Neonatal Respiratory Distress - PowerPoint PPT Presentation

About This Presentation
Title:

Neonatal Respiratory Distress

Description:

Neonatal Respiratory Distress ( Neonatology Lecture ) – PowerPoint PPT presentation

Number of Views:4824
Slides: 60
Provided by: Username withheld or not provided
Tags:

less

Transcript and Presenter's Notes

Title: Neonatal Respiratory Distress


1
Respiratory Distress in Newborn
2
Neonatal Respiratory Distress Signs and symptoms
  • Tachypnea (RR gt 60/min)
  • Nasal flaring
  • Retraction
  • Grunting
  • /- Cyanosis
  • /- Desaturation
  • Decreased air entry

3
Down score
4
Neonatal Respiratory Distress Etiologies
  • Systemic
  • Metabolic (e.g., hypoglycemia, hypothermia or
    hyperthermia)
  • metabolic acidosis
  • anemia, polycythemia
  • Cardiac
  • Congenital heart disease cyanotic or acyanotic
  • Congestive heart failure
  • Persistent pulmonary hypertension of the newborn
    (PPHN)
  • Neurological (e.g., prenatal asphyxia, meningitis)
  • Pulmonary
  • Transient tachypnea of the newborn (TTN)
  • Respiratory distress syndrome (RDS)
  • Pneumonia
  • Meconium aspiration syndrome (MAS)
  • Air leak syndromes
  • Pulmonary hemorrhage
  • Anatomic
  • Upper airway obstruction
  • Airway malformation
  • Rib cage anomalies
  • Diaphragmatic disorders
  • (e.g., congenital diaphragmatic hernia,
    diaphragmatic paralysis)

5
Pulmonary
  • 1- Transient tachypnea of newborn
  • 2- Hyaline membrane disease
  • 3- Meconium aspiration syndrome (MAS)
  • 4- Pneumonia
  • 5- Air Leak Syndromes

6
Transient Tachypnea of Newborn
  • TTN (known as wet lung) is a relatively mild,
    self limiting disorder of near-term or term
  • Delay in clearance of fetal lung fluid results in
    transient pulmonary edema. The increased fluid
    volume causes a reduction in lung compliance and
    increased airway resistance.

7
Transient Tachypnea of Newborn
  • Risk factors
  • Maternal asthma
  • C- section
  • Macrosomia, maternal diabetes
  • Prolonged labor, Excessive maternal sedation
  • Fluid overload to the mother,Delayed clamping of
    the umbilical cord .

8
Transient Tachypnea of Newborn
  • Usually near-term or term
  • Tachypnea immediately after birth or within 6 hrs
    after delivery, mild to moderate respiratory
    distress.
  • These manifestations usually persist for 12-24
    hrs, but can last up to 72 hrs
  • Auscultation usually reveals good air entry with
    or without crackles
  • Spontaneous improvement of the neonate is an
    important marker of TTN.

9
Transient Tachypnea of Newborn
  • Chest x-ray
  • Prominent perihilar streaking (due to engorgement
    of periarterial lymphatics)
  • Fluid in the minor fissure
  • Prominent pulmonary vascular markings
  • Hyperinflation of the lungs, with depression of
    diaphragm
  • ? Chest x-ray usually shows evidence of clearing
    by 12-18 hrs with complete resolution by 48-72 hrs

10
chest X-ray Transient Tachypnea of Newborn
Fluid in the fissure
11
General Management of Respiratory Distress
  • Supplemental oxygen or MV, if needed.
  • Continuously monitor with pulse oximeter.
  • Obtain a chest radiograph.
  • Correct metabolic abnormalities
    (acidosis,hypoglycemia).
  • Obtain a blood culture begin an antibiotic
    coverage (ampicillin gentamicin)

12
General Management
  • Provide an adequate nutrion. Infants with
    sustained RR gt60 breaths/min should not be fed
    orally should be maintained on gavage feedings
    for RR 60-80 breaths/min, and NPO with IV fluids
    or TPN for more severe tachypnea

13
Pulmonary
  • 1- Transient tachypnea of newborn
  • 2- Hyaline membrane disease
  • 3- Meconium aspiration syndrome (MAS)
  • 4- Pneumonia
  • 5- Air Leak Syndromes

14
Respiratory Distress Syndrome
  • Also called as hyaline membrane disease
  • Most common cause of respiratory distress in
    premature infants, correlating with structural
    functional lung immaturity.
  • primarily affects preterm infants its incidence
    is inversely related to gestational age and
    birthweight.
  • 15-30 of those between 32-36 weeks gestation,
    in about 5 beyond 37 weeks' gestation

