Newborn Respiratory Disorders

Introduction: Respiratory distress (RD) is a common problem in neonatal period. It is an important cause of neonatal mortality. There are many causes of respiratory distress, among them, transient tachypnea of newborn (TTN), respiratory distress syndrome (RDS) and perinatal asphyxia are commonest causes. Timely and appropriate therapy is essential to prevent ongoing injury and improve outcome. The aim of this study was to determine the prevalence and to identify the causes of respiratory distress in neonatal intensive care unit (NICU) in Combined Military hospital (CMH) Sylhet and to observe the hospital outcome of these babies.
 Material and Methods: A descriptive type of crosssectional study was conducted in CMH Sylhet over a period of one year from April 2018 to March 2019. All live newborns delivered at CMH Sylhet during the study period were included and observed for development of respiratory distress.
 Results: All newborns (n=287), delivered at this hospital over the period of 12 months, were observed for respiratory distress. The overall prevalence of respiratory distress was 19.2 %. Prevalence was 10.8 % in full term, 7.3 % in preterm and 1.1% in post term. There was male predominance (54.5%) and two third (71.1%) were born by cesarean section. Transient tachypnea of newborn was found to be the commonest 47.3% cause of respiratory distress followed by respiratory distress syndrome 29.1%, perinatal asphyxia (10.9%), congenital pneumonia 3.6%, congenital heart disease 3.6%, septicaemia 3.6% and meconium aspiration syndrome (MAS) 1.9%. All babies required high flow oxygen initially, subsequently Bubble CPAP and mechanical ventilation was required in 8 (14.5%) and 1(1.8%) cases respectively. Mortality was 1.8% in neonates with respiratory distress syndrome with pneumothorax with septicaemia requiring mechanical ventilation.
 Conclusion: In this series, RDS in newborn majority of cases were due to TTN followed by respiratory distress syndrome and perinatal asphyxia. Mortality was mainly related to pneumothorax with septicaemia, RDS was more common in births related to caesarian section.
 J Bangladesh Coll Phys Surg 2021; 39(1): 4-8

Transient tachypnea of the newborn (TTN) is one of the most common causes of neonatal respiratory distress (RD). However, distinguishing TTN from other causes of RD may be difficult during the first 12:24 h after birth. Lung ultrasonography (LUS) has been successfully utilized in the diagnosis and differential diagnosis of neonatal RD. This study aimed to investigate the diagnostic value of LUS for early diagnosis of TTN as well as differentiate it from other causes of neonatal RD in near and full term Egyptian neonates. LUS was performed in 65 near and full term neonates presented with RD within the first 12:24 hours of admission in NICU of Suez Canal University, Ismailia, Egypt. Among the 65 neonates included in the study, 73.8% were diagnosed to have TTN, 18.5% were diagnosed to have pneumonia, 4.6% had meconium aspiration syndrome (MAS) and 3.1% had respiratory distress syndrome (RDS). The Double lung point has 69.6% sensitivity, 100% specificity, 100% PPV and 39.1% NPV for detecting TTN. We have novel data showing a positive correlation between the degree of alveolar-interstitial syndrome (AIS) and the type of oxygen support offered to neonates diagnosed with TTN. We found LUS to be a reliable and non-invasive tool for the early diagnosis of TTN and its differentiation from other causes of neonatal RD in near and full term Egyptian neonates.

