RSPT 2353 Neonatal and Pediatric Respiratory Care

Neonatal Assessment and Examination

ObjectivesAt the conclusion of this class the student will

understand:• Antenatal/PerinatalAssessment of the neonate• NRP procedures for the Resuscitation of the newborn

and neonate• Apgar Score assessment parameters• Perinatal and intrapartum monitoring of the neonate• Routine stabilization of the newborn in L and D• Potential abnormalities of the neonate• Risk factors for High Risk Deliveries• Examination and assessment of the pediatric patient• Differences between neonate and pediatric

assessment

Antenatal Assessment of the Newborn

Assessment of the newborn begins before the actual delivery, with the mothers history

• Maternal history- Term of pregnancy (pre/post term)- Incompetent cervix- Toxic habits during pregnancy- Hypertension and diabetes Mellitus- Infectious diseases- Placenta, Umbilical Cord and Fetal Membranes- Disorders of amniotic fluid volume

Antenatal Assessment of the Newborn

Assessment of the newborn begins before the actual delivery

• Several procedures and monitoring techniques are used to assess the fetus in-utero- Ultrasound- Amniocentesis- Non-stress test and Contraction Stress test; Fetal Heart rate monitoring- Fetal Biophysical Profile see pg. 26

Intrapartum Monitoring

During complicated, high risk delivery labor it is typical to monitor for

Fetal Heart Rate to assess the status of the fetus prior to birth- Decelerations (variable or late “decels”) of the fetal heart rate indicate hypoxia or acidemia that are clinically significant

Scalp Blood pH are drawn with severe variable or late decels and more precisely defines the immediate risk to the fetus. If > 7.25 forceps or C-section may be avoided

High-Risk ConditionsRisk factors for preterm delivery include• Previous preterm delivery• Premature rupture of membranes PROM• Maternal genital infections• Non genital infections• Chorioamnionitis (infection of fetal membranes or

amniotic fluid)• Conditions that over-distend the uterus

- Multiple gestations- Polyhydraminos

• Placental conditions• Abnormalities of the cervix• Fetal anomalies• Incompetent cervix

Preterm LaborPreterm labor is defined as labor before 37 weeks

of gestational age. It complicates around 8% of pregnancies and is associated with significant neonatal morbidity including

• Sepsis NEC• RDS Visual and hearing dysfunction• IVH Cerebral palsy• ROP• BPDThe lower the gestational age the more severe the

risk become

Examination and Assessment of Neonatal Patient

Physical Examination– Auscultation of the heart and lungs– Vital signs- Hr 110-160, temperature 97.6F,

RR 45-60 +/-– Acrocyanosis- blue hands and feet with

decreased perfusion to extremities– Mottling- irregular areas of dusky skin,

alternating with areas of pale skin– Vernix caseosa- gray-white cheeselike

substance

The 5 Factors of APGAR

The previous 5 factors of assessment of a newborn are the APGAR score

• APGAR scores are assessed at 1 min and 5 min intervals

• APGAR of 7 or better baby is considered in good condition. Transfer to NBN

• APGAR of 6 or less indicates baby might have problems. Transfer to NICU

Neonatal Assessment and Resuscitation

Preparation is the key to effective L and D room management

• Equipment in delivery room must be present prior to the birth

• The appropriate personnel must be present• The efforts of the OBY/GN and Neonatologist

must be coordinated and professional• The RN and RT must work as a team with the

MD to ensure all appropriate interventions are available to EVERY newborn that is considered to be high - risk

Routine Stabilizing the NewbornInitial Stabilizing of the neonateDrying – Immediately dry the fluids of the patient

- Necessary to prevent cold stress- Use pre-warmed towels in a stack of 5

Warming- Cold stress increases oxygen consumption and impedes effective resuscitation- Hyperthermia increases in oxygen consumption

Airway- Bulb syringe nose and mouth- Suction catheter for NT/NG suctioning 6f- 10f gauge- Negative pressure should not exceed 80 to 100 mm hg- Meconium (if present) suction infant’s mouth, pharynx, and nose as the infant’s head is delivered- Can the catheter pass down both nares? (choanal atresia)Stimulation- Flicking the bottom of feet, rubbing the back, and drying with the towel all serve to safely stimulate the newborn

