ABNORMAL PATTERNS OF BREATHING IN NEWBORN: WHEN TO TREAT? Yousef K. Abu-Osba Neonatal Intensive Care Unit Jordan Hospita

1. ABNORMAL PATTERNS OF BREATHING IN NEWBORN: WHEN TO TREAT? Yousef K. Abu-Osba Neonatal Intensive Care Unit Jordan Hospital and Medical Center, Amman, Jordan .

2. Outline • Normal breathing and lung volumes. • Asphyxia – apnea: obstructed / central. Regulation of Upper Airway Maintaining Muscles During Progressive Asphyxia. • Evaluation of Response Time of a Transcutaneous Oxygen Tension Electrode. • Hiccups in Infants: Characteristics and Effects on Ventilation. • Sighs in Newborn Infants: Characteristics and Effects. • Breathing Pattern and Transcutaneous Oxygen Tension During Motor Activity in Preterm Infants. • Coordination of Breathing and Swallowing in Human Infants. • Periodic Breathing. .

3. BREATHING IN UTERO BY THE HUMAN FETUS . A: Displacement of the maternal abdominal wall. B: Fetal chest-wall movements. C Maternal ECG.

4. FIRST BREATH EFFECT OF GASEOUS EXPANSION OF THE LUNG .

5. POSTNATAL CHANGES IN ARTERIAL BLOOD GASES .

6. DEFINITION OF STANDARD STATIC LUNG VOLUMES . A typical spirographic tracing: quiet breathing, followed by maximum inspiration, followed by maximum expiration, followed by quiet breathing.

7. VENTILATORY CONTROLS .

8. INTERACTION OF STIMULI TO THE RESPIRATORY CENTER .

9. PULMONARY VENTILATION .

10. Regulation of Upper Airway Maintaining Muscles During Progressive Asphyxia O. P. Mathew, B. T. Thach, Y. K. Abu-Osba,andR. T. Brouillette From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Divisions of Neonatology and Neurology, St. Louis, Children's Hospital, St. Louis Pediatric Research 18(9): 819-822, 1984 .

11. Regulation of Upper Airway Maintaining Muscles During Progressive Asphyxia GG AND DIAPHRAGMATIC ACTIVITY DURING CONTROL PERIOD AND IMMEDIATELY FOLLOWING AIRWAY OCCLUSION IN ADULT RABBIT .

12. Regulation of Upper Airway Maintaining Muscles During Progressive Asphyxia GG and diaphragmatic activity during late in hyperpnea and early in gasping .

13. Regulation of Upper Airway Maintaining Muscles During Progressive Asphyxia GG AND DIAPHRAGMATIC ACTIVITY DURING THE LAST THREE GASPS .

14. Regulation of Upper Airway Maintaining Muscles During Progressive Asphyxia EMG ACTIVITY OF GG AND DIAPHRAGM DURING THE LAST THREE GASPS .

15. Effect of Experimental Obstructive Apnea In Rabbits . Arrow A: normal regular breathing. Arrow B: obstructed airway. Arrow C: release of obstruction. Arrow D: return of regular breathing

16. SIGNIFICANT EFFECT OF CENTRAL APNEA . Bradycardia occurring 15 to 20 seconds after the onset of apnea

17. Chronology of Asphyxia and Resuscitation in Newborn Rabbits .

18. Evaluation of Response Time of a Transcutaneous Oxygen Tension Electrode Yousef K. Abu-Osba Bradley T. Thach,andRobert T. Brouillette From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Divisions of Neonatology and Neurology, St. Louis Children's Hospital, St. Louis, Missouri, USA Pediatr Res 15:143-146, 1981 .

19. Evaluation of Response Time of a Transcutaneous Oxygen Tension Electrode In vivo determination of a transcutaneous Po2 electrode LT and RT after arterial occlusion release .

20. Evaluation of Response Time of a Transcutaneous Oxygen Tension Electrode .

21. Evaluation of Response Time of a Transcutaneous Oxygen Tension Electrode tcPO2 electrode lag and 95% response time for step charges in PO2 in vivo and in vitro studies .

