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Respiratory Disorders of the


Arnold M. Lintag, M.D.,

I. Transition to Pulmonary
II. First Breath

Problems with LBW infants

A. Compliant chest wall

B. FRC is small
C. Abnormalities in ventilation perfusion ratio
III. Periodic Breathing

Periodic Breathing
A. Pattern
B. Found in prematures up to 36th
C. Considered normal
IV. Apnea > 20 sec. plus bradycardia

A. Due to primary disorders

B. Idiopathic Apnea of Prematurity
1. Upper airway obstruction
2. Immaturity
3. Mixed
C. Short apnea - central
D. Long apnea - mixed
CNS IVH, drugs, seizures, hypoxic injury, herniation,
neuromuscular disorders

Respiratory Pneumonia, obstructive airway lesions,

atelectasis, extreme prematurity (<1,000 g),
laryngeal reflex, phrenic nerve paralysis, severe
hyaline membrane distress, pneumothorax

Sepsis, necrotizing enterocolitis, meningitis

Infectious (bacterial, fungal, viral)

Oral feeding, bowel movement,

Gastrointestinal gastroesophageal reflux, esophagitis intestinal
Metabolic Glucose, calcium, PO2, sodium,

ammonia, organic acids, ambient temperature,


Hypotension, hypertension, heart failure,
anemia, hypovolemia, vagal tone

Immaturity of respiratory center, sleep state,
upper airway collapse
IV. Apnea
E. Clinical manifestations
1. Rare on first day
2. Apnea with prematurity occurs on 2nd -
7th day of life
3. 2nd week - warrants investigation
F. Treatment:
1. Theophylline
2. Treat the underlying cause
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome
A. Incidence
1. 50% of all neonatal deaths
2. 60 to 80% < 28 wks.
3. 15-30% 32-36 wks.
4. 5% beyond term
5. Term - IDM
6. Preterm male
7. Reduced incidence - maternal hypertension,
PROM, opiate addiction, antenatal corticosteroid
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome
B. Pathophysiology
1. Insufficient amounts of surfactant
a. 20 weeks - good concentration - does
not reach surface of the lungs
b. 28-32 weeks - not enough amounts
reaching the surface
c. > 35 weeks - mature amounts
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome

B. Pathophysiology
2. Components of Surfactants
3. Surfactant synthesis depends on:
a. Normal pH
b. Temperature
c. perfusion
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome

4. Important synthesis maybe depressed by:

a. asphyxia c. pulmo. ischemia
b. hypoxemia
hypovolemia hypoglycemia cold
d. epithelial lining maybe injured by high oxygen
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome

B. Pathophysiology
4. Ischemia -- necrosis -- damage
capillary endothelium -- transudation of
fluids into alveoli entrapping necrotic

tissue, RBG, proteins-- hyaline

V. Hyaline Membrane Disease or
Respiratory Distress Syndrome

C. Clinical Manifestations:
1. “Golden Period” - 72 hours after delivery
2. Sign Symptoms of respiratory distress
which worsens
3. Occasional rales, decreased breath sounds
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome
D. Prevention
1. Prenatal check-ups
2. L/S ratio
3. Betamethasone to mothers in their < 32nd
week of gestation and may deliver within 42-
72 hours. L/S ratio shows lung maturity
4. Surfactant Therapy
V. Hyaline Membrane Disease or
Respiratory Distress Syndrome
E. Diagnosis: Chest X-ray -- “white out” appearance
F. Treatment
1. Mechanical ventilation
2. Supportive
a. temperature
b. oxygenation
c. acidosis
d. electrolytes
e. blood glucose
3. Antibiotics
VI. Interstitial Pulmonary Fibrosis

(Bronchopulmonary Dysplasia: Wilson Mikity

A. Found in prematures < 32 weeks
B. Found in terms with a history of Meconium
C. Clinical Manifestations
VI. Interstitial Pulmonary Fibrosis

D. Increasing dependency on O2
E. Roentgenogram: hyper lussent “bubbly”
appearance because several small areas of
atelectasis-cystic lesions
F. Treatment Supportive
VII. Transient Tachypnea of the
A. Usually in Cesarean deliveries
B. slow absorption of fetal lung fluids

C. Clinical Manifestation
1. Tachypneic
2. Cyanosis relieved by Oxygen
3. Recovers after 3 days
D. Treatment is supportive
VIII. Air Leak Syndromes
A. Pneumothorax
1. Incidence
a. 1 - 2%
b. males
c. term and postterm
d. Meconium aspiration
e. mechanical ventilation
f. vigorous resuscitation
g. RDS
VIII. Air Leak Syndromes
A. Pneumothorax
2. Pathogenesis
a. alveolar rupture - pulmonary interstitial
b. alveolar rupture - perivascular sheaths

pneumomediastinum <--- base of lungs

subcutaneous emplysema
VIII. Air Leak Syndromes
A. Pneumothorax
3. Clinical Manifestations
a. asymptomatic - hyperresonance,
decreased breath sounds, crepitant rales
b. symptomatic - dyspnea, tachypnea, cyanosis
- displacement of the heart
towards the unaffected side
VIII. Air Leak Syndromes
A. Pneumothorax
4. Diagnosis
Chest x-ray - hyperlucency on the affected
5. Treatment
a. supportive
b. observe if air leak is small
c. Chest tube attached to underwater seal
if severe
IX. Meconium Aspiration

A. Fetal distress and hypoxia in term or

B. Pathogenesis
1. First Breath - aspirate
2. Small airway obstruction, ‘ball-valve”
3. Chemical pneumonitis
IX. Meconium Aspiration

C. Clinical Manifestations
--- tachypnea, grunting, cyanosis, retractions
after delivery
D. Diagnosis
1. History
2. Chest X-ray: flattening of the diaphragm,
patchy infiltrates on both lungs
IX. Meconium Aspiration

E. Treatment:
1. Direct laryngoscopy and suction
2. Mechanical ventilation
3. Supportive
F. Complications:
1. Pneumothorax
2. Persistent fetal circulation
X. Persistent fetal Circulation
A. Found in term and post term infants with:
1. Birth asphyxia
2. MAS
3. Hypoglycemia
4. Polycythemia
5. Pulmonary hypoplasia --- diaphragmatic hernia
6. Oligohydramnios
7. Pleural effusions
8. Idiopathic
X. Persistent fetal Circulation
B. Pathophysiology
--- increased pulmonary vascular resistance -
persistence of R to L shunting

C. Clinical Manifestations: (within 12 hours)

1. Tachypnea
2. Severe cyanosis
3. Retractions
4. Shock
X. Persistent fetal Circulation

D. Diagnosis
1. Hypoxia is labile and out of proportion -
chest roentgenograms
2. Unresponsive to oxygen by cannula or
3. Right to left shunting by Doppler flow
studies in foramen ovale and ductus
X. Persistent fetal Circulation

E. Treatment:
1. Treat underlying cause
2. Mechanical ventilation-hyperventilation-
decrease pCO2
3. Tolazoline-alpha adrenergic antagonist
- increase fluids plus dopamine
4. Extracorporeal Membrane Oxygenation
XI. Pulmonary Hemorrhage

A. Found in ICU patient’s with stormy

B. Bleeding through endotracheal tube, nostrils,
month usually reddish and frothy
C. Indicative of a terminal course