Respiratory disease Respiratory disease in the newbornin the newborn

Dr. Rozin Ilya Dr. Rozin Ilya

הצגת מיקרההצגת מיקרה בניתוח קיסרי דחוף עקב חוסר 40תינוק שנולד בשבוע •

התקדמות וניטור עם סימני סבל עוברי..38.0אם עם חום סביב לידה עד •בלידה מים מקוניאליים, תינוק ללא נשימה ספונטאנית,רפוי,•

כחול.בוצע אינטובציה וסקשיון מהקנה עם תוכן נוזל מקוניאלי. •

הנשמה למשך דקה עם הופעת נשימות ספונטאניות,עליה בטונוס.דופק טוב.

בוצע אקסטובציה עם נשימות עצמוניות וסימני מצוקה •נשימתית קלה.קיבל חמצן סביבתי.

)עקב צבע וטונוס( 9\8אפגר •תינוק הועבר למעקב במחלקת תינוקות. •

הצגת מיקרההצגת מיקרהסימני מצוקה .35%במחלקה נזקק לחמצן בכיפה עד •

ל בתצרוכת חמצןנשימתית שהלכה וגברה יחד עם עליה .88%-90% ריווי חמצן בדם עם 100% ובהמשך ל 60%

בוצעו בדיקות דם – בעבודה. גזים בדם עם •pH7.19,pCO2 75,pO2 35,

Bic19,BE-6 . בעיקר בבסיסי הריאות יותר מימין Patchצילום חזה עם •

עם ציור ריאתי מעוט וצל הלב תקין..I.Vהוחל טיפול אנטיביוטי ומתן נוזלים •להמשך טיפול ובירור עובר למחלקת לטיפול נמרץ פגים.•

הצגת מיקרההצגת מיקרה נשאר O2,אך CO2הונשם מייד אחרי קבלתו עם שיפור ב •

SatO2 חמצן. 100%נמוך,למרות עליה בלחצי הנשמה ו .85%הייתה סביב

לב עם מבנה תקין,ECHOלצורך הערכה קרדיאלית בוצע •.PFO רחב עם דלף מימין לשמאל ו PDAנצפה

עם ppm 20 עד Nitric Oxideלאור הממצאים הוחל מתן •.45% וירידה בתצרוכת חמצן ל 95% ל SatO2עליה ב

.Dopamineבשל לחץ דם גבולי לגילו הוחל מתן •בהמשך חל שיפור הדרגתי,כעבור מספר ימים עבר •

ימים.שחרור 7אקסטובציה ונשאר עם חמצן סביבתי למשך לבית במצב טוב.

Signs and symptomsSigns and symptoms

• Cyanosis • Grunting • Nasal flaring • Retraction • Tachypnea• Decreased breath sounds with rales and /

or rhonchi• Pallor• Apnea

CausesCauses Central or peripheral nervous system

hypoventilation:

- Birth asphyxia

- Intracranial hypertension, hemorrhage

- Over sedation ( direct or through maternal rout )

- Diaphragm palsy

- Neuromuscular disease

- Seizure

CausesCauses

Respiratory disease: Upper airway:

- Choanal atresia / stenosis

- Pier Robin syndrome

- Intrinsic airway obstruction ( laryngeal / bronchial / tracheal / stenosis )

- Extrinsic airway obstruction ( bronchogenic cyst, duplication cyst, vascular

compression )

CausesCauses

Respiratory disease:

Lower airway:

- Respiratory distress syndrome - Transient tachypnea

- Meconium aspiration

- Pneumonia ( sepsis )

- Pneumothorax

- Congenital diaphragmatic hernia

- Pulmonary hypoplasia

CausesCausesCardiac right to left shunt:

Abnormal connection ( pulmonary blood flow normal or increased ):

- Transposition of great artery

- Total anomalous pulmonary venous return

- Truncus arterious

- Hypoplastic left heart syndrome

- Single ventricle or tricuspid atresia with VSD & without PS

CausesCausesCardiac right to left shunt:

Obstructed pulmonary blood flow ( pulmonary blood flow decreased ):

