Control of Breathing

Higher Control Centres

MEDULLARY & CAROTID CHEMORECEPTORS DRUG EFFECTS e.g. OPIATES & CAFFEINE

RESPIRATORY CENTRE (Medulla)

STRETCH & PROPRIOCEPTORS
LUNGS & CHEST WALL

RESPIRATORY REFLEXES

CRANIAL & SPINAL MOTOR NEURONES

INSPIRATION

Chemoreceptors
Medulla Oblongata and Carotid Body Respond to changes in pH, CO2 and O2 Resetting of carotid chemoreceptors occurs at birth in response to oxygenation Not essential at initiation of respiration but used for control of breathing Responses are weak in the immediate newborn period and in preterm babies

Response to Hypoxia
+
Older Infant

Breathing Efforts Term baby Preterm baby

Time in Minutes

Fetus
5 mins

Respiratory Reflexes

Hering-Breuer reflexes
inflation inhibition of breathing Prolonged inhalation expiratory muscle contraction Rapid deflation prolonged inspiratory response
Lung

Heads paradoxical reflex

Rapid

inflation diaphragmatic contraction (sigh)

wall distortion shallow inspiratory efforts

Intercostal phrenic inhibitory reflex

Chest

Irritant reflexes Upper airway reflexes

irritation/ suction apnoea Liquid in larynx apnoea
Nasal

Lung Mechanics

Total lung capacity Tidal volume Functional residual capacity Vital capacity Inspiratory & expiratory reserve volumes Residual volume

Definitions

Tidal volume = volume of gas each breath

5 - 7 mL/Kg in babies
200 400 mL/kg/min

Minute volume = vol. of gas each minute

Minute volume = Tidal volume x resp. rate PaCO2 inversely MV PaCO2 by tidal volume or resp. rate Dead Space = Vol. of lung not involved in ventilation (eg, airways and ET tubes)

Compliance

Compliance is a measure of the distensibility of the lung Compliance = Change in Volume (L)
Change in Pressure (cm H2O)

Lung disease decreases compliance

RDS (Alveolar collapse) TTN (Fluid in insterstitium) BPD (Lung fibrosis) Pneumothorax (Lung compression)

Surfactant improves compliance (beware over distension)

Airways Resistance
Measure of the pressure gradient needed for gas to flow through a tube Airway resistance = Pressure difference (RAW) Gas flow Poiseuilles equation

R R

airway length 4 1/ radius AW

AW

Small & long ET tubes Subglottic stenosis

Work of Breathing

Energy required to produce change in lung volume

Increases with decreased compliance Increases with increased resistance

If energy required to breath exceeds capacity to supply oxygen to provide that energy then respiratory failure develops requiring mechanical ventilation

Pressure Volume Curves (Lung hysteresis loops)

VOLUME EXP

INSP

PRESSURE

Pressure Volume Curves (Lung hysteresis loops)

VOLUME HIGH COMPLIANCE

LOW COMPLIANCE

PRESSURE

Pressure Volume Curves (Lung hysteresis loops)

VOLUME

HIGHER RESISTANCE

LOWER RESISTANCE

PRESSURE

Questions on Anatomy & Physiology

Neonatal respiratory disease Aims:Overview of neonatal respiratory disease Pathophysiology Clinical presentation Aetiology X-ray appearances Treatments

Hyaline membrane disease Clinical:Usually preterm Tachypnoea > 60 Indrawing/ retraction/ recession Grunting Nasal flaring Cyanosis in air Presents within a few hours of life

HMD - Aetiology
Surfactant deficiency Structurally immature lungs

HMD - Treatment
Oxygen CPAP Mechanical ventilation Surfactant replacement

TTN Clinical:Usually close to term Tachypnoea 100-120/min Overinflated chest No grunting/ retraction Settles within 24-48 hours

TTN - Aetiology
Delayed fetal lung fluid clearance Caesarean section - no squeeze of thorax at birth Mum not in labour - no catecholamine surge to promote absorption of fetal lung fluid

TTN - treatment
Prevention - avoid early elective caesarean sections at term Oxygen supplementation and IV fluids until resolution

