SEMINAR ON

NEONATAL RESPIRATORY
CARE

MODERATED BY: SHYAM KRISHNAN

ASSISTANT PROFESSOR
SENIOR SCALE
PRESENTED BY: A SAMPATH KUMAR
MPT 2ND YEAR
 CONTENTS
Introduction
Embryological development of respiratory system
Anatomical & Physiological differences of neonates
Assessment of neonate
Respiratory issues in neonates
Physiotherapeutic technique in respiratory conditions
Ventilators in neonates
References
 INTRODUCTION
For a physiotherapist to evaluate assess & treat
pediatric patients or patients with cardiopulmonary
dysfunction is common but when patient is less than
16inches & less then 1500gm, is connected to multiple
monitors & indwelling tubes first encountered in
Neonatal Intensive Care Unit is a daunting environment

Neonatal unit (NNU) is a distinctly different environment

from both adult & pediatric intensive care units
 Physical therapists have a vital role to play in NICU
& have a responsibility to recognize both neonates
physical & developmental problems related to their
age, stage of development & size

Many of same principles of PT management

employed for children & adults can be applied
safely to this patient group if done with skill & full
consideration of their special needs .
 EMBRYOLOGICAL
DEVELOPMENT OF THE LUNGS
EMBRYONIC STAGE (3-5 WEEKS)
lungs first appear as a small bud arising from
esophagus on 24th day of embryonic life

On 28th day of gestation ,this bud branches into

right & left lung buds. Between 30th & 32nd day ,
primitive lobar bronchi begin to appear 2 on
left lung & 3 on right lung bud

By end of 5th week cartilage can be seen in

trachea
Anterior view
posterior view

28 days

32 days
PSEUDO GLANDULAR PERIOD (WEEKS 6-16)

During this period airways grow 40 days

by dichotomous branching so
that by week 16 all generations
of airway from trachea to
terminal bronchioles is formed.

During this period pulmonary

circulation also develops,
cartilage & lymphatic formation
occur & cilia appear week 10
onwards
CANALICULAR PERIOD (WEEKS 17-24)
During this time, terminal bronchioles continue to
proliferate & primitive respiratory bronchioles
begin to appear.

lung mass becomes highly vascularized& lung

lobes are clearly recognizable.

At about 20th week of gestation, lymphatic

vessels begin to appear.
 TERMINAL SAC PERIOD (WEEKS
24 TERM)
The terminal sac period begins at 24th week of gestation &
continues until term (between the 38th -42nd week of
gestation)

The structures that appeared in canalicular period continue

to proliferate & entire acinus (respiratory bronchioles,
alveolar ducts, alveolar sacs, and alveoli) develops

The type I & type II alveolar cells can be identified at this

time, & pulmonary surfactant begins to appear
 ANATOMICAL & PHYSIOLOGICAL
DIFFERENCES OF NEONATES
Many anatomical & physiological differences exist
between infants & older children & adults

These differences increase infant vulnerability to

respiratory distress, airway obstruction & respiratory
failure

Some differences are protective & functional in

healthy baby but cause problem in sick or
compromised infant.
ANATOMICAL DIFFERENCES

A high larynx which enables the newborn to breath &

swallow simultaneously to approximately up to 3 to
4 months of age

High laryngeal position & relatively low resistance of

nasal airway passage contribute to the possibility
that a neonate could be an obligate nose breather

Lymphatic tissue may be enlarged in small infant &

may contribute to upper way obstruction
 Channels for collateral-ventilation in lungs (pores
of Kohn and Lamberts canals) are found in
small numbers in lungs of newborns

RML & RUL have fewer collateral channels may

be associated with atelectasis in neonates

Rib cage configuration is circular in the horizontal

plane & diaphragms angle of insertion is
horizontal
PHYSIOLOGICAL DIFFERENCES
Decreased compliance (or distensibility) of
neonates lungs

Neonates normally exhibit irregular respiratory

patterns (the more immature infant, the more
irregular breathing pattern) Apnoea occurring for
long enough periods of time to produce
bradycardia is considered serious.

