Causes, risk factors and outcomes in neonates with respiratory failure

Nội dung text: Causes, risk factors and outcomes in neonates with respiratory failure

1. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 CAUSES, RISK FACTORS AND OUTCOMES IN NEONATES WITH RESPIRATORY FAILURE Nguyen Thanh Nam*; Cao Thi Bich Hao* Pham Van Dem**; Dong Khac Hung***; Nguyen Tien Dung* Summary Objectives: To determine some causes, risk factors and outcomes in neonates with respiratory failure. Subjects and methods: A descriptive and prospective study on 139 neonates who were diagnosed respiratory failure after birth (case group) and 278 neonates without respiratory failure (control group) were admitted in Pediatric Department, Bachmai Hospital. Results: Mortality rate in neonates was 15.1%. The average of gestational age in neonates with respiratory failure was 34 weeks, significantly lower than the control group with 38 weeks (p < 0.001). The mean birth weight of case group (2,057 Gr) was significantly lower than control group (2,893 Gr) (p < 0.001). The most causing respiratory failure was respiratory disease 38.9%, premature 30.9%. The relative risk in neonates without risk factor was 0.24. Co- operated with pediatrician in neonates with risk factor of case group (64.7%) was significantly higher than control group (30.9%). Asphyxia rate at 1st mimute after birth of control group (11.2%) was significantly lower than case group (69.1%) (p < 0.001). Respiratory distress in newborn babies who have Apgar score at 1st minute ≤ 7 points was 17.8. Respiratory distress in newborn babies who were delivered by elective cesarean section without labour was 40.3. Respiratory distress in newborn babies whose mothers suffered from disease was 3.7. Conclusion: The mortality was high in neonates with respiratory failure. The most causing respiratory failure was respiratory disease. Premature, low birth weight increased respiratory failure. In addition, asphyxia rate after birth, delivered by elective cesarean section without labour and mother’s disease were common risk factors of respiratory distress in neonates. Co-operation between obstetrician and pediatrician are very important. * Keywords: Neonates; Respiratory failure; Causes; Risk factors. INTRODUCTION of neonates with respiratory failure such as maternal disease, problems at delivery, Respiratory failure is a common disease premature birth, cesarean delivery (CS), in neonates and is a common cause of especially CS without labour, neonatal treatment in neonatal intensive care unit. resuscitation [5, 7]... these factors can be There are many diseases such as hyaline intervened to reduce the risk factors of membrane disease; meconium aspiration respiratory failure. The objectives of the syndrome; pneumonia; pulmonary study is to: Find some causes, treatment hemorrhage, congenital heart defects [2]... results and factors affecting in neonatal There are many factors that affect the rate respiratory failure. * Bachmai Hospital ** Vietnam National University Hanoi *** Vietnam Military Medical University Corresponding author: Nguyen Thanh Nam (bsntnam@gmail.com) Date received: 30/07/2017 Date accepted: 09/09/2017 662
2. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 SUBJECTS AND METHODS symptoms: blood gases are criteria for the diagnosis of acute respiratory failure [2]: 1. Subjects. Pa02 50 - Case group: 139 neonates who were mmHg and pH < 7.1 - 7.2; chest X-ray [1]: born at Department of Obstetrics - Bachmai normally, bilateral lungs enlarge badly, Hospital and were diagnosed as respiratory ground-glass opacity nodules, stagnant failure, hospitalized and treated at Neonatal air bronchograms. Intensive Care room at Department of - Control group: 278 neonates at Pediatrics, Bachmai Hospital from 1 - 2013 Department of Obstetrics who were moved to 12 - 2015. Acute respiratory failure is to the neonatal room at Department of defined as lung dysfunction, causes failure Pediatrics, Bachmai Hospital without at gas exchange, oxygen is decreased respiratory failure from 1 - 2013 to 12 - 2015. and carbon dioxide is increased, so the lung is not able to hold on Pa02, PaC02 2. Methods. and pH in threshold criteria [2]. Diagnosis Descriptive and prospective study. of acute respiratory failure based on clinical and paraclinical symptoms. RESULTS Clinical symptom of respiratory failure 1. General characteristics of the groups. [1, 2]: respiratory failure is defined as one of the signals: respiratory distress: From January, 2013 to December, 2015, tachypnoea > 60 breaths/min or slow we evaluated 139 neonates with respiratory breathing < 40 breaths/min; chest