A powerpoint presentation on the respiratory illness seen in newborns/neonates.
the diseases mentioned in this presentation are among the most commonly seen in the population.
2. • Neonates: Newborn, terminology describes children from birth to 1
month of life.
• The lungs are the last organs to develop intrauterinely,
• in fact, they continue to develop until at least 8 years of age.
• Respiratory disorders are the most frequent cause of admission in
preterm and term infants.
• They often arise due to failure of transition from fetal to extrauterine
environment.
6. INITIAL MANAGEMENT/SUPPORT OF
CHILDREN WITH RESPIRATORY DISTRESS
• Supplementary O2: delivered through a hood or bag/mask
ventilation
• Non-invasive positive pressure ventilation (NIPPV)
• Continuous Positive Airway Pressure (CPAP)
• Mechanical Ventilation
Fluid should be administered to patients whose symptoms do
not resolve despite oxygen support,
7. SUPPLEMENTARY O2
• Oxygen concentration are set PaO2 of 50-70 mmHg and 60-80
in preterm and term infants respectively, any higher will likely
result in retinopathy of prematurity (ROP).
• Warm and Humidified O2 should be given so as to prevent
secretions from cooling, and bronchospasm from cooling.
• Umbilical Artery Catheter or Radial Artery Catheter for
monitoring ABG and blood sampling.
8. CPAP
• CPAP is indicated if patients are unresponsive to supplementary
O2.
• When FiO2 >40% is required to maintain PaO2 at acceptable
levels.
• In patients with disorders of limited duration ( Mild RDS, diffuse
atelectasis)
• Delivers oxygen at 5-7 cm H20, which prevents the alveoli from
collapsing as well as the prevention of atelectasis.
9. MECHANICAL VENTILATION/INTUBATION
• Indicated in neonates less that 1000 gr or <28 weeks of
gestation.
• When other support methods have failed.
• Diameters and marks for endotracheal tubes are:
2.5mm for <1250 gr 7cm for 1 kg
3mm for 1250-2500 gr 8cm for 2 kg
3.5 for >2500gr 9cm for 3 kg
• Ventilators can be set to deliver fixed pressures or volumes:
AC –assist control
IMV –intermittent mandatory ventilation
10. Adjunctive treatment used with
Mechanical Ventilation are:
• Paralytics and sedatives
(midazolam)
• Nitric Oxide
• Weaning (by lowering ventilation
pressure)
Complications of Ventilator usage
may include:
• Pneumothorax
• Asphyxia due to wrong intubation
• BPD
• Ulceration, Erosion etc
12. RESPIRATORY DISTRESS SYNDROME
• Respiratory distress syndrome is primarily caused by lack of
surfactant in the lungs of the neonate. Onset is usually hours
after birth. The risk of developing RDS increases with
decreasing gestational age, i.e(risk is higher in premature
neonates.)
• Maternal risk factors include maternal hypertension, prolonged
rupture of membrane, while maternal corticosteroid usage is a
protective risk factor
• Due to increase surface tension due to surfactant deficiency,
atelectasis occurs, followed by inflammation and pulmonary
edema.
15. TRANSIENT TACHYPNEA OF NEWBORN
• TTN is a result of delayed resorption of fetal lung fluid, it is
mostly seen in infants delivered by caesarean section, and it
may accompany other respiratory disorders such as RDS and
MAS.
• Patients are likely to present with high levels of secretions
• Treatment is mostly supportive, as disease is limited
16. MECONIUM ASPIRATION SYNDROME
• Occurs as a result of fetal distress, which results in passage of meconium within
the uterus and subsequently aspirated, triggering lung injury.
• post-term infants are more at risk because of increased stress factors in uterus
and reduced amniotic fluid, leading to less dilute meconium.
• Mechanisms of injury include:
1. non specific cytokine release
2. airway obstruction
3. surfactant inactivation
4. chemical pneumonia
Comorbidities include PP hypertension, atelectasis, pneumomediastinum,
pneumothorax.
19. MECONIUM ASPIRATION SYNDROME
Treatment:
• Suctioning: as soon as head is delivered; prior to first breath
• Oxygen
• Mechanical Ventilation
• Support treatment with surfactant, antibiotics.
• nitric oxide if PPH developed
20. PERSISTENT PULMONARY HYPERTENSION
occurs due to persistence of pulmonary arteriolar
vasoconstriction, which results in decrease pulmonary blood flow
and R-L shunting.
• It is mostly seen in postterm infants, and associated with MAS.
• Other causes include perinatal asphyxia, premature dustus
arteriosus closure (maternal NSAID usage), polycythemia etc.
