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Respiratory Distress in Newborn

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Respiratory Distress in Newborn Leena Mane PGY 3 Resident Emory Family Medicine Rhea Mane Specialist * * * * * * * * * * * * * * * * * * * * * * Question A ... – PowerPoint PPT presentation

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Title: Respiratory Distress in Newborn


1
Respiratory Distress in Newborn
  • Leena Mane
  • PGY 3 Resident
  • Emory Family Medicine
  • Rhea Mane
  • Specialist

2
Question
  • A male infant weighing 3000 g (6 lb 10 oz) is
    born at 36 weeks' gestation, with normal Apgar
    scores and an unremarkable initial examination.
    At 48 hours of age he is noted to have dusky
    episodes while feeding, and does not feed well.
    On repeat examination the child is tachypneic,
    with subcostal retractions. Lung sounds are clear
    and there is no heart murmur.

3
What Next ?
4
Tests labs
  • Pulse oximetry on room air is 82.
  • Arterial blood gases on 100 oxygen show a pCO2
    of 26 mm Hg (N 27-40), a pO2 of 66 mm Hg (N
    83-108),
  • blood pH of 7.50 mg/dL (N 7.35-7.45), and a base
    excess of -2 mmol/L (N -10 to -2).

5
Labs
  • Hemoglobin- 22.0g/dl (N13.0- 20.0)
  • Hematocrit- 66 (N 42- 66)
  • WBC- 19,000/mm3 (N9000-30,000)
  • Blood cultures- Pending.
  • Chest X-ray- Increased vascular marking, Large
    thymus.

6
Most likely diagnosis
  • 1- Transient tachypnea of newborn
  • 2- Congenital heart disease
  • 3- Hyaline membrane disease
  • 4- Neonatal sepsis
  • 5- Hyperviscosity syndrome

7
Transient Tachypnea of Newborn
  • Most common cause of respiratory distress.
  • 40 cases.
  • Residual fluid in fetal lung tissues.
  • Risk factors- maternal asthma, c- section, male
    sex, macrosomia, maternal diabetes

8
TTN
  • Tachypnea immediately after birth or within two
    hours, with other predictable signs of
    respiratory distress.
  • Symptoms can last few hours to two days.
  • Chest radiography shows diffuse parenchymal
    infiltrates, a wet silhouette around heart, or
    intralobar fluid accumulation

9
X-ray
Fluid in the fissure
10
Respiratory Distress Syndrome
  • Also called as hyaline membrane disease
  • Most common cause of respiratory distress in
    premature infants, correlating with structural
    functional lung immaturity.
  • 1/3 infants born between 28 to 34 weeks, but less
    than 5 of those born after 34 weeks.
  • Pathophysiology- surfactant deficiency- increase
    in alveolar surface tension- decrease in
    compliance.

11
RDS
  • Hyaline membrane- combination of sloughed
    epithelium, protein edema.
  • Diagnosis of respiratory distress should be
    suspected when grunting, retraction or other
    typical distress symtoms occur in premature
    infant.
  • CXR- homogenous opaque infiltrates air
    bronchograms.

12
Meconium Aspiration Syndrome
  • Incidence- 1.5- 2 in term or post term infants.
  • Meconium is locally irritative, obstructive
    medium for for bacterial culture
  • Meconium aspiration causes significant
    respiratory distress. Hypoxia occurs because
    aspiration occurs in utero.
  • CXR- Patchy atelectasis or consolidation.

13
Infections
  • Pneumonia Sepsis have various manifestations
    including typical signs of distress as well as
    temperature instability.
  • Common pathogen- Group B Streptococcus, Staph
    aureus, Streptococcus aureus, Streptococcus
    Pneumoniae,Gm neg rods

14
Infections ctd.
  • Risk factors- prolonged rupture of membranes,
    prematurity, maternal fever.
  • CXR- bilateral infiltrates suggesting in utero
    infection.

15
Other causes-
  • Congenital malformations-Pulmonary hypoplasia,
    congenital emphysema, esophageal atresia
    diaphragmatic hernia.
  • Neurological causes- hydrocephalus intracranial
    hemorrhage.
  • Metabolic derangements-hypoglycemia,
    hypocalcaemia, polycythemia.