Neonates compensate for respiratory difficulties by

increasing rate rather than depth of ventilation.
 Newborns sleep up to 20 hours per day & may
spend up to 80% of sleep in rapid eye movement
(REM) sleep (as compared with 20% REM sleep in
adults)

Work of breathing is further increased because of

30% reduction in FRC during REM sleep

Diaphragm of neonate has a reduced percentage

(apprx 25%as compared with 50% in an adult) of
type I, red slow-twitch fatigue resistant, & high
 ASSESSMENT OF NEONATE
Complete history of labor & delivery
Assessment of infant including Apgar score &
gestational age scores
Clinical course of infant from birth to present

History of respiratory distress & o ,ventilation

2
assistance provided since birth
Arterial blood gas history

Report on previous chest radiographs

Mode & frequency of nutrition & feeding

Physician orders
 CHEST EVALUATION
Observation & inspection :

1. Signs of respiratory distress a)

Retractions- suprasternal, subcostal, substernal ,
intercostal b)
Nasal flaring - reflex dilation of dilatores naris
muscle c) Expiratory grunting d)
Stridor- on inspiration obstruction / collapse of UA
e) Head bobbing use of accessory respiratory
muscles f) Bulging intercostal muscles occurs
when obstruction to expiration
 Chest configuration : Barrel-shaped chest , funnel
chest
Skin colour: a) cyanosis
b) plethora- redness
#polycythemia c) pallor
Breathing pattern : a)
tachypnea b) irregularity of
respiration premature infants periodic
breathing c) apnea
Coughing & Sneezing
AUSCULTATION
Stethoscope employed for neonatal examination is
identical to adult model in all aspects except size.
Auscultate intubated/tracheostomy - empty
ventilator tubing water which can mask breath
sounds & mimic adventitious sounds.

PALPATION
Mediastinum
Subcutaneous emphysema , edema , rib #
PERCUSSION
Presence of pneumothoraces , diaphragmatic
hernia , enlarged liver , masses
Performed by one finger directly on chest
(direct percussion)
OTHERS
Primitive reflexes
Muscle tone

Limb movements & postures

Sucking & swallowing

Deep tendon reflexes

Joint range of motion

 RESPIRATORY ISSUES IN
NEONATES
Pulmonary problems related to Immaturity
Pulmonary problems related to Neonatal Distress &
Asphyxia
Respiratory complications of Gastroesophageal Reflux
Pulmonary problems secondary to Surgery
Respiratory problems consequent to Neonatal Icu
Management
 PULMONARY PROBLEMS RELATED TO
IMMATURITY

Idiopathic respiratory distress syndrome (IRDS) also

called Hyaline membrane disease (HMD) alveolar
collapse because of a deficiency of surfactant

Pathology- O/I lungs with ARDS appear red, heavy &

airless

Exudative stage:
First 6 hours - capillary congestion and intra luminar
aggregation of platelets, fibrin and neutrophils in
pulmonary artery.
Between 12- 24 hours - capillary congestion progresses to
periarterial and interstitial haemorrhage.
Proliferative stage:
1-3 weeks - after lung injury characterized by
proliferation of type II pneumocytes, fibroblasts and myo
fibroblasts

Fibrotic stage:
3 weeks - lungs are typically

remodelled by collagenous tissue

Clinical signs and symptoms-

Tachypnea

Intercostals and Sternal retractions

Nasal flaring and

Expiratory grunting
NEONATAL DISTRESS & ASPHYXIA
Meconium Aspiration Syndrome (MAS) - 5% of
infants who are meconium stained at birth.
Meconium is faecal material that accumulates in
utero.

Pathophysiology
Meconium directly alters the amniotic fluid,
reducing antibacterial activity irritating to fetal
skin increasing erythema toxicum.
 Most severe complication of meconium passage in
utero is aspiration of stained amniotic fluid before,
during, and after birth.

Aspiration induces hypoxia via 3 major pulmonary

effects :
Airway obstruction
Surfactant dysfunction and
Chemical Pneumonitis
 RESPIRATORY COMPLICATIONS OF
GASTROESOPHAGEAL REFLUX
Retrograde entry of acidic gastric contents into
oesophagus most likely related to an incompetent
sphincter & delayed gastric emptying

Risk factors : Prematurity, Birth asphyxia,

perinatal stress, neonatal stress, delayed gastric
emptying, congenital anomalies of upper GI tract,
acquired problem of upper intestinal tract,
diaphragmatic defects, respiratory disease and
medication
PULMONARY PROBLEMS SECONDARY TO SURGERY
Infants have decreased nervous system irritability
Diaphragmatic hernia is a defect of posterior
diaphragm where abdominal contents may herniate
into chest cavity
Esophageal atresia and Tracheoesophageal (TE)
fistulas feeding results in excessive saliva,
respiratory distress and choking, dyskinesia of the
distal oesophagus, uncoordinated peristalsis.
RESPIRATORY PROBLEMS CONSEQUENT TO
NEONATAL ICU MANAGEMENT
Bronchopulmonary dysplasia (BPD) - change
& alteration of normal development of airway
passage of the lung tissue
Commonly associated with use of mechanical
ventilation in premature infants with IRDS
Onset : first few days - 1 month.
 PHYSIOTHERAPY MANAGEMENT
OF NEONATES
Indications for CPT
CPT
 Contraindications

