F SYL2017 / 20A06: Outline how the respiratory system of a neonate differs from that of an adult

20A06: Exam Report​

Outline how the respiratory system of a neonate differs from that of an adult.

20% of candidates passed this question.

This question required an outline of the anatomical, mechanical and functional differences. It was expected that factors leading to an increased work of breathing and oxygen cost would be mentioned. The mechanics of expiration were not often included in candidates’ answers. Immaturity of the alveoli and peripheral chemoreceptors were common omissions. Inaccuracies regarding upper airway anatomy and compliance of the chest wall cost some candidates marks. The question did not call for an explanation of the relative difficulty of intubation. Discussion of pathophysiology due to airway obstruction, causes of central apnoea or sensitivity to drugs was not required. Many answers included inaccurate information. Points which were often missed 3 were difference in bronchial angles, number of alveoli, number of type 1 fibres in diaphragm, ciliary function and peripheral chemoreceptors.

F1ii / 20A06: Outline how the respiratory system of a neonate differs from that of an adult

Infant = birth →28 days

Feature

Head & occiput

Neonate

Larger relative to body size

Comment

↑risk of neck flexion & airway obstruction when supine

Feature

Tongue

Neonate

Large

Comment

↓size of oral cavity →easily opposes palate to cause airway obstruction when unconscious

Feature

Epiglottis

Neonate

Short, narrow, softer, horizontally positioned

Comment

Angled posteriorly away from long axis of trachea

Difficult to control w MAC Blade

Requires Miller Straight Blade

Feature

Trachea

Neonate

Shorter, smaller, narrower

Soft & 6x more compliant

Comment

↑risk of obstruction

↑risk of subglottic stenosis w prolonged / recurrent intubation

Feature

Airway shape

Neonate

Funnelled

Narrowest part is cricoid cartilage (VC in adult)

Comment

Uncuffed tubes required

Subglottic airway is completely encircled by cricoid ring & unable to expand

Feature

Larynx location

Neonate

Cephalad

Cricoid C2 – 3 cf. C4 – 5 in adults

Comment

Brings epiglottis + palate in close proximity →therefore makes infants obligate nose breathers

Feature

Nares

Neonate

Much smaller

Comment

50% of airway R) & easily obstructed

Lung Mechanics

Feature

Chest wall

Newborn

Highly compliant (to allow birth canal) & horizontal ribs

Comment

Therefore minimal thoracic component to ventilation

Feature

Diaphragm

Newborn

1° muscle of breathing

Low [Type I]

High oxidative capacity fibres

Comment

Susceptible to fatigue

↑WOB

Lung Volumes

Feature

Alveolar ventilation

Newborn

MV 220mL/kg

VT 7mL/kg (same)

→Resp rate is much higher

Comment

X 2 adult

↑WOB

Feature

RR

Newborn

25 – 40

Short time constant so ↑RR to ↑alv. ventilation

Comment

Therefore ↑WOB

Feature

FRC

Newborn

30mL/kg

Comment

Same

Feature

Closing capacity

Newborn

CC > FRB

↑A-a gradient 30mmHg cf. 5mmHg

Comment

Small airway closure →gas trapping →in normal VT

Therefore ↑venous admixture

Feature

Dead space

Newborn

3mL/kg

Comment

Higher (2mL/kg) but v significant

Any ↓alveolar ventilation will produce rapid hypoxia

Feature

Lung compliance

Newborn

↓ cf. adult

Comment

Due to ↓surfactant production in first few days →↑WOB

Ventilatory Control

  • Immature response + hypoxia
  • This is especially impaired by hypothermia
  • Periodic respiration is normal →5 – 10 sec pauses, up to 6 per hour during sleep
  • Prominent HERING-BREUR REFLEX →high VT & overinflation →inhibits inspiration →extended expiration

O2 Transport

  • HbF (2α, 2β) →p50 (19mmHg) →↑affinity for O2
  • ↑[Hb] = 180g/dL = ↑O2 carrying capacity for ↑BMR
  • At birth 95% HbF →by 6 month 99% HbAdult