22. Hiccups in Infants: Characteristics and Effects on Ventilation Robert T. Brouillette,* Bradley T. Thach, Yousef K. Abu-Osba, and Suzanne L. Wilson From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Divisions of Neonatology and Neurology, St. Louis, Children's Hospital. .

23. Hiccups in infants: Characteristics and effects on ventilation CLINICAL DATA ON UNINTUBATED PATIENTS .

24. Hiccups in infants: Characteristics and effects on ventilation– Unintubated NB Three portions of a record of 0.98 kg. unintubated patient. A. Breathing appears regular in the minute before the onset of hiccups. B. The first three hiccups (H) are shown to demonstrate the effect of hiccups on eupneic breathing early in the hiccupping spell. Following the first hiccup, there is a 10.5-second period in which no eupneic inspiratory effort is made. The first eupneic inspiratory effort (OB1) is completely obstructed as shown by the absence of flow while the second (OB2) appears partially obstructed as shown by the minimal flow with large esophageal pressure decrease. Note the decrease in heart rate from 180 to 138 beats/minute (bpm). C. Recording from the third minute of the spell. Hiccups now do not interfere with tidal breathing as much as they had earlier in the spell. The gain has been decreased on the esophageal pressure scale where hiccups appear as brief, powerful inspiratory efforts. The first and third hiccups are completely obstructed. After a brief inspiratory flow, the second hiccup is also obstructed. .

25. Hiccups in infants: Characteristics and effects on ventilation– Unintubated NB . A portion of the record from a 1.32 kg unintubated baby. Five eupneic inspirations are shown preceding the first hiccup (H). Hiccups are seen as brief, powerful inspiratory efforts on the abdominal circumference channel without inspiratory flow. Note the decrease in respiratory rate, the bradycardia to 73 beats/minute (bpm) and the two obstructed eupneic inspirations (OB1, OB2).

26. Hiccups in infants: Characteristics and effects on ventilation– Unintubated NB . . Minute ventilation in the minute before (control) and in the first four minutes of the hiccupping spell in five unintubated infants. Minute ventilation decreases in the first minute of the spell (P < 0.0025) and remains significantly decreased in the second and third minutes (P < 0.05). Minute ventilation in the third and fourth minutes is significantly increased from that in the first minute (P < 0.025). Values shown are mean +SEM.

27. Hiccups in infants: Characteristics and effects on ventilation CHARACTERISTICS OF HICCUPS AND EUPNEIC BREATHS IN UNINTUBATED SUBJECTS . *First 5 hiccups in each spell. †Five breaths chosen at random from the minute preceding the onset of hiccups. ‡Values expressed as mean + SD.

28. Hiccups in infants: Characteristics and effects on ventilation Characteristics of eupnea in the minute preceding the onset of hiccups and in the first minute of the hiccupping spell-unintubated patients *Values expressed as mean +SD. *Values expressed as mean +SD. . *Values expressed as mean +SD.

29. Hiccups in infants: Characteristics and effects on ventilation- Intubated NB Tracings from Subject 2, a 1.05 kg, 27-hour-old boy who was intubated and ventilated for recurrent apneic episodes. The respirator was set in an intermittent mandatory ventilation mode allowing the baby to breathe between respirator breaths. A, Electrocardiogram, flow and tidal volume in the minute before the onset of hiccups. Breathing appears regular with flow rates less than 100 ml/sec, B, Tracing shortly after the onset of hiccups. Flow traces of hiccups are characterized by brief inspiratory flows up to 250 ml/sec. Tidal volumes of hiccups may exceed those of tidal ventilation depending on the phase of the respiratory cycle in which the hiccup occurs. Hiccup "A," which comes at end-inspiration, augments the preceding eupneic inspiration. Hiccup "B," which comes at end-expiration, independently produces an inspiratory volume. Arterial Pco2 decreased from 37 to 24 mm Hg during this hiccupping spell. Two types of ECG artifacts due to hiccups can be appreciated: high-frequency spikes (S) mimicking abnormal QRS complexes; and low-frequency waves (W). .