wall failure and 278 neonates without respiratory recessions, paradoxical movement of the failure who were treated at Department of chest wall; nasal flaring; grunting or apnoea, Pediatrics. The average gestational age cyanosis; Apgar score after birth at of the case group (34 weeks) was 1 minute, 5 minutes based on heart rate, significantly lower than the control group respiratory effort, muscle tone, response with 38 weeks (p < 0.001). The average to stimulation and skin coloration (total weight of the case group (2,057 Gr) was score: ≤ 3: severe asphyxia, 4 - 6 points: significantly lower than the control group moderate asphyxia, ≥ 7: normal). Subclinical with 2,893 Gr (p < 0.001). Chart 1: Gestational age distribution in the study. 663
3. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 In 139 neonates with respiratory failure, 28% of the neonates were smaller than 32 weeks while in the control group, 0.4% of the neonates were smaller than 32 weeks. Neonates without respiratory failure were primary as full term infants. So prematrure infants had significantly higher risk of neonatal respiratory failure (p < 0.001). Table 1: Some common causes of respiratory failure. Respiratory failure Causes n % Hyaline membrane disease 15 10.8% Asphyxia 22 15.8% Transient tachypnoea of the newborn baby 14 10.1% Pneumonia 3 2.2% Patent ductus arteriosus 22 15.8% Pulmonary arterial hypertension 5 3.6% Sepsis 4 2.9% Respiratory failure due to premature birth 43 30.9% Brain hemorrhage 1 0.7% Hypoglycemia 7 5% Other congenital heart defects 1 0.7% Other diseases 2 1.4% Total 139 100% In 139 neonates with respiratory failure who were required mechanical ventilation, the cause of lung was 38.9% and asphyxia had the largest number. Congenital heart defects were primary as patent ductus arteriosus, pulmonary arteria hypertension. Premature infant was a cause which had high rate with 30.9 percent of neonates with respiratory failure. Chart 2: Results of treatment for respiratory failure. In 139 neonates with respiratory failure, the discharged rate was 84.9%, the mortality rate was 21 (15.1%). 664
4. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 Table 2: Relationship between neonatal weight and respiratory failure. Groups Case group Control group OR Weight n % n % (95%CI) Weight < 2,500 Gr 91 65.5% 73 26.3% 5.324 Weight 2,500 Gr 48 34.5% 205 73.7% (3.429 - 8.267) Total 139 100% 278 100% p < 0.001 The lower neonatal weight was, the higher rate of respiratory failure was. In this study, the rate of respiratory failure in the low birth weight group was 65.5%, while the rate of low birth weight in the control group was significantly smaller than 26% (p < 0.001). If neonatal weight is smaller than 2,500 Gr, neonates will have a risk of respiratory failure is 5.324 (95%CI; 3.429 - 8.267). Table 3: Role of co-operation with pediatrist in neonatal resuscitation. Groups Case group Control group OR Pediatrician n % n % (95%CI) Neonate is not at risk 49 35.3% 192 69.1% 0.244 Neonate has risk factors 90 64.7% 86 30.9% (0.158 - 0.375) Total 139 100% 278 100% p < 0.001 Neonates who were not at risk had a rate of respiratory failure (35.5%) was significantly lower than control group (69.1%) (p < 0.001). Neonate was not at risk whose risk of postpartum respiratory failure was only 0.244 (95%CI; 0.158 - 0.375). Table 4: Apgar scores at the first minute and respiratory failure. Groups Case group Control group OR Apgar scores n % n % (95%CI) Apgar ≤ 7 96 69.1% 31 11.2% 17.888 Apgar > 7 43 30.9% 247 88.8% (10.592 - 29.875) Total 139 100% 278 100% p < 0.001 Apgar score at the first minute 7 in the control group had higher rate than in the case group (69.1% vs. 11.2%) (p < 0.001). Children with Apgar score at the first minute 7 had a risk of respiratory failure (17.888) (95%CI; 10.592 - 29.875). As a result, the baby's appearance of asphyxia immediately after birth (the first minute) warns the risk of respiratory failure in the next hours. Table 5: CS without labor and the rate of respiratory failure. Groups Case group Control group OR CS without labour n % n % (95%CI) Yes 59 42.4% 5 1.8% 40.268 No 80 57.6% 273 98.2% (15.631 - 103.736) Total 139 100% 278 100% p < 0.001 665
5. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 Cesarean delivery without labour had a significant effect on the risk of postpartum respiratory failure (p < 0.001). The risk of neonatal respiratory failure was 40.268 (95%CI; 15.631 - 103.736) CS without labour. Table 6: The effect of maternal factors on the postpartum respiratory failure. Groups Case group Control group p OR Maternal factors n % n % (95%CI) History of maternal Abnormal 38 27.3% 52 18.7% 0.043 1.635 pregnancy Normal 101 72.7% 226 81.3% (1.012 - 2.641) Maternal disease Yes 73 52.5% 121 43.5% 0.083 1.435 during pregnancy No 66 47.5% 157 56.5% (0.954 - 2.16) Maternal problem at Yes 95 68.3% 102 36.7% < 3.725 delivery 0.001 No 44 31.7% 176 63.3% (2.417 - 5.743) History of maternal pregnancy was associated with postpartum respiratory failure (p = 0.043). The risk of postpartum respiratory failure was 1.635 (95%CI; 1.012 - 2.641) times when the mother had a history of abnormal pregnancy. Maternal disease during pregnancy was not associated with postpartum respiratory failure (p = 0.083). Maternal problem during labor had an effect on the incidence of postpartum respiratory failure (p < 0.001). The risk of pediatric respiratory failure was 3.725 (95%CI: 2.417 - 5.743) times when mothers had medical diseases during labor. DISCUSSION pneumonia...), cardiovascular disease (patient ductus arteriosus, pulmonary hypertension...), The study was carried out from 1 - 2013 respiratory failure in premature birth.... to 12 - 2015, 139 neonates who were However, the rate of lung disease, respiratory diagnosed as respiratory failure were disease and respiratory failure in premature transferred from the Department of birth was still high, 38.9% and 30.9% Obstetrics to the Neonatal Intensive Care respectively. These pathologies are potentially Unit room at Department of Pediatrics, preventable and treatable if the prognosis Bachmai Hospital for treatment. During of the risk factors that affects the respiratory the admission process, we evaluated and status of the postnatal children to timely exploited the maternal history and recorded therapeutic intervention, limiting the negative the factors related to the pregnancy and impact on the respiratory function of children childbirth to find out some causes and risk when they begin to adapt to life outside factors related to the possibility of being uterus. This is the role of management of respiratory failure of the baby after birth. pregnancy and childbirth in the per partum In 139 neonates who were diagnosed and postpartum period, especially in the as respiratory failure hospitalized, the causes per partum period, which directly affect of the disease varies from lung and respiratory infant’s status. In our study, the obstetric diseases (hyaline membrane disease, history of the mother (giving birth prematurely, asphyxia, meconium aspiration syndrome, miscarriage, fetal death, etc.) had an effect 666
6. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 on neonatal respiratory failure risk (p = 0.043), that in the control group (26%) (p < 0.001). risk of neonatal respiratory failure was If neonatal weight is smaller than 2,500 Gr, OR = 1.635 (95%CI; 1.012 - 2.641) when neonates will have a risk of respiratory the mother has a history of abnormal failure 5.324 (95%CI; 3.429 - 8.267). Mahoney pregnancy. Huynh Thi Duy Huong had reported that the rate of respiratory distress detail risk factor of respiratory distress of late preterm was 28.9% and term was such as: fetal death [2]. The common 5.3%, the early term infants (35 weeks) risk complications during CS were hypertension, of respiratory distress was 9 times compared cardiovascular disease, renal failure, with term baby (38 - 40 weeks) [6]. systemic disease (lupus), pregnancy toxicity, preeclampsia, HELLP syndrome If these Cesarean delivery on maternal request conditions were detected and controlled, it is also one of neonatal respiratory distress would reduce the risk of postpartum risk factors. According to our study, the respiratory failure. Maternal health factors respiratory distress rate was 42.4% in CS as risks for postnatal child were also reported on maternal request group and was only 1% by foreign authors such as Khairy et al who in the rest. This difference has statistical found that pregnant women with congenital significance (p < 0.05). This problem was heart had risk factors that directly affected investigated by Ray et al in women with their health and their infants, in which no indication of labor at 34 - 37 gestation giving birth prematurely and respiratory weeks, suggesting that more than 25% of distress accounted for a high proportion of neonates have severe respiratory failure neonates receiving postpartum support [4]. after delivery [7]. According to a study by Gelfand et al presented risk factors for Liu et al (2005), full-term infants undergoing meconium aspiration in infants including CS on maternal request increased the risk hypertension, gestational diabetes, of respiratory distress [5]. It is an issue for