CPT
POSITIONING
Positioning for postural drainage (PD) employs 12
classic positions to drain bronchopulmonary segments.
12 postural drainage positions vary from 450 sitting to
450 head down & prone to side lying to supine
Positioning may also be helpful to infants with
pulmonary dysfunction because of the effects of some
position on ventilation/perfusion ratio, lung
volumes & capacities
Prone in particular has shown to improve oxygenation,
increase lung compliance, regular pattern of respiration,
& enhanced lung volume.
 Precautions & contraindications for postural
drainage in a neonate
Position Precaution Contraindicatio
n
Prone Umbilical arterial Untreated tension
catheter pneumothorax
CPAP in nose Recent
tracheoesophage
al fistula
Excessive Corpulmonale
abdominal
distention
Abdominal
incision
Anterior chest
tube
Tredlenberg Distended
abdomen
Corpulmonale
MANUAL PERCUSSION & VIBRATION
Percussion & Vibration are techniques used to
accelerate the loosening & movement of secretions
& mucous plugs in the conducting airways
Manual percussion may be performed with fully
cupped hand, four fingers cupped,& three
fingers with middle finger tented, or thenar &
hypothenar surfaces of hand
Vibration can be administered manually or with a
mechanical vibrator
 Postural drainage, Percussion & vibration
should be administered for atleast 3 to 5 minutes
per position to be effective.
Time for postural drainage in each position must
be longer, at least 20 to 30 minutes.
Precautions & CI for chest percussion of
neonate:
Precaution

Poor condition of Subcutaneous

skin emphysema

Coagulopathy Bronchospasm

Presence of a chest Prematurity(less than

tube 28 weeks gestational
age)

Apnoea and Persistent fetal

bradycardia circulation

Cardiac dysarhythmias Signs of respiratory

Contraindications:
Intolerance to treatment as rib
fracture
Hemoptysis
Precautions & CI for vibration of a neonate:

Precaution
Contraindications
Increased irritability
UntreatedPneumothorax
Persistent fetal circulation
Hemoptysis
Apnoea and bradycardia

AIRWAY SUCTIONING
It is usually required to help infant clear the
secretions loosened by bronchial drainage
treatment
It may be considered an emergency procedure if a
large airway or tube becomes obstructed by
New born ETT size Suction
secretions catheter
size
>1000 gm 2.5 mm 5F
1000-2000 3.0mm 5-6 F
gm
2000-3000 3.5mm 6-7 F
gm
3000-4000 4.0mm 7-8 F
SUCTION PROCEDURE

Contd..
INDICATIONS FOR SUCTIONING
Absolute
 COMPLICATIONS &
Infection
Accidental extubation

Atelectasis

Blood pressure instability

Increased ICP

Hypoxemia

Hypercapnia

Bradycardia

Pneumothorax

Mucosal damage
HUMIDIFICATION
Narrow diameter of ET tubes used in preterm
infants can easily be blocked by even a small
amount of thick mucus.
Efficient humidification is therefore extremely
important in small infants.
Excessive gas temperature can result in
hyperpyrexia & tachycardia
Inadequate gas temperature can cause

hypothermia, apnea, acidosis & stress

AIRWAY MANAGEMENT
Airway management methods in infants &
children are unique because of anatomical
differences between neonates & adults.
The selection of infants & pediatric sized masks,
oral airways, suction catheters, laryngoscope
blades
INTUBATION
Endotracheal intubation is generally safe mode of
airway management in infants & children, even
when used for extended period
Infants age & weight can be used for estimating
proper ET tube size & depth of insertion , if tube
is too small in diameter, a leak may result
decreasing delivered minute ventilation
Inappropriate large ET tube can cause mucosal
trauma
 Most neonatal & paediatric ET tubes are uncuffed to
eliminate cuff related problems
Incidence of aspiration is increased with cuffless ET
tubes
Clinician must confirm tube placement after each
airway manipulation portable end tidal CO2
monitoring device may be used to determine the
proper tube placement
COMPLICATIONS OF ET INTUBATION
 CONTINUOUS POSITIVE AIRWAY
PRESSURE [CPAP]
Spontaneous breathing can be supported with
CPAP in which a constant pressure is maintained
above baseline throughout inspiration &
expiration
CPAP maintains inspiratory & expiratory pressures
above ambient ,which improves FRC & static lung
compliance
INDICATIONS
Lung disease
Respiratory distress lung
Tachypnea volume in chest radiograph
Retraction/ Pneumonia
RDS
accessory muscle use
PaO2< 50 with FIO2 >0.50
Grunting Other
Nasal flaring post extubation failure
Head bobbing

