Infant Lung Disease and Associated Complications

Mary P. Martinasek, BS, RRTMary P. Martinasek, BS, RRT

Director of Clinical EducationDirector of Clinical Education

Hillsborough Community CollegeHillsborough Community College

Respiratory Distress Syndrome

RDS , formerly called Hyaline RDS , formerly called Hyaline Membrane disease (HMD)Membrane disease (HMD)

Primary cause of respiratory Primary cause of respiratory disordersdisorders

70% preterm deaths, 30% neonatal 70% preterm deaths, 30% neonatal deathsdeaths

Etiology - deficiency in surfactantEtiology - deficiency in surfactant Premature pulmonary systemPremature pulmonary system

Risk Factors associated with RDS

Less than 35 weeks gestationLess than 35 weeks gestation Maternal diabetesMaternal diabetes Hx of RDS in siblingHx of RDS in sibling White maleWhite male PFC (Persistent Fetal Circulation)PFC (Persistent Fetal Circulation) Prenatal maternal complicationPrenatal maternal complication Abnormal placental conditionsAbnormal placental conditions Umbilical cord disordersUmbilical cord disorders

Pathophysiology of RDS

Decreased Decreased surfactantsurfactant

__ Surface Tension

__ Compliance

Stiffer Lungs

Wide spread atelectasis

Worsening V/Q

_FRC&

_WOB __ PaO2& __ PaCO2

Respiratory Acidosis

Capillary damage

Alveolar Necrosis

&

Clinical Signs of RDS

Respiratory Rate > 60 bpmRespiratory Rate > 60 bpm GruntingGrunting RetractingRetracting Nasal flaringNasal flaring CyanosisCyanosis HypothermiaHypothermia CXR = underaeration, opaque, CXR = underaeration, opaque,

ground glass appearance ground glass appearance

Treatment of RDS

Maternal steroids Maternal steroids Artificial surfactant therapyArtificial surfactant therapy Adequate hydrationAdequate hydration ThermoregulationThermoregulation Goal = support the patient’s Goal = support the patient’s

respiratory system while minimizing respiratory system while minimizing complicationscomplications

Complication of RDS

ICH occurs in 40% of < 1500 gramsICH occurs in 40% of < 1500 grams Barotrauma = pulmonary air leaksBarotrauma = pulmonary air leaks InfectionInfection PDAPDA

Airleak Identification

100 points!!!

ICH - Grade 1

Reverse JeopardyReverse Jeopardy

For 100 points!!!For 100 points!!!

Exactly how many grams equal 1 Exactly how many grams equal 1 pound?pound?

Clinical Scenario

1500 gram infant born at 28 weeks 1500 gram infant born at 28 weeks gestation. Exhibiting signs of respiratory gestation. Exhibiting signs of respiratory distress.distress.

ABG = 7.20 60 (CO2) 45 (02) -6 (BE)ABG = 7.20 60 (CO2) 45 (02) -6 (BE) Select an appropriate mode initial of Select an appropriate mode initial of

therapytherapy N.C. @ 2 LPMN.C. @ 2 LPM Head Hood at 35%Head Hood at 35% Nasal cpap +4 Fio2=40 %Nasal cpap +4 Fio2=40 %

BPD

Chronic infant who was exposed to Chronic infant who was exposed to long term oxygen and high pressureslong term oxygen and high pressures

Infant on supplemental oxygen for Infant on supplemental oxygen for > 30 days exhibiting the classic x-> 30 days exhibiting the classic x-ray findingsray findings

Pathophysiology of BPD

Oxygen toxicityOxygen toxicity BarotraumaBarotrauma Presence of PDAPresence of PDA

CXR in BPD Stage IStage I

First 3 days of lifeFirst 3 days of life Ground glass appearance on x-rayGround glass appearance on x-ray

Stage IIStage II 3 - 10 days3 - 10 days Opaque, obscure cardiac markingsOpaque, obscure cardiac markings

Stage IIIStage III 10 - 20 days10 - 20 days Cyst formationsCyst formations

Stage IVStage IV 28 days28 days Increased lung density, larger cystsIncreased lung density, larger cysts

Stage 1Stage 1

Stage 2Stage 2

Stage 3Stage 3

Stage 4Stage 4

Treatment of BPD

Avoidance of factors that lead to Avoidance of factors that lead to developmentdevelopment

Adequate ventilatory humidificationAdequate ventilatory humidification CPT and bronchodilatorsCPT and bronchodilators Fluid managementFluid management NutritionNutrition

