Respiratory Emergencies in the Neonate

Question 1

Signs of respiratory distress?

Answer 1

High RR (>60) o Laboured breathing Beware retinopathy of prematurity if on high O2 levels

Chest wall recessions

Nasal flaring

Expiratory grunting (PAP)

Cyanosis (if severe)

Question 2

What is Transient Tachypnoea of the Neonate (TTN)?

Answer 2

Most common cause of respiratory distress in term infants

short -lived <48 hours, rapid breathing.

due to delay in resorption of lung fluid

Question 3

Investigations for TTN?

Answer 3

Cyanosis, high RR (i.e. >60)

CXR → fluid in horizontal fissure

Diagnosis made after exclusion of other causes

Question 4

Management for TTN?

Answer 4

Usually settles within first day of life

Additional O2 if required

Question 5

What is persistent pulmonary hypertension?

Answer 5

life threatening condition due to high pulmonary vascular resistance - right to left shunting within the lungs.

associated with birth asphyxia, meconium aspiration, septicaemia, RDS

Question 6

Signs and symptoms of persistent pulmonary hypertension?

Answer 6

Cyanosis after birth

Absent heart murmurs and signs of HF

Question 7

Investigations for persistent pulmonary hypertension?

Answer 7

CXR - normal sized heart but some pulmonary oligaemia

o Echocardiogram (urgent) = ensure no cardiac defect

Question 8

Management of persistent pulmonary hypertension?

Answer 8

Medications:

§ O2

§ NO (inhaled)

§ Sildenafil

o Ventilation:
Mechanical ventilation / circulatory support

High-frequency (oscillatory) ventilation

(SEVERE) Extracorporeal membrane oxygenation (ECMO) ± heart and lung bypass

Question 9

What is Chronic Lung Disease of Prematurity (CLD)?

Answer 9

• When infection, barotrauma or iatrogenic injury causes chronic lung problems
• lung damage due to pressure and volume trauma from artificial ventilation, O2 toxicity

more common in premature infants, with low birthweight or gestational age

Question 10

Signs and symptoms of CLD?

Answer 10

23-26weeks progresses from ventilation to CPAP to supplementary O2.

initially positive response but then an increase in O2 and ventilation requirements

barotrauma or iatrogenic injury causes chronic lung problems

Question 11

Investigations for CLD?

Answer 11

CXR à widespread opacification

CBG or VBG à acidosis, hypercapnia, hypoxia

Question 12

Management of CLD?

Answer 12

Respiratory support = prolonged artificial ventilation à wean to CPAP à wean to additional O2

(±) Corticosteroid therapy – dexamethasone for short term clinical improvement (limit use due to concern about abnormal neuro development and other adverse effects)

Question 13

What is Respiratory Distress Syndrome?

Answer 13

Deficiency of surfactant (phospholipids and proteins produced by type II pneumocytes)

Question 14

Who is at risk of RDS?

Answer 14

Common if born <28w gestation

50% born 26-28w
25% born 30-31w

male, diabetic mothers

Question 15

Signs and symptoms of RDS?

Answer 15

Delivery (up to 4 hours)

High RR (>60)
Laboured breathing with recessions and nasal flaring
Expiratory grunting (baby trying to make +ve airway pressure)
Cyanosis (if severe)

Question 16

Investigations for RDS?

Answer 16

Clinical diagnosis
Pulse Oximetry
CXR -> pneumothorax, ground-glass, indistinct heart border

Question 17

Management for RDS?

Answer 17

Antenatal:
Steroid therapy (delivery <34w)
Tocolytic therapy so steroids have at least 24 hours to work

Postnatal:
O2 and ventilation
CPAP or artificial ventilation

Question 18

What is a pneumothorax and what causes it in a newborn?

Answer 18

A collapsed lung

Due to RDS or ventilation used to treat RDS.

Question 19

What can pneumothorax lead to in the newborn?

Answer 19

pulmonary interstitial emphysema - collection of air outside the alveoli, due to alveoli rupture

Question 20

What is meconium aspiration and ileus?

Answer 20

respiratory distress in the newborn due to presence of meconium in trachea - mechanical obstruction –> pneumonia/infection

increased risk the greater age

Question 21

Risk factors for MA?

Answer 21

GA >42 weeks
fetal distress/hypoxia
meconium stained amniotic fluid
maternal history of smoking/substance abuse
oligohydroamnios
chorioamniotis

Question 22

Signs and symptoms of MA?

Answer 22

Respiratory distress – increased RR, chest retraction and hypoxia

Question 23

Investigations of MA?

Answer 23

CXR

FBC/CRP/Culture

Question 24

Management of MA?

Answer 24

Observe
IV ampicillin/gentamicin
O2 and NIV

Question 25

What is meconium ileus?

Answer 25

thick sticky meconium that hasnt passed within 24 hours

child may vomit it rather than passing through stool

associated with cystic fibrosis and biliary atresia.