Lecture 62: Dr.

Cohen, Clinical Correlations Respiratory Distress in a Newborn • Respiratory Distress Case #1: – 30 wk gestation newborn in respiratory distress – Exam reveals premature baby with no abnormalities except lung distress Prematurity: – < 37 weeks gestational age (however 37-38 wks still have higher morbity rate than if allowed to go to full term of 42 wks) – Risk factors include low socioeconomic status, inadequate prenatal care, poor nutrition, poor education and intercurrent or untreated illness or infection – Complications include RDS (respiratory distress syndrome), apnea (typically central and obstructive), IVH (interventricular hemorrhage), infections, hypothermia, metabolic (hypercalcemic, low blood glucose, etc), GI, renal, and hyperbilirubinemia RDS: – Common cause of morbidity – Male predominance – Low gestational age (almost 100% at 25 wks, doesn't reach 0% until over 38 weeks) – Maternal diabetes – Perinatal asphyxia – Caused by a decreased production and secretion of surfactant – Failure to develop FRC and alveoli tend to collapse – Surfactant synthesis depends on pH, temp and perfusion – Hypoxia, asphyxia, hypovolemia and cold may worsen condition – Atelectasis (collapse of alveoli) makes lungs less compliant – Increased work of breathing – Ventilation/Perfusion mismatches - hypoxia 2 Causes of RDS: – Fetal Lung Development  Pseudoglandular Stage (7-17 wk gestation): branching that yields fetal lung  Canalicular Stage (16-25 wk): pre-viable lung becomes potentially viable, development of air-blood barrier, development of Type II cells and beginning of surfactant production  Saccular and Alveolar Stages (25 wks): final branching, potential increase in lung volume for gas exchange *POTENTIAL FOR VIABLE BABY  Surface area and lung volume increase exponentially after 25 wks – Surfactant  Made by type II alveolar cells  Made of phosphatidylcholine and SP-A, B, C and D  SP-B is required for life  Has polar and non-polar end  Alveolus wants to collapse due to water surface tension however

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surfactant acts by reducing surface tension of water Laplace’s Law (decrease T thereby decreasing P) Saline lungs would eliminate air-water interface and therefore less pressure is required

Vicious circle – Clinical manifestations:  Signs occur within minutes of birth  Tachypnea respiratory rate mechanical pulmonary dysfunction, acid-base imbalance, blood gas abnormalities • minimize work of breathing by adjusting resp. rate • Pts w/ stiff lungs breath fast and shallow • Pts w/ increased resistance breath slower and deeper Grunting • Expiration through a partially closed vocal cord • Produces an elevated transpulmonary pressure in the absence of airflow V/Q ration is enhances b/c of increased airway pressure and lung volume Intercostal and subcostal retractions Retractions are caused by use of accessory muscles of respiration • Due to decreased compliance Nasal flaring

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Enlargement of nostrils during inspiration to reduce resistance (by power of 4) Nasal resistance contributes to airway resistance

• Poiseuille’s Law Cyanosis • Fick's Law of Diffusion • Increased membrane thickness decreases the rate of diffusion What do you see? – Breath sounds may be diminished or normal; they may havea harsh quality or fine rales or crackles Natural Course – Progressive worsening or cyanosis and distress – BP falls – Fatigue, cyanosis and pallor increase – Apnea and irregular resp appear – Acidosis – Peaks at 3 days w/ gradual improvement if infant survives Diagnosis – CXR (Chest X-Ray)  Fine reticular granularity ("ground glass appearance") – Air bronchograms – Lab

 Hypoxemia  Hypercarbia (increased pCO2) – Metabolic acidosis Differential Dx – Group B strep Pneumonia – Cyanotic Heart Disease – Persistent Pulmonary Hypertension – Pneumothorax – Aspiration Pneumonia Treatment – *Treat the basic defect = Prematurity  Gentle handling and minimal disturbance  Isolette to maintain neutral core temp and reduce O2 consumption  IV fluids, glucose, electrolytes and nutrition – RDS  Warm humidified O2 should be administered to keep pO2 between 5570mmHg (>90% Saturation)  Continuous positive airway pressure by nasal prongs  Mechanical ventilation  Antibiotics  Exogenous surfactant administration • Has improved survival, increased compliance and reduced vent pressures Has not reduced incidence of chronic lung disease and has complications – Complication includes pneumothorax – Inadequate exchange of O2 and CO2 – Treat secondary manifestations such as circulatory insufficiency and metabolic acidosis – Careful monitoring of heart rate, respiratory rate, BP, fluids and electrolytes Prognosis – Mortality from RDS has decreased to about 10%

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