• In mothers using NSAIDs prior to birth
Hypertrophy of pulmonary vessels=R-L shunting= systemic
hypoxemia, eventually leads to right heart dilation, RHF…
Severe cyanosis is marked for PPH
21. PERSISTENT PULMONARY HYPERTENSION
DIAGNOSIS
• Presence of cyanosis that does not responding to O2 treatment
(persistent cyanosis)
• Echocardiogram
• X-ray
Dıfferentıal dx: congenital heart disease.
22.
23. PERSISTENT PULMONARY HYPERTENSION
TREATMENT
• O2
• Nitric Oxide
• Sildenafil
• Mechanical Ventilation
• ECMO
• Circulatory support: IV solutions administration
In general, most treatment measures are supportive.
24. NEONATAL PNEUMONIA
• Divided into early and late onset, the latter occurring 7 days
after birth. Early onset pneumonia is part of generalized sepsis
occurring within hours after birth.
• Occurs in infants that require prolonged intubation
• Vertical transmission from mother; Group B streptococcus, E.
coli, klebsiella in early onset pneumonia.
• S. aureus is the most common causative agent in late onset
pneumonia.
• STDs such as chlamydia may also cause pneumonia.
26. BRONCHOPULMONARY DYSPLASIA
Chronic lung disease resulting primarily from prolonged
ventilation, as well as prematurity.
BPD is affected by the following factors:
• Degree of prematurity
• High O2 concentrations
• Infection
• Prolonged ventilation
Other factors may include pulmonary air-leak
syndromes(pulmonary interstitial emphysema), high peak
inspiratory pressures, increased pulmonary pressure and male
sex.
27. BRONCHOPULMONARY DYSPLASIA
Infants with BPD are more vulnerable to inflammatory that result
from mechanical ventilation, which leads to the disruption of
lung development:
• Fewer alveoli
• Larger alveoli
• Thickened interstitium
28. BRONCHOPULMONARY DYSPLASIA
DIAGNOSIS
The initial requirement for the diagnosis of BPD is continuous O2
(>21%) administration for at least 28 days
• X-ray: multicystic appearance as well as exudative fluid.
• Unable to wean from ventilator
32. PULMONARY AIR-LEAK SYNDROME
These are a set of complications that may occur following any
respiratory disorder, leading to air escaping to surrounding
structures. These include:
• Pulmonary interstitial emphysema
• Pneumomediastinum
• Pneumothorax
• Pneumopericardium
• Pneumoperitoneum
• Subcutaneous emphysema
33. CASE #1
• E.B (protocol No: 362116) Male.
Born after 39th gestational week via C/S to a 21 year old mother on
25/12/2018. BW: 2090 gr. Was tranferred to our NICU two days post-
term with respiratory distress, low saturation with suspected pneumonia.
Patient was intubated prior to arrival. He was started on Sildenafil after
a diagnosis of pulmonary hypertension was made. He was
administered dobutamin and dormicum for support and sedation
respectively. He was constantly followed up for suspected congenital heart
disease and pulmonary hypertension.
• On physical examination, he was hypotonic, cyanotic, and intubated,
intercostal and subcostal retractions were present along with tachypnea.
34. • He received cranial and abdominal USG to rule out additional causes
on RD. Echocardiography showed right to left shunting consistent
with pulmonary hypertension. Lung X-ray showed active infiltration
in the lung parenchyma.
• By 5th post-natal day, general condition of patient had worsened: he
was hypotonic, not feeding, lacked spontaneous respiration despite
resolution of intercostal retractions. Despite receiving sildenafil,
vancomycin, meropenem, surfactant, ilioprost as well as other
supportive treatment, patient went into cardiac arrest and
subsequently died despite rescusitation efforts.
• Final diagnosis was: PPH.
35.
36.
37. REFERENCES
• Gallacher, David J., et al. “Common Respiratory Conditions of
the Newborn.” Breathe, vol. 12, no. 1, 2016, pp. 30–42.,
doi:10.1183/20734735.000716. ( 10.1183/20734735.000716
• Porter, Robert S., and Justin L. Kaplan. The Merck Manual of
Diagnosis and Therapy / Robert S. Porter, Editor-in-Chief ;
Justin L. Kaplan, Senior Assistant Editor. Merck Sharp & Dohme
Corp., 2011.
• radiopaedia.com
Notes de l'éditeur
Respiratory symptoms in children are likely to be exacerbated due to the narrow airway compared to adult, thus great care should be taken in managing not just neonates, but also infants. If unresponsive to these initial treatments, Fluid may be required to increase cardiac output, before moving on to bag ventilation of CPAP.
Neonates less that 28 gestational week or <1000 gr are directly intubated so that they can receive surfactant treatment.
AC delivers full breath with each patient inspiration, while IMV sets a number of breaths within a time period with a window to allow the patient to take spontaneous breaths without triggering the ventilator.
Ball valve mechanism*
CPAP could lead to potential pulmonary air leak syndrome, thus close follow up is advised.
