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.
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 Cooperated with pediatrician in neonates with risk factor of case group (64.7%) was significantly st higher than control group (30.9%) Asphyxia rate at mimute after birth of control group (11.2%) was significantly lower than case group (69.1%) (p < 0.001) Respiratory distress in st newborn babies who have Apgar score at minute ≤ 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 Respiratory failure is a common disease in neonates and is a common cause of treatment in neonatal intensive care unit There are many diseases such as hyaline membrane disease; meconium aspiration syndrome; pneumonia; pulmonary hemorrhage, congenital heart defects [2] There are many factors that affect the rate of neonates with respiratory failure such as maternal disease, problems at delivery, premature birth, cesarean delivery (CS), especially CS without labour, neonatal resuscitation [5, 7] these factors can be intervened to reduce the risk factors of respiratory failure The objectives of the study is to: Find some causes, treatment results and factors affecting in neonatal 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 TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 SUBJECTS AND METHODS Subjects - Case group: 139 neonates who were born at Department of Obstetrics - Bachmai Hospital and were diagnosed as respiratory failure, hospitalized and treated at Neonatal Intensive Care room at Department of Pediatrics, Bachmai Hospital from - 2013 to 12 - 2015 Acute respiratory failure is defined as lung dysfunction, causes failure at gas exchange, oxygen is decreased and carbon dioxide is increased, so the lung is not able to hold on Pa02, PaC02 and pH in threshold criteria [2] Diagnosis of acute respiratory failure based on clinical and paraclinical symptoms Clinical symptom of respiratory failure [1, 2]: respiratory failure is defined as one of the signals: respiratory distress: tachypnoea > 60 breaths/min or slow breathing < 40 breaths/min; chest wall recessions, paradoxical movement of the chest wall; nasal flaring; grunting or apnoea, cyanosis; Apgar score after birth at minute, minutes based on heart rate, respiratory effort, muscle tone, response to stimulation and skin coloration (total score: ≤ 3: severe asphyxia, - points: moderate asphyxia, ≥ 7: normal) Subclinical symptoms: blood gases are criteria for the diagnosis of acute respiratory failure [2]: Pa02 < 60 mmHg, and/or PaCO2 > 50 mmHg and pH < 7.1 - 7.2; chest X-ray [1]: normally, bilateral lungs enlarge badly, ground-glass opacity nodules, stagnant air bronchograms - Control group: 278 neonates at Department of Obstetrics who were moved to the neonatal room at Department of Pediatrics, Bachmai Hospital without respiratory failure from - 2013 to 12 - 2015 Methods Descriptive and prospective study RESULTS General characteristics of the groups From January, 2013 to December, 2015, we evaluated 139 neonates with respiratory failure and 278 neonates without respiratory failure who were treated at Department of Pediatrics The average gestational age of the case group (34 weeks) was significantly lower than the control group with 38 weeks (p < 0.001) The average weight of the case group (2,057 Gr) was significantly lower than the control group with 2,893 Gr (p < 0.001) Chart 1: Gestational age distribution in the study 663 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 2.2% Patent ductus arteriosus 22 15.8% Pulmonary arterial hypertension 3.6% Sepsis 2.9% Respiratory failure due to premature birth 43 30.9% Brain hemorrhage 0.7% Hypoglycemia 5% Other congenital heart defects 0.7% Other diseases 1.4% 139 100% Total 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 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 (95%CI) Weight n % n % Weight < 2,500 Gr 91 65.5% 73 26.3% Weight 2,500 Gr 48 34.5% 205 73.7% 5.324 (3.429 - 8.267) 139 100% 278 100% p < 0.001 Total 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 (95%CI) Pediatrician n % n % Neonate is not at risk 49 35.3% 192 69.1% 90 64.7% 86 30.9% 0.244 (0.158 - 0.375) 139 100% 278 100% p < 0.001 Neonate has risk factors Total 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 Apgar scores n % Apgar ≤ 96 Apgar > 43 139 Total Control group OR (95%CI) n % 69.1% 31 11.2% 30.9% 247 88.8% 17.888 (10.592 - 29.875) 100% 278 100% p < 0.001 Apgar score at the first minute 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 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 (95%CI) CS without labour n % Yes 59 