Objective To explore the value of integrated cardiopulmonary ultrasound in etiological diagnosis, disease monitoring, and prognosis evluation of neonates with hypoxemia. Methods Forty-five neonates with hypoxemia admitted to the Department of Neonatology, Hangzhou First People's Hospital, Zhejiang University Medical College from January to August 2018 were selected as a study group, and 20 non-hypoxic neonates who were hospitalized during the same period were selected as a control group. All the neonates underwent integrated cardiopulmonary ultrasonic examination. Echocardiography was used to diagnose structural diseases and to assess cardiac function. Pulmonary ultrasound was used to assess the condition of the lungs. The results of ultrasonography and clinical etiology were comprehensively analyzed. Results Of the 45 neonates with hypoxemia, the clinical causes included respiratory distress syndrome, congenital heart disease, meconium aspiration syndrome, temporary respiratory increase, post-asphyxia resuscitation and so on. In these neonates, echocardiography showed left heart failure in 8 cases, right heart failure in 1, and pulmonary hypertension in 33. Pulmonary ultrasound showed varying degrees of increased B-lines and local pulmonary consolidation. The total scores of bilateral lungs ranged from 0 to 30, with the most common scores ranging from 13 to 24, and the maximum score of unilateral lung was 18. There were no significant abnormalities of echocardiography or pulmonary ultrasound in the 20 neonates of the control group. In the study group, eight patients with decreased left ventricular function developed diffuse alveolar-interstitial syndrome in the lungs, and one case with decreased right heart function showed A-lines, with a unilateral lung score of 2. Conclusion Integrated cardiopulmonary ultrasound can provide clues and evidence for clinical etiology diagnosis, and monitor and predict disease progression with the advantages of no radiation, convenienience, and low cost. Key words: Neonate; Hypoxemia; Ultrasonography; Lung; Heart

Since the recognition of nitric oxide (NO) as a key endothelial-derived vasodilator molecule in 1987, the field of NO research has expanded to encompass many areas of biomedical research. It is now well established that NO is an important signaling molecule throughout the body. The therapeutic potential of inhaled NO as a selective pulmonary vasodilator was suggested in a lamb model of pulmonary hypertension and in patients with pulmonary hypertension in 1991.1,2 Because NO is scavenged by hemoglobin (Hb) on diffusing into the blood and is thereby rapidly inactivated, the vasodilatory effect of inhaled NO is limited largely to the lung. This is in contrast to intravenously infused vasodilators that can cause systemic vasodilation and severe systemic arterial hypotension. Recent data indicate that inhaled NO can be applied in various diseases. For example, studies suggest that inhaled NO is a safe and effective agent to determine the vasodilatory capacity of the pulmonary vascular bed. This article summarizes the pharmacology and physiology of inhaled NO and reviews the current uses of inhaled NO for the treatment, evaluation, and prevention of cardiovascular and respiratory diseases. ### Chemistry of NO Gas NO is a colorless, odorless gas that is only slightly soluble in water.3 NO and its oxidative byproducts (eg, NO2 and N2O4) are produced by the partial oxidation of atmospheric nitrogen in internal combustion engines, in the burning cinder cones of cigarettes, and in lightning storms. Medical-grade NO gas is produced under carefully controlled conditions, diluted with pure nitrogen, and stored in the absence of oxygen. The recent article by Williams4 provides a review of the chemistry of NO. ### Therapeutic Versus Endogenous NO Concentrations in the Airway Although early studies of inhaled NO in the treatment of pulmonary hypertension used concentrations of 5 to 80 ppm, it has since been realized that concentrations >20 ppm provide little additional …

Background: Respiratory distress in neonates is the most common cause of admission to a neonatal ICU in a tertiary care hospital. Identification of risk factors associated with development of severe distress and early diagnosis of cause is very important in the management of neonatal distress for better clinical outcome. Methods: 100 consecutive born neonates with respiratory distress were studied and assessed for development of severe distress against onset, duration, oxygen requirement and outcome in terms of final diagnosis, mortality and treatment interventions. Serial chest X- rays were done at 1 hour and 6 hours of onset of distress to identify abnormal findings. Association of multi variable risk factors both maternal and neonatal was studied for development of severe respiratory distress. Results: Transient tachypnoea of newborn (60%) was the commonest cause of newborn respiratory distress. Development of severe distress was more when onset is at 6 hours after birth (77%), duration persists more than 24 hours (65.5%) Oxygen requirement in number of days increases depending on diagnosis TTNB 100% for <1 day, MAS 95.4% for 2 days and RDS 100% for 3 days. Ventilation was done in 3 cases and there was no mortality. Conclusions: Transient tachypnea of the newborn is the most common cause of respiratory distress in newborn. Almost 50% of newborn with respiratory distress develop severe respiratory distress which require intensive monitoring. Risk factors like high maternal age, primigravida mothers, more than 4 per vaginal examinations, meconium stained liquor, cesarean delivered newborns, Small for gestation age, and 1 min Apgar score less than 7, birth weight less than 2.5Kg and male sex of newborn were associated with severe respiratory distress in newborns.

