Respiratory Distress in Newborn

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Respiratory Distress in Newborn

• Leena Mane
• PGY 3 Resident
• Emory Family Medicine
• Rhea Mane
• Specialist

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Question

• A male infant weighing 3000 g (6 lb 10 oz) is
  born at 36 weeks' gestation, with normal Apgar
  scores and an unremarkable initial examination.
  At 48 hours of age he is noted to have dusky
  episodes while feeding, and does not feed well.
  On repeat examination the child is tachypneic,
  with subcostal retractions. Lung sounds are clear
  and there is no heart murmur.

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What Next ?
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Tests labs

• Pulse oximetry on room air is 82.
• Arterial blood gases on 100 oxygen show a pCO2
  of 26 mm Hg (N 27-40), a pO2 of 66 mm Hg (N
  83-108),
• blood pH of 7.50 mg/dL (N 7.35-7.45), and a base
  excess of -2 mmol/L (N -10 to -2).

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Labs

• Hemoglobin- 22.0g/dl (N13.0- 20.0)
• Hematocrit- 66 (N 42- 66)
• WBC- 19,000/mm3 (N9000-30,000)
• Blood cultures- Pending.
• Chest X-ray- Increased vascular marking, Large
  thymus.

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Most likely diagnosis

• 1- Transient tachypnea of newborn
• 2- Congenital heart disease
• 3- Hyaline membrane disease
• 4- Neonatal sepsis
• 5- Hyperviscosity syndrome

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Transient Tachypnea of Newborn

• Most common cause of respiratory distress.
• 40 cases.
• Residual fluid in fetal lung tissues.
• Risk factors- maternal asthma, c- section, male
  sex, macrosomia, maternal diabetes

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TTN

• Tachypnea immediately after birth or within two
  hours, with other predictable signs of
  respiratory distress.
• Symptoms can last few hours to two days.
• Chest radiography shows diffuse parenchymal
  infiltrates, a wet silhouette around heart, or
  intralobar fluid accumulation

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X-ray
Fluid in the fissure
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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.
• 1/3 infants born between 28 to 34 weeks, but less
  than 5 of those born after 34 weeks.
• Pathophysiology- surfactant deficiency- increase
  in alveolar surface tension- decrease in
  compliance.

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RDS

• Hyaline membrane- combination of sloughed
  epithelium, protein edema.
• Diagnosis of respiratory distress should be
  suspected when grunting, retraction or other
  typical distress symtoms occur in premature
  infant.
• CXR- homogenous opaque infiltrates air
  bronchograms.

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Meconium Aspiration Syndrome

• Incidence- 1.5- 2 in term or post term infants.
• Meconium is locally irritative, obstructive
  medium for for bacterial culture
• Meconium aspiration causes significant
  respiratory distress. Hypoxia occurs because
  aspiration occurs in utero.
• CXR- Patchy atelectasis or consolidation.

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Infections

• Pneumonia Sepsis have various manifestations
  including typical signs of distress as well as
  temperature instability.
• Common pathogen- Group B Streptococcus, Staph
  aureus, Streptococcus aureus, Streptococcus
  Pneumoniae,Gm neg rods

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Infections ctd.

• Risk factors- prolonged rupture of membranes,
  prematurity, maternal fever.
• CXR- bilateral infiltrates suggesting in utero
  infection.

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Other causes-

• Congenital malformations-Pulmonary hypoplasia,
  congenital emphysema, esophageal atresia
  diaphragmatic hernia.
• Neurological causes- hydrocephalus intracranial
  hemorrhage.
• Metabolic derangements-hypoglycemia,
  hypocalcaemia, polycythemia.

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Congenital Heart disease

• Cyanotic Heart Disease-
• Tetralogy of fallot- ( VSD, Pulmonary stenosis,
  overriding aorta, RVH)
• Tricuspid atresia
• Transposition of great vessel
• Total anamolous pul. venous return
• Truncus arteriosus.

