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    Physiology of Transition Period in Neonates With Respect To Respiratory System

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    Hasnania
    1) The physiology of the respiratory system in neonates is uniquely adapted for the transition from fetal to newborn life outside the womb. Factors such as surface tension, surfactant production, lung compliance, and control of breathing differ significantly from adults. 2) Removal of lung fluid after birth relies on forces like negative intrathoracic pressure created by the first breath as well as lymphatic and capillary drainage, allowing for expansion of the alveolar sacs. Immature control of breathing and low respiratory reserve make neonates prone to desaturation. 3) Conditions like respiratory distress syndrome, persistent pulmonary hypertension of the newborn, and meconium aspiration syndrome can arise

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    Physiology of Transition Period in Neonates With Respect To Respiratory System

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    Hasnania
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    1) The physiology of the respiratory system in neonates is uniquely adapted for the transition from fetal to newborn life outside the womb. Factors such as surface tension, surfactant production, lung compliance, and control of breathing differ significantly from adults. 2) Removal of lung fluid after birth relies on forces like negative intrathoracic pressure created by the first breath as well as lymphatic and capillary drainage, allowing for expansion of the alveolar sacs. Immature control of breathing and low respiratory reserve make neonates prone to desaturation. 3) Conditions like respiratory distress syndrome, persistent pulmonary hypertension of the newborn, and meconium aspiration syndrome can arise

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    fisiologi respirasi

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    Physiologyoftransitionperiod Rs 130908033858

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    1) The physiology of the respiratory system in neonates is uniquely adapted for the transition from fetal to newborn life outside the womb. Factors such as surface tension, surfactant production, lung compliance, and control of breathing differ significantly from adults. 2) Removal of lung fluid after birth relies on forces like negative intrathoracic pressure created by the first breath as well as lymphatic and capillary drainage, allowing for expansion of the alveolar sacs. Immature control of breathing and low respiratory reserve make neonates prone to desaturation. 3) Conditions like respiratory distress syndrome, persistent pulmonary hypertension of the newborn, and meconium aspiration syndrome can arise

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    © All Rights Reserved
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    25 views17 pages

    Physiology of Transition Period in Neonates With Respect To Respiratory System

    Uploaded by

    Hasnania
    1) The physiology of the respiratory system in neonates is uniquely adapted for the transition from fetal to newborn life outside the womb. Factors such as surface tension, surfactant production, lung compliance, and control of breathing differ significantly from adults. 2) Removal of lung fluid after birth relies on forces like negative intrathoracic pressure created by the first breath as well as lymphatic and capillary drainage, allowing for expansion of the alveolar sacs. Immature control of breathing and low respiratory reserve make neonates prone to desaturation. 3) Conditions like respiratory distress syndrome, persistent pulmonary hypertension of the newborn, and meconium aspiration syndrome can arise

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    of 17

    PHYSIOLOGY OF TRANSITION PERIOD

    IN NEONATES WITH RESPECT


    TO RESPIRATORY SYSTEM

    Speaker: Dr Bhagirath.S.N
    Moderator: Dr Sarika
    Prenatal development of the lungs
    Some concepts….

    Surface Tension
    Property of the surface of a liquid that allows it to resist an external force. (by virtue
    of cohesive forces between its molecules)

    What exactly does surfactant do..?


    It forms a monolayer that adheres closely to the alveolar interface and prevents
    the sac from collapsing once the fluid is removed..

    How then is the fluid removed..?


    Most of it is expelled by the upper airways.
    Rest of it is drained by the lymphatics and capillaries.

    What provides the force required to force open the partially


    collapsed fluid filled alveolar sacs..?
    A negative intrathoracic pressure of -30 to -70 cms of H2O that is created by the
    first gasp of air.

    What induces this gasp of air..?


    Clamping of the cord asphyxiates the baby provoking a violent gasp of air.
    Some concepts….(continued)

    So, does this first gasp of air represent the first breath…?
    • Boddy & Robinson ((1971) were among the first to demonstrate foetal breathing
    in-utero.

    • Patrick et al (1980) demonstrated the presence of fetal breathing >30% of the


    time in utero and further recorded a increase in movements subsequent to a
    maternal meal.

    • Motoyama demonstrated a increase in FRC on inducing hypercapnia in the fetus.

    So, the traditional concept that the first gasp represents the first breath now stands
    challenged.

    Why does the fetus need to breathe when the placenta is breathing for it..?
    • Unclear. But thought to be as a prenatal practice for postnatal life and probably to
    act as a stimulus for lung development…
    Respiratory rate
    O2 consumption is neonates is double that of an adult

    Minute ventilation is very high

    Minute ventilation is the product of respiratory rate and tidal volume

    Since tidal volume is almost same as a child/adult on a volume/Kg/body weight


    measure, the only factor that can be augmented is the rate.

    This explains why the respiratory rate is so high in a neonate.

    Analogous to increasing heart rate to compensate for the fixed stroke volume, so that
    on the whole cardiac output remains maintained.
    Respiratory reserve
    Lung volume of the neonate is disproportionately small in relation to body size

    Further complicated by the increased metabolic rate (O2 consumption/unit body


    weight being twice as that of adults)

    This calls for increased ventilatory requirements.

