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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:

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    1. Case Conference Maria Victoria B. Pertubal M.D. PGY1

    2. Case • 33 weeker preterm male • NSVD • APGAR 9/9 • BW 1990g • Admitted to NICU for prematurity and LBW • labored breathing

    3. 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

    4. Other differential diagnoses? • Cardiac causes: • Cyanotic congenital heart disease • 5T’s • Other Systemic disorders: • Hypothermia • Hypoglycemia • Anemia ; polycythemia • Metabolic acidosis

    5. Initial Work-up • Chest X-ray • ABG • CBC, Blood culture • BMP, glucose

    6. CXR • C

    7. 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

    8. Respiratory Distress Syndromeaka. Hyaline Membrane disease (HMD)

    9. 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.

    10. Other Risk factors • maternal diabetes • multiple births • cesarean delivery • precipitous delivery • asphyxia, • cold stress • maternal history of previously affected infants.

    11. Reduced risk in.. • pregnancies with chronic or pregnancy-associated hypertension • maternal heroin use • prolonged rupture of membranes • antenatal corticosteroid prophylaxis.

    12. Etiology and Pathophysiologyof RDS: Surfactant deficiency (decreased production and secretion)

    13. 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.)

    14. The Premature Lung • Both decreased in quantity and quality of surfactant • LESS QUALITY due to: • Less protein content • PhosphatidylINOsitol> PhosphatidylGLYcerol

    15. Figure 95-4 Nelson pediatrics

    16. 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

    17. CXR: diffuse reticulogranular ground-glass appearance with airbronchogram A. Severe RDS B. Moderate RDS

    18. 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

    19. 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

    20. 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

    21. 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

    22. 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

    23. 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

    24. 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

    25. Complications of RDS: • Endotracheal tube complications • Bronchopulmonary dysplasia (BPD) • Pulmonary air leak • Pneumothorax • Pneumomediastinum • Pulmonary interstitial emphysema (PIE)

    26. pneumothorax

    27. Pneumothorax, Left

    28. case

    29. pneumomediastinum

    30. pneumomediastinum

    31. Pulmonary interstitial emphysema

    32. Pulm Interstitial empysema Pneumomediastinum pneumopericardium Subcutaneous emphysema Courtesy of Gerardo Cabrera-Meza, MD

    33. 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>