RSPT 2353 Neonatal and Pediatric Respiratory Care

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RSPT 2353 Neonatal and Pediatric Respiratory Care

• Neonatal Assessment and Examination

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Objectives

• At 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

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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

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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

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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 gt 7.25 forceps or
  C-section may be avoided

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High-Risk Conditions

• Risk 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

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Preterm Labor

• Preterm 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
• BPD
• The lower the gestational age the more severe the
  risk become

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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

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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

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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

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Routine Stabilizing the Newborn

• Initial Stabilizing of the neonate
• Drying 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 infants
  mouth, pharynx, and nose as the infants
  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

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Assessing the Newborn

• Respiratory 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

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Self-Inflating AMBU vs. Anesthesia Bags

• 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

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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

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NRP Medications

• Few Newborns require a full NRP approach to
  resuscitation, but when drugs are used
• Epinephrine-Cardiac arrest-Asystole
• Volume 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.

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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

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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

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Correlation of Ballard Score with Gestational Age
Score Week
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
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Silverman Score

• Used for assessing the magnitude of respiratory
  distress
• Pg. 49, fig 5-3

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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

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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

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Congenital Diaphragmaic Hernia
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Abdomenal Abnormalites at Birth

• 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

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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

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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

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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

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Pediatric Assessment

• Pediatric 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

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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

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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

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Pediatric Assessment

• In cases where an obvious diagnosis isnt clear
  from examination and evaluation of the
  aforementioned data the clinician is able to
  offer a
• Working Diagnosis
• and or a
• Differential Diagnosis

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RSPT 2453 Neonatal and Pediatric Respiratory Care

• Neonatal L and D Emergenc

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NEONATAL EMERGENCIES

• Delivery Room Management
• Follow 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 ABCs
  apply

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NEONATAL EMERGENCIES

• Hypoxic-Ischemic Encephalopathy (HIE)
• Mild increased irritability and jitteriness,
  exaggerated primitive reflexes, lasting lt24 hrs.
• Moderate lethargy, /- seizures, suppressed
  primitive reflexes, lasting gt24 hrs.
• Severe stupor or coma, seizures absent
  primitive reflexes, lasting gt 5 days

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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

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NEONATAL EMERGENCIES

• Neonatal Seizures
• Etiology
• 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

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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

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NEONATAL EMERGENCIES

• Acute 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

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NEONATAL EMERGENCIES

• Acute Respiratory Disorders
• Respiratory 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)

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NEONATAL EMERGENCIES

• Acute Respiratory Disorders
• Meconium 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

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NEONATAL EMERGENCIES

• Acute 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

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NEONATAL EMERGENCIES

• Acute Respiratory Disorders
• Persistent 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 -gt L shunting
• Treatment
• Correction of metabolic acidosis and hypovolemia

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NEONATAL EMERGENCIES

• Acute Respiratory Disorders
• PPHN (cont)
• Treatment
• Minimize agitation
• Consider creation of respiratory and/or metabolic
  alkalosis pH gt 7.50 pCO2 lt20 TORR
• High-frequency oscillatory ventilation
• Inhaled nitric oxide
• ECMO

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NEONATAL EMERGENCIES

• Acute Respiratory Disorders
• Pneumothorax
• 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.

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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.

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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

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NEONATAL EMERGENCIES

• Metabolic Disorders
• Hypoglycemia plasma glucose concentration lt 30
  mg first day of life then lt 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

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NEONATAL EMERGENCIES

• Metabolic Disorders
• Hypocalcemia
• Types early, late, decreased ionized calcium
• Definition Term lt 8 mg
• Preterm lt 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

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Post-Resuscitative Care

• Once 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

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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

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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.