15
Physiologic abnormalities
  • Surfactant deficiency- increase in alveolar
    surface tension.
  • Lung compliance decreased to 10-20 of normal
  • Atelectasisareas not ventilated
  • Decrease alveolar ventilation
  • Reduce lung volume
  • Areas not perfused

16
Surfactant Function
Normal Expiration With Surfactant
Abnormal RespirationWithout Surfactant
17
17
18
Risk factors
  • Prematurity
  • Maternal diabetes
  • Multiple births
  • Elective cesarean section without labor
  • Perinatal asphyxia
  • Cold stress
  • Genetic disorders

19
Decreased risk
  • Chronic intrauterine stress
  • Prolonged rupture of membranes
  • Antenatal steroid prophylaxis

20
Clinical Manifestations
  • Appear within minutes of birth may not be
    recognized for several hours in larger preterm
  • Tachypnea (gt60 breaths/min), nasal flaring,
    subcostal and intercostal retractions, cyanosis
    expiratory grunting
  • Breath sounds may be normal or diminished and
    fine rales may be heard
  • Progressive worsening of cyanosis dyspnea. BP
    may fall fatigue, cyanosis and pallor increase
    grunting decreases.
  • Apnea and irregular respirations are ominous
    signs
  • In most cases, symptoms and signs reach a peak
    within 3 days, after which improvement occurs
    gradually.

21
Chest x-ray
  • Findings can be graded according to the severity
  • Grade 1 (mild cases) the lungs show fine
    homogenous ground glass shadowing
  • Grade 2 widespread air bronchogram become
    visible
  • Grade 3 confluent alveolar shadowing
  • Grade 4 complete white lung fields with
    obscuring of the cardiac shadow

22
Grade 1
23
Grade 2
24
Grade 3
25
Grade 4
26
Management
  • Prevention
  • Lung maturity testing lecithin/sphingomyelin
    (L/S) ratio
  • Tocolytics to inhibit premature labor.
  • Antenatal corticosteroid therapy
  • ? They induce surfactant production and
    accelerate fetal lung maturation.
  • ? Are indicated in pregnant women 24-34
    weeks' gestation at high risk of preterm delivery
    within the next 7 days.
  • ? Optimal benefit begins 24 hrs after
    initiation of therapy and lasts seven days.

27
Prevention
  • Antenatal corticosteroid therapy consists of
    either
  • ? Betamethasone 12 mg/dose IM for 2 doses, 24
    hrs apart, or
  • ? Dexamethasone 6 mg/dose IM for 4 doses, 12 hrs
    apart
  • Early surfactant therapy prophylactic use of
    surfactant in preterm newborn lt27 weeks'
    gestation.
  • Early CPAP administration in the delivery room.

28
Treatment
  • Administer oxygen
  • Initiate CPAP as early as possible in infants
    with mild RDS
  • Start MV if respiratory acidosis (PaCO2 gt60 mmHg,
    PaO2 lt50 mmHg or SaO2 lt90) with an FiO2 gt0.5, or
    severe frequent apnea.
  • Administer surfactant therapy early rescue
    therapy within 2 hrs after birth is better than
    late rescue treatment when the full picture of
    RDS is evident.

29
Types of Surfactant
  • Natural Surfactants contain appoproteins SP-B
    SP-C
  • Curosurf (extract of pig lung mince)
  • Survanta (extract of cow lung mince)
  • Infasurf (extract of calf lung)
  • Synthetic Surfactantsdo not contain proteins
  • Exocerf
  • ALEC
  • Lucinactant (Surfaxin)

30
Surfactant Therapy for RDS
  • Improvement in compliance, functional residual
    capacity, and oxygenation
  • Reduces incidence of air leaks
  • Decreases mortality

30
31
Mode of administration of Surfactant
  • Dosing may be divided into 2 alliquots and
    adminitered via a 5-Fr catheter passed in the ET

32
Insure technique
  • Intubation-
  • surfactant-
  • extubation to CPAP

33
Pulmonary
  • 1- Transient tachypnea of newborn
  • 2- Hyaline membrane disease
  • 3- Meconium aspiration syndrome (MAS)
  • 4- Pneumonia
  • 5- Air Leak Syndromes

34
Meconium Aspiration Syndrome
  • Risk Factors
  • Post-term pregnancy
  • Pre-eclampsia, eclampsia, maternal hypertension,
  • Maternal diabetes mellitus
  • IUGR
  • Evidences of fetal distress (e.g.,abnormal
    biophysical profile)

35
Clinical Manifestations
  • Meconium staining amniotic fluid (meconium
    stained nails, skin umbilical cord )
  • Some infants may have mild initial respiratory
    distress, which becomes more severe hours after
    delivery.
  • Pneumothorax and/or pneumomediastinum
  • PPHN in severe cases
  • Hypoxia to other organs (e.g., seizures,
    oliguria)

36
Pathophysiology
37
Chest x-ray Areas of hyperexpansion mixed with
patchy densities and atelectasis
38
Management
  • In the DR or OR
  • Visualization of the vocal cords tracheal
    suctioning before ambu-bagging should be done
    only if the baby is not vigorous
  • In the NICU
  • Empty stomach contents to avoid further
    aspiration.
  • Suction frequently perform chest physiotherapy.

