extrapulmonary respiratory problems during the first week
TRANSCRIPT
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Extrapulmonary Respiratory Problems
During the First Week of Life
Jon Palmer, VMD, DACVIM Chief, Neonatal Intensive Care Service
New Bolton Center, University of Pennsylvania, USA
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Online Lecture Notes
PDF files of slides
iveccs15.nicuvet.com
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Neonatal Respiratory Problems
Upper airway obstruction Pharyngeal collapse
Dysphagia Aspiration pneumonia
Central Respiratory Control Tachypnea Tachypnea syndromes
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Terminal C-section History
Mare Metastatic melanomas Admitted as a high risk pregnancy Progressive abdominal distention
Hemoperitoneum
Terminal c-section during an acute bleed
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Terminal C-section
Foal’s major problems NE – somnolent, hypotonia, seizures
Cluster breathing periodic respiratory pauses NG – dysmotility – 6 days NN – oliguria, high FxNa, fluid retention,
hyponatremia, low creatinine clearance Other: Sepsis, coagulopathy, hyperglycemia,
candidiasis
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Pharyngeal Collapse Hypotonia
Soon after birth Upper airway flutter
At 24 hr Exaggerated respiratory effort
Quite lungs Paradoxical respiration Physical exam – pharyngeal collapse Phenobarbital therapy
Increase obstruction Pharyngeal Collapse
Primary Secondary
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Hypoventilation
Time 2:16a pH 7.174 Pco2 74.4 Po2 75.8 SAT 96.2 INO2 7 lpm
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Hypoventilation
Time 2:16a 3:27a pH 7.174 7.266 Pco2 74.4 59.0 Po2 75.8 84.4 SAT 96.2 100 INO2 7 lpm 10 lpm
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Upper Airway Abnormalities Transient Pharyngeal Paresis
Hypotonic pharyngeal collapse Primary Peripheral neuropathy?
Neonatal Encephalopathy?
Secondary Weakness/fatigue
Most resolve within days
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Primary Pharyngeal Paresis
Syndrome Appear normal initially Stressed
Respiratory rate and effort increase Negative pressure in the pharynx Pharyngeal collapse Self perpetuating obstruction
Respiratory failure followed by cardiovascular failure Dysphagia may be present
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Secondary Pharyngeal Paresis
Generalized weakness Critically ill
Generalized hypotonia Fatigue Recumbent
Watch for collapse
Phenobarbital can induce Major cause hypoventilation in treated cases
HYPP (Hyperkalemic Periodic Paralysis)
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Endotracheal Tube Stent
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Endotracheal Tube Stent
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Dysphagia
Milk regurgitation from the nares
Cleft palate
Very rare cause of milk at nares
Pharyngeal dysfunction
Esophageal dysmotility
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Dysphagia No Aspiration
Esophageal dysmotility Failure to clear the cervical esophagus Appear to nurse normally and effectively Lower their head
Sneeze or shake head Milk flow from one or both nostrils Few drops to 60 ml
Delay of up to 5 minutes
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Dysphagia No Aspiration
Esophageal dysmotility Transient problem
Once to several days Etiology?
Neonatal Encephalopathy Esophageal dysmotility
Aspiration rare Swallowing normal Guard airway
Aerophagia Most common reason
For milk coming from the nostril
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Dysphagia Aspiration Pneumonia
Dysphagia secondary to pharyngeal paresis Degree of dysfunction variable
Upper airway obstruction Pharyngeal collapse With or without dysphagia
Mild dysphagia – milk out nose Severe dysphagia – milk aspirated Most severe - aspirate saliva
Duration variable days to months Therapy – feeding management
Congenital esophageal stricture Secondary megaesophagus More danger of aspiration
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Dysphagia Aspiration Pneumonia
Other reasons - older foal
Botulism
Choke
Primary oral candidiasis
Strangles
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Aspiration Pneumonia Normal Pharyngeal Function
Weak foals Neonatal Encephalopathy
Poorly coordinated swallowing Prematurity Fatigue Heavily producing mares
Musculoskeletal problems Contracture Laxity
Fractured ribs Tachypnea Bottle feeding
Weak foals Inexperienced caregivers
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Upper Airway Abnormalities Upper Airway Obstruction
Bilateral or unilateral choanal atresia Choanal hypoplasia Epiglottic cysts/malformations Wry nose/ facial deformities Guttural pouch
Tympany Empyema
Palate malformations
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Central Respiratory Control Neonatal Encephalopathy
Changes in respiratory patterns Apneustic breathing “Periodic breathing”
Cluster breathing With periodic respiratory pauses With apnea
Apnea (> 20 seconds) Periods of up to 3-4 minutes
Ataxic breathing
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Central Respiratory Control Neonatal Encephalopathy
Changes in ventilation Hypoventilation
Respiratory acidosis Central - inappropriate hypercapnia Mechanical - upper airway obstruction Weakness
Appropriate hypercapnia Balancing a metabolic alkalosis Normal/alkalotic pH
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Central Respiratory Control Neonatal Encephalopathy
Changes in ventilation Hyperventilation
Respiratory alkalosis Abnormal central control Diagnosis by exclusion Central
Appropriate hypocapnia Balancing a metabolic acidosis
Normal /acidotic pH Hypoxia
Usually not tachpneic
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Reasons for Tachypnea Pulmonary disease Diaphragmatic hernia Pain
Contracture Fractured ribs
Distress/fear Hyperthermia for any reason Tachycardia for any reason Tachypnea Syndromes
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Tachypnea Syndromes Central hyperthermia/tachypnea
Temperatures as high as 42 C Loss of diurnal variability
Transient Tachypnea Transient Tachypnea of the Neonate (TTN) Begnin Neonatal Tachypnea
Central Hyperventilation Usually have normal respiratory rates/ TV
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Case: Central Hyperventilation
48 hr old STD Filly Neonatal Encephalopathy (NE) History
Premature placental separation Neonatal encephalopathy 48 hr stood on own 1st time
Problems NE, Septic shock, anemic, etc. Salmonella shedder
8 day hospital stay
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Adm pH 7.449 Pco2 26.1 Po2 58.4 SAT 91.7 Cont 10.8 HCO3 18.3 BE -4.2 FIO2 RA Lac
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Adm 1 hr pH 7.449 7.433 Pco2 26.1 28.8 Po2 58.4 135.6 SAT 91.7 99.4 Cont 10.8 9.4 HCO3 18.3 19.4 BE -4.2 -3.7 FIO2 RA 5 lpm Lac 5.7
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Adm 1 hr 4 hr 24 hr 60 hr pH 7.449 7.433 7.471 7.452 7.474 Pco2 26.1 28.8 32.5 28.3 33.9 Po2 58.4 135.6 136.3 127.7 68.8 SAT 91.7 99.4 99.6 99.4 94.9 Cont 10.8 9.4 10.1 10.1 9.2 HCO3 18.3 19.4 23.9 20 25.1 BE -4.2 -3.7 1 -2.9 2.1 FIO2 RA 5 lpm 5 lpm 3 lpm RA Lac 5.7 6.2 6.5 3.7
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