?

Pseudoglandular Stage
Cannalicular
Saccular
Alveolar

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What is the pseudoglandular stage?

6-16 weeks
Subdivision to form bronchial tree

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What is the cannalicular stage?

16-28 weeks
terminal and respiratory bronchial develop
development of Type 1 and Type 2 ( endogenous surfactant synthesis)
Pneumocytes

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What is the saccular stage?

28-36 weeks
further branching of bronchioles
terminal sacs develop forming bunches of primitive alveoli

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What is the alveolar stage?

36 weeks - 2 years
pulmonary fluid is absorbed after birth
air/liquid interface (facilitated by surfactant) forms alveolar lining
surface tensions minimised - alveolar expansion

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What are the signs and symptoms of problems in transition?

respiratory distress –> tachypnoae, grunting
Extrapulmonary signs;
central cyanosis
sort cardiac murmur
baby seems “shocked”
pallor
delayed capillary refill
slightly hypotonic, mild head lag, absent moro reflex
low mean BP
seizures
hypoglycaemia
hypertonia
tachycardia
hypothermia

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What is TTN?

Transient Tachypnea of the Newborn
Delayed clearance of foetal lung fluid

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What is the management for TTN?

if infant is stable with sats >90% in RA, place in incubator in the delivery suite or PN ward and observe for one hour
if symptoms persist after one hour or sats are <90% at initial assessment or infant looks unwell –> admit to neonatal unit

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What does TTN look like?

Classic “streaky” appearance –> “wet lungs”
absence of “thoracic squeeze” - premature birth, precipitous birth, LSCS
retained fluid = bronchial collapse, areas of air trapping, hyperinflation
poorly ventilate alveoli leads to hypoxemia

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What is RDS?

Respiratory Distress Syndrome
pulmonary/lung insufficiency
disease of structural immaturity of the lung and deficiency of alveolar surfactant
condition of increasing respiratory distress, commencing at or shortly after birth, increasing in severity until progressive resolution occurs among survivors, usually between the 2 and 4 day

What was RDS previously called?

HMD “hyaline membrane disease”

How to prevent RDS?

the risk of respiratory morbidity is increased in babies born by CS before labour, but this risk decreases significantly after 39 weeks.
therefore planned CS should not be carried out before 39 weeks

What are the predisposing factors of RDS?

prematurity
type of delivery …?
male sex (2-3:1) females at lower risk
maternal diabetes
acute perinatal hypoxia-ischaemia
race: Caucasian infants at higher risk and experience greater severity
multiple pregnancy with increased risk with 2nd town
choriomnionitis
asphyxia at birth (hypoxia, acidosis)
hypothermia
familial predisposition: surfactant protein B deficiency

How to prevent RDS?

mother at high risk should be transferred to a perinatal centre
single course of prenatal steriods should be given if threatened preterm labour from 23-34 wks gestation
antibiotics should be given to mothers with PPROM

How do you identify respiratory distress?

tachypnoe
nasal flaring
sternal recession
intercostal
grunting
apnoea
peripheral oedema

What does RDS look like?

ground glass or whiteout appearance
atelectasis = complete or partial collapse of a lung or lobe of a lung … collapsed alveoli

What is the treatment of RDS?

Oxygen CPAP/High flow/mechanical ventilation surfactant replacement supportive care

What are the goals of CPAP therapy?

to improve oxygenation decrease work of breathing (WOB) promotion of the FRC and gas exchange increase lung volumes avoid intubation

When should surfactant therapy be given?

babies with RDS should be given this almost all babies <27 wks gestation increased WOB on high flow/CPAP/ invasive ventilation requiring greater that 30% oxygen signs of worsening respiratory acidosis on the cap blood gas analysis maternal course of steriods given

What nursing care and management should be given in NNU

usually supportive supplemental oxygen IV fluids if marked tachypnoea present minimal handling parental bonding colostrum for comfort oral care & trophic feeding Neonatal Iniviualised Developmental Care and Assessment Programme (NIDCAP) pain relief, comfort support of parents is vital

What is SUPC?

Sudden Unexpected Postnatal Collapse “a term or near-term infant who is well at birth, assigned to routine postnatal care and who collapses unexpectedly within the first 7 days of life, requiring resuscitation with intermittent positive pressure ventilation, and who either dies, requires ongoing intensive care or develops an encephalopathy”

What are the 3 sub-categories of SUPC?

1. unrecognised, underlying pathology 2. suggestion of accidental suffocation 3. no cause can be determined

What do you do if the infant is discovered limp, not breathing, cyanosed or pale?

initiate resuscitation while calling for help parents to be regularly debriefed by paediatric team ongoing care depends on outcomes of resuscitation care may include TH, ventilation, or palliative care

How to prevent SUPC

improve awareness staff training unobtrusive surveillance ?value of continuous O2 sat monitoring; regular early warning system scoring

What is MAS?

Meconium Aspiration Syndrome “respiratory distress in an infant that has been born through meconium stained amniotic fluid (MSAF) whose symptoms cannot otherwise be explained”

Is suctioning of meconium-stained liqour from baby's nose & mouth recommended?

What is meconium composed of?

intestinal epithelial cells solids (vernix, lanugo, squamous cells) mucus, blood, minerals lipids intestinal secretions (bile salts, pancreatic and liver enzymes) water (85-95%)

What is the pathophysiology of MAS?

intrauterine distress can stimulate peristalsis and relaxation of the anal sphincter releasing meconium into the amniotic fluid meconium introduced into the lungs as a result of subsequent fetal gasping

What are the MAS NICU Nursing Care Priorities?

inotropic support monitor for and treat seizure activity monitor fluid and electrolyte requirements sedation antibiotic cover physiotherapy nutrition maintaining airway function skin care care and support of parents minimal handling

What long term neurological defects from MAS?

hypoxia seizure activity severe asphyxia

What is Pneumothorax?

“… if a baby fails to improve despite resuscitative measures or suddenly develops severe respiratory distress.”

What are symptoms of pneumothorax?

pallor tachypnoea cyanosis increase in oxygen requirements unequal chest movements

What does Pneumothorax look like?

"air leak" air in the pleural space

What causes Pneumothorax?

from rupture of alveoli secondary to high inspiratory pressure needed to expand previously uninflated lungs from uneven distribution of inflating pressures among alveoli

What is conservative treatment in Pneumothorax?

admit to SCBU/HDU continous monitoring of vital signs administer O2 if required via nasal prongs lie baby on affected side, or prone and elevate head minimal handling SSC to reduce stress and crying NG feeding/IV fluids and trophic feeding