Neonatal Respiratory Distress.ppt
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Respiratory Distress in Newborn
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Neonatal Respiratory Distress Signs and symptoms
Tachypnea (RR > 60/min)
Nasal flaring
Retraction
Grunting
+/- Cyanosis
+/- Desaturation
Decreased air entry
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Down score
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Neonatal Respiratory Distress Etiologies
Pulmonary
Transient tachypnea of the newborn (TTN)
Respiratory distress syndrome (RDS)
Pneumonia
Meconium aspiration syndrome (MAS)
Air leak syndromes
Pulmonary hemorrhage
Systemic Metabolic (e.g., hypoglycemia, hypothermia or hyperthermia)
metabolic acidosis
anemia, polycythemia
Cardiac• Congenital heart disease;
cyanotic or acyanotic• Congestive heart failure• Persistent pulmonary
hypertension of the newborn (PPHN)
Neurological (e.g., prenatal asphyxia, meningitis)
Anatomic
Upper airway obstructionAirway malformationRib cage anomalies
Diaphragmatic disorders (e.g., congenital
diaphragmatic hernia,
diaphragmatic paralysis)
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Pulmonary 1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome (MAS)
4- Pneumonia
5- Air Leak Syndromes
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Transient Tachypnea of Newborn
TTN (known as wet lung) is a relatively mild, self limiting disorder of near-term or term
Delay in clearance of fetal lung fluid results in transient pulmonary edema. The increased fluid volume causes a reduction in lung compliance and increased airway resistance.
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Transient Tachypnea of Newborn
Risk factors: Maternal asthma
C- section
Macrosomia, maternal diabetes
Prolonged labor, Excessive maternal sedation
Fluid overload to the mother,Delayed clamping of the umbilical cord .
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Transient Tachypnea of Newborn Usually near-term or term
Tachypnea immediately after birth or within 6 hrs after delivery, mild to moderate respiratory distress.
These manifestations usually persist for 12-24 hrs, but can last up to 72 hrs
Auscultation usually reveals good air entry with or without crackles
Spontaneous improvement of the neonate is an important marker of TTN.
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Transient Tachypnea of Newborn
Chest x-ray : Prominent perihilar streaking (due to engorgement of
periarterial lymphatics)
Fluid in the minor fissure
Prominent pulmonary vascular markings
Hyperinflation of the lungs, with depression of diaphragm
► Chest x-ray usually shows evidence of clearing by 12-18 hrs with complete resolution by 48-72 hrs
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chest X-ray: Transient Tachypnea of Newborn
Fluid in the fissureFluid in the fissure
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General Management of Respiratory Distress Supplemental oxygen or MV, if needed.
Continuously monitor with pulse oximeter.
Obtain a chest radiograph.
Correct metabolic abnormalities (acidosis,hypoglycemia).
Obtain a blood culture & begin an antibiotic coverage (ampicillin + gentamicin)
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General Management
Provide an adequate nutrion. Infants with sustained RR >60 breaths/min should not be fed orally & should be maintained on gavage feedings for RR 60-80 breaths/min, and NPO with IV fluids or TPN for more severe tachypnea
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Pulmonary 1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome (MAS)
4- Pneumonia
5- Air Leak Syndromes
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Respiratory Distress Syndrome Also called as hyaline membrane disease Most common cause of respiratory distress in
premature infants, correlating with structural & functional lung immaturity.
primarily affects preterm infants; its incidence is inversely related to gestational age and birthweight.
15-30% of those between 32-36 weeks‘ gestation, in about 5% beyond 37 weeks' gestation
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Physiologic abnormalities
Surfactant deficiency- increase in alveolar surface tension.