Objectives: Respiratory distress is one of the most common causes of admission in Neonatal intensive care unit (NICU). There are many causes of respiratory distress, among them, transient tachypnoea of newborn, respiratory distress syndrome and perinatal asphyxia are commonest causes. The aim of this study was to identify the etiology of respiratory distress in special care baby unit (SCABU) in BIRDEM General Hospital and to observe the immediate hospital outcome of these babies. Methods: A retrospective study was conducted in SCABU, BIRDEM. Data were collected from all patients files admitted in to SCABU during the period from January to December 2011. Results: A total of 562 patients were admitted, among them 192 cases were admitted due to respiratory distress (34.1%). There was male predominance (64.6%). Two third (65.6%) babies were inborn and majority (84.4%) were born by caesarian section and preterm babies were more (65.6%). The commonest causes of respiratory distress in our study were transient tachypnea of newborn (43.2%), respiratory distress syndrome (30.2%), perinatal asphyxia (25%), septicaemia (16.1%) congenital pneumonia (11.9%), congenital heart disease (10.4%). All babies required oxygen initially, subsequently mechanical ventilation and Bubble CPAP was required in 48 (25.0%) and 8(04.1%) cases respectively. Mortality was 16.7% and was highest in neonates with respiratory distress syndrome (RDS) (71.8%) followed by septicaemia (40.6%) and perinatal asphyxia (37.3%). Among neonates requiring mechanical ventilation 56.2% died. Conclusion: Transient tachypnoea of newborn (TTN), respiratory distress syndrome (RDS), perinatal asphyxia and septicaemia were the common etiology for respiratory distress. Mortality was very high in RDS and septicaemia. Birdem Med J 2013; 3(1): 19-22 DOI: http://dx.doi.org/10.3329/birdem.v3i1.17122

Introduction: Infant cardiopulmonary resuscitation outside the delivery room can follow one of two national guidelines: Neonatal Resuscitation Program (NRP), or Pediatric Advanced Life Support (PALS). Important differences exist between NRP and PALS guidelines. There are no published recommendations concerning the chronologic age at which to change from NRP to PALS guidelines. This study was designed to investigate current resuscitative practices outside the delivery room for infants cared for in Neonatal-Perinatal (N-P) and Pediatric Critical Care (PCC) medicine fellowship programs with regard to the use of NRP or PALS guidelines. Methods: Surveys were mailed to the program director of all one hundred fifty-eight ACGME accredited N-P and PCC medicine fellowship programs in the US. The survey included questions regarding the existence of written resuscitative policies for infants regarding the use of PALS versus NRP, provider certification requirements in NRP and PALS, resuscitation leadership, and the age after birth at which infants are resuscitated using PALS rather than NRP guidelines. Results: Of the 158 programs surveyed, 98 responded (62%). Of those responding only one center (1%) reported having a written policy concerning the use of NRP versus PALS. Significant differences were seen in provider certification requirements in NRP and PALS. There were significant differences in the time to change from NRP to PALS guidelines between responding N-P programs and PCC fellowship programs. None of the responding PCC programs reported using NRP guidelines past two months of age, while 35% of N-P programs continued to resuscitate infants using NRP guidelines up to 1 year of life. Twenty seven percent of responding N-P programs reported using "NRP only" for infant resuscitation. Conclusions: We found no consensus regarding the age at which infants are resuscitated with PALS rather than NRP in responding N-P and PCC fellowship programs. Our findings suggest that compared to infants cared for under the supervision of physicians in PCC medicine fellowship programs, infants cared for under the supervision of physicians in N-P medicine fellowship programs are much more likely to be resuscitated using NRP guidelines. While it is unclear if this variation in clinical practice has a significant effect on outcomes, this variation in practice makes it difficult to define the current standard of care for infant resuscitation in N-P and PCC fellowship programs and requires further investigation.

