37 weeks gestational age 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. Apnea (typically central and obstructive), IVH (interventricular hemorrhage), infections, hypothermia, metabolic (hypercalcemic, low blood glucose, etc), GI,
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Lecture 62: Dr. Cohen, Clinical Correlations Respiratory Distress In
37 weeks gestational age 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. Apnea (typically central and obstructive), IVH (interventricular hemorrhage), infections, hypothermia, metabolic (hypercalcemic, low blood glucose, etc), GI,
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37 weeks gestational age 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. Apnea (typically central and obstructive), IVH (interventricular hemorrhage), infections, hypothermia, metabolic (hypercalcemic, low blood glucose, etc), GI,
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– 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 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 • 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 55- 70mmHg (>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%