Case Conference. Maria Victoria B. Pertubal M.D. PGY1. Case. 33 weeker preterm male NSVD APGAR 9/9 BW 1990g Admitted to NICU for prematurity and LBW labored breathing. What are your considerations?. Respiratory causes:
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Case Conference Maria Victoria B. Pertubal M.D. PGY1
Case • 33 weeker preterm male • NSVD • APGAR 9/9 • BW 1990g • Admitted to NICU for prematurity and LBW • labored breathing
What are your considerations? • Respiratory causes: • Respiratory Distress Syndrome (RDS) aka Hyaline Membrane Disease (HMD) • Transient tachypnea of the Newborn (TTN) • Pneumonia • Air leak / pneumothorax • Persistent pulmonary hypertension • aspiration syndromes (meconium, amniotic fluid), • congenital anomalies such as cystic adenomatoid malformation, pulmonary lymphangiectasia, diaphragmatic hernia, and lobar emphysema
Other differential diagnoses? • Cardiac causes: • Cyanotic congenital heart disease • 5T’s • Other Systemic disorders: • Hypothermia • Hypoglycemia • Anemia ; polycythemia • Metabolic acidosis
Initial Work-up • Chest X-ray • ABG • CBC, Blood culture • BMP, glucose
CXR • C
Hospital course: • 1st hospital day : NCPAP, FiO2 25-35% • O2 sats 93-95% • 2nd hospital day: NCPAP, FiO2 35-50% • SC/IC retractions, O2 sats 88-92% • Repeat CXR, ABG
Incidence • primarily in premature infants • male > females • white infants • inversely related to gestational age and birthweight. • 60-80% of <28 wk of gestational age • 15-30% of 32 - 36 weekers, • rarely in those >37 wk.
Other Risk factors • maternal diabetes • multiple births • cesarean delivery • precipitous delivery • asphyxia, • cold stress • maternal history of previously affected infants.
Reduced risk in.. • pregnancies with chronic or pregnancy-associated hypertension • maternal heroin use • prolonged rupture of membranes • antenatal corticosteroid prophylaxis.
Etiology and Pathophysiologyof RDS: Surfactant deficiency (decreased production and secretion)
SurFactant Facts • 90% Lipids (Phospholipids) • 10% Proteins (4 Surfactant specific) • -A,-B,-C,-D • produced by type 2alveolar cells Nelson Pediatrics Figure 95-2(From Jobe AH: Fetal lung development, tests for maturation, induction of maturation, and treatment. In Creasy RK, Resnick R, editors: Maternal-fetal medicine: principles and practice, ed 3, Philadelphia, 1994, WB Saunders.)
The Premature Lung • Both decreased in quantity and quality of surfactant • LESS QUALITY due to: • Less protein content • PhosphatidylINOsitol> PhosphatidylGLYcerol
Clinical Manifestations • Tachypnea • Nasal flaring, • Expiratory grunting • Intercostal, subxiphoid, and subcostal retractions, • Cyanosis or pallor • breath sounds are decreased • diminished peripheral pulses. • urine output often low in the first 24 to 48 hours and peripheral edema
CXR: diffuse reticulogranular ground-glass appearance with airbronchogram A. Severe RDS B. Moderate RDS
Other Laboratory findings • Arterial blood gas • hypoxemia that responds to supplemental oxygen. • PCO2 initially is normal or slightly elevated, but may increases as the disease worsens. • hyponatremia
Management • DELIVERY ROOM: Provide warmth, position head, clear air, stimulate baby. 2. Assisted ventilation (MV, CPAP, NIPPV) 3. Surfactant therapy 4. Inhaled NO 5. Glucocorticoid (post-natal) 6. Other supportive care • Fluid status monitoring • Early nutrition
Surfactant therapy • Types available- Survanta(Bovine); Curosurf(porcine); Infrasurf (Calf); Exosurf(synth) • Indications: • Prophylactic therapy – immediately after birth • Early-rescue therapy – during the 1st few hours after birth. • AAP recommends to give when the diagnosis of RDS is established; • Continued therapy - clinical evidence of persistent disease
Ventilatory support • to improve oxygenation and elimination of CO2 w/o causing pulmonary injury/toxicity • Criteria for mechanical ventilation • Respiratory acidosis- pH <7.20, PaCO2 >60 mm Hg • Hypoxia- PaO2 <60 mm Hg oxygen, O2sats <85% despite supplementation of 70 % on nasal CPAP • Severe apnea • CPAP, HFV, NIPPV- alternative to mechanical ventilation
Other treatment options: (controversial) • Inhaled Nitric oxide • Mosty benefits or late preterm infants with persistent pulmonary hypertension through: • reduced lung inflammation, • improved surfactant function, • Slows down hyperoxic lung injury, • promotes lung growth • Not commonly used due to cost
Other treatment options: (controversial) • Postnatal glucocorticoids • given in the first day of life • improves pulmonary and circulatory function and decreases the incidence of BPD • Limitations of use: • short-term complications: intestinal perforation, metabolic instability; • long-term abnormal neurodevelopmental outcomes
Prevention • Avoidance of unnecessary or poorly timed cesarean section, • appropriate management of high-risk pregnancy and labor • Antenatal corticosteroids for all women in preterm labor (24-34 wk of gestation) who are likely to deliver a fetus within 1 wk
Complications of RDS: • Endotracheal tube complications • Bronchopulmonary dysplasia (BPD) • Pulmonary air leak • Pneumothorax • Pneumomediastinum • Pulmonary interstitial emphysema (PIE)
Pulm Interstitial empysema Pneumomediastinum pneumopericardium Subcutaneous emphysema Courtesy of Gerardo Cabrera-Meza, MD
References: • Carlo, W. Respiratory Distress Syndrome (Hyaline Membrane Disease) Nelson Textbook of Pediatrics. 2011 • Welty, Stephen. Treatment and complications of respiratory distress syndrome in preterm infants. Uptodate may2011 • http://www.uptodate.com.elibrary.einstein.yu.edu/contents/treatment-and-complications-of-respiratory-distress-syndrome-in-preterm-infants?source=see_link#H17 • Fernandes, Caraciolo. Pulmonary Air Leak in the Newborn. Uptodate. May 2011 <http://www.uptodate.com.elibrary.einstein.yu.edu/contents/treatment-and-complications-of-respiratory-distress-syndrome-in-preterm-infants?source=see_link#H25> • <http://www.vanuatumed.net/MODULES/07_WomensChildrens/_N+P_WomensChildrens/139_Jackson/ISSUES/139_LI4_files/image001.jpg> • StapornMaung-In, M.D <http://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-42/case42.HTM>