Neonatal Diseases

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Neonatal Diseases

• MODULE E

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Objectives

• Identify the key pathophysiologic changes that
  occur with each disease.
• Describe the therapeutic intervention needed to
  treat each of the diseases.

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Perinatal Diseases and Other Problems with
Prematurity

• Retinopathy of prematurity (ROP)
• Patent Ductus Arteriosus
• Hypoglycemia
• Cold Stress
• Intraventricular Intracerebral hemorrhaging

• Bronchopulmonary dysplasia
• Wilson Mikity Syndrome
• Apnea of prematurity
• Necrotizing enterocolitis
• RDS

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Retinopathy of Prematurity (ROP)

• Formerly known as Retrolental Fibroplasia (RLF).
• Initially described in 1940/1950s following
  increased incidence of blindness with babies in
  incubators.
• Incidence today
• 25 to 35 of preemies up to 35 weeks

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Physiology of the Developing Eye

• Capillaries of retina begin branching at 16
  weeks.
• End of pseudoglandular period.
• Capillaries begin at optic nerve and grow
  anteriorly toward the ora serrata which is the
  anterior end of the retina.
• Growth is not complete until 40 weeks.
• Premature infants dont have complete growth.
• As the capillary network expands, arteries and
  veins form in its path.
• ROP is the failure of this network to develop.

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Oxygen and ROP

• In the presence of high PaO2, the retinal vessels
  constrict.
• Prolonged exposure to high PaO2 will lead to
  necrosis of the vessels (vaso-obliteration).
• The body attempts to correct for this by over
  perfusing the good arteries, which leads to
  hemorrhage in the vitreous.
• This hemorrhage leads to scar tissue development
  and blindness.

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Stages and Zones of ROP

• 5 stages, with 5 having the retina completely
  detached.
• Three Zones of the eye (zone 1 is the worst)

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RDS - Respiratory Distress Syndrome

• aka IRDS or Hyaline Membrane Disease
• Associated with lung immaturity and a deficiency
  in surfactant production.
• Immaturity of other organ systems.
• Decreased Compliance increased WOB.
• Severe hypoxemia may result in multiple organ
  failure.
• May be associated with PPHN (PFC) or PDA.

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RDS - Respiratory Distress Syndrome

• Symptoms worsen for first 48-72 hours.
• Stabilization
• Slow recovery
• With progression of the disease, scar tissue
  replaces the normal alveolar tissue.
• Hyaline Membrane

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Clinical Signs

• History of prematurity
• f above 60/min
• Grunting
• Retractions
• Flaring of nostrils
• Cyanosis
• Severe hypoxemia on blood gases
• Hypothermia flaccid muscle tone

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X-ray Findings

• Diffuse White-out (Radiopaque)
• Atelectasis
• Air bronchograms
• Reticulogranular Pattern
• Fishing net
• Ground Glass Appearance

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Treatment

• Attempt to accelerate lung maturity by
  pharmacological means.
• Steroids
• Tocolysis Delay labor with b-Adrenergic Agents
• (Terbutaline)
• Thermoregulation

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Treatment

• Artificial Surfactant
• CPAP or mechanical ventilation
• High Frequency Ventilation
• ECMO

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Recovery Phase

• Complications
• ROP
• Bronchopulmonary dysplasia
• Chronic lung disease (COPD for Neonates)
• Intraventricular hemorrhage
• Brain dysfunction
• Necrotizing Enterocolitis
• Intrapulmonary Hemorrhage
• Full Recovery

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Bronchopulmonary Dysplasia

• Other Name
• Neonatal Chronic Lung Disease (NCLD)
• Progressive chronic lung disease that presents
  with persistent respiratory problems at 28 days
  or later, radiographic changes and oxygen
  dependency

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Bronchopulmonary Dysplasia

• Criteria
• Preterm infants
• Prolonged oxygen concentrations (O2 toxicity)
• Positive pressure ventilation (barotrauma)
• Patent ductus arteriosus (PDA)
• Time exposure to oxygen and positive pressure
• Malnutrition

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Bronchopulmonary Dysplasia

• Not all babies with RDS develop BPD.
• Pattern begins to unfold within the first 3-4
  days of life that places a neonate at high risk
  of developing BPD.

