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RESPIRATORY DISEASES
OF THE NEWBORN
Early Development
foregut
Week 5: the left and right lung buds push into the
pericardioperitoneal canals (primordial of pleural cavity)
Week 6: the descent of heart and lungs into the thorax.
Pleuroperitoneal foramen closes
bronchi
Week 24: the bronchi divide 14 more times and the
respiratory bronchioles develop
By birth, there will be an additional 7 divisions of bronchi
STAGE 4: Alveolar
Period (late fetal
period to 8 years)
95% of mature
alveoli develop after
birth. A newborn
has only 1/6 to 1/8
of the adult number
of alveoli and lungs
appear denser on xray
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newborn
Relatively mild, self limited disorder, usually affecting
infants who are born at or near term gestation.
Ineffective clearance of amniotic fluid from lungs with
delivery
Most often seen at birth or shortly after
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TTN presents:
Respiratory Assessment (usually within 6H of life)
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TTN
X-Ray findings
Prominent Perihilar streaking
Mild to moderate cardiomegaly
Coarse, fluffy density
Hyperinflation with flattening of diaphragm
Fluid in fissure
Labs
FBC within normal limits
ABG/CBG showing mild to moderate hypercapnia, hypoxemia with
a respiratory acidosis
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TTN
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TTN
Have delayed reabsorption of fetal lung fluid which
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Surfactant Deficiency
(RDS, HMD)
One of the most common problems associated with a
premature infant
Decreased surfactant production in lungs of pre-term
infants
Manifestation caused by diffuse alveolar atelectasis,
edema and cell injury.
With decreased surfactant production, alveoli collapse,
become atelectatic, yielding poor lung function and
increasing signs of respiratory distress
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RDS
History
Gestational age < 38 weeks
Prenatal care
Diabetes (controlled vs uncontrolled)
Perinatal infection
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amniocentesis
Lecithin-sphingomyelin (L/S) ratio risk of RDS low if ratio >2.0
TDx-Fetal Lung Maturity (FLM II) measures surfactant-albumin ratio
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RDS presents:
Respiratory Assessment
Tachypnea > 60 bpm
Nasal flaring
Grunting
Retracting
Apnea/ irregular respiratory pattern
Rales (crackles)
Diminished breath sounds
Cyanosis
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RDS
X-Ray
Loss of volume
Reticulogranular pattern or ground glass appearance
Air bronchograms
Bell shaped thorax
Air leak, pulmonary interstitial emphysema
Loss of heart borders/ atelectasis
White out
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RDS
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RDS
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RDS
Laboratory Results
ABG/VBG
Hypoxia
Hypercarbia
Acidosis
distress
Always check electrolytes, especially glucose, potassium and
calcium
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Several types
Survanta (bovine lung extract)
Infasurf (calf lunf extract)
Curosurf (porcine lung extract)
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dose via a feeding tube that is cut to a length just slightly longer
than that of the ETT
Baby is ventilated for at least 30 seconds, or until stable between
quarter doses.
Changes in positioning of the infant are routine and intended to
facilitate distribution.
Careful observation is necessary. Desaturation, bradycardia and
apnea are common adverse effects.
Subsequent doses of survanta, if needed, are given at 6H intervals
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RDS complication
Acute
Air leak Pneumothorax, Pneumomediastinum,
penumopericardium, interstitial emphysema
Infection from catheters, respiratory equipment
Intracranial hemorrhage
Patent Ductus Arteriosus
Long term
Bronchopulmonary dydplasia
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MAS
Composition of meconium
Epithelial cells
Fetal hair
Mucus
Bile
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Maternal HT
Maternal DM
Maternal heavy cigarette smoking
Maternal chronic respiratory or Cardio vascular disease
Post term pregnancy
Pre-eclampsia/eclampsia
Oligohydramnios
IUGR
Abnormal fetal HR pattern
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MAS
Ball-valve effect
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MAS
Management on delivery
Determine whether infant is vigorous (HR>100, Spontaneous
respiration, good tone)
If vigorous, continue routine care regardless of meconium
consistency (clear mouth and nose of secretions, dry, stimulate and
reposition)
If not vigorous, intubate infant under direct laryngoscopy, perform
intratracheal suctioning with meconium aspirator or large bore
suction catheter. Apply continuous suction as tube is withdrawn.
Repeat as necessary until little additional meconium is recovered,
or until resuscitation needs to be initiated.
In questionable cases, it is safer to intubate and suction as MAS
can occur in infants delivered through thinly stained amniotic fluid.
PPV should be avoided until tracheal suctioning is accomplished if
possible
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MAS
Meconium aspirator
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MAS
Postnatal Management
Gentamicin)
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MAS
Respiratory Assessment
Tachypnea
Nasal flaring
Grunting
Retracting
Apnea/ irregular respiratory pattern
Decreased breath sounds/ wet/ rhonchi
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MAS
Clinical Assessment
Color
Pale/gray
Cyanotic
Stained skin
X-Ray
Increased AP diameter
Hyperinflation
Atelectasis
Course irregular patchy infiltrate
Pneumothorax
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MAS
Areas of opacification due to atelectasis bilaterally
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MAS
Coarse irregular patchy infiltrate with emphysema
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respiratory distress:
O2 head box
CPAP
Mechanical ventilation
down the tracheobronchial tree and allow more time for meconium
removal.
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MAS
Surfactant
Endogenous surfactant activity may be inhibited by meconium.
Surfactant therapy may improve oxygenation and reduce
pulmonary complications.
It is not routinely indicated, however it may be helpful in those
infants whose clinical status continues to deteriorate.
Inhaled Nitric oxide (NO)
Selective pulmonary vasodilation.
Activate guanylate cyclase and increases cyclic GMP and acting
directly on the vascular smooth muscle
ECMO
Extracorporeal membrane oxygenation (ECMO) is a treatment that
uses a pump to circulate blood through an artificial lung back into
the bloodstream of a very ill baby. This system provides heart-lung
bypass support outside of the baby's body.
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MAS
Acute Complication
Air Leak Pneumothorax or pnuemopericardium
PPHN
Chronic lung disease may result from prolong mechanical
ventilation
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Persistent Pulmonary
Hypertension (PPHN)
a failure of normal pulmonary vasculature relaxation at or
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PPHN
Idiopathic - 20%
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PPHN
History
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Cardiac signs
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PPHN - Management
General measures:
Preventing and treating
- Hypothermia
- Hypoglycaemia
- Hypocalcaemia
- Hypovolaemia
- Anaemia
Avoid excessive noise, discomfort and agitation.
Minimal handling
Sedation
Morphine given as an infusion at 10-20 mcg/kg/hr. Morphine is a safe
sedative and analgesic even in the preterm infants.
Midazolam not recommended for preterms < 34 weeks gestational
age, associated with adverse long term neurodevelopmental outcomes.
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Ventilation
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Circulatory support
Inotropes for circulatory support improve cardiac output and enhances
systemic oxygenation.
Its use is poorly substantiated in PPHN, especially with the use of inhaled
nitric oxide (iNO), which through its pulmonary vasodilating effect helps to
improve cardiac output and the systemic blood pressure.
Aim to keep the mean arterial pressure > 50 mmHg in term infants.
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Vasodilators
Inhaled nitric oxide (iNO)- selective pulmonary vasodilator.
- In term and near term infants (>34 weeks gestational age) reduces
need for Extra Corporeal Membrane Oxygenation (ECMO)(Dose: 5-20 ppm).
Prostacycline and Sildenafil. These are not recommended for routine use
as their safety and efficacy had not been tested in large randomized
trials.
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Neonatal Pneumonia
Intrauterine infection or during delivery
Most are bacterial in origin
Pneumonia that becomes clinically evident
1 of 3 routes:
Hematogenous
Ascending
Aspiration
Intrapartum pneumonia
Intrapartum pneumonia is acquired during passage
Postnatal pneumonia
Postnatal pneumonia in the first 24 hours of
Etiology
Group B Streptococcus (GBS)
gondii,
Enterococci
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Causes
Prematurity
Meconium
Maternal hx of STDs
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Respiratory Assessment
Tachypnea
Colorful secretions
Rales, rhonchi
Cyanosis
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Clinical Assessment
Gray, pale color
Lethargy
Temperature instability
Skin rash-pettechia
Tachycardia
Glucose issues
Hypoperfusion
Oliguria
Changed in behaviour
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X-Ray
Patchy infiltrates (aspiration)
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Pneumonia
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Pneumonia
Lab
FBC
Cultures
CRP
Management
Start antibiotic immediately when diagnosis is suspected (IV C-penicillin /
Ampicillin & Gentamicin)
Adjust Antibiotics according to culture & sensitivity result
Supportive therapy
Respiratory: ensure adequate oxygenation
CVS: support BP and perfusion
Fluid and nutrition support