respiratory problems in the newborn infant: evaluation and etiology dr.abdulrahman alnemri, md...
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Respiratory Problems in the Newborn Infant:
Evaluation and Etiology
Dr.AbdulRahman Alnemri , MD
Assistance professor
Head of Neonatal unit
pediatric Department, KKUH
Development
At 4 wks
12– 16 wks
16-24 wk
–24 wk
Embryonic
Glandular
Canalicular
Alveolar
Respiratory Distress
History, physical examination Downes' or RDS score - clinical Arterial blood gases Pulse oximetry - SaO2 Chest x-ray Serum glucose and calcium; central hematocrit; WBC and differential; platelet count Maternal vaginal culture Newborn surface (e.g., ear canal, gastric aspirate) smears, cultures (?); blood culture; urine culture (?); CSF culture (?)
Signs and Symptoms
• Tachypnea - above 60-80/minute • Grunting - prevents alveolar collapse • Retractions - compliant chest wall • Flaring of alae nasi, open mouth - decreases resistance • Cyanosis in room air • PaO2 below 60 mmHg (torr) in FIO2 >0.4 • Reduced air entry • Apnea • Stridor
Evaluation and Etiology
Medical• Respiratory distress syndrome• Wet lung (transient tachypnea, • Aspiration syndromes
(meconium, blood)• Persistent pulmonary hypertension
of the newborn• Pneumonia/sepsis• Hypoplastic lungs• Cardiac lesions• Central nervous system
Surgical Diaphragmatic
hernia/eventration Esophageal atresia with or
without TE fistula Lobar emphysema Pneumothorax Pleural effusion Airway disorders Cystic lesions Mass lesions Phrenic nerve paralysis
Respiratory Distress Syndrome
870 gm 28 wks infant , Borne to 27ys old mother G4 p3. By SVD, Abgar Score 6 , 8After initial resuscitation Tachypnea, grunting, Cynosis, IC& SC retractionTachycardiaHypoperfusionHypoxia O2 Sat 85% 0n 100% Oxygen
What is (are) D/D? How to you manage this infant?
Pathogenesis
Inadequate Pulmonary Surfactant
Diffuse alveolar atelectasis HypoxiaHypercapnea
Mtabolic&Resp.Acidosis
TachypneaGrundingCynosis
HypotensionTachycardia
Management
Step 1Stablization Investigation
Treatment
Step2
Diagnosis
Surfactant Replacement therapy
TimingTiming Dose
Complications
Pulmonary Hemorrhage Pneumothorax
IVH + PDA + NEC
ROP
CLD or BPD
Infection
Wet Lung (TTN)
• Predisposing factors • Cesarean section without labor• Perinatal distress • infants of diabetic mothers • Breech • Delayed cord clamping• Maternal sedation And IV large volumes
Signs and symptoms
• Term or near term male infant• Tachypnea (80-120 breaths per minute) • Mild retraction• Mild Cyanosis • Hyperaeration • Occasional grunting and nasal flaring
Chest x-ray
• Increased markings centrally • Fluid in fissures and costophrenic angles • Hyperaeration may be present
Cont. Wet Lung
• Blood gases, SaO2 • Hypoxemia • Acidosis or alkalosis may be present • Resolution one to five days; most improve
during the first 24 hours • Management: oxygen, occasionally
CPAP/PEEP
Pneumonia
Term infant 2.85kg boy, Borne to 34 yeas old mother G6 P4 +1 unbookedPresented with SROM > 36 hsImmediately after birth he started to hasSever respiratory distress , associated with very soft ejection systolic murmurWhat is (are) the diagnosis?How do you manage this infant?
Air leak syndrome
• 31 wks ,1200gm , admited to NICU with milde RDS, Connected to CMV with good blod gases and oxygen saturation.
• 2nd day developed sudden deterioration became hypoxic, skin mottling and low BP
• What is your diagnosis ?• How do you manage this inbfant?
Air Leak Syndrome
Pneumothorax PIE
Pneumomediastinum Pneumopericardium
Meconium Aspiration
Term boy infant IDM born to 30 ys old mother with prolong second stage, Thick MSAFHow do you resuscitate this infant?