- Pulmonic atresia with intact ventricular septum

- Tetralogy of Fallot

- Tricuspid atresia

- Single ventricle with Pulmonic stenosis

- Ebstein malformation of the tricuspid valve

- Persistent fetal circulation ( PPHN )

- Critical Pulmonic Stenosis with PFO or ASD

CausesCauses

Methemoglobinemia:

- congenital ( hemoglobin M, methemoglobin reductase deficiency )

- Acquired ( nitrates, nitrites )

Other:

- Hypoglycemia - Adrenogenital syndrome - Polycythemia - Blood loss

Transient tachypnea of newbornTransient tachypnea of newborn • Usually in normal preterm or term vaginal delivery or C/S

• Early onset of tachypnea, retraction, cyanosis ( O2 < 40%)

• Usually recover rapidly within 3 day

• In auscultation – clear sound

• Chest x- ray : prominent pulmonary vascular marking, fluid in the intralobar fissures, overaeration, flat diaphragms, rarely pleural effusion.

• Secondary to slow absorption of fetal lung fluid resulting in decreased pulmonary compliance and tidal volume and increased dead space

• Treatment is supportive

Meconium aspirationMeconium aspiration• Found in 10-15% of births • Usually occurs in term or post-term infants • Meconium aspiration pneumonia – in 5% • Require mechanical ventilation – 30%• Death 3-5%• Pathogenesis: - peripheral and proximal airway obstruction - inflammatory and chemical pneumonitis - remodeling of pulmonary vasculature - atelectasis > V / Q mismatch - air trapping > air leaks - persistent pulmonary hypertension - acidosis, hypoxemia, hypercapnea

Meconium aspirationMeconium aspiration• In clinical signs – respiratory distress, - tachypnea persistent from few days to several weeks, - hypoxia and metabolic acidosis.

• In chest x-ray – overdistention, typical – patchy infiltrates, coarse streaking of both lung, signs of PPH

• Therapy – supportive care ( mechanical ventilation, used of exogenous surfactant, ECMO )

• Prevention – for depressed infant – intubations with suction.

Persistent pulmonary Persistent pulmonary hypertension of newbornhypertension of newborn

• Occurs in term and post-term infants• Predisposition factors: - birth asphyxia, - meconium aspiration pneumonia, - early onset sepsis, - RDS, - hypoglycemia, polycythemia, - maternal use of NSAID (PDA closed) or SSRI, - pulmonary hypoplasia (result of diaphragmatic

hernia), - oligohydramnios, - pleural effusion.

Persistent pulmonary Persistent pulmonary hypertension of newbornhypertension of newborn

• In pathophysiology – this is circulation with fetal pattern of right to left shunting through the PDA and Foramen Ovale after birth.

• PPHN is often idiopathic.• Some infants have low plasma arginine and nitric

oxide metabolite concentration and polymorphisms of the carbamoyl phosphate synthase gene – defect NO production.

• Incidence: 1/500 – 1/1500 live birth.• Survival varies with underline diagnosis.

Persistent pulmonary Persistent pulmonary hypertension of newbornhypertension of newborn

• In clinical picture: - infant become ill in the delivery room or within first 12 hr - initial signs may be minimal

• Diagnosis: - hypoxia unresponsive to 100% of oxygen - gradient pO2 between preductal and postductal

site of blood sampling > 20 mmHg or SatO2 > 5% by pulse oxymetry. - by ECHO – right to left shunt ,tricuspid regurgitation. - x-ray chest

• D.D. – cyanotic heart disease.

Persistent pulmonary Persistent pulmonary hypertension of newbornhypertension of newborn

• Treatment : - Correcting predisposition disease - Oxygen administration - Talazoline – non selective alpha-adrenergic

antagonist - Hyperventilation ( pCO2 =25 mmHg with pH 7.50-

7.55) - Sedation ( Fentanyl ) - paralytic drugs – controversial - Inotropic therapy - Nitric Oxide ET inhalation ( reduce ECMO by 40% ) - Prostacyclin (PGI 2) I.V.

Persistent pulmonary Persistent pulmonary hypertension of newbornhypertension of newborn

- Extracorporeal Membrane Oxygenation ( ECMO ) – is form of cardiopulmonary bypass that augments systemic perfusion and provides gas exchange.