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Bronchopulmonary Dysplasia

• Lung Pathology
• Mucosal hyperplasia of small airways.
• Destruction of type I cells.
• Inflammation and destruction of alveoli and
  capillary bed.
• Lungs are cystic in some areas and atelectatic in
  others.

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Chest X-Ray

• Radiology
• Honeycomb appearance
• Diaphragms are flattened
• Cystic appear (hyperlucent)
• Atelectasis (radiopaque)

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HMD to BPD 3 Hour
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HMD to BPD Day 13
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HMD to BPD Day 19
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HMD to BPD 3 Months
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Clinical Presentation

• Tachypnea
• Retractions
• Mucous plugging
• Hyperinflation of chest barrel chest
• Cyanotic spells
• Poor ABG

• Wheezing
• Inadequate growth
• Increased WOB
• Increased oxygen consumption
• Pulmonary hypertension and Cor Pulmonale

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Goals of Bronchopulmonary Dysplasia

• Prevention of BPD.
• Provide enough calories to support growth.
• Wean slowly off oxygen.
• Limit peak inspiratory pressures on ventilator.
• CPAP or HFV
• Keep FiO2 levels as low as possible.
• May need to keep PaO2 levels lower.

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Complications of Bronchopulmonary Dysplasia

• Gastroesophageal reflux and feeding intolerance
  leads to aspiration.
• Decreased Ca and phosphorus (bone fractures.
• Loss sight or hearing (ROP).
• Chronic infections.
• Pneumothorax.
• Cerebral palsy.
• Limit Fluid intake develop pulmonary edema.

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Bronchopulmonary Dysplasia

• Death is usually due to
• Cor Pulmonale
• Infection
• Sudden Death

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Discharge of patients with BPD

• Home Care
• Oxygen CPT
• Mechanical ventilators
• Medications
• Diuretics or cardiac meds
• Special Attention to nutritional needs
• Frequent re-admissions back into the hospital.

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Necrotizing Enterocolitis (NEC)

• Injury to the intestinal mucosa due to
  hypoperfusion, hypoxia or hyperosmolar feedings.
• The mucosa cannot secrete the protective layer of
  mucus and it becomes vulnerable to bacterial
  invasion.
• Intestinal ischemia may result in necrosis and
  gangrene of the intestine.
• Complication of RDS.
• Highest incidence in lowest birth weight infants.

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Necrotizing Enterocolitis (NEC)

• Intestinal dilation (distended loops of intestine
  with gas).
• Gastric ileus (obstruction)
• Abdominal distention.
• Rectal bleeding
• Bloody stool
• Feeding is difficult.

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Treatment

• Stop feedings.
• Nasogastric Suctioning
• Hyperalimentation IV.
• Antibiotics.
• 20 require surgery.

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Intraventricular Hemorrhage (IVH)

• Premature infants and low birth weight infants
  are the greatest risk.
• Diagnosed by ultrasound or CT scan.
• Seen with increased incidence in children of
  alcoholic mothers.
• 4 grades of IVH.
• Grade 1 - Bleeding occurs just in a small area of
  the ventricles.
• Grade 2 - Bleeding also occurs inside the
  ventricles.
• Grade 3 - Ventricles are enlarged by the blood.
• Grade 4 - Bleeding into the brain tissues around
  the ventricles.

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Etiology And History of IVH
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Grades of IVH
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IVH Treatment

• Prevent Occurrence
• Supportive

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Wilson-Mikity Syndrome

• Seen in premature and LBW infants.
• Less than 1500 grams at birth.
• Emphysema of little babies.
• Lung immaturity with rupture of the alveolar
  septa.
• Similar to BPD except babies have not been
  ventilated.
• Treatment is supportive.
• Oxygen and mechanical ventilation.
• Some question as to whether it is a separate
  syndrome or not.