Airleak Syndromes
Pneumothorax Pneumomediatinum Pneumopericardium Pulmonary interstitial emphysema

Pneumothorax Clinical:May be asymptomatic May be life threatening Sudden deterioration in gas exchange Poor colour Hypotension and tachycardia Unilateral overexpanded thorax

Pneumothorax - aetiology

Uneven alveolar ventilation Air trapping and high pressure swings Tracking of air from pulmonary interstitial emphysema

Pneumothorax - predisposing factors

Spontaneous in 1% of all babies Increases with mechanical ventilation Increased x 4 with HMD Increased x 16 with CPAP Increased x 34 with IPPV

Pneumothorax - prevention
Early surfactant therapy Avoid overdistension

Volume

guarantee Low PIP

Short inspiratory time Faster ventilation rates - entrainment HFOV Trigger ventilation - no proven benefit Paralysis - no proven benefit

Pneumothorax - Treatment
None if asymptomatic Nitrogen washout technique - high FiO2 in term babies only Chest drain if tension pneumothorax or on mechanical ventilation Emergency needle thoracocentesis

Pulmonary interstitial emphysema

Mainly occurs in preterm babies ventilated for HMD Gas trapping in perivascular sheaths Increased incidence at lower gestations

PIE - Clinical features

Severe hypoxaemia and CO2 retention Deteriorating clinical condition

X- Ray Overinflation with gross cystic changes

PIE - Treatment
Lower PEEP and PIP Paralysis High rate low pressure ventilation ? HFOV ? Selective bronchial intubation

Persistent pulmonary hypertension of the newborn

Clinical features

Severe hypoxaemia (cyanosed in 100% O2) No severe lung disease Evidence of R to L shunt (pre vs. postductal) Structurally normal heart

PPHN - Aetiology and predisposing factors

Failure of NO synthase Asphyxia/ acidosis Infection Diaphragmatic hernia Alveolar capillary dysplasia Meconium aspiration syndrome

PPHN - treatment
Minimal handling Inotropic support Ventilation - maintain low normal CO2 Paralysis Hyperventilation - ? Risk of PVL HFOV Nitric Oxide Pulmonary vasodilators

Tolazoline/

Prostacyclin/ MgSO4

Meconium aspiration syndrome Clinical:

Meconium passage prior to delivery Meconium in pharynx and trachea Respiratory distress post delivery with typical X-ray changes

MAS - Aetiology
Asphyxia and intrauterine stress Passage of meconium + gasping movements Inhalation usually prior to delivery

MAS - effects of meconium

Ball valve effect - air trapping Chemical irritation and pneumonitis Superinfection with bacteria Surfactant inhibition

MAS - Management
Prevention in delivery suite Minimal handling Maintain normoxaemia May need ventilation + ? Paralysis Surfactant lavage Antibiotics

Pulmonary haemorrhage Clinical

Sudden deterioration Copious bloody secretions from airway Hypotension Pallor Hypoxaemia

Pulmonary haemorrhage Aetiology

Usually preterm HMD with PDA Post surfactant therapy Coagulopathy Congestive cardiac failure

Pulmonary haemorrhage Treatment

Ventilation with high PEEP Surfactant Indomethacin for PDA Treat coagulopathy

Chronic lung disease Clinical

Protracted respiratory insufficiency and oxygen requirement beyond 28th day or 36th week post conceptional age Very preterm with early ventilation for HMD

CLD - Aetiology
Ventilation Oxygen toxicity PROM Chorioamnionitis Inflammation Proteolytic enzymes

CLD - prevention
Minimise ventilation and oxygen exposure HFOV Early surfactant Corticosteroids Early extubation

CLD treatment
Minimise ongoing barotrauma Nutrition Permissive hypercapnia Diuretics Bronchodilators Corticosteroids - controversial Home oxygen therapy

Summary

Knowledge of respiratory anatomy Physiology of adaptation at birth Surfactant Gas exchange Gas transport Lung mechanics
Application of knowledge to the clinical management of babies with respiratory disease