Background: Meconium aspiration syndrome (MAS) is a life-threatening respiratory disorder in infants born through meconium-stained amniotic fluid (MSAF). Although anecdotal data concerning the efficacy of intrapartum oropharyngeal and nasopharyngeal suctioning of MSAF are conflicting, the procedure is widely used. We aimed to assess the effectiveness of intrapartum suctioning for the prevention of MAS.Methods: A prospective quasi randomized control trial, assessor blind, single centre study was done at Department of neonatology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan. Patients were enrolled over a total period of 16 months started from January 2016 to April 2017. 312 patients with MSAF of any consistency, gestational age at least 37 weeks, and cephalic presentation were randomly assigned to suctioning of the oropharynx and nasopharynx (including the hypopharynx) before delivery of the shoulders (n=127), or no suctioning before delivery (n=185). Postnatal delivery-room management followed Neonatal Resuscitation Program guidelines. The primary outcome was incidence of MAS. Clinicians diagnosing the syndrome and designating other study outcomes were masked to group assignment. An informed consent waiver was used.Results: No significant difference between treatment groups was seen in the incidence of MAS [36 (26.7%) suction versus 36 (19.5%) no suction; p = 0.167], mortality in suction [5 (3.91%) versus no suction 5 (2.74%); p = 0.779], or in the duration of ventilation, oxygen treatment, and hospital care. There was statistically significant difference in need for mechanical ventilation for MAS [13 (10.23%) vs 4 (2.2%); p = 0.005], any respiratory support for MAS 25 (19.7%) suction versus 18 (9.7) p = 0.019).Conclusions: Routine intrapartum suctioning of infants born through MSAF does not reduce the incidence of MAS. On the contrary, intrapartum suctioning might result in complications like more infant required neonatal resuscitation and respiratory support.

Pulmonary Hypertension: From an Orphan Disease to a Public Health Problem

Surfactant in meconium aspiration syndrome

Background and aim Meconium-aspiration syndrome (MAS) is a common cause of respiratory distress. MAS is a serious disease that affects neonates born through meconium-stained amniotic fluid. The pathophysiology of MAS is multifactorial, inflammation has an important role in MAS, so anti-inflammatory drugs like corticosteroids may be effective in the treatment of MAS. Budesonide is a nonhalogenated glucocorticoid that can reduce vascular permeability, inhibit secretion of mucus, relieve edema and spasm, and help pulmonary ventilation. In this study we aimed to find out the effect of early nebulized budesonide in the treatment of MAS. Patients and methods This was a prospective study conducted during the period from October 2017 to July 2018 at El-Minia General Hospital and Al-Azhar University Hospital, Assiut. Intervention: budesonide inhalation in a dose of 50 mg every 12 h till clinical recovery, whichever was earlier. Results The present study revealed that nebulized budesonide improves the clinical outcome of newborns with MAS in terms of lowering the duration of O2 dependency, duration of respiratory distress, duration of hospital stay, duration of radiograph clearance, time for full feeding (P&lt;0.001), and thus early discharge from the NICU. Conclusion Early nebulized budesonide is effective in treating MAS and has high safety with almost no short-term complications.

