Respiratory disease in the newborn

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Respiratory disease in the newborn

• Dr. Rozin Ilya

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Signs and symptoms

• Cyanosis
• Grunting
• Nasal flaring
• Retraction
• Tachypnea
• Decreased breath sounds with rales and / or
  rhonchi
• Pallor
• Apnea

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Causes

• Central or peripheral nervous system
  hypoventilation
• Birth asphyxia
• Intracranial hypertension, hemorrhage
• Over sedation ( direct or through maternal rout )
• Diaphragm palsy
• Neuromuscular disease
• Seizure

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Causes

• 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 )

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Causes

• Respiratory disease
• Lower airway
• - Respiratory distress syndrome
• - Transient tachypnea
• - Meconium aspiration
• - Pneumonia ( sepsis )
• - Pneumothorax
• - Congenital diaphragmatic hernia
• - Pulmonary hypoplasia

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Causes

• Cardiac 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

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Causes

• Cardiac 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

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Causes

• Methemoglobinemia
• - congenital ( hemoglobin M, methemoglobin
  reductase deficiency )
• - Acquired ( nitrates, nitrites )
• Other
• - Hypoglycemia
• - Adrenogenital syndrome
• - Polycythemia
• - Blood loss

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Transient tachypnea of newborn

• Usually in normal preterm or term vaginal
  delivery or C/S
• Early onset of tachypnea, retraction, cyanosis (
  O2 lt 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

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Meconium 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 gt V / Q
  mismatch
• - air trapping gt air
  leaks
• - persistent
  pulmonary hypertension
• - acidosis,
  hypoxemia, hypercapnea

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Meconium 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.

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Persistent pulmonary hypertension 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.

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Persistent pulmonary hypertension 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.

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Persistent pulmonary hypertension 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 gt
  20 mmHg or
• SatO2 gt 5 by pulse
  oxymetry.
• - by ECHO right to left
  shunt ,tricuspid
• regurgitation.
• - x-ray chest
• D.D. cyanotic heart disease.

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Persistent pulmonary hypertension 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.

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Persistent pulmonary hypertension 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)
  (gt 605-620)
• - PaO2 lt 40 mmHg
• - Acidosis and Shock pHlt7.25 or hypotension

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Congenital 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.

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Pneumonia

• 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.

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Pneumonia

• 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.

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Extrapulmonary air leak syndrome

• 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.

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Extrapulmonary 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
• its result of tamponade of the
  systemic and
• pulmonary vein.

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Extrapulmonary 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

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Differential diagnosis with cyanotic CHD

• Central cyanosis
• Lack or minimal respiratory distress signs
• Systolic murmur
• Evaluation by ECHO
• Chest x-ray
• Hyperoxic test

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TGA
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TARVR
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Hyperoxic 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

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Evaluation and first line therapy a child with
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

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Thank you