Abnormal breathing
patterns Apnea of
prematurity
Obstructive sleep
apnea
 CONTRAINDICATIONS
Need for intubation or mechanical ventilation
upper airway abnormalities that CI nasal CPAP- eg
Tracheoesophageal fistula
Severe cardiovascular instability
Desturation or Bradycardia
Ventilatory failure inability to maintain paco2 <60
mmhg & pH>7.25

Source : AARC clinical practice

guideline
 MECHANICAL VENTILATION
Conventional mechanical ventilation is delivery
of bulk flow of humidified gas into & out of
lungs

Removal of CO2 measured by PCo2 is related to

alveolar ventilation

Gas moves from ventilator across an artificial

airway in response to change in pressure
INDICATIONS
Apnea
Respiratory failure Congenital
pao2< 50 mm hg abnormalities
paco2 > 65 mm hg
Congenital
Pulmonary disease
RDS diaphragmatic Hernia
MAS Congenital heart
Pneumonia
disease
ARDS
Neurological Post surgery
Asphyxia Thoracic surgery
Head trauma
Spinal muscular atrophy
Muscular dystrophy
 MODES OF VENTILATION
Most commonly used mode in infants are SIMV &
PSV & most ventilators have capacity of combining
both modes
Mode can either be PCV or VCV
PCV SIMV is used routinely as of pressure is limited so
chances of barotrauma reduce
PCV SIMV is frequently used in children when
compliance is greatly reduced in ARDS
VCV SIMV is more commonly used when lungs have
normal compliance as in neuromuscular diseases
VENTILATOR SETTINGS &
PARAMETERS
Peak inspiratory pressure
Positive End Expiratory
pressure
Tidal volume

Ventilator rate

Inspiratory time

Oxygen concentration /
Fio2
Mean airway pressure
 NON INVASIVE VENTILATION/
NPPV
Assisted ventilation may be provided without an
artificial airway & is typically referred to as NPPV
Commonly used device is BIPAP
It support spontaneous breathing in neonates
much in same way as PSV does
NPPV may be used in short term to manage ARF
that is likely to reverse pulmonary edema
 WEANING FROM MECHANICAL
VENTILATION
Goal of weaning from mechanical ventilation is
to facilitate effective spontaneous breathing
as work of breathing is gradually returned to
normal
 CONSIDERATIONS FOR
EXTUBATION
Spontaneous respiratory rate
Presence of apnea or periodic breathing
Normal work of breathing
Acceptable amount & consistency of respiratory
secretions
Normal vital signs
Minimal sedation needs
Spo2 > 90%
Spontaneous Vt > 4-5ml/kg
 EQUIPMENT COMMONLY USED IN
NICU
Radiant warmer
Self contained incubator

Thermal shield

Oxygen hood

Mechanical ,Pressure,

Volume ventilator

Negative pressure ventilator

High frequency ventilator

Nasal & nasopharyngeal

prongs
Resuscitation bag

Vitals monitor

Pulse oximeter

Intravenous infusion pump

 RECENT ADVANCE
Respiratory Care Year in Review 2013: Neonatal
Respiratory Care, Pulmonary Function Testing, and
Pulmonary Rehabilitation Respir Care, May 2014
59:5 777-787
Abstract
Respiratory care practice includes neonatal
respiratory care, pulmonary function testing, &
pulmonary rehabilitation. The purpose of this paper
is to review the recent literature related to these
topics in a manner that is most likely to have
interest to the readers of Respiratory Care.
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Ammani Prasad.S .Paediatric respiratory care ,champman &

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Nicholas DG, Mccloskey JJ, Rogers MC. Respiratory distress

syndrome. Rogers MC. Textbook of paediatric intensive care,
second ed. Maryland, williams & Wilkins, 1992; p.296-304.

Donn, Sinha. Manual of Neonatal Respiratory Care. Mosby;

p.303-305

Tecklin JS. Respiratory failure in neonates, Irwin S, Teckiln JS.

Cardio pulmonary physical therapy, Missouri, mosby
Elsevier, 2004; p.400-25.
 Mackenzie CF. Chest physiotherapy in intensive care
unit, 2nd edition, chapter-9, p.281-320.

Betit P, Thompson J. neonatal and paediatric care.

Wilkins RL, Stoller JK, Kacmarek RM. Egans.
Fundamentals of respiratory care, 10th ed. Missouri,
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Bares DV, Wood A. The infant at high risk for

developmental delay. Tecklin JS. Paediatric physical
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Fox WW, Spitzer AR, shutack JG. Positive pressure

ventilation: pressure and timed cycled ventilators, 4th ed.
Philadelphia, W.B.Saunders, 1998; p.146-63.