Assessing the NewbornRespiratory Effort

- RR & breathing pattern- Presence of retraction, flaring, grunting- Normal: RR 45 – 60, mild intercostal retractions no nasal flaring, grunting or wheezing

Heart Rate- Primary indicator of distress- If less than 100 apply PPV- If less than 60 begin compressions with PPV- If zero, full NRP protocol must be initiated immediately

Color- Baby should “pink up” within 30 secs of blow-by 1.0 FiO2- Acrocyanosis may persist, blue hands and feet- Mottling indicates poor perfusion, hypovolemia, cardiac problems or hypothermia

Tone- Flexion of the extremities is normal, baby moves all - Babies muscle tone floppy indicates problems

Reflex - Baby should cough, sneeze or react visibly to NT suction catheter- A slight grimace is acceptable- No reaction at all is indicative of baby being very depressed

Self-inflating bag- Refills without supplementary gas flow- Has intake valve, room air dilutes the oxygen concentration delivered by the bag- Inappropriate for newborn, neonatal or pediatric use

Anesthesia bag- Inflates only from a compressed gas source of air, oxygen, or both, usually attached to a device called a “blender”- Anesthesia bag offers the advantage of being able to provide a more precise control of oxygen concentrations- Lung compliance can be better assessed

Self-Inflating AMBU vs. Anesthesia Bags

Intubation Indications

• Endotracheal intubation- indicated when bag-mask ventilation is ineffective, tracheal suctioning is required,

• For thick meconium in a respiratory depressed neonate for the purpose of suctioning the meconium prior to 1st breath

• When prolonged ventilation is anticipated• Always based on the babies APGAR and

other scores along with clinical presentation

NRP MedicationsFew Newborns require a full NRP approach to

resuscitation, but when drugs are used:Epinephrine

-Cardiac arrest-AsystoleVolume expanders

- To correct hypovolemia- NS is used most frequently

Naloxone- Narcotic depressed neonate

Sodium Bicarbonate- Metabolic acidosis- Watch for acute vasodilation resulting in low blood pressure

Fluid resuscitation- 20cc/Kg body wt.

Thorax Deformities

Chest Deformaties are usually rare and non – life threatening:

Pectus carinatum- A protruding sternum and or xiphoid process- Pigeon Breasted

Pectus excavatum- a concave asymmetry of the chest wall- Funnel chested

Ballard Score

• Used for estimating gestational age

• Derived from neurologic and physical signs

• Is the most universally accepted assessment of gestational age performed post partum

Score Week

5 26

10 28

15 30

20 32

25 34

30 36

35 38

40 40

45 42

50 44

Correlation of Ballard Score with Gestational Age

Silverman Score

• Used for assessing the magnitude of respiratory distress

• Pg. 49, fig 5-3

Abnormal Cardiac Sounds Murmurs

Murmurs, clicks, rubs and other Abnormal Cardiac Sounds

• Described as a soft to loud harsh sounds and are a result of:– Ductus arteriosus (PDA)– PPHN (persistent pulmonary hypertension of the

newborn) combination of PDA and left to right shunting, resulting in a persistent fetal circulation

– Atrial septal defect (ASD)– Ventricular septal defect

Abdomenal Abnormalites at Birth

• Distention- characterized by tightly drawn skin through which you can easily see engorged subcutaneous vessels.

• Enterocolitis- a bowel infection by sepsis, peritonitis, bowel perforation, and significant mortality

• Diaphragmatic hernia- abdominal contents displaced in the chest

Congenital Diaphragmaic Hernia

• Prunebelly syndrome- lack of abdominal musculature

• Omphalocele- protrusion of membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord

• Gastroschisis- a defect in the abdominal wall lateral to the midline with protrusion of the intestines

Abdomenal Abnormalites at Birth

Examination of the Head, Neck, Eyes/Ears and Throat

HEENT examination indicates several abnormalities

Includes all the structures of the head, throat, posterior neck

• Examination of the ears- Low-set ears indicative of many syndromes

• Examination of the eyes• A modified Age-specific Glascow Coma Scale

can be used to assess a newborns neurological status

Musculoskeletal System, Spine and Extremities

MS system and Extremities give many indications of internal abnormalities:

• Skin tags

• Clubfoot

• Spina bifida- failure of the embryonic neural tube to form correctly in the third to fifth week of gestation

• Myelomeningoceles- defect over the spine

Cry

A newborn or infants cry is one of the primary indicators of abnormalities:

• Loud and vigorous- healthy infant• Grunting cry- RDS• Hoarse cry-laryngeal edema• Cat like cry- chromosme abnormality• High-pitched cry- neurological deficit

– Neurologic assessment- Moro reflex- startle reaction to sound or touch similar to lowed to fall back slightly

Pediatric AssessmentPediatric assessment is based more on

historical data and information gathering, as well as the presenting complaint(s) to include:

• History and assessment

• Chief complaint

• Medical history

• Family history

• Environmental history

Pediatric Assessment Once a RELIABLE history is obtained, pediatric

assessment becomes a matter of physical assessment:Inspection

- RR- Retractions- AP diameter- Digital clubbing

Palpation- Tactile fremitus- Position of trachea- Diaphragmatic excursion

Percussion- Pneumothorax- Pleural effusion

Auscultation- Breath sounds- Bowel sounds- Heart sounds

Pediatric Assessment

Once a thorough history and physical examination have been completed, further assessment is performed incorporating:

Lab values- CBC, ABG, H/h, etc.- CXR- PFT- CScan, MRI- Specialized testing specific for differential diagnosis

Pediatric AssessmentIn cases where an obvious diagnosis isn’t

clear from examination and evaluation of the aforementioned data the clinician is able to offer a:

Working Diagnosis

and or a

Differential Diagnosis

RSPT 2453 Neonatal and Pediatric Respiratory Care

Neonatal L and D Emergenc

NEONATAL EMERGENCIES

Delivery Room ManagementFollow the principles of the Neonatal

Resuscitation Program• A = establish an airway• B = assess breathing• C = evaluate color

• Time is of the essence!• No matter what the defect, the basics of

ABC’s apply

NEONATAL EMERGENCIESHypoxic-Ischemic Encephalopathy

(HIE) – Mild: increased irritability and jitteriness,

exaggerated primitive reflexes, lasting <24 hrs.

– Moderate: lethargy, +/- seizures, suppressed primitive reflexes, lasting >24 hrs.

– Severe: stupor or coma, seizures absent primitive reflexes, lasting > 5 days

NEONATAL EMERGENCIES

HIE (cont)– Treatment

• Respiratory: avoid pulmonary hypertension• Minimal handling• Maintain normal systemic arterial pressure and

adequate cerebral perfusion• Treat seizures if present• Maintain normoglycemia• Avoid fluid overloading

NEONATAL EMERGENCIES

Neonatal SeizuresEtiology

• Onset 0-3 d: HIE, intracranial hemorrhage,, hypoglycemia, hypocalcemia

• Onset 4-10 d: Infection, cerebral dysgenesis, hypocalcemia

• Uncommon: Most drug withdrawals, intoxication from maternal local anesthetics, benign familial neonatal seizures

NEONATAL EMERGENCIES

Seizures (cont)– Treatment: minimize physiologic and

metabolic derangements• Support ventilation and perfusion• Correct metabolic derangements• Phenobarbitol: 20 mg/kg load; additional doses of

5 mg/kg until total of 40 mg/kg• Others: Phenytoin, benzodiazepines

NEONATAL EMERGENCIESAcute Respiratory Disorders of Any Type

Require Assisted ventilation or oxygen to attain adequate gas exchange and oxygenation via:

• Oxygen administration• CPAP• Mechanical Ventilation• High frequency ventilation (oscillator)• ECMO• NO Administration• Liquid Ventilation

NEONATAL EMERGENCIES

Acute Respiratory DisordersRespiratory Distress Syndrome (RDS)

• Etiology: decreased alveolar surfactant causing atelectasis, loss of functional residual capacity, alterations in ventilation-perfusion ratio and uneven distribution of ventilation. Hyaline membrane formation.