100 Points!!100 Points!!

Persistent Pulmonary Hypertension

PPHNPPHN Formerly called Persistent fetal Formerly called Persistent fetal

circulationcirculation

(PFC)(PFC) R/O Congenital heart diseaseR/O Congenital heart disease Hyperoxia testHyperoxia test Hyperoxia-Hyperventilation test ??Hyperoxia-Hyperventilation test ?? EchocardiogramEchocardiogram

Treatment of PPHN

Nitric Oxide (NO)Nitric Oxide (NO) HyperventilationHyperventilation TolazolineTolazoline DopamineDopamine ECMO (extracorporeal membrane ECMO (extracorporeal membrane

oxygenationoxygenation High frequency ventilationHigh frequency ventilation

Reverse JeopardyReverse Jeopardy

What color tank is NO?What color tank is NO? What color tank is NO2?What color tank is NO2?

100 points100 points

Transient Tachypnea of the Newborn

TTNTTN Aka RDS IIAka RDS II Term infants delivered via cesarean Term infants delivered via cesarean

sectionsection Signs of RDSSigns of RDS CXR - streaky infiltratesCXR - streaky infiltrates R/O pneumoniaR/O pneumonia TreatmentTreatment

O2, Cpap if necessaryO2, Cpap if necessary

TTN x-rayTTN x-ray

6 hours2 days

Meconium Aspiration Syndrome

Term and Postterm infantsTerm and Postterm infants Asphyxia in utero Asphyxia in utero blood shifts to vital blood shifts to vital

organs organs relaxation of anal sphincter relaxation of anal sphincter Gasping respirations Gasping respirations meconium meconium

aspiratedaspirated Ball valve effect - air trappingBall valve effect - air trapping Furthers hypoxemia and hypercarbiaFurthers hypoxemia and hypercarbia Air leakAir leak InflammationInflammation Persistent pulmonary hypertensionPersistent pulmonary hypertension

Diagnosis and Treatment

Aspiration of meconiumAspiration of meconium Classic sign of RDSClassic sign of RDS Irregular densities on CXRIrregular densities on CXR TreatmentTreatment

Suction meconiumSuction meconium PeepPeep Low peak pressuresLow peak pressures AntibioticsAntibiotics amnioinfusionamnioinfusion

MAS x-rayMAS x-ray

Asphyxia

Major complication is hypoxic-Major complication is hypoxic-ischemic encephalopathyischemic encephalopathy Periventricular leukomalaciaPeriventricular leukomalacia

Tubular necrosis of kidneys and GI Tubular necrosis of kidneys and GI effectseffects

Liver damageLiver damage Lung damageLung damage

PVR, surfactant disruption PVR, surfactant disruption RDS RDS

PVLPVL

Wilson- Mikity Syndrome

AKA - Pulmonary dysmaturityAKA - Pulmonary dysmaturity BPD lung changes in unventilated BPD lung changes in unventilated

infantinfant SignsSigns

Hyperpnea, cyanosis, retractions, Hyperpnea, cyanosis, retractions, hypercarbia, respiratory acidosishypercarbia, respiratory acidosis

TreatmentTreatment SupportiveSupportive Ventilated to treat apneaVentilated to treat apnea O2 to treat hypoxemiaO2 to treat hypoxemia

Air leak syndrome

Increased incidence in RDS, MAS, TTNIncreased incidence in RDS, MAS, TTN Mostly caused by mechanical ventilationMostly caused by mechanical ventilation

PneumothoraxPneumothorax Spontaneous vs. tensionSpontaneous vs. tension ↑ ↑ HR, cyanosis, apnea, HR, cyanosis, apnea, BPBP Transillumination, CXRTransillumination, CXR

PneumomediastinumPneumomediastinum PneumopericardiumPneumopericardium PIE (pulmonary interstitial emphysema)PIE (pulmonary interstitial emphysema)

Peep, high PIP, prolonged I timesPeep, high PIP, prolonged I times

PIE x-rayPIE x-ray

Apnea

Cessation of breathing leading to Cessation of breathing leading to bradycardia and/or cyanosisbradycardia and/or cyanosis

Nonobstructive apnea (Central) = Nonobstructive apnea (Central) = absence of airflow and ventilatory absence of airflow and ventilatory efforteffort

Obstructive apnea = absence of Obstructive apnea = absence of airflow despite ventilatory effortairflow despite ventilatory effort

Central or Nonobstructive Apnea

Apnea of prematurityApnea of prematurity Chemoreceptor sensitivityChemoreceptor sensitivity Arousal responseArousal response Stimulation of airway reflexesStimulation of airway reflexes Dysfunction of the respiratory centersDysfunction of the respiratory centers Dysfunction of the ventilatory musclesDysfunction of the ventilatory muscles Dysfunction of the peripheral nervous Dysfunction of the peripheral nervous

systemsystem TreatmentTreatment = caffeine or theophylline = caffeine or theophylline