42.4% 1.8% No 80 57.6% 273 98.2% 40.268 (15.631 - 103.736) 139 100% 278 100% p < 0.001 Total n % 665 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 Maternal factors Case group Control group n % n % Abnormal 38 27.3% 52 18.7% Normal 101 72.7% 226 81.3% Maternal disease during pregnancy Yes 73 52.5% 121 43.5% No 66 47.5% 157 56.5% Maternal problem at delivery Yes 95 68.3% 102 36.7% No 44 31.7% 176 63.3% History of maternal pregnancy p OR (95%CI) 0.043 1.635 (1.012 - 2.641) 0.083 1.435 (0.954 - 2.16) < 0.001 3.725 (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 The study was carried out from - 2013 to 12 - 2015, 139 neonates who were diagnosed as respiratory failure were transferred from the Department of Obstetrics to the Neonatal Intensive Care Unit room at Department of Pediatrics, Bachmai Hospital for treatment During the admission process, we evaluated and exploited the maternal history and recorded the factors related to the pregnancy and childbirth to find out some causes and risk factors related to the possibility of being respiratory failure of the baby after birth In 139 neonates who were diagnosed as respiratory failure hospitalized, the causes of the disease varies from lung and respiratory diseases (hyaline membrane disease, asphyxia, meconium aspiration syndrome, 666 pneumonia ), cardiovascular disease (patient ductus arteriosus, pulmonary hypertension ), respiratory failure in premature birth However, the rate of lung disease, respiratory disease and respiratory failure in premature birth was still high, 38.9% and 30.9% respectively These pathologies are potentially preventable and treatable if the prognosis of the risk factors that affects the respiratory status of the postnatal children to timely therapeutic intervention, limiting the negative impact on the respiratory function of children when they begin to adapt to life outside uterus This is the role of management of pregnancy and childbirth in the per partum and postpartum period, especially in the per partum period, which directly affect infant’s status In our study, the obstetric history of the mother (giving birth prematurely, miscarriage, fetal death, etc.) had an effect TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 on neonatal respiratory failure risk (p = 0.043), risk of neonatal respiratory failure was OR = 1.635 (95%CI; 1.012 - 2.641) when the mother has a history of abnormal pregnancy Huynh Thi Duy Huong had detail risk factor of respiratory distress such as: fetal death… [2] The common complications during CS were hypertension, cardiovascular disease, renal failure, systemic disease (lupus), pregnancy toxicity, preeclampsia, HELLP syndrome… If these conditions were detected and controlled, it would reduce the risk of postpartum respiratory failure Maternal health factors as risks for postnatal child were also reported by foreign authors such as Khairy et al who found that pregnant women with congenital heart had risk factors that directly affected their health and their infants, in which giving birth prematurely and respiratory distress accounted for a high proportion of neonates receiving postpartum support [4] Gelfand et al presented risk factors for meconium aspiration in infants including hypertension, gestational diabetes, preeclampsia, chronic heart disease [3] Prematures and low birthweight are risk factors that increase rate of respiratory distress after birth We evaluated 139 neonates with respiratory failure and 278 neonates without respiratory failure who were treated at Department of Pediatrics The average gestational age of the case group (34 weeks) was significantly lower than the control group with 38 weeks (p < 0.001) The average weight of the case group (2,057 Gr) was significantly lower than the control group (2,893 Gr) (p < 0.001) The rate of respiratory failure in the low birth weight < 2,500 Gr (65.5%) in case group was significantly higher than that in the control group (26%) (p < 0.001) If neonatal weight is smaller than 2,500 Gr, neonates will have a risk of respiratory failure 5.324 (95%CI; 3.429 - 8.267) Mahoney reported that the rate of respiratory distress of late preterm was 28.9% and term was 5.3%, the early term infants (35 weeks) risk of respiratory distress was times compared with term baby (38 - 40 weeks) [6] Cesarean delivery on maternal request is also one of neonatal respiratory distress risk factors According to our study, the respiratory distress rate was 42.4% in CS on maternal request group and was only 1% in the rest This difference has statistical significance (p < 0.05) This problem