    Relative to the increased ventilatory requirements the lung surface area available
    for gas exchange is less

    i.e. the respiratory reserve is less


    Implication
    Primary reason why neonates become rapidly desaturated with hypoventilation or
    apnea of relatively short duration
    Compliance-ability of the lungs & thorax to expand
    To not react is to be compliant; To react is to be less compliant;

    Neonatal
    lung

    Adult
    lung
    What determines the recoiling nature of the lung & the chest wall..?

    Elastic fibers in the lung tissue, elastic rib cage architecture, good diaphragmatic
    effort all of which are either deficient or immature in the neonate.
    Compliance …(contd)

    Neonates have a high compliance because:

    • Poorly developed intercostal muscles

    • Pliable rib cage (cartilaginous)

    • Poor diaphragmatic effort due to abundance of type 2 fast twitch, low oxidative
    fibers that contract in quick succession but invariably fatigue early.

    Anaesthetic implication

    • Under general anesthesia the neonatal lungs are more prone to collapse as
    skeletal muscle relaxation ensues around the chest wall, what precious little
    rigidity that prevented the collapse is now lost.
    Surfactant
    • Secreted by type 2 pneumocytes
    • Chemically: dipalmitoylphosphatidylcholine
    • maintains distensibility of alveoli by reducing surface tension

    • Laplace law: The gas pressure (P) needed to keep equilibrium between the
    collapsing force of surface tension (γ) and the expanding force of gas in an
    alveolus of radius r is expressed as P = 2 γ/r

    • decreased levels are seen in premature babies and babies born to diabetic
    mothers
    • decreased levels predispose to respiratory distress syndrome (RDS) , which
    includes:
    1. Alveolar collapse
    2. Decreased compliance
    3. Hypoxia
    4. Increased work of breathing
    5. Ultimately respiratory failure.
    Control of breathing
    • The respiratory centers are still immature and are unable to control breathing
    effectively.
    • Neonatal response to hypercapnia is less compared to a child but none the
    less is mounted in the form of hyperventilation albeit for short durations.
    • Under conditions of hypothermia, initial hyperventilatory response may be
    blunted.

    • Periodic breathing
     breathing is interposed with repetitive short apneic spells lasting 5 to 10
    seconds without haemoglobin desaturation or cyanosis
     Seen in both REM and NREM sleep.
     thought to be due to changes in respiratory mechanics rather than reduced
    sensitivity to CO2
    Control of breathing….(Contd.)
    •Apnea of prematurity & hypoxia
     unexplained cessation of breathing for 15 seconds or longer or a shorter
    respiratory pause associated with bradycardia (heart rate <100), cyanosis, or
    pallor
     may be related to an immature respiratory control mechanism
     thought to be due to changes in respiratory mechanics rather than reduced
    sensitivity to CO2
    Persistent pulmonary hypertension of newborn
    • Collapsed fluid filled alveoli, collapsed capillaries and decreased perfusion offer
    resistance to flow of blood through pulmonary vasculature in utero

    • i.e. pulmonary vascular resistance is high in utero

    • If the same resistance due to any reason is encountered in the post natal
    period, then the pressure in the pulmonary artery is elevated to overcome such
    resistance.

    • i.e. pulmonary artery hypertension ensues..


    Precipitating factors include:
    1. Hypoxia
    2. Preterm
    3. Birth asphyxia
    4. Meconium aspiration
    5. Sepsis
    6. Congenital diaphragmatic hernia
    7. Maternal use of NSAIDs.
    Persistent pulmonary hypertension of newborn….(Contd)
    Other risk factors include:
    1. Maternal diabetes
    2. Asthma
    3. Caesarean delivery

    Increased pulmonary artery pressure Ductus arteriosus is thrown open

    Increased right ventricular pressure Hypoxia & normal to elevated


    PaCO2

    Increased right atrial pressure


    • Treatment
    Increase tissue oxygenation
    Throws open the foramen ovale Target PaO2 -50-70 mm of Hg
    Mechanical ventilation
    High frequency ventilation
    Blood reaches the aorta Exogenous surfactant
    Alkalinisation
    ECMO
    Sildenafil
    as pulmonary artery pressure is
    Persistent pulmonary hypertension of newborn….(Contd)
    •Meconium aspiration
     this is different from meconium aspiration at labour
    This happens in utero.
    Seen when the fetus has been exposed to prolonged periods of hypoxia
    Can predispose to persistent pulmonary hypertension of newborn.
    References….

    Ganong’s review of physiology


    23rd edition
    P582, 584

    Guyton & Hall’s Text book of Physiology


    11th edition
    P1022, 1023
    References….

    Clinical Anesthesia by Paul.G.Barash


    6th edition
    P1127, 1129

    Miller’s Anesthesia
    7th Edition, Vol 1
    P889. 890
    References….

    Physiology for anesthetists


    Wolters Kluwer
    Chapter 4

    Smith’s anesthesia for infants and


    children
    Motoyama and Davis
    Chapter 6

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