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THE TERM NEONATE WITH RESPIRATORY DISTRESS. N. Ambalavanan MD University of Alabama at Birmingham Department of Pediatrics Division of Neonatology May 2003. Overview of talk. The emphasis is on evaluation and diagnosis Management will depend mainly on the diagnosis.

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The term neonate with respiratory distress l.jpg

THE TERM NEONATE WITH RESPIRATORY DISTRESS

N. Ambalavanan MD

University of Alabama at Birmingham

Department of Pediatrics

Division of Neonatology

May 2003


Overview of talk l.jpg
Overview of talk

  • The emphasis is on evaluation and diagnosis

  • Management will depend mainly on the diagnosis


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EVALUATION OF NEONATES WITH RESPIRATORY DISTRESS

History

Premature delivery

Postmature delivery

Fetal distress

Meconium-stained

fluid Maternal diabetes

Oligohydramnios/

polyhydramnios

Decreased fetal movements

Traumatic delivery

Drugs

Cesarean section

Vaginal bleeding


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EVALUATION OF NEONATES WITH RESPIRATORY DISTRESS

Physical Exam

Major signs:

cyanosis, tachypnea

grunting, retraction, flaring

Stridor, wheezes,

hoarseness, and other

airway findings

Cardiovascular

assessment

Blood pressure

Neurologic assessment

Abdominal assessment

Chest wall assessment

Temperature


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EVALUATION OF NEONATES WITH RESPIRATORY DISTRESS

Laboratory Workup

Chest radiograph

Arterial blood gas

Blood glucose

Central hematocrit

White blood cell

and differential

If indicated:

Blood culture

Echocardiogram

Other diagnostic

imaging


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Neonate with respiratory distress

Abnormal

Chest X-Ray ?

No

Look for

abnormalities

of:

Yes

Common

Uncommon

Diaphrag. Hernia

Trach-Esoph fistula

Cysts, tumors

Hypoplasia

Hemorrhage

Cong. Lobar Emph.

Lymphangiectasia

Sequestration

AV fistulae

Resp Distress Synd

Transient Tachypnea

Aspiration Syndr.

Pneumonia

Air leaks

Effusion

Pulmonary Edema

Perfusion, BP, HCT

Neuro-muscular

Upper or lower

airway

Diaphragm or

Chest wall

Cardiac problems

Other or

Mixed findings

Abdomen


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Neonate with Acute Respiratory Distress

Abnormal

Yes

No

Lungs

by Chest

Radiograph

Abnormalities in

Common

Uncommon

Respiratory distress

Diaphragmatic hernia

Perfusion

Neuro

-

Diaphragm

syndrome

Tracheoesophageal

BP

muscular

or Chest

Transient

fistula

HCT

Findings

Wall

tachypnea

Cysts and tumors

Pneumonia

Congenital lobar

Aspiration syndromes

emphysema

Pneumothorax and

Pulmonary hypoplasia

Anemia

Asphyxia

Chest wall

air leaks

Accessory or sequestered lobes

Polycythemia

Intracranial

disorders

Pulmonary edema

Pulmonary

Hypotension

hemorrhage

Diaphragmatic

Pleural effusion

lymphangiectasia

Hypovolemia

Neuromuscular

disorders

Pulmonary hemorrhage

Pulmonary

disorders

arteriovenous fistula

Drugs

CVS

Other

Airway

Abdominal

Findings

or Mixed

Findings

Findings

or Echo

Findings

Upper Airway

Persistent fetal

Ascites

Sepsis

Laryngeal

circulation

Necrotizing

Acidosis

Lower airway

Cyanotic congenital

enterocolitis

Hypothermia,

hear disease

Abdominal mass

cold stress

Obstructive lesions

Omphalocele

Hyperthemia

Gastroschisis

Hypoglycemia

Congestive heart

Methemoglobinemia

failure


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NEONATE WITH ACUTE RESPIRATORY DISTRESS

Abnormal lungs by chest radiograph - common

Respiratory distress Pneumothorax syndrome and air leaks Transient tachypnea Pulmonary edema Pneumonia Pleural effusion

Aspiration syndromes




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ABNORMAL RADIOGRAPHIC FINDINGS