Lung compliance decreased to 10-20% of normal
Atelectasis…areas not ventilated
Decrease alveolar ventilation
Reduce lung volume
Areas not perfused
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Normal Expiration With Surfactant
Surfactant Function
Abnormal RespirationWithout Surfactant
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Compliance
Pressure
Volume
Opening pressures
Maximal volume
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Risk factors Prematurity
Maternal diabetes
Multiple births
Elective cesarean section without labor
Perinatal asphyxia
Cold stress
Genetic disorders
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Decreased risk
Chronic intrauterine stressProlonged rupture of membranesAntenatal steroid prophylaxis
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Clinical Manifestations Appear within minutes of birth may not be recognized for several
hours in larger preterm
Tachypnea (>60 breaths/min), nasal flaring, subcostal and intercostal retractions, cyanosis & expiratory grunting
Breath sounds may be normal or diminished and fine rales may be heard
Progressive worsening of cyanosis & dyspnea. BP may fall; fatigue, cyanosis and pallor increase & grunting decreases.
Apnea and irregular respirations are ominous signs
In most cases, symptoms and signs reach a peak within 3 days, after which improvement occurs gradually.
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Findings can be graded according to the severity:
Grade 1 (mild cases): the lungs show fine homogenous ground glass shadowing
Grade 2: widespread air bronchogram become visible
Grade 3: confluent alveolar shadowing
Grade 4: complete white lung fields with obscuring of the cardiac shadow
Chest x-ray:
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Grade 1
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Grade 2
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Grade 3
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Grade 4
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Management
Prevention: Lung maturity testing: lecithin/sphingomyelin (L/S) ratio
Tocolytics to inhibit premature labor.
Antenatal corticosteroid therapy:
► They induce surfactant production and accelerate fetal lung maturation.
► Are indicated in pregnant women 24-34 weeks' gestation at high risk of preterm delivery within the next 7 days.
► Optimal benefit begins 24 hrs after initiation of therapy and lasts seven days.
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Prevention Antenatal corticosteroid therapy consists of either :
□ Betamethasone 12 mg/dose IM for 2 doses, 24 hrs apart, or
□ Dexamethasone 6 mg/dose IM for 4 doses, 12 hrs apart
Early surfactant therapy: prophylactic use of surfactant in preterm newborn <27 weeks' gestation.
Early CPAP administration in the delivery room.
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Treatment Administer oxygen
Initiate CPAP as early as possible in infants with mild RDS
Start MV if respiratory acidosis (PaCO2 >60 mmHg, PaO2 <50 mmHg or SaO2 <90%) with an FiO2 >0.5, or severe frequent apnea.
Administer surfactant therapy: early rescue therapy within 2 hrs after birth is better than late rescue treatment when the full picture of RDS is evident.
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Types of Surfactant
Natural Surfactants: contain appoproteins SP-B & SP-C
Curosurf (extract of pig lung mince)
Survanta (extract of cow lung mince)
Infasurf (extract of calf lung)
Synthetic Surfactants:do not contain proteins
Exocerf
ALEC
Lucinactant (Surfaxin)
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Surfactant Therapy for RDSSurfactant Therapy for RDS
Improvement in compliance, functional residual capacity, and oxygenation
Reduces incidence of air leaks
Decreases mortality
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Mode of administration of Surfactant Dosing may be
divided into 2 alliquots and adminitered via a 5-Fr catheter passed in the ET
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Insure technique
Intubation- surfactant- extubation to CPAP
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Pulmonary 1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome (MAS)
4- Pneumonia
5- Air Leak Syndromes
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Risk Factors: Post-term pregnancy
Pre-eclampsia, eclampsia, maternal hypertension,
Maternal diabetes mellitus
IUGR
Evidences of fetal distress (e.g.,abnormal biophysical profile)
Meconium Aspiration Syndrome
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Clinical Manifestations
Meconium staining amniotic fluid (meconium stained nails, skin & umbilical cord )
Some infants may have mild initial respiratory distress, which becomes more severe hours after delivery.
Pneumothorax and/or pneumomediastinum
PPHN in severe cases
Hypoxia to other organs (e.g., seizures, oliguria)
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Pathophysiology
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Chest x-ray: Areas of hyperexpansion mixed with patchy densities and atelectasis
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Management
In the DR or OR: Visualization of the vocal cords & tracheal suctioning before
ambu-bagging should be done only if the baby is not vigorous
In the NICU: Empty stomach contents to avoid further aspiration.
