Neonatal Diseases MODULE E
Objectives • Identify the key pathophysiologic changes that occur with each disease. • Describe the therapeutic intervention needed to treat each of the diseases.
Retinopathy of prematurity (ROP) Patent Ductus Arteriosus Hypoglycemia Cold Stress Intraventricular & Intracerebral hemorrhaging Bronchopulmonary dysplasia Wilson Mikity Syndrome Apnea of prematurity Necrotizing enterocolitis RDS Perinatal Diseases and Other Problems with Prematurity
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
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 don’t have complete growth. • As the capillary network expands, arteries and veins form in its path. • ROP is the failure of this network to develop.
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.
Stages and Zones of ROP • 5 stages, with 5 having the retina completely detached. • Three Zones of the eye (zone 1 is the worst)
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.
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
Clinical Signs • History of prematurity • f above 60/min • Grunting • Retractions • Flaring of nostrils • Cyanosis • Severe hypoxemia on blood gases • Hypothermia & flaccid muscle tone
X-ray Findings • Diffuse “White-out” (Radiopaque) • Atelectasis • Air bronchograms • Reticulogranular Pattern • “Fishing net” • Ground Glass Appearance
Treatment • Attempt to accelerate lung maturity by pharmacological means. • Steroids • Tocolysis: Delay labor with b-Adrenergic Agents • (Terbutaline) • Thermoregulation
Treatment • Artificial Surfactant • CPAP or mechanical ventilation • High Frequency Ventilation • ECMO
Recovery Phase • Complications • ROP • Bronchopulmonary dysplasia • Chronic lung disease (COPD for Neonates) • Intraventricular hemorrhage • Brain dysfunction • Necrotizing Enterocolitis • Intrapulmonary Hemorrhage • Full Recovery
Bronchopulmonary Dysplasia • Other Name • Neonatal Chronic Lung Disease (NCLD) • Progressive chronic lung disease that presents with persistent respiratory problems at 28 days or later, radiographicchanges and oxygen dependency
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
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.
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.
Chest X-Ray • Radiology • “Honeycomb” appearance • Diaphragms are flattened • Cystic appear (hyperlucent) • Atelectasis (radiopaque)
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 Clinical Presentation
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.
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.
Bronchopulmonary Dysplasia • Death is usually due to: • Cor Pulmonale • Infection • Sudden Death
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.
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.
Necrotizing Enterocolitis (NEC) • Intestinal dilation (distended loops of intestine with gas). • Gastric ileus (obstruction) • Abdominal distention. • Rectal bleeding • Bloody stool • Feeding is difficult.
Treatment • Stop feedings. • Nasogastric Suctioning • Hyperalimentation IV. • Antibiotics. • 20% require surgery.
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.
IVH Treatment • Prevent Occurrence • Supportive
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.
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.
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.
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.
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.