39
Management
  • Consider CPAP, if FiO2 requirements gt0.4 however
    CPAP mayaggravate air trapping and must be used
    cautiously.
  • Mechanical ventilation in severe cases (paCO2
    gt60 mmHg orpersistent hypoxemia (paO2 lt50 mmHg).
  • Correct systemic hypotension (hypovolemia,
    myocardial dysfunction).
  • Manage PPHN, if present
  • Manage seizures or renal problems, if present.
  • Surfactant therapy in infants whose clinical
    status continue todeteriorate.

40
Pulmonary
  • 1- Transient tachypnea of newborn
  • 2- Hyaline membrane disease
  • 3- Meconium aspiration syndrome (MAS)
  • 4- Pneumonia
  • 5- Air Leak Syndromes

41
Pneumonia
  • Common organisms
  • GBS
  • gramve organisms (e.g. E.Coli,
    Klebsiella,Pseudomonas)
  • , Staph. aureus, Staph. epidermidis
  • Candida.
  • acquired viral infections (e.g., HSV, CMV).

42
Clinical Manifestations
  • Early manifestations may be nonspecific (e.g.,
    poor feeding, lethargy, irritability, cyanosis,
    temperature instability
  • Respiratory distress signs may be superimposed
    upon RDS or BPD.
  • In a ventilated infant, the most prominent change
    may be the need for an increased ventilatory
    support.
  • Signs of pneumonia (dullness to percussion,
    change in breathsounds, rales or rhonchi) are
    difficult to appreciate.

43
Chest x-rays infiltrates or effusion
44
Chlamydia pneumonia with features of an
interstitial pneumonitis and characteristic
widespread interstitial changes.
44
45
Management
  • Initiate ampicillin and gentamicin IV modify
    according to culture results and continue therapy
    for 14 days.
  • If there is a fungal infection, an antifungal
    agent is used.

46
Pulmonary
  • 1- Transient tachypnea of newborn
  • 2- Hyaline membrane disease
  • 3- Meconium aspiration syndrome (MAS)
  • 4- Pneumonia
  • 5- Air Leak Syndromes

47
Air Leak Syndromes
  • Risk Factors
  • MV,MAS, surfactant therapy without decreasing
    pressure support in ventilated infants
  • vigorous resuscitation,
  • prematurity
  • pneumonia

48
Clinical Manifestations
  • Spontaneous pneumothorax may be asymptomatic or
    only mildly symptomatic (i.e., tachypnea and ?O2
    needs).
  • In unilateral cases, chest asymmetry is noted,
    mediastinum shift to the opposite side.
  • If the infant is on ventilatory support will have
    sudden onset of clinical deterioration (i.e.,
    cyanosis, hypoxemia, hypercarbia respiratory
    acidosis associated with decreased breath sounds
    and shifted heart sounds).

49
Tension pneumothorax
  • (a life-threatening condition) ? ?cardiac output
    and obstructive shock urgent drainage prior to a
    radiograph is mandatory.

50
Chest x-ray Right-sided pneumothorax
51
Right-sided tension pneumothorax with mediastinal
shift. Both lungs demonstrate opacification of
alveolar collapse.
52
Left-sided pneumothorax under tension. There is
pulmonary interstitial emphysema in the right
lung and a small basal right pneumothorax.
53
Others
  • Pneumomediastinum
  • It can occur with aggressive ETT insertion,
    Ryle's feeding tube
  • insertion, lung disease, MV, or chest
    surgery (e.g., TEF).
  • Pneumopericardium
  • Pneumoperitoneum
  • Subcutaneous emphysema
  • Systemic air embolism

54
Chest x-ray with Pneumomediastinum
55
Massive Pneumoperitoneum in MV neonate
56
Chest x-ray with pneumopericardium
57
Severe bilateral PIE affecting the right more
than the left lung there is gross cardiac
compression. A chest drain is in situin the
right hemithorax.
58
Management
  • Conservative therapy close observation of
    the degree of respiratory distress as well
    as oxygen saturation, without any other
    intervention aiming at spontaneous resolution
    and absorption of air.
  • Needle aspiration should be done for
    suspected cases of pneumothorax with
    deteriorating general condition until intercostal
    tube is inserted.
  • Decompression of air leak according to the type
    (intercostal tube insertion in case of
    pneumothorax).

59
Thank You
Thank You
Write a Comment
User Comments (0)
About PowerShow.com