Neonatal Respiratory Distress

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Respiratory Distress in Newborn
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Neonatal Respiratory Distress Signs and symptoms

• Tachypnea (RR gt 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

• 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)

• Pulmonary
• Transient tachypnea of the newborn (TTN)
• Respiratory distress syndrome (RDS)
• Pneumonia
• Meconium aspiration syndrome (MAS)
• Air leak syndromes
• Pulmonary hemorrhage

• Anatomic
• Upper airway obstruction
• Airway malformation
• Rib 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 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 gt60 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
• Atelectasisareas not ventilated
• Decrease alveolar ventilation
• Reduce lung volume
• Areas not perfused

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Surfactant Function
Normal Expiration With Surfactant
Abnormal RespirationWithout Surfactant
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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 stress
• Prolonged rupture of membranes
• Antenatal steroid prophylaxis

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Clinical Manifestations

• Appear within minutes of birth may not be
  recognized for several hours in larger preterm
• Tachypnea (gt60 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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Chest x-ray

• 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

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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 lt27 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 gt60 mmHg,
  PaO2 lt50 mmHg or SaO2 lt90) with an FiO2 gt0.5, 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 Surfactantsdo not contain proteins
• Exocerf
• ALEC
• Lucinactant (Surfaxin)

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Surfactant 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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Meconium Aspiration Syndrome

• Risk Factors
• Post-term pregnancy
• Pre-eclampsia, eclampsia, maternal hypertension,
• Maternal diabetes mellitus
• IUGR
• Evidences of fetal distress (e.g.,abnormal
  biophysical profile)

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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 gt0.4 however
  CPAP mayaggravate air trapping and must be used
  cautiously.
• Mechanical ventilation in severe cases (paCO2
  gt60 mmHg orpersistent hypoxemia (paO2 lt50 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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Pneumonia

• Common organisms
• GBS
• gramve 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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