preeclampsia, chronic heart disease [3]. gynecologists to do more research to have more concrete evidence in choosing a safe Prematures and low birthweight are risk birth route for both mother and newborn baby. factors that increase rate of respiratory Obstetrical-neonatal care co-operation distress after birth. We evaluated 139 module is important and effective in reducing neonates with respiratory failure and 278 the rate of respiratory distress and asphyxia neonates without respiratory failure who in the delivery room especially in the case were treated at Department of Pediatrics. of preterm as well as full-term infants The average gestational age of the case whose mothers have chronically diseases, group (34 weeks) was significantly lower contributes to restrict postpartum morbidity, than the control group with 38 weeks particularly in cases of respiratory failure, (p < 0.001). The average weight of the preterm infants. In our study, pediatric case group (2,057 Gr) was significantly resuscitation during childbirth was essential lower than the control group (2,893 Gr) for children with respiratory failure at birth (p < 0.001). The rate of respiratory failure (64.7%), while 30.9% of children in the control in the low birth weight < 2,500 Gr (65.5%) group needed support of the pediatric in case group was significantly higher than resuscitation. Pediatric patients, who did 667
7. TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 not have any risk, needed for coordination - There are many factors that influence of pediatric resuscitation (OR = 0.244; the rate of neonatal respiratory failure related 95%CI: 0.158 - 0.375; p < 0.001). This to maternal pregnancy, maternal morbidity combination is highly appreciated in the during labor, CS without labour, effective world and is being implemented in obstetrics postpartum resuscitation and premature and pediatrics hospitals. It is especially labor, low weight... These factors can be valuable in general hospitals because of intervened to reduce the rate of respiratory the proportion of mothers with medical failure, asphyxia when pregnancy is managed conditions that need to be intervened had strictly, proper diagnosis and treatment of increased more and more, it is necessary maternal disease, holding on relationship to have other support from the fields of between Department of Obstetrics and internal medicine, cardiology combined Department of Pediatrics in caring for with obstetrics and pediatrics to treat both neonates after birth. mother and child properly. The Apgar score provides an accepted REFERENCES and convenient method for reporting the 1. Nguyễn Tiến Dũng. Hội chứng suy hô status of the newborn infant immediately hấp sơ sinh. Chu kỳ sinh học: bệnh lý mẹ, thai after birth and the response to resuscitation nhi và trẻ sơ sinh. Nhà xuất bản Y học, Hà if needed. According to our observation, nội. 2012, tr.181-197. Apgar score 7 at the first minute at risk 2. Nguyễn Công Khanh và CS. Sách giáo for respiratory distress was OR = 17.888 khoa Nhi khoa. Chương 10: Bệnh lý sơ sinh - (95%CI; 10.592 - 29.875; p < 0.001). Thus, Bệnh lý phổi gây suy hô hấp sơ sinh. Nhà xuất bản Y học, Hà Nội. 2016, tr.232-246. neonatal resuscitation after birth will have reduced the rate of neonatal respiratory 3. Gelfand S.L et al. Meconium stained fluid: approach to the mother and the baby. distress. Pediatric and obstetrics combination Pediatr Clin N Am. 2004, 51, pp.655-667. actually plays an important role in reducing 4. Khairy P et al. Pregnancy outcomes in the risk of neonatal respiratory distress. women with congenital heart disease. CONCLUSION Circulation. 2006, 113, pp.517-524. - The mortality rate from respiratory 5. Liu J et al. High-risk factors of respiratory failure is high: 15.1% of neonates with distress syndrome in term neonates: A fetrospective case-control study. Balkan Med respiratory failure. J. 2014, 31, pp.64-68. - Common causes of neonatal respiratory 6. Mahoney A.D et al. Respiratory disorders failure are causes of lung or pulmonary in moderately preterm, late preterm, and early diseases such as asphyxia, hyaline term infants. Clin Perinatol. 2013, 40, pp.665-678. membrane disease, pneumonia, transient 7. Ray C.L et al. Caesarean before labour tachypnoea of the newborn baby..., between 34 and 37 weeks: What are the risk congenital heart defects such as patent factors of severe neonatal respiratory ductus arteriosus, pulmonary arterial distress?. European Journal of Obstetrics & hypertension... and respiratory failure in Gynecology and Reproductive Biology. 2006, premature birth, all of them can be intervened. 127, pp.56-60. 668