Criteria: - Oxygenation Index: (MAP * FiO2 * 100) / PaO2 (35-60) - Alveolar Arterial Oxygen Gradient: FiO2 (P-47) – PaO2 – PaCO2 [FiO2 + (1-FiO2) / R] P – barometric pressure(760), R – respiratory quotient(0.8)

(> 605-620) - PaO2: < 40 mmHg - Acidosis and Shock: pH<7.25 or + hypotension

Congenital diaphragmatic herniaCongenital diaphragmatic hernia

• May be due to defective formation of the pleuroperitoneal membrane.

• Associated with pulmonary hypoplasia.• Incidence of CDH 1/2000 – 1/5000 live birth • Female : Male = 2 : 1• Defect more common – left (85%)• Most common sporadic.• Associated anomalies in 30% (CNS lesion,

Esophageal Artesia, omphalocele, CVS lesion)• Initial management – aggressive respiratory support

with immediately intubation. Surfactant therapy commonly use, but no study for that is beneficial.

PneumoniaPneumonia

Bacterial infection is possible cause of neonatal respiratory distress.

Common pathogens include:- group B streptococci (GBS),- Staphylococcus aureus, - Streptococcus pneumoniae, - gram-negative enteric rods.

Pneumonia and sepsis have various manifestations, including the typical signs of distress as well as

temperature instability.

PneumoniaPneumonia Risk factors for pneumonia include:- prolonged rupture of membranes,- prematurity, - maternal fever.

Prevention of GBS infection through screening and antepartum treatment reduces rates of early-onset disease including pneumonia and sepsis, by 80 percent.

Intrapartum antibiotics at least four hours before delivery.

Chest radiography helps in the diagnosis, with bilateral infiltrates suggesting in utero infection.

Pleural effusions are present in 2/3 of cases. Serial blood cultures may be obtained to later identify an

infecting organism.

Extrapulmonary air – leak Extrapulmonary air – leak syndromesyndrome

Pneumothorax, defined as air in the pleural space, can be a cause of neonatal respiratory distress when pressure within the pulmonary space exceeds extrapleural pressure.

It can occur spontaneously or as a result of infection, meconium aspiration, lung deformity, or ventilation barotrauma.

The incidence of spontaneous pneumothorax is 1 to 2 percent

in term births, but it increases to about 6 percent in premature births.

Extrapulmonary air – leak syndromeExtrapulmonary air – leak syndrome

Pneumomediastinum occurs in at least 25% of patients with pneumothorax

Usually asymptomatic

Subcutaneous emphysema often asymptomatic and pathognomonic of pneumomediastinum

If trapped air is great – neck veins are distended and

- blood pressure is low it’s result of tamponade of the systemic

and pulmonary vein.

Extrapulmonary air – leak syndromeExtrapulmonary air – leak syndrome

Pulmonary interstitial emphysema (PIE) may: - precede the development of a pneumothorax - occur independently

In pathogenesis: - increased alveolar-arterial oxygen gradient - increased intrapulmonary shunting - progressive enlargement of blebs of air may result in cystic dilatation. In therapy with oxygen and high frequency ventilation

Differential diagnosis with Differential diagnosis with cyanotic CHDcyanotic CHD

• Central cyanosis

• Lack or minimal respiratory distress signs

• Systolic murmur

• Evaluation by ECHO

• Chest x-ray

• Hyperoxic test

TGA

TARVR

Hyperoxic testHyperoxic test

• Placing in 100% oxygen concentration

• During for 5 to 10 minutes

• Sampling arterial gas or monitoring oxygenation non invasively

• If PaO2 level higher than 100 mmHg - good

• If PaO2 level above 40-50 mmHg – sign to right to left shunting

Evaluation and first line therapy a child Evaluation and first line therapy a child with cyanosiswith cyanosis

• Anamnesis• Clinical signs and symptoms• Oxygen therapy• Blood gas measurement• CBC and blood culture• Chest x-ray • ECG if need • NPO• Fluid intravenously • Stomach decompression • Mechanical ventilation if need