• Treatment: Adequate ventilation and oxygenation: CPAP, positive pressure ventilation, oxygen; close monitoring of pH, pCO2, pO2; exogenous surfactant replacement (~100 mg/kg phospholipid)

NEONATAL EMERGENCIES

Acute Respiratory DisordersMeconium Aspiration Syndrome (MAS)

• Rarely occurs before 38 wk gestation • Presentation: respiratory distress, tachypnea,

prolonged expiratory phase, hypoxemia, meconium staining of nails, skin, umbilical cord, increased A-P diameter

• Persistent pulmonary hypertension frequently associated with MAS

• Pulmonary abnormalities related to acute airway obstruction, decreased tissue compliance and parenchymal disease

NEONATAL EMERGENCIESAcute Respiratory Disorders

– MAS (cont)• Treatment

– Prevention– Rapid correction of acidosis and hypoxemia– Exogenous surfactant– Mechanical ventilation

» Low CPAP/PEEP» Low PIP with rapid rate and short inspiratory

time» High frequency ventilation

– Nitric oxide– ECMO

NEONATAL EMERGENCIES

Acute Respiratory DisordersPersistent Pulmonary Hypertension of the

Newborn (PPNH)• Multiple etiologies primary or secondary• Present with labile hypoxemia inappropriate for the

degree of pulmonary parenchymal disease.• May have documented R -> L shunting• Treatment

– Correction of metabolic acidosis and hypovolemia

NEONATAL EMERGENCIESAcute Respiratory Disorders PPHN (cont)

• Treatment–Minimize agitation–Consider creation of respiratory and/or

metabolic alkalosis: pH > 7.50; pCO2 <20 TORR

–High-frequency oscillatory ventilation–Inhaled nitric oxide–ECMO

NEONATAL EMERGENCIES

Acute Respiratory DisordersPneumothorax

• Can occur in up to 25% of ventilated infants• Presentation: grunting, tachypnea,

cyanosis, retractions• Tension pneumothorax results in SHOCK• Treatment: Needle aspiration to relieve

tension followed by insertion of chest tube.

NEONATAL EMERGENCIES

Acute Respiratory Disorders Congenital Diaphragmatic hernia (CDH)

• 90% occur on left• DO NOT BMV IF YOU SUSPECT A CDH –

INTUBATE IMMEDIATELY• CDH is no longer considered a surgical

emergency; stabilize the infant and adequately ventilate until the pulmonary hypertension is resolved.

NEONATAL EMERGENCIES

Acute Respiratory Disorders Apnea of prematurity

• Must rule out other causes of apnea• Treatment

–Supportive- Oxygen- Fluid resuscitation

–Caffeine citrate: loading dose: 20 mg/kg IV; maintenance dose: 5 mg/kg IV/PO q 24 hours

NEONATAL EMERGENCIES

Metabolic DisordersHypoglycemia: plasma glucose concentration

< 30 mg% first day of life; then < 40 mg%

• Etiology: inadequate glucose production or excessive glucose utilization

• Treatment: 2 – 4 ml/kg 10% D/W followed by 100 ml/kg/day 10% D/W

NEONATAL EMERGENCIES

Metabolic DisordersHypocalcemia

Types: early, late, decreased ionized calcium• Definition: Term < 8 mg %

Preterm < 7 mg %• Treatment: Seizures: 1 ml/kg 10 % calcium

gluconate IV over 10 minutes with constant monitoring of heart rate; oral: 2 – 8 ml/kg/day 10% calcium gluconate in4 divided doses

Post-Resuscitative CareOnce a newborn or neonate has been resuscitated

optimal care must be provided including:• Frequent assessment• Careful monitoring• ABG and other lab studies• Treatment of hypotensive states, seizures

- Volume expanders- Vasopressors

• Maintaining Glucose levels, adequate ventilation and oxygenation, electrolyte balance and many other considerations

Lecture Summary

• Many infants are born with obvious abnormalities at birth, with many being discovered in the L and D room, but not always

• Good assessment skills are required for RTs that respond to High-Risk Deliveries

• Some post partum abnormalities can be resolved simply, other require a high level of intervention

• Anytime an infant or newborn demonstrates respiratory insufficiency intervention must be swift and appropriate to the condition

Lecture Summary

Skills required to work in L and D include- Intubation- Accurate assessment of resp distress- NT/NG suctioning- NRP certification- MV management- ABG interpretation- etc.