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Neonatal Respiratory Distress

Neonatal Respiratory Distress. Priscilla Joe, MD Children’s Hospital and Research Center at Oakland. Neonatal Respiratory Disease. Upper airway disease True parenchymal disease Airleak syndromes Disorders of development Primary pulmonary vascular disease. Upper Airway Disease.

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Neonatal Respiratory Distress

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  1. Neonatal Respiratory Distress Priscilla Joe, MDChildren’s Hospital and Research Center at Oakland

  2. Neonatal Respiratory Disease • Upper airway disease • True parenchymal disease • Airleak syndromes • Disorders of development • Primary pulmonary vascular disease

  3. Upper Airway Disease • Choanal atresia • Pierre Robin sequence • Vascular rings

  4. Choanal Atresia Pierre Robin Syndrome

  5. ChoanalAtresia/Upper Airway Obstruction • Cyanotic when quiet or at rest, pink with crying • Inability to pass suction catheter through nares • Stridor

  6. Upper airway obstruction • Insert an oral airway • Provide oxygen • Suction secretions • May require intubation

  7. Fetal Lung Characteristics • Decreased blood flow • caused by compression of the pulmonary capillaries by fetal lung fluid • Pulmonary arteries • thick muscular layer present, very reactive to hypoxemia • Lung fluid secretion • fetal lungs secrete fluid, adequate lung volume is necessary for fetal development • Fetal breathing • contributes to fetal lung development, moves fluid in and out of fetal lung • Surfactant • necessary amount to support breathing after birth, present after ~ 34 weeks gestation

  8. Transition • Clearance of fetal lung fluid • Increased compliance • Increased pulmonary blood flow

  9. Respiratory Distress Syndrome • Disease of surfactant defiency • Surfactant decreases surface tension and improves lung compliance • Surface tension: intrinsic tendency for alveoli to collapse

  10. Prematurity: Males Second born twins C-section Caucasian race Secondary surfactant deficiency: Maternal diabetes Asphyxia Pneumonia Pulmonary hemorrhage Meconium aspiration Oxygen toxicity RDS: Risk Factors

  11. RDS: Clinical Findings • Non-specific findings of respiratory distress • Grunting • Flaring • Retracting • O2 requirement

  12. RDS: Radiography Alveolar disease: • Diffuse reticular granular or “ground glass”pattern • Air bronchograms • Underaeration

  13. RDS: Treatment • Maintain FRC (CPAP vs. intubation) • Surfactant replacement • Exogenous surfactants • Survanta 4cc/kg • Infasurf 3cc/kg

  14. Surfactant Therapy for RDS • Decreases mortality • Greatest benefit when used with antenatal steroids • Improvement in compliance, functional residual capacity, and oxygenation • Reduces incidence of air leaks

  15. Congenital Pneumonia Common organisms: • Group B streptococcus • E.Coli, Klebsiella • Chlamydia, Ureaplasma, mycoplasma • Listeria • TORCH • H. Influenza (nontypeable)

  16. Pneumonia: Risk Factors • Maternal chorioamnionitis • Prolonged rupture of membanes • Prematurity • Postnatal exposures: Poor hand washing, open skin lesions, contaminated blood products, infected breast milk

  17. Pneumonia • Inflammation and edema • Bronchial plugging • Surfactant inactivation • Alveolar collapse • Ventilation/perfusion mismatch • Desaturation

  18. Pneumonia: Clinical Findings • Presents with non-specific findings of respiratory distress • Grunting • Flaring • Retracting • O2 requirement

  19. Pneumonia: Radiography • There are no classic x-ray findings, in fact, the X-ray in pneumonia can look like anything • Fairly normal • Classic RDS • Classic for MAS

  20. Pneumonia: Treatment • Respiratory support as indicated with either O2 or positive pressure • Treatment with appropriate antimicrobials • Initial ampicillin/gentamicin or ampicillin/cefotaxime • Broader spectrum antibiotics for nosocomial bacteria

  21. Meconium Aspiration Syndrome • Meconium contains epithelial cells and bile salts • Released with intrauterine stress or asphyxia • Present in 15% of all newborns. • Only 5-10% develop MAS

  22. Meconium Aspiration • Airway plugging, with air trapping • Inflammation, leading to inactivation of surfactant • Surfactant inactivation leads to decreased compliance, and alveolar collapse • Alveolar collapse = loss of FRC • Loss of FRC = V/Q mismatch • V/Q mismatch = desaturation

  23. Meconium aspiration: Xray • Areas of hyperexpansion mixed with patchy densities and atelectasis

  24. Pneumothorax • May occur spontaneously during delivery • Most common when receiving positive pressure • Space occupying lesion within the chest displacing lung, and if under tension, compromising venous return

  25. Pneumothorax: Clinical Findings • Presents with non-specific signs of respiratory distress • Grunting • Flaring • Retracting • O2 requirement • Unequal, decreased breath sounds

  26. Pneumothorax: Treatment • O2 as needed • Nitrogen washout (pneumo contains 21% O2, >75% nitrogen, if lung has 100% O2, nitrogen will diffuse out of pneumothorax) • Try to avoid positive pressure if able • Evacuate as needed by thoracentesis or chest tube

  27. Developmental disturbances • Pulmonary hypoplasia • Congenital diaphragmatic hernia • Skeletal deformities

  28. Pulmonary hypoplasia • Cannot be assessed radiographically, pulmonary hypoplasia is a pathologic diagnosis • Suspect pulmonary hypoplasia if: • Rupture of membranes with anhydramnios • Renal anomalies • Restriction of the chest wall • Congenital diaphragmatic hernia

  29. Diaphragmatic Hernia • Scaphoid abdomen • Bowel sounds in the chest • Other associated anomalies • Decreased breath sounds • Severe hypoxemia

  30. Diaphragmatic Hernia • Wide range in clinical presentation • Herniation of bowel leads to altered development of the lungs bilaterally

  31. Persistent Pulmonary Hypertension of the Newborn • Primary pulmonary hypertension is a pure vascular disease • More often present in a mixed picture as in the setting of meconium aspiration syndrome or asphyxia

  32. PPHN • In response to an asphyxia event in utero, the fetus diverts all blood flow possible to vital organs (brain/heart/adrenals) • This leads to vasoconstriction of non-vital vascular beds, including the pulmonary bed • Remodeling of smooth muscle can occur

  33. PPHN Increased PVR PDA RV outflow PA Aorta

  34. PPHN: Clinical Findings • Respiratory distress with hypotension • Hypoxemia out of proportion to degree of distress • Difference in pre and post ductal sats • Right hand • Lower extremities • Hyperoxia test

  35. Decreases R L shunt: Decrease PVR Increase pulmonary blood flow Hyperoxia Hypocarbia Lack of acidosis Increases R L shunt: Increase PVR Decrease pulmonary blood flow Hypoxia Hypercarbia Acidosis PPHN

  36. PPHN: Treatment • Improve pulmonary blood flow: • Keep well saturated • Normocarbia • Avoid: • Hypoxia • Hypercarbia • Acidosis • Supportive care: temperature regulation, fluids and lytes, antibiotics

  37. PPHN: Treatment • Conventional ventilation or HFOV • Nitric oxide • Surfactant replacement • ECMO

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