Neonatal Respiratory Disorders M.

Khashaba, MD
Professor of Pediatrics Mansoura University

Introduction
Birth involves changing from the intrauterine state where the placenta is the primary organ of respiration, to life outside the uterus where the lung is the organ of gas exchange.

M.Khashaba,MD professor of Pediatrics,Mansoura

Respiration involves a system that includes the lung and other structures, including the muscles of the diaphragm and chest.

M.Khashaba,MD professor of Pediatrics,Mansoura

Control of respiration involves the brain and, specifically, the respiratory center, sensors that respond to hypoxia and hypercapnia, and the nerves that conduct impulses to and from these structures.

M.Khashaba,MD professor of Pediatrics,Mansoura

Neonatal respiratory disease result from problems with any or all of these structures.

M.Khashaba,MD professor of Pediatrics,Mansoura

Definition
• Tachypnea > 60 /min • GFR (Grunting , Flaring & Retraction) • + cyanosis

M.Khashaba,MD professor of Pediatrics,Mansoura

Causes of respiratory distress
Obstruction of the airway
123Choanal atresia Congenital stridor Tracheal or bronchial stenosis 1234-

Lung parenchymal disease
Meconium aspiration Respiratory distress syndrome Pneumonia Transient tachypnea of the newborn (retained lung fluid) 5- Pneumothorax 6- Atelectasis 7- Congenital lobar emphysema

Non-pulmonary causes
123Heart failure Intracranial lesions Metabolic acidosis 1-

Miscellaneous
Disorders of the diaphragm e.g. (diaphragmatic hernia) 2- Pulmonary haemorrhage 3- Pulmonary hypoplasia

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• • • • • •

Transient tachypnea of the newborn (TTN) Respiratory Distress Syndrome (RDS) Meconium aspiration syndrome (MAS) Air leak syndromes Pneumonia Apnea

M.Khashaba,MD professor of Pediatrics,Mansoura

•Definition:

I - Transient Tachypnea of the Newborn (TTN)

A benign disease of near-term or term infants who have respiratory distress shortly after delivery that resolves within 3-5 days.

•Risk factors:
Cesarean section Macrosomia Prolonged labor Male sex Excessive maternal sedation Low Apgar score (<7 at 1 min)

M.Khashaba,MD professor of Pediatrics,Mansoura

•Clinical Presentation
The infant is usually near-term or term and shortly after delivery has tachypnea (>80 breaths/min). The infant may also have grunting, nasal flaring, rib retraction, and cyanosis. The disease usually does not last longer than 72 hours.
M.Khashaba,MD professor of Pediatrics,Mansoura

• Investigations:
Laboratory studies: Blood gases CBC Radiologic studies: Chest X-ray: Perihilar streaking, mild cardiomegaly, increased lung volume and fluid in the minor fissure, and perhaps fluid in the pleural space

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• Management:
A – General: Oxygenation. Fluid restriction. Feeding as tachypnea improves.

B – Confirm the diagnosis by excluding other causes of tachypnea e.g. pneumonia, congenital heart disease, HMD.
M.Khashaba,MD professor of Pediatrics,Mansoura

•Outcome & prognosis
The disease is self-limited. Respiratory symptoms improve as intrapulmonary fluid is mobilized.

M.Khashaba,MD professor of Pediatrics,Mansoura

Hyaline Membrane Disease – 2
((Respiratory Distress Syndrome
•Definition
Hyaline membrane disease (HMD) is also called respiratory distress syndrome (RDS). Usually occurs in a preterm newborn with respiratory difficulty

M.Khashaba,MD professor of Pediatrics,Mansoura

•Incidence
HMD occurs in about 25% of infants born at 32 weeks gestation. The incidence increases with increasing prematurity.

M.Khashaba,MD professor of Pediatrics,Mansoura

• Clinical Picture:
 It starts at birth but may appear within first hours.  Presents with worsening respiratory distress.  Tachypnea, grunting on expiration, and retractions of the chest wall.

M.Khashaba,MD professor of Pediatrics,Mansoura

• Investigations
A- Laboratory studies: Blood gases: reveal hypoxia, hypercarbia, acidosis. Complete blood picture to rule out infection. B- Chest X-ray study: Ground glass appearance with air bronchogram.

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• Management
General • Basic support including thermal regulation and parenteral fluid . • Oxygen administration, preferably heated ad humidified 30-40% O2 by head box. • Respiratory support is needed if the patient continues to deteriorate.
M.Khashaba,MD professor of Pediatrics,Mansoura

Respiratory Support
Continuous positive airway pressure (CPAP). Assisted ventilation.

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• Specific
* surfactant replacement therapy

• Outcome
*

RDS account for 20% of all neonatal deaths.

M.Khashaba,MD professor of Pediatrics,Mansoura

3 – Meconium Aspiration Syndrome (MAS)
•Definition
The respiratory distress secondary to

meconium aspiration by the fetus in utero or by the newborn during labor and delivery. The aspirated meconium can cause airway obstruction and an intense inflammatory reaction.
M.Khashaba,MD professor of Pediatrics,Mansoura

• Clinical presentation
 Meconium staining of amniotic fluid before birth.  Meconium staining of baby after birth.  Airway obstruction  Respiratory distress and increased anteroposterior diameter of the chest
M.Khashaba,MD professor of Pediatrics,Mansoura

• Investigations • Laboratory studies: • Chest X-ray: – patchy infiltrates – increased anteroposterior diameter – flattening of the diaphragm. Blood gas analysis

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• Management
A-Prenatal management: – Identification of high-risk pregnancy. – Monitoring of fetal heart rate during labor. B-Delivery room management: (if amniotic fluid is
meconium stained) – Suction of the oropharynx.

– Visualization of vocal cords & tracheal suction before bagging.
M.Khashaba,MD professor of Pediatrics,Mansoura

C- Management of the newborn in the

neonatal unit: – General management. – Respiratory management. – Cardiovascular management.

M.Khashaba,MD professor of Pediatrics,Mansoura

• General management:
Empty the stomach contents to avoid further aspiration.
*

* Correction of metabolic abnormalities e.g. hypoxia, acidosis, hypoglycemia, hypocalcemia and hypothermia * Surveillance for multi organ hypoxic/ischemic damage (brain, kidney, heart and liver)

M.Khashaba,MD professor of Pediatrics,Mansoura

• Respiratory management * Antibiotic coverage.

* Oxygenation (maintain high saturation >95%) * Assisted ventilation (avoid hypercarbia and respiratory acidosis).

M.Khashaba,MD professor of Pediatrics,Mansoura

• Cardiovascular management
* Correct systemic hypotension ( myocardial dysfunction). * * Treat persistent pulmonary hypertension. (Maintain low PCO2 level < 40mmHg & ensure adequate O2 saturation above 95%).

M.Khashaba,MD professor of Pediatrics,Mansoura

Air Leak Syndromes – 4
•Definition
.Pneumomediastinum, pneumothorax, pulmoanry interstitial emphysema and pneumopericardium . . Same pathophysiology. . Overdistension of alveolar sacs or terminal airways leads to disruption of airway integrity, resulting in dissection of air into surrounding spaces.
M.Khashaba,MD professor of Pediatrics,Mansoura

•Incidence
Most commonly seen in infants with lung disease who are on ventilatory support and may occur spontaneously. The more severe the lung disease, the higher the incidence of pulmonary air leak.

M.Khashaba,MD professor of Pediatrics,Mansoura

• Risk factors
– Ventilatory support . – Meconium Aspiration Syndrome. – Vigorous resuscitation.

M.Khashaba,MD professor of Pediatrics,Mansoura

•Clinical