was investigated by Ray et al in women with no indication of labor at 34 - 37 gestation weeks, suggesting that more than 25% of neonates have severe respiratory failure after delivery [7] According to a study by Liu et al (2005), full-term infants undergoing CS on maternal request increased the risk of respiratory distress [5] It is an issue for gynecologists to more research to have more concrete evidence in choosing a safe birth route for both mother and newborn baby Obstetrical-neonatal care co-operation module is important and effective in reducing the rate of respiratory distress and asphyxia in the delivery room especially in the case of preterm as well as full-term infants whose mothers have chronically diseases, contributes to restrict postpartum morbidity, particularly in cases of respiratory failure, preterm infants In our study, pediatric resuscitation during childbirth was essential for children with respiratory failure at birth (64.7%), while 30.9% of children in the control group needed support of the pediatric resuscitation Pediatric patients, who did 667 TẠP CHÍ Y - DƢỢC HỌC QUÂN SỰ SỐ CHUYÊN ĐỀ HÌNH THÁI HỌC-2017 not have any risk, needed for coordination of pediatric resuscitation (OR = 0.244; 95%CI: 0.158 - 0.375; p < 0.001) This combination is highly appreciated in the world and is being implemented in obstetrics and pediatrics hospitals It is especially valuable in general hospitals because of the proportion of mothers with medical conditions that need to be intervened had increased more and more, it is necessary to have other support from the fields of internal medicine, cardiology combined with obstetrics and pediatrics to treat both mother and child properly - There are many factors that influence the rate of neonatal respiratory failure related to maternal pregnancy, maternal morbidity during labor, CS without labour, effective postpartum resuscitation and premature labor, low weight These factors can be intervened to reduce the rate of respiratory failure, asphyxia when pregnancy is managed strictly, proper diagnosis and treatment of maternal disease, holding on relationship between Department of Obstetrics and Department of Pediatrics in caring for neonates after birth The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed According to our observation, Apgar score at the first minute at risk for respiratory distress was OR = 17.888 (95%CI; 10.592 - 29.875; p < 0.001) Thus, neonatal resuscitation after birth will have reduced the rate of neonatal respiratory distress Pediatric and obstetrics combination actually plays an important role in reducing the risk of neonatal respiratory distress REFERENCES CONCLUSION - The mortality rate from respiratory failure is high: 15.1% of neonates with respiratory failure - Common causes of neonatal respiratory failure are causes of lung or pulmonary diseases such as asphyxia, hyaline membrane disease, pneumonia, transient tachypnoea of the newborn baby , congenital heart defects such as patent ductus arteriosus, pulmonary arterial hypertension and respiratory failure in premature birth, all of them can be intervened 668 Nguyễn Tiến Dũng Hội chứng suy hô hấp sơ sinh Chu kỳ sinh học: bệnh lý mẹ, thai nhi trẻ sơ sinh Nhà xuất Y học, Hà nội 2012, tr.181-197 Nguyễn Công Khanh CS Sách giáo khoa Nhi khoa Chương 10: Bệnh lý sơ sinh Bệnh lý phổi gây suy hô hấp sơ sinh Nhà xuất Y học, Hà Nội 2016, tr.232-246 Gelfand S.L et al Meconium stained fluid: approach to the mother and the baby Pediatr Clin N Am 2004, 51, pp.655-667 Khairy P et al Pregnancy outcomes in women with congenital heart disease Circulation 2006, 113, pp.517-524 Liu J et al High-risk factors of respiratory distress syndrome in term neonates: A fetrospective case-control study Balkan Med J 2014, 31, pp.64-68 Mahoney A.D et al Respiratory disorders in moderately preterm, late preterm, and early term infants Clin Perinatol 2013, 40, pp.665-678 Ray C.L et al Caesarean before labour between 34 and 37 weeks: What are the risk factors of severe neonatal respiratory distress? European Journal of Obstetrics & Gynecology and Reproductive Biology 2006, 127, pp.56-60 ... Prematures and low birthweight are risk factors that increase rate of respiratory distress after birth We evaluated 139 neonates with respiratory failure and 278 neonates without respiratory failure. .. 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, ... and pH in threshold criteria [2] Diagnosis of acute respiratory failure based on clinical and paraclinical symptoms Clinical symptom of respiratory failure [1, 2]: respiratory failure is defined