RDS - reticulogranular, ground glass appearance, decreased lung volume, air bronchograms

TTN - fluid in fissure, interstitial fluid

Pneumonia - infiltrates

MAS - variable




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NEONATE WITH ACUTE RESIRATORY DISTRESS

Abnormal lungs by chest radiograph - uncommon

Diaphragmatic hernia Accessory or

Tracheoesophageal fistula sequestered lobes

Cysts and tumors Pulmonary

Congenital lobar lymphangiectasia

emphysema Pulmonary

Pulmonary hypoplasia arteriovenous Pulmonary hemorrhage fistula


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Meconium Asp. Syndrome

with Pneumothorax





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AIR LEAKS

  • Pneumothorax

  • Pulmonary interstitial emphysema

  • Pneumomediastinum

  • Pneumopericardium

  • Pneumoperitoneum

  • Pulmonary venous air embolism

  • Subcutaneous emphysema

  • Others



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THORACIC CYSTS AND TUMORS

Teratoma Gastric cyst

Cystic hygroma Hemangioma

Neurogenic tumor Angiosarcoma

neuroblastoma Mediastinal goiter

ganglioneuroma Thymoma

neurofibroma Mesenchymoma

Bronchial or bronchogenic cyst Lipoma

Intrapulmonary cyst Cystic adenomatoid malformation



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ORGANISMS THAT MAY CAUSE PNEUMONIA IN THE NEONATE

Bacterial

Group B Strep

E. coli

Klebsiella

S. aureus

S. epidermidis

Listeria

Enterobacter

H. influenzae

S. pneumoniae

Pseudomonas

Bacteroides

Others


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ORGANISMS THAT MAY CAUSE PNEUMONIA IN THE NEONATE

Viral

Cytomegalovirus

Adenovirus

Rhinovirus

Respiratory

syncytial virus

Parainfluenza

Enterovirus

Rubella

Herpes simplex

Varicella


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ORGANISMS THAT MAY CAUSE PNEUMONIA IN THE NEONATE

Others

Candida (and other fungi)

Ureaplasma

Mycoplasma

Chlamydia

Syphilis

Pneumocystis carinii

Tuberculosis



Pleural effusion l.jpg
PLEURAL EFFUSION

  • Hydrothorax* - hydrops, tumor, pneumonia, congenital viral infection, congestive heart failure, transient tachypnea, Turner syndrome

  • Chylothorax* - spontaneous, complication of thoracic surgery

  • Hemothorax* - traumatic, ruptured vessel, disseminated intravascular coagulation, and other bleeding diatheses

    * Complications of central line placement may result in any of these .


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ABNORMALITIES IN PERFUSION, BLOOD PRESSURE, AND HEMATOCRIT

  • Anemia

  • Polycythemia

  • Hypotension

  • Hypovolemia


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Paralyzed right diaphragm

from phrenic N. palsy


Slide30 l.jpg

ABNORMALITIES WITH NEUROMUSCULARFINDINGS

  • Asphyxia

  • Intracranial hemorrhage

  • Neuromuscular disorders

  • Drugs


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NEUROMUSCULAR DISORDERS

  • Myopathies

  • Myasthenia gravis

  • Werdnig-Hoffman disease

  • Spinal cord disorder

  • Poliomyelitis

  • Others



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ABNORMALITIES IN DIAPHRAGM OR CHEST WALL

