RSPT 2353 Neonatal and Pediatric Respiratory Care

1. RSPT 2353 Neonatal and Pediatric Respiratory Care Neonatal Assessment and Examination

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

19. Correlation of Ballard Score with Gestational Age

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

22. 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

23. 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

24. Congenital Diaphragmaic Hernia

26. 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

30. 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

33. 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

38. 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

39. 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

40. 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

41. 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

42. Pediatric Assessment In 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

43. RSPT 2453 Neonatal and Pediatric Respiratory Care Neonatal L and D Emergenc

44. 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 ABC’s apply

45. NEONATAL EMERGENCIES Hypoxic-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

46. 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

47. 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

48. 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

49. NEONATAL EMERGENCIES Acute Respiratory Disorders of Any Type RequireAssisted 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

50. 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)