30. Hiccups in infants: Characteristics and effects on ventilation Electrocardiographic Changes Associated With Hiccups . Electrocardiographic trace from 0.96 kg, 8-day-old, unintubated neonate. The arrows point to the high-frequency spike artifacts of three hiccups. The wave artifact is best seen after the second spike.

31. Sighs in Newborn Infants: Characteristics and Effects Yousef K. Abu-Osba The Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Divisions of Neonatology and Neurology, St. Louis, Children's Hospital. Neonatal Intensive Care Unit, Jordan Hospital, Jordan .

32. Sighs in Newborn Infants: Characteristics and Effects Normal Sigh During Regular Breathing .

33. Sighs in Newborn Infants: Characteristics and Effects Effectof Sigh on tcPO2 Significant increase in tcPO2 occurs 30 sec following sighs during regular breathing .

34. Sighs in Newborn Infants: Characteristics and Effects Sigh Followed by Regular Breaths Then Brief Central Apnea .

35. Sighs in Newborn Infants: Characteristics and Effects Sigh Followed by Central Apnea .

36. Sighs in Newborn Infants: Characteristics and Effects Sigh Followed by Obstructed Breathing Effort& Sigh .

37. Sighs in Newborn Infants: Characteristics and Effects Sigh Followed by Obstructive Apnea .

38. Sighs in Newborn Infants: Characteristics and Effects Sigh Followed by Mixed Apnea .

39. Sighs in Newborn Infants: Characteristics and Effects Sigh Followed by Mixed Apnea and Bradycardia .

40. Sighs in Newborn Infants: Characteristics and Effects Rate of Change in tcPO2 Post Sighs Followed by Apnea Compared to Control Sighs .

41. Breathing Pattern and Transcutaneous Oxygen Tension During Motor Activity in Preterm Infants Yousef K. Abu-Osba,Robert T. Brouillette,* Suzanne L. Wilson, and Bradley T. Thach, From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Divisions of Neonatology and Neurology, St. Louis, Children's Hospital. AM REV RESPIR DIS 1982,125:382-387 .

42. Breathing Pattern and Transcutaneous Oxygen Tension During Motor Activity in Preterm Infants CLINICAL DATA AND MAJOR MEDICAL DIAGNOSIS AND THERAPY . Data from 16 episodes occurring in 8 patients. Data given are the means of the mean value from each patient (n =8). *p < 0.01 (paired t test, n = 8), ** p > 0.05 (NS)

43. Breathing Pattern and Transcutaneous Oxygen Tension During Motor Activity in Preterm Infants Polygraphic tracing and behavioral observations during agitation . Onset of squirming activity at arrow A. Onset of crying at arrow B. Note appearance of CO2 in expired oral air occurring with cry, signaling transition to oral breathing.

44. Breathing Pattern and Transcutaneous Oxygen Tension During Motor Activity in Preterm Infants CHANGES IN RESPIRATION OCCURRING WITH SQUIRMING ASSOCIATED WITH >10 MM HG IN TCPO2 (MEANS + SD) . Data from 16 episodes occurring in 8 patients. Data given are the means of the mean value from each patient (n =8). *p < 0.01 (paired t test, n = 8), ** p > 0.05 (NS)

45. Coordination of Breathing and Swallowing in Human Infants Suzanne L. Wilson,Bradley T. Thach,Robert T. Brouillette, and Yousef K. Abu-Osba From the Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, and the Divisions of Neonatology and Neurology, St. Louis Children's Hospital, St. Louis, Missouri, USA J. Appl. Physiol: 50(4): 651-858, 1981 .

46. Coordination of Breathing and Swallowing in Human Infants CLINICAL INFORMATION .

47. Coordination of Breathing and Swallowing in Human Infants POLYGRAPHIC TRACING OF PHARYNGEAL PRESSURE AND EMG DURING SWALLOWING .

48. Coordination of Breathing and Swallowing in Human Infants Polygraphic Tracings of Swallows Interrupting Early Inspiration .

49. Coordination of Breathing and Swallowing in Human Infants Polygraphic tracing of a spontaneous swallow interrupting inspiration .

50. Coordination of Breathing and Swallowing in Human Infants Polygraphic tracing of a spontaneous swallow interrupting expiration .