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Respiratory Distress in the Newborn, not RDS

Respiratory Distress in the Newborn, not RDS. Dr. Alona Bin-Nun NICU Shaare Zedek. Respiratory Distress in the Newborn – Clinical Presentation. Cyanosis Grunting Retractions Tachypnea Nasal flaring Extreme: Apnea, Shock. More Common Causes of Respiratory Distress. RDS Pneumonia

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Respiratory Distress in the Newborn, not RDS

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  1. Respiratory Distress in the Newborn, not RDS Dr. Alona Bin-Nun NICU Shaare Zedek

  2. Respiratory Distress in the Newborn – Clinical Presentation • Cyanosis • Grunting • Retractions • Tachypnea • Nasal flaring • Extreme: Apnea, Shock

  3. More Common Causes of Respiratory Distress • RDS • Pneumonia • Meconium Aspiration • Transient Tachypnea • Hypothermia • Hypoglycemia

  4. Acute Life Threatening Emergencies Presenting in Respiratory Distress • Choanal Stenosis • Meconium Aspiration • Tension Pneumothorax • Diaphragmatic Hernia

  5. Developmental Choanal Atresia Pierre Robin sequence Infection Sepsis Meningitis Metabolic Hypoglycemia Hypothermia Acidosis CNS Infection Hemorrhage Edema Blood Blood loss, Hypovolemia Anemia Polycythemia Major Causes of Respiratory Distress in the Newborn: Extrathoracic

  6. Developmental RDS Hypoplastic lungs T-E fistula Cystic Malformation Cong. Lobar Emphysema Infection Pneumonia Congenital/Acquired viral/bacterial Aspiration Meconium Blood Amniotic Fluid Air Leak PIE Pneumothorax Pneumomediastinum Cardiac Cong. Heart disease IDM Misc Persistent Pulmonary Hypertension of the Newborn (PPHN) Wet Lungs Pulm. Hemorrhage Major Causes of Respiratory Distress in the Newborn Intrathoracic

  7. Evaluation of Infant with Respiratory Distress - History • Pregnancy- Hydramnios, Diabetes • Labor • Delivery: C/S or vaginal • Evidence of Infection • Meconium • Apgar Scores • Resuscitation

  8. Evaluation of Infant with Respiratory Distress – Physical Examination • Degree of respiratory distress • Cyanosis • Air entry • Heart murmur • Temperature • Scaphoid abdomen • Position of PMI

  9. Laboratory Tests • O2 saturation • X-ray: AP+lateral. Assess both lungs and heart • Blood gas • Hct • Dextrostix • BP • Transillumination • Hyperoxia test • Nasogastric catheter (radio opaque) • Evaluate for sepsis

  10. Management of Newborn with Respiratory Distress (1) • Clear airway, esp. meconium • Oxygen • Ventilation • mask bagging → intubation • Cyanosis • CO2 retention • apnea • Correct Acidosis

  11. Management of Newborn with Respiratory Distress (2) • Arterial Catheter, follow blood gases • Correct • Hypoglycemia • Hypothermia • Shock • Anemia or polycythemia • Drain Pneumothorax • Antibiotics (for unexplained persistent respiratory distress)

  12. Clinical Presentation Frequently term infant C/S Mild respiratory distress Moderate O2 requirement Duration: 2-5 days X-ray Ill defined hazy central markings Fade towards periphery Slight cardiomegaly Transient Tachypnea

  13. Clinical Presentation Frequently term infant C/S Mild respiratory distress Moderate O2 requirement Duration: 2-5 days X-ray Ill defined hazy central markings Fade towards periphery Slight cardiomegaly Pathogenesis Delayed removal of alveolar fluid Treatment Supportive Prognosis Excellent Transient Tachypnea

  14. Bacterial GBS, E.coli, other Gram negative Viral CMV, rubella, herpes, RSV Routes of Infection Ascending (PROM) Hemtogenous Aspiration of infected material Time of Infection Before, during or after delivery X-ray Focal infiltrates Can be diffuse Can be indistinguishable from RDS Evaluation Tracheal culture Evaluate for sepsis Screen for TORCH Treatment Antibiotics Supportive Pneumonia