Respiratory distress is one of the commonest problem seen in neonates during admission in Neonatal Intensive Care Unit. Hyaline Membrane disease, Meconium Aspiration Syndrome, septicemia, congenital pneumonia, Transient Tachypnea of Newborn are the major causes of respiratory distress in neonates. Bubble Continuous Positive Airway Pressure is a non-invasive respiratory support delivered to a spontaneously breathing newborn to maintain lung volume during expiration. The main objective of this study was to observe the outcome of respiratory distress in neonates with Bubble Continuous Positive Airway Pressure. This was a descriptive cross-sectional study conducted at Kathmandu Medical College Teaching Hospital over six months (October 2018 - March 2019) period. All preterm, term and post term babies with respiratory distress were included. Ethical clearance was received from Institutional Review Committee of Kathmandu Medical College and statistical analysis was done with SPSS 19 version. Sixty three babies with respiratory distress were included in this study with 45 (71%) male predominance. The mean birth weight receiving Bubble Continuous Positive Airway Pressure was 2661.75±84 gms and gestational age was 36.67±3.4 wks. The Bubble Continuous Positive Airway Pressure was started at 8.05±2 hr of life and duration of Bubble Continuous Positive Airway Pressure required for settling respiratory distress was 95.71±3 hrs. Out of 63 babies, improvement of respiratory distress in neonates with Bubble Continuous Positive Airway Pressure was 39 (61%) with confidence interval of 38% to 62% whereas 24 (39%) babies required mechanical ventilation and other modalities. This study concludes usefulness of Bubble Continuous Positive Airway Pressure in neonates with respiratory distress.

Background and aims To investigate the association between serum mean platelet volume (MPV) levels and meconium stained amniotic fluid (MSAF). Methods MPV, serum reactive protein and haemoglobin levels, leukocyte and thrombocyte counts were measured in 106 infants with MSAF and 78 healthy control infants for comparison. Demographic factors including gestational age, birth weight, gender, delivery mode, parity, maternal pregnancy diseases, intrauterine infections, maternal smoking and severity of meconium aspiration syndrome were recorded. Results The mean values of MPV in infants with MSAF were significantly lower than in the control group statistically (p 0.05). There was no statistically significant difference in MPV levels in the infants with meconium aspiration syndrome (MAS) compared to the study group (p > 0.05). A 9.90 fl [area under the curve (AUC: 0.788)] optimal cutoff value of MPV with a sensitivity of 78.1% and specificity of 74.3% was determined in infants with MSAF. Conclusions Our data suggest that the MPV levels were significantly lower in infants with MSAF than that in healthy infants. This might be associated with hypoxic process. However, the MPV levels were statistically similar between MSAF and MAS, leading to a failure of detecting patients with or without severe disease.

A New Classification of Pulmonary Hypertension

Objectives: This study aims to study the neonatal COVID-19 incidence and outcome in District Hospital, Ballari. Materials and Methods: This is a retrospective analytic study of 171 neonates born to COVID-19-positive pregnant women delivered at District Hospital, Ballari, Karnataka, during the period of April 2020–September 2020. Results: The study was conducted among 171 babies delivered to COVID-19-positive pregnant women delivered in District Hospital, Ballari. Out of which, 62 babies were admitted in SNCU for various indications such as respiratory distress syndrome (4), meconium aspiration syndrome (8), other causes of respiratory distress (13), birth asphyxia (8), neonatal jaundice (14), hypoglycemia (1), preterm care (8), and neonatal COVID-19 (1). Out of 171 neonates born to COVID-19-positive mothers, only 7 (4%) neonates were tested positive for reverse transcription-polymerase chain reaction. A total of three babies were symptomatic, among those, two had refusal of feeds and one had respiratory distress and hypernatremic dehydration. Conclusion: In this study, COVID-19-positive neonates had milder manifestation with transmission rate of 4%. All symptomatic babies got cured and discharged successfully with average length of stay for 4 days. Although our conclusions are limited, the findings conclude that neonatal COVID-19 outcome is not as severe as seen in adults.