Download Respiratory Distress in the Newborn

Respiratory Distress in the
Newborn, not RDS
Dr. Alona Bin-Nun
NICU
Shaare Zedek
Respiratory Distress in the
Newborn – Clinical Presentation
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Cyanosis
Grunting
Retractions
Tachypnea
Nasal flaring
• Extreme: Apnea, Shock
More Common Causes of
Respiratory Distress
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RDS
Pneumonia
Meconium Aspiration
Transient Tachypnea
Hypothermia
Hypoglycemia
Acute Life Threatening Emergencies
Presenting in Respiratory Distress
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Choanal Stenosis
Meconium Aspiration
Tension Pneumothorax
Diaphragmatic Hernia
Major Causes of Respiratory Distress
in the Newborn: Extrathoracic
• Developmental
– Choanal Atresia
– Pierre Robin sequence
• Infection
– Sepsis
– Meningitis
• Metabolic
– Hypoglycemia
– Hypothermia
– Acidosis
• CNS
– Infection
– Hemorrhage
– Edema
• Blood
– Blood loss,
Hypovolemia
– Anemia
– Polycythemia
Major Causes of Respiratory Distress
in the Newborn Intrathoracic
• Developmental
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RDS
Hypoplastic lungs
T-E fistula
Cystic Malformation
Cong. Lobar Emphysema
• Infection
– Pneumonia
– Congenital/Acquired
viral/bacterial
• Aspiration
– Meconium
– Blood
– Amniotic Fluid
• Air Leak
– PIE
– Pneumothorax
– Pneumomediastinum
• Cardiac
– Cong. Heart disease
– IDM
• Misc
– Persistent Pulmonary
Hypertension of the
Newborn (PPHN)
– Wet Lungs
– Pulm. Hemorrhage
Evaluation of Infant with
Respiratory Distress - History
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Pregnancy- Hydramnios, Diabetes
Labor
Delivery: C/S or vaginal
Evidence of Infection
Meconium
Apgar Scores
Resuscitation
Evaluation of Infant with Respiratory
Distress – Physical Examination
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Degree of respiratory distress
Cyanosis
Air entry
Heart murmur
Temperature
Scaphoid abdomen
Position of PMI
Laboratory Tests
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O2 saturation
X-ray: AP+lateral. Assess both lungs and heart
Blood gas
Hct
Dextrostix
BP
Transillumination
Hyperoxia test
Nasogastric catheter (radio opaque)
Evaluate for sepsis
Management of Newborn with
Respiratory Distress (1)
• Clear airway, esp. meconium
• Oxygen
• Ventilation
– mask bagging → intubation
– Cyanosis
– CO2 retention
– apnea
• Correct Acidosis
Management of Newborn with
Respiratory Distress (2)
• Arterial Catheter, follow blood gases
• Correct
– Hypoglycemia
– Hypothermia
– Shock
– Anemia or polycythemia
• Drain Pneumothorax
• Antibiotics (for unexplained persistent
respiratory distress)
Transient Tachypnea
• Clinical Presentation
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Frequently term infant
C/S
Mild respiratory distress
Moderate O2 requirement
Duration: 2-5 days
• X-ray
– Ill defined hazy central
markings
– Fade towards periphery
– Slight cardiomegaly
Transient Tachypnea
• Clinical Presentation
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Frequently term infant
C/S
Mild respiratory distress
Moderate O2 requirement
Duration: 2-5 days
• X-ray
– Ill defined hazy central
markings
– Fade towards periphery
– Slight cardiomegaly
• Pathogenesis
– Delayed removal of
alveolar fluid
• Treatment
– Supportive
• Prognosis
– Excellent
Pneumonia
• Bacterial
– GBS, E.coli, other Gram
negative
• Viral
– CMV, rubella, herpes, RSV
• Routes of Infection
– Ascending (PROM)
– Hemtogenous
– Aspiration of infected
material
• Time of Infection
– Before, during or after
delivery
• X-ray
– Focal infiltrates
– Can be diffuse
– Can be indistinguishable
from RDS
• Evaluation
– Tracheal culture
– Evaluate for sepsis
– Screen for TORCH
• Treatment
– Antibiotics
– Supportive
Meconium Aspiration Syndrome
(MAS)
Effects of Meconium Aspiration
Meconium Aspiration
Chemical
pneumonitis