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Hyperoxia Test

• Obtain ABGgt Then place the patient on 100 O2
  for 10 minutes then repeat ABG , If the cyanosis
  is pulmonary , the PaO2 should be increased by 30
  mm of Hg. If the cause is cardiac , there will be
  minimal improvement in PaO2.

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Treatment

• Can be generalized disease specific
• Oxygenation can be enhanced by blow by oxygen,
  nasal canula or mechanical ventilation in severe
  cases.
• Surfactant administration may be required.
• Antibiotics are often indicated if bacterial
  infection is suspected clinically or because of
  leucocytosis, neutropenia or hypoxia.

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Treatment

• Fluids should be restricted in acute phase
• Fluids should be limited for insensible losses
  replacement of Urine output.
• Mortality morbidity is lower in premature
  infants who were fluid restricted as compared to
  similar infants

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Transient Tachypnea of Newborn

• Rx is supportive because the condition is usually
  self limited.
• Oral lasix has not shown to significantly improve
  status.
• Prenatal administration of steroids 48hrs before
  elective C- section _at_ 37- 39 weeks gestation
  reduces TTN but this has not become common
  practice.

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Respiratory distress Syndrome

• General intervention for oxygenation.
• Prenatal administration of corticosteroids
  between 24- 34 wks gestation reduces risk of
  respiratory distress when risk of preterm
  delivery is high.
• Post natal steroids may decrease mortality but
  may increase risk of cerebral palsy.

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Meconium Aspiration Syndrome

• Use minimal stimulation keep head down to
  prevent breathing of meconium
• Standard practice of suctioning the mouth nares
  upon head delivery before body delivery is not
  recommended.
• Amnioinfusion does not decrease the incidence of
  meconium aspiration syndrome perinatal death.

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Algorithm
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Evaluation

• Detailed history
• Differential diagnosis changes with EGA, GBS
  status prophylaxis, duration of rupture of
  membrane, color of amniotic fluid, maternal
  temperature, maternal tachycardia, fetal heart
  tracing
• Physical signs- look for apnea, tachypnea or
  cyanosis, cardiac auscultation for murmur.
• Lung auscultation - asymmetrical chest movements-
  in pneumothorax ,crackles in pneumonia, clear in
  TTN, persistent pulmonary HTN.

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Algorithm
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Treatment

• Mild distress- observation pulse oximetry
• Severe distress- immediate resucitation, CXR, and
  laboratory tests
• Tests- blood culture, blood gas, blood glucose,
  CBC with Diff,lumbar puncture if indicated, pulse
  oximetry.

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Answer

• Cyanotic congenital heart disease can appear at
  the time of ductus closure. A heart murmur is not
  usually audible, and murmurs heard this early are
  usually not due to heart disease. The failure to
  correct hypoxemia with 100 oxygen is diagnostic
  for abnormal mixing of blood from the right and
  left circulations.
• Transient tachypnea presents earlier, and the
  hypoxia corrects with supplemental oxygen.
• Hyaline membrane disease can occur at 36 weeks,
  but would cause problems in the first hours of
  life. It can make oxygenation difficult, but
  would cause extreme distress with CO2 retention
  in such cases.

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Answer

• This patient has the energy to hyperventilate and
  has slight respiratory alkalosis as a result.
  Neonatal sepsis can cause V/Q mismatching and
  hypoxia, and can have a delayed presentation.
  Concern would be high enough in this case that
  the patient would probably receive broad-spectrum
  antibiotics while awaiting culture results. On
  the other hand, the clinician would not want to
  be distracted from the evidence for congenital
  heart disease.
• The baby is polycythemic from poor intake in the
  first 2 days of life. The hyperviscosity syndrome
  can occur when the hematocrit is over 65. It can
  cause poor feeding, tachypnea, and sluggishness,
  but does not cause hypoxia.

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Thank You