On admission to NICU he showed sever respiratory distress sever hypoxia
What is the diagnosis and D/D? How do you manage such infant?What are the complications?
Congenital Diaphragmatic hernia
• Term baby presented with cyanosis at birth• Physical exam refealed respiratory distress,
a scaphoid abdomen, decrease breath sound on the left side.
• What is the diagnosis ?• What is the immediate treatment ?• What is the long term management ?
ItubationN.G suction
ECHOCOxygenation
AlkalosisInotrope support
Nitric OxideSurfactantSedation
AntibioticIV Nutrition
.Surgical Repair
CDH
ECMO
Persistent Pulmonary Hypertension (persistent fetal circulation)
• Secondary to another disorder (e.g., respiratory distress syndrome, aspiration, pneumonia, diaphragmatic hernia)
• Affects primarily near-, full- and post-term infants • Increased pulmonary vascular resistance -->
intracardiac right-to-left shunt (PDA, foramen ovale) --> hypoxemia, acidosis --> increased resistance --> increased shunt
•Etiology
• Acute pulmonary vasoconstriction (e.g., acidosis, hypoxia, RDS, pneumonia; hyperviscosity)
• Increased pulmonary vascular smooth muscle with its extension (e.g., perinatal distress, aspiration ?) to arterioles surrounding alveoli
• Decreased number of pulmonary blood vessels with excessive muscle (e.g., diaphragmatic hernia, other thoracic space-occupying lesions)
Esophageal Atresia withTEF
Term female newborn 3kg, presented with vomiting and abdominal distension
O/E Mild respiratory distress no dismorphic featurs had exseisve salivation
What is (are) the D/D?
What is the line of management?
Esophageal Atresia withTEF
• General • Esophageal atresia with distal (TE)
fistula (85%) • Esophageal atresia (10%) • H-type fistula (4-6%)
.Signs and symptoms
• Maternal polyhydramnios in 30-70% of patients
• Excessive secretions and drooling after birth • Choking, coughing and cyanosis with feedings • Inability to pass an orogastric tube to the
stomach • Respiratory distress • Congenital anomalies (50%) -VACTERL or
VATER
X-ray
• Dilated proximal pouch in the mediastinum • Right upper lobe pneumonia or atelectasis
(overflow of secretions) • Gastric dilatation and excessive air in the
bowel loops if a fistula is present • No air in abdomen if a fistula is absent
Initial management
• Intermittent suction or aspiration of the upper pouch, nasopharynx
• Head and chest elevated 45 degrees from the horizontal
• Prevent excessive crying • Antibiotics • Surgery when stable - gastrostomy should
be done early
Congenital lobar emphysema
• Location is usually left upper lobe, right middle lobe or right upper lobe, unless due to an aberrant vessel related to congenital heart disease
• Partial obstruction of the airway on expiration leads to overdistention of the lobe; there is often abnormal bronchial cartilage
• Intraluminal obstruction • Extraluminal compression, often associated with
congenital heart disease (lower lobes)
Signs and symptoms
• Progressive respiratory distress • Wheezing • Cyanosis • Asymptomatic
.Chest x-ray
• Overdistention of the lobe • Compression of surrounding lobes • Mediastinal shift • Radiolucent lobe
Differential diagnosis
• Lung cyst • Tension pneumothorax • Compensatory emphysema due to
contralateral atelectasis • Pneumatocele
Initial management
• Ventilatory support with 100% oxygen • Alkalosis • Good lung uppermost • Surgery
Pleural effusion (bilateral or unilateral)
Etiology • Chylothorax • Hydrops fetalis (immunologic or nonimmunologic) • Pneumonia • Turner syndrome • Wet lung • Congestive heart failure • Hemothorax • Parenteral nutrition or fluid extravasation
Airway Obstruction
• Foreign material• Congenital subglottic stenosis• Choanal atresia• Micrognathia (Peirre Robin syndromes )• Macroglossia ( Trisomy 21 )• Laryngeal web, Laryngeal spasm• Vocal cord paralysis• Tracheo/laryngomalacia
RDRD HMD
MAS
CDH
Pneumonia
Thanks