16
Congenital Heart disease
  • Cyanotic Heart Disease-
  • Tetralogy of fallot- ( VSD, Pulmonary stenosis,
    overriding aorta, RVH)
  • Tricuspid atresia
  • Transposition of great vessel
  • Total anamolous pul. venous return
  • Truncus arteriosus.

17
Hyperoxia Test
  • Obtain ABGgt Then place the patient on 100 O2
    for 10 minutes then repeat ABG , If the cyanosis
    is pulmonary , the PaO2 should be increased by 30
    mm of Hg. If the cause is cardiac , there will be
    minimal improvement in PaO2.

18
Treatment
  • Can be generalized disease specific
  • Oxygenation can be enhanced by blow by oxygen,
    nasal canula or mechanical ventilation in severe
    cases.
  • Surfactant administration may be required.
  • Antibiotics are often indicated if bacterial
    infection is suspected clinically or because of
    leucocytosis, neutropenia or hypoxia.

19
Treatment
  • Fluids should be restricted in acute phase
  • Fluids should be limited for insensible losses
    replacement of Urine output.
  • Mortality morbidity is lower in premature
    infants who were fluid restricted as compared to
    similar infants

20
Transient Tachypnea of Newborn
  • Rx is supportive because the condition is usually
    self limited.
  • Oral lasix has not shown to significantly improve
    status.
  • Prenatal administration of steroids 48hrs before
    elective C- section _at_ 37- 39 weeks gestation
    reduces TTN but this has not become common
    practice.

21
Respiratory distress Syndrome
  • General intervention for oxygenation.
  • Prenatal administration of corticosteroids
    between 24- 34 wks gestation reduces risk of
    respiratory distress when risk of preterm
    delivery is high.
  • Post natal steroids may decrease mortality but
    may increase risk of cerebral palsy.

22
Meconium Aspiration Syndrome
  • Use minimal stimulation keep head down to
    prevent breathing of meconium
  • Standard practice of suctioning the mouth nares
    upon head delivery before body delivery is not
    recommended.
  • Amnioinfusion does not decrease the incidence of
    meconium aspiration syndrome perinatal death.

23
Algorithm
24
Evaluation
  • Detailed history
  • Differential diagnosis changes with EGA, GBS
    status prophylaxis, duration of rupture of
    membrane, color of amniotic fluid, maternal
    temperature, maternal tachycardia, fetal heart
    tracing
  • Physical signs- look for apnea, tachypnea or
    cyanosis, cardiac auscultation for murmur.
  • Lung auscultation - asymmetrical chest movements-
    in pneumothorax ,crackles in pneumonia, clear in
    TTN, persistent pulmonary HTN.

25
Algorithm
26
Treatment
  • Mild distress- observation pulse oximetry
  • Severe distress- immediate resucitation, CXR, and
    laboratory tests
  • Tests- blood culture, blood gas, blood glucose,
    CBC with Diff,lumbar puncture if indicated, pulse
    oximetry.

27
Answer
  • Cyanotic congenital heart disease can appear at
    the time of ductus closure. A heart murmur is not
    usually audible, and murmurs heard this early are
    usually not due to heart disease. The failure to
    correct hypoxemia with 100 oxygen is diagnostic
    for abnormal mixing of blood from the right and
    left circulations.
  • Transient tachypnea presents earlier, and the
    hypoxia corrects with supplemental oxygen.
  • Hyaline membrane disease can occur at 36 weeks,
    but would cause problems in the first hours of
    life. It can make oxygenation difficult, but
    would cause extreme distress with CO2 retention
    in such cases.

28
Answer
  • This patient has the energy to hyperventilate and
    has slight respiratory alkalosis as a result.
    Neonatal sepsis can cause V/Q mismatching and
    hypoxia, and can have a delayed presentation.
    Concern would be high enough in this case that
    the patient would probably receive broad-spectrum
    antibiotics while awaiting culture results. On
    the other hand, the clinician would not want to
    be distracted from the evidence for congenital
    heart disease.
  • The baby is polycythemic from poor intake in the
    first 2 days of life. The hyperviscosity syndrome
    can occur when the hematocrit is over 65. It can
    cause poor feeding, tachypnea, and sluggishness,
    but does not cause hypoxia.

29
Thank You
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