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Meconium Aspiration

• Disease of term or post term neonates.
• Asphyxia occurs before, during or after the onset
  of labor.
• Relaxation of the anal sphincter with release of
  the meconium (first stool).
• Treatment is immediate suctioning antibiotics.
• Intubate with endotracheal
• tube and with a meconium aspirator.

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Meconium Aspiration

• Usually associated with PFC and infection.
• Pneumothorax may result from the hyperinflation.
• An emergency tension pneumothorax is treated with
  a needle aspiration followed by chest tube
  insertion.

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Ball-Valve Effect
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Transient Tachypnea of the Newborn (TTN)

• RDS type II.
• Occurs in term or near term infants born by
  cesarean section.
• Caused by the retention of lung fluid following
  birth.
• Baby is born with respiratory distress and rapid
  f (80 100/min or higher).
• Evaporation of lung fluid.

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Transient Tachypnea of the Newborn

• X-ray findings are similar for RDS, TTN, and
  pneumonia.
• Pleural effusions may be present.
• May be started on broad spectrum antibiotics.
• Lung maturity is found.
• Usually good APGAR scores.
• Frequent turning is helpful to eliminate lung
  fluid.

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Transient Tachypnea of the Newborn

• ABG show oxygenation problem.
• Ventilation is usually normal.
• If ventilation is started, the baby will wean
  quickly.
• Process of elimination.

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Tracheoesophageal Fistula or Atresia

• Fistula is an abnormal communication between two
  passages or cavities.
• Atresia is the absence or closure of a normal
  body orifice or tubular passage.
• TEF is a congenital abnormality resulting in
  respiratory distress.
• Most common type is an upper esophageal atresia
  and a lower tracheal-esophageal fistula.

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Diagnosis

• The nurse/physician will try to pass a catheter
  into the stomach.
• Bronchoscopy or ultrasound is used to diagnose.
• May be seen on chest-x-ray.

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Clinical Manifestations

• Constant pooling of oral, nasal and pharyngeal
  secretions/drooling.
• Continuous or sporadic respiratory distress.
• Choking on feedings.
• Repeated vomiting with or after feedings.
• Persistent upper lobe pneumonia or atelectasis
  due to aspiration.
• Gastric distention.

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Treatment of TEF

• Surgical correction is needed.
• Supportive care until surgery.
• Aspiration is a major concern.
• A gastric feeding tube is usually placed in the
  esophageal pouch to remove secretions.
• Keep in 30 degree upright position.
• Infant is fed with a gastrostomy tube until
  surgery.

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Choanal Atresia

• A congenital malformation of bone or a membrane
  causing partial or complete obstruction of one or
  both of the choana.
• The obstruction results in asphyxia since infants
  are nose breathers early in life.
• Respiratory Distress subsides when the baby cries.

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Diagnosis

• A catheter or probe fails to pass through the
  infants nose. Often the nose has a large
  accumulation of thick secretions.
• If the obstruction is a membrane, it may be
  punctured to provide relief of the respiratory
  distress.

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Clinical Manifestations

• Clinical Signs
• Respiratory distress
• Cyanosis
• Retractions
• Pooling of nasal secretions

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Treatment

• Treatment
• Insertion of an oral airway to facilitate mouth
  breathing.
• If distress continues, then intubate and
  ventilate.

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Diaphragmatic Hernia

• CDH is a congenital condition in which the
  abdominal organs herniate into the chest cavity
  through the diaphragm.
• Life threatening condition.
• Lung tissue is compressed.

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Diaphragmatic Hernia

• Most common defect is in the posterolateral
  region of the diaphragm in an area called the
  foramen of Bochdalek.
• Left side herniation is more frequent (85-90).
• Stomach, spleen intestines can enter the chest.
• Scaphoid (boat shaped) Abdomen is present.

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Diaphragmatic Hernia

• The baby will be in respiratory distress at
  birth.
• PMI may be shifted.
• Breath sounds diminished.
• Bowel sounds can be heard over lung fields.
• Confirmed with chest x-ray.
• Lungs are hypoplasitc (underdeveloped).

