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Respiratory Distress in the Newborn, not RDS Dr. Alona Bin-Nun NICU Shaare Zedek Respiratory Distress in the Newborn – Clinical Presentation • • • • • Cyanosis Grunting Retractions Tachypnea Nasal flaring • Extreme: Apnea, Shock More Common Causes of Respiratory Distress • • • • • • RDS Pneumonia Meconium Aspiration Transient Tachypnea Hypothermia Hypoglycemia Acute Life Threatening Emergencies Presenting in Respiratory Distress • • • • 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 – – – – – 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 • • • • • • • Pregnancy- Hydramnios, Diabetes Labor Delivery: C/S or vaginal Evidence of Infection Meconium Apgar Scores Resuscitation Evaluation of Infant with Respiratory Distress – Physical Examination • • • • • • • Degree of respiratory distress Cyanosis Air entry Heart murmur Temperature Scaphoid abdomen Position of PMI Laboratory Tests • • • • • • • • • • 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 – – – – – 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 – – – – – 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 • • • • • • Prevention Oxygen, CPAP Assisted ventilation NO Drain pneumothorax Antibiotics • General measures, correct: – – – – – hypovolemia metabolic acidosis hypoglycemia hypocalcemia anemia • Further Sequelae – – – – – 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 – – – – – Associated with prematurity and hydramnios Increased salivation Choking and dyspnea on feeding Aspiration pneumonia Other abnormalities (VACTER association) • Diagnosis – – – – 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 – – – – 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 – – – – – – 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 • • • • • • • • • • 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 • • • • • • Spontaneous RDS CPAP and mechanical ventilation Resuscitation Pulmonary hypoplasis Post thoracotomy Treatment of Pneumothorax • Observe only if: – – – – Minimal respiratory distress Minimal oxygen requirement Breathing spontaneously Maintaining good BP • Indications for drainage – – – – – – Tension pneumothorax Cyanosis Apnea Deteriorating blood gases Assisted ventilation Shock