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
- Author: Krisoula Zahariou