Bacterial
pneumonitis
Proximal
Airway
Occlusion
Peripheral
Airway
Occlusion
Complete
Asphyxia
Atelectasis
Ball valve
Intrapulmo
nary Shunt
Extraalveolar air
Hypoxemia and Acidodis
PPHN
Partial
Treatment of MAS
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Prevention
Oxygen, CPAP
Assisted ventilation
NO
Drain pneumothorax
Antibiotics
• General measures,
correct:
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hypovolemia
metabolic acidosis
hypoglycemia
hypocalcemia
anemia
• Further Sequelae
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CP
ATN
Anoxic liver + coagulopathy
NEC
Anoxic Myocardial damage
T-E Fistula classification
Esophagial Atresia and T-E Fistula
• Embryology
– Interruption of division of foregut into trachea and esophagus
• Clinical Picture
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Associated with prematurity and hydramnios
Increased salivation
Choking and dyspnea on feeding
Aspiration pneumonia
Other abnormalities (VACTER association)
• Diagnosis
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X-ray: dilated proximal esophageal pouch, curling of NG catheter
Dye studies
Air in abdomen: presence or absence of fistula
Endoscopy
• Preoperative Care
– Treat Pneumonia
– Prevent gastric reflux – upright position
– Suctioning of proximal pouch
• Definitive treatment
– Surgery
• Prognosis
– Survival
– Depends on birth weight, prematurity, other
congenital abnormalities
Diaphragmatic Hernia
Diaphragmatic Hernia
• Treatment
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Intubate and ventilate
Do not mask bag
Gastric tube
Beware of
pneumothorax
– Surgery
• Post op:
– Ventilation and
oxygenation:
problematic
• Outcome
– Poor due to lung
hypoplasia
Pneumothorax
Pneumothorax
• Accumulation of air in pleural cavity
• Common cause of respiratory distress.
• Pathogenesis
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Overdistension of alveoli
Rupture of air into interstitial space
Tracking to hilum along periventricular and peripheral sheaths
Air enters mediastinum
Rupture into pleural space
Rupture of subpleural bleb directly into pleural space
• Results
– Decreased lung volume
– Decreased cardiac output
Pneumothrax
↑ intrapleural pressure
Compression of large
intrathoracic veins
↓ lung volume
Mediatinum shift
↑ pulm. Vascular
resistance
↑ central venous pressure
↓ venous return
↓ cardiac output
Mechanisms leading
to reduction of CO
Clinical Presentation of
Pneumothorax
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Grunting
Tachypnea
Apnea
Cyanosis
Bradycardia
Shock
Sudden deterioration in ventilated infant
Shifting of heart sounds
Chest asymmetry
Decreased air entry
Pneumothorax: Diagnosis (1)
• If infant’s life threatened, don’t wait for Xray, do diagnostic needle aspiration !!
• Transillumination
Pneumothorax: Diagnosis (2)
• X-ray
– Seperation of lung from chest wall
– Absent lung marking peripherally
– Shift of mediastinum in tension pneumothorax
– Bilateral tension: no shift, small heart
– Lateral: air collection beneath sternum
Pneumothorax: Diagnosis (3)
• Associated with PIE
– Pneumomediastinum
– Pneumopericardium
Spinnaker sail sign: The thymus, wedge-shaped, extending from the rt.
hemidiaphragm to the superior mediastinum (white arrows),is displaced by a
collection of gas under pressure (black arrows).
Causes of Pneumothorax
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Spontaneous
RDS
CPAP and mechanical ventilation
Resuscitation
Pulmonary hypoplasis
Post thoracotomy
Treatment of Pneumothorax
• Observe only if:
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Minimal respiratory distress
Minimal oxygen requirement
Breathing spontaneously
Maintaining good BP
• Indications for drainage
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Tension pneumothorax
Cyanosis
Apnea
Deteriorating blood gases
Assisted ventilation
Shock