Suction frequently & perform chest physiotherapy.
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Management Consider CPAP, if FiO2 requirements >0.4; however CPAP
mayaggravate air trapping and must be used cautiously.
Mechanical ventilation: in severe cases (paCO2 >60 mmHg orpersistent hypoxemia (paO2 <50 mmHg).
Correct systemic hypotension (hypovolemia, myocardial dysfunction).
Manage PPHN, if present
Manage seizures or renal problems, if present.
Surfactant therapy in infants whose clinical status continue todeteriorate.
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Pulmonary 1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome (MAS)
4- Pneumonia
5- Air Leak Syndromes
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PneumoniaPneumoniaCommon organisms: GBS
gram–ve organisms (e.g. E.Coli, Klebsiella,Pseudomonas)
, Staph. aureus, Staph. epidermidis
Candida.
acquired viral infections (e.g., HSV, CMV).
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Clinical Manifestations
Early manifestations may be nonspecific (e.g., poor feeding, lethargy, irritability, cyanosis, temperature instability
Respiratory distress signs may be superimposed upon RDS or BPD.
In a ventilated infant, the most prominent change may be the need for an increased ventilatory support.
Signs of pneumonia (dullness to percussion, change in breathsounds, rales or rhonchi) are difficult to appreciate.
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Chest x-rays: infiltrates or effusion
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Chlamydia pneumonia with features of an interstitial pneumonitis and characteristic widespread interstitial changes.
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Management
Initiate ampicillin and gentamicin IV; modify according to culture results and continue therapy for 14 days.
If there is a fungal infection, an antifungal agent is used.
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Pulmonary 1- Transient tachypnea of newborn
2- Hyaline membrane disease
3- Meconium aspiration syndrome (MAS)
4- Pneumonia
5- Air Leak Syndromes
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Air Leak Syndromes
Risk Factors: MV,MAS, surfactant therapy without
decreasing pressure support in ventilated infants
vigorous resuscitation,
prematurity
pneumonia
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Clinical Manifestations Spontaneous pneumothorax may be asymptomatic or
only mildly symptomatic (i.e., tachypnea and ↑O2 needs).
In unilateral cases, chest asymmetry is noted, mediastinum shift to the opposite side.
If the infant is on ventilatory support will have sudden onset of clinical deterioration (i.e., cyanosis, hypoxemia, hypercarbia & respiratory acidosis associated with decreased breath sounds and shifted heart sounds).
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Tension pneumothorax
(a life-threatening condition) → ↓cardiac output and obstructive shock; urgent drainage prior to a radiograph is mandatory.
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Chest x-ray: Right-sided pneumothorax
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Right-sided tension pneumothorax with mediastinal shift. Both lungs demonstrate opacification of alveolar collapse.
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Left-sided pneumothorax under tension. There is pulmonary interstitial emphysema in the right lung and a small basal right pneumothorax.
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Others
Pneumomediastinum
It can occur with aggressive ETT insertion, Ryle's feeding tube
insertion, lung disease, MV, or chest surgery (e.g., TEF).
Pneumopericardium
Pneumoperitoneum
Subcutaneous emphysema
Systemic air embolism
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Chest x-ray with Pneumomediastinum
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Massive Pneumoperitoneum in MV neonate
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Chest x-ray with pneumopericardium
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Severe bilateral PIE affecting the right more than the left lung; there is gross cardiac compression. A chest drain is in situin the right hemithorax.
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Management
Conservative therapy: close observation of the degree of respiratory distress as well as oxygen saturation, without any other intervention aiming at spontaneous resolution and absorption of air.
Needle aspiration should be done for suspected cases of pneumothorax with deteriorating general condition until intercostal tube is inserted.
Decompression of air leak according to the type (intercostal tube insertion in case of pneumothorax).
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Thank You …
Thank You …