Obstructive apnea

Anatomic abnormalitiesAnatomic abnormalities Pierre Robin Syndrome Pierre Robin Syndrome

(micronathia)(micronathia) choanal atresia, laryngeal webs, choanal atresia, laryngeal webs,

vocal cord paralysis, enlarged tonsils vocal cord paralysis, enlarged tonsils and adenoidsand adenoids

Treatment = pharmacologic agents, Treatment = pharmacologic agents, surgerysurgery

100 points100 points

What is choanal atresia and what is the classic sign?

Pierre Robin SyndromePierre Robin Syndrome

100 points100 points

What is this x-ray terminology for this condition?

Retinopathy of Prematurity

AKA = ROPAKA = ROP Formerly known as RLF (Retrolental Formerly known as RLF (Retrolental

Fibroplasia)Fibroplasia) Scar formation behind lens of eyeScar formation behind lens of eye FactorsFactors

Immature retinovascularityImmature retinovascularity Oxygen administrationOxygen administration

Pathophysiology

Capillaries begin branching at 16 Capillaries begin branching at 16 weeksweeks

Begin at optic nerve and grow toward Begin at optic nerve and grow toward the ora serrata (anterior end of the ora serrata (anterior end of retina)retina)

Reach ora serrata at 40 weeksReach ora serrata at 40 weeks In the presence of high PaO2 vessels In the presence of high PaO2 vessels

constrict constrict vaso-obliteration vaso-obliteration (necrosis)(necrosis)

1 = Partial vascularization with distinct demarcation line2 = Ridge develops at demarcation line, stopping normal vascular development

3 = Blood vessels within ridge grow wildly toward center of eye, and scar tissue develops. 4 = Scar tissue pulls the retina, causing partial detachment

Treatment of ROP

Cryotherapy = -20 degrees C. Cryotherapy = -20 degrees C. Nitrous Oxide behind the eye and Nitrous Oxide behind the eye and freeze the avascular portion of freeze the avascular portion of vesselvessel Complications - scarring, cell Complications - scarring, cell

destruction, retinal detachmentdestruction, retinal detachment Laser therapy - photocoagulationLaser therapy - photocoagulation

Complication - scarring, choroidal Complication - scarring, choroidal hemorrhage, painhemorrhage, pain

Intracranial/Intraventricular

Hemorrhage ICH and IVHICH and IVH Majority of hemorrhages in neonate Majority of hemorrhages in neonate

are periventricular/ Intraventricular are periventricular/ Intraventricular (IVH)(IVH)

Preterm and Infants <1500 grams Preterm and Infants <1500 grams high riskhigh risk

Germinal matrix most commonGerminal matrix most common

IVH Fluctuations in blood flow and immaturity Fluctuations in blood flow and immaturity

of cerebral vascular system to regulate of cerebral vascular system to regulate flow leads to bleedsflow leads to bleeds

Triggering factorsTriggering factors ShockShock AcidosisAcidosis Hypernatremia, transfusion of bloodHypernatremia, transfusion of blood SeizuresSeizures Rapid expansion of blood volumeRapid expansion of blood volume VentilatorVentilator Trendelenburg positionTrendelenburg position Maternal alcohol intakeMaternal alcohol intake

Signs of germinal matrix bleeding

ApneaApnea HypotensionHypotension Drop in HctDrop in Hct FlaccidityFlaccidity Bulging fontanellesBulging fontanelles Tonic posturingTonic posturing

IVH Classifications

Grade O - No bleedingGrade O - No bleeding Grade I - bleeding in germinal matrix Grade I - bleeding in germinal matrix

onlyonly Grade II - germinal matrix + Grade II - germinal matrix +

ventriclesventricles Grade III - ventricles dilatedGrade III - ventricles dilated Grade IV - extend to parenchymaGrade IV - extend to parenchyma

Complications/ Treatment of IVH

Post hemorrhagic hydrocephalus Post hemorrhagic hydrocephalus (PHH)(PHH) Obstructed CSF outflow/impairment of Obstructed CSF outflow/impairment of

CSF resorptionCSF resorption Lumbar puncture and shuntsLumbar puncture and shunts Cerebral palsy, vision loss, hearing loss, Cerebral palsy, vision loss, hearing loss,

epilepsy, mental retardationepilepsy, mental retardationTreatmentTreatment

Avoid factors that lead to occurrenceAvoid factors that lead to occurrencesupportivesupportive