  15. Meconium Aspiration Syndrome (MAS)

  16. Effects of Meconium Aspiration Meconium Aspiration Chemical pneumonitis Bacterial pneumonitis Proximal Airway Occlusion Peripheral Airway Occlusion Complete Partial Asphyxia Atelectasis Ball valve Intrapulmonary Shunt Extra-alveolar air Hypoxemia and Acidodis PPHN

  17. Prevention Oxygen, CPAP Assisted ventilation NO Drain pneumothorax Antibiotics General measures, correct: hypovolemia metabolic acidosis hypoglycemia hypocalcemia anemia Further Sequelae CP ATN Anoxic liver + coagulopathy NEC Anoxic Myocardial damage Treatment of MAS

  18. T-E Fistula classification

  19. Esophagial Atresia and T-E Fistula • Embryology • Interruption of division of foregut into trachea and esophagus • Clinical Picture • Associated with prematurity and hydramnios • Increased salivation • Choking and dyspnea on feeding • Aspiration pneumonia • Other abnormalities (VACTER association) • Diagnosis • X-ray: dilated proximal esophageal pouch, curling of NG catheter • Dye studies • Air in abdomen: presence or absence of fistula • Endoscopy

  20. Preoperative Care • Treat Pneumonia • Prevent gastric reflux – upright position • Suctioning of proximal pouch • Definitive treatment • Surgery • Prognosis • Survival • Depends on birth weight, prematurity, other congenital abnormalities

  21. Diaphragmatic Hernia

  22. Diaphragmatic Hernia

  23. Treatment Intubate and ventilate Do not mask bag Gastric tube Beware of pneumothorax Surgery Post op: Ventilation and oxygenation: problematic Outcome Poor due to lung hypoplasia

  24. Pneumothorax

  25. Pneumothorax • Accumulation of air in pleural cavity • Common cause of respiratory distress. • Pathogenesis • Overdistension of alveoli • Rupture of air into interstitial space • Tracking to hilum along periventricular and peripheral sheaths • Air enters mediastinum • Rupture into pleural space • Rupture of subpleural bleb directly into pleural space • Results • Decreased lung volume • Decreased cardiac output

  26. Pneumothrax ↑ intrapleural pressure Compression of large intrathoracic veins ↓ lung volume Mediatinum shift ↑ pulm. Vascular resistance ↑ central venous pressure ↓ venous return ↓ cardiac output Mechanisms leading to reduction of CO

  27. Clinical Presentation of Pneumothorax • Grunting • Tachypnea • Apnea • Cyanosis • Bradycardia • Shock • Sudden deterioration in ventilated infant • Shifting of heart sounds • Chest asymmetry • Decreased air entry

  28. Pneumothorax: Diagnosis (1) • If infant’s life threatened, don’t wait for X-ray, do diagnostic needle aspiration !! • Transillumination

  29. Pneumothorax: Diagnosis (2) • X-ray • Seperation of lung from chest wall • Absent lung marking peripherally • Shift of mediastinum in tension pneumothorax • Bilateral tension: no shift, small heart • Lateral: air collection beneath sternum

  30. Pneumothorax: Diagnosis (3) • Associated with PIE • Pneumomediastinum • Pneumopericardium

  31. Spinnaker sail sign: The thymus, wedge-shaped, extending from the rt. hemidiaphragm to the superior mediastinum (white arrows),is displaced by a collection of gas under pressure (black arrows).

  32. Causes of Pneumothorax • Spontaneous • RDS • CPAP and mechanical ventilation • Resuscitation • Pulmonary hypoplasis • Post thoracotomy

  33. Treatment of Pneumothorax • Observe only if: • Minimal respiratory distress • Minimal oxygen requirement • Breathing spontaneously • Maintaining good BP • Indications for drainage • Tension pneumothorax • Cyanosis • Apnea • Deteriorating blood gases • Assisted ventilation • Shock

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