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Treatment of Diaphragmatic Hernias

• Orogastric tube is inserted to remove air.
• Do not manually ventilate these infants.
• Overdistension of stomach will worsen problem.
• Intubate to prevent air in the stomach and
  intestines.
• High Frequency Ventilation, ECMO
• High mortality rate.
• Pneumothorax is common.

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Treatment of Diaphragmatic Hernias

• Prenatal ultrasound can accurately diagnose a CDH
  in utero (in utero repair has been successfully
  accomplished)!!

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Persistent Pulmonary Hypertension of the Newborn
(PPHN)

• Formerly Persistent Fetal Circulation (PFC)
• Pulmonary hypertension after birth caused by
  asphyxia and which prevents the transition of
  fetal to newborn circulation.
• It may be a primary disorder or a secondary
  disorder
• RDS
• TTN
• Pneumonia
• Cold Stress
• Meconium aspiration
• Diaphragmatic hernia

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Persistent Pulmonary Hypertension of the Newborn
(PPHN)

• Blood is shunted Right to Left across the ductus
  arteriosus.
• The Apgar is usually 5 or less at 1 and 5
  minutes.

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Signs and Symptoms

• Tachypnea
• Retractions
• Cyanosis
• Breath sounds are clear if no pulmonary disease
  is present.
• Refractory to oxygen therapy (true shunt).
• Difference in pre post ductal blood gases.

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Diagnostic Testing

• Hyperoxia Test
• If PaO2 does not increase with 100 oxygen,
  suspect a cardiac shunt
• Not specific for PFC
• Compare preductal and postductal PaO2
• If shunt is present Preductal gt Postductal.
• 15 to 20 mm Hg and with FiO2
• Hyperoxia-Hyperventilation Test
• Most definitive.
• Hyperventilate until PaCO2 is 20 25 mm Hg
• Alkalosis will reduce pulmonary hypertension and
  PaO2 will improve.
• Echocardiography ultrasound of the heart
• Cardiac Catheterization

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Treatment for PPHN

• Oxygen therapy to maintain PaO2 greater than 50
  60 mm Hg.
• Mechanical ventilation.
• Nitric Oxide
• ECMO, HFV
• Keep glucose and electrolytes normal.

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Pneumothorax

• Cyanosis
• Tachypnea
• Grunting
• Nasal flaring
• PMI is shifted
• Diminished or absent breath sounds

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Confirmation of a Pneumothorax

• Transillumination
• Bed Side
• Chest x-ray

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Treatment of Pneumothorax

• Emergency treatment .
• Needle Aspiration
• 2nd intercostal space
• Chest Tube.
• Given the baby 100 oxygen until chest tube is
  inserted.

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Infections

• Pneumonia infection in the lungs.
• Septicemia infection in the bloodstream.
• Meningitis infection/inflammation of the
  covering of the brain and spinal cord.
• Urinary Tract Infections
• Conjunctivitis infection or inflammation of the
  eye.
• Omphalitis infection/inflammation of the
  umbilical stump.

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Pneumonia

• Transplacental
• Acquired at birth
• Amniotic fluid.
• Premature rupture of membranes greater than 12-24
  hours (PROM).
• Postnatal
• Invasive lines.
• Respiratory equipment.
• Hospital Personnel.

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Pneumonia

• Premature infants are at greater risk.
• Group B Beta Hemolytic Streptococci Escherichia
  Coli are the most common organisms.
• PFC is usually a consequence of pneumonia.

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Diagnosis of Pneumonia

• Chest x-ray
• Very difficult to distinguish between Pneumonia,
  RDS TTN.
• Culture and Sensitivity.

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Postnatally Acquired Pneumonia

• Klebsiella
• Pseudomonas
• Methicillin-Resistant Staphylococcus (MRSA)
• Resistant to penicillin type drugs.
• Candida Albicans (fungal).

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Viruses that affect the Newborns

• Herpes Virus
• Respiratory Syncytial Virus (RSV)
• Rubella
• Adenovirus
• Cytomegalovirus
• Chlamydia