  • Diaphragmatic disorders

  • Chest wall disorders


Diaphragmatic disorders l.jpg
DIAPHRAGMATIC DISORDERS

  • Diaphragmatic hernia

  • Congenital eventration of the diaphragm

  • Diaphragm paralysis

  • Anterior diaphragmatic defect

  • Neuromuscular disorders

  • Accessory diaphragm

  • Agenesis of the diaphragm


Chest wall disorders l.jpg
CHEST WALL DISORDERS

  • Achondrogenesis

  • Chondroectodermal dysplasia

  • Osteogenesis imperfecta

  • Spondylocostal dysplasia

  • Others

  • Failure of sternal fusion

  • Benign and malignant tumors

  • Asphyxiating thoracic dystrophy

  • Achondroplasia

  • Thanatophoric dwarfism


Slide36 l.jpg

ABNORMAL AIRWAY

  • Upper airway

  • Laryngeal

  • Lower airway


Airway disorders l.jpg
AIRWAY DISORDERS

Upper Airway

Choanal atresia/stenosis Cystic hygroma

Trauma Thyroglossal duct cyst

Hemangioma Micrognathia

Teratoma Macroglossia

Encephalocele Benign and malignant

tumors


Airway disorders38 l.jpg
AIRWAY DISORDERS

Laryngeal

Laryngomalacia Cystic lesion

Vocal cord paralysis Benign and malignant

Hemangioma tumors

Atresia, stenosis, or web Acquired lesion

Congenital laryngeal

stridor


Airway disorders39 l.jpg
AIRWAY DISORDERS

Lower Airway

Tracheomalacia Bronchial atresia

Tracheoesophageal Abnormal branching

fistula Cystic lesion

Hemangioma Benign and malignant

Vascular ring tumors

Congenital tracheal Acquired lesion

stenosis


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Dextrocardia with

complex congenital heart disease




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ABNORMALITIES IN CARDIOVASCULAR FINDINGS

OR ECHOCARDIOGRAM

  • Persistent fetal circulation

  • Cyanotic congenital heart disease

  • Obstructive lesions

  • Congestive heart failure


Slide44 l.jpg

ABNORMALITIES IN ABDOMINAL FINDINGS

  • Ascites

  • Necrotizing enterocolitis

  • Abnormal mass

  • Omphalocele

  • Gastroschisis


Slide45 l.jpg

OTHER ABNORMALITIES

OR MIXED FINDINGS

  • Sepsis

  • Acidosis

  • Hypothermia, cold stress

  • Hyperthermia

  • Hypoglycemia

  • Methemoglobinemia


Slide46 l.jpg

Neonate with respiratory distress

Abnormal

Chest X-Ray ?

No

Look for

abnormalities

of:

Yes

Common

Uncommon

Diaphrag. Hernia

Trach-Esoph fistula

Cysts, tumors

Hypoplasia

Hemorrhage

Cong. Lobar Emph.

Lymphangiectasia

Sequestration

AV fistulae

Resp Distress Synd

Transient Tachypnea

Aspiration Syndromes

Pneumonia

Air leaks

Effusion

Pulmonary Edema

Perfusion, BP, HCT

Neuro-muscular

Upper or lower

airway

Diaphragm or

Chest wall

Cardiac problems

Other or

Mixed findings

Abdomen


Management l.jpg
Management

  • Management depends on diagnosis

  • Maintenance of adequate gas exchange

    • Maintain Airway

    • Oxygenation and Carbon dioxide elimination

    • Adequate pH

    • Adequate cardiac output and perfusion

  • Surgery

    • Pneumothorax/Cysts/Diaphragmatic hernia

  • Supportive therapy

    • Thermoregulation, Nutrition, Fluid and Electrolyte balance, etc

    • Antimicrobial therapy


Maintenance of gas exchange l.jpg
Maintenance of gas exchange

  • Respiratory management depends on diagnosis

  • Usual sequence:

    No support  O2 hood  CPAP  Mechanical ventilation (conventional)

    High Frequency ventilation  add Nitric Oxide  ECMO

  • Surfactant may be useful in term infants with respiratory failure

    (Lotze et al. J Pediatr 132:40, 1998; Greenough. Eur J Pediatr 159:635, 2000)


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Indications for mechanical ventilation

  • Clinical:Absolute: Apnea (intractable), gasping, cyanosis not responsive to O2 by hood

    Relative: Severe tachypnea / retractions

  • Laboratory (while on CPAP or FiO2 > 0.7):

    pH < 7.25 with PCO2> 60 mm Hg

    (or) PO2< 45- 50 and / or SpO2 < 85 %

  • Other: Surgical procedures, compromised airway


Term infants with pphn l.jpg
Term infants with PPHN

Confirm diagnosis of PPHN

Correct underlying abnormalities (hypothermia, acidosis, hypocalcemia, hypoglycemia, polycythemia)

Conservative mechanical ventilation

Trial of hyperventilation

If low PO2, trial of rescue therapies

MetabolicHFVSurfactantVasodilatorsECMO

Alkalosis ? NO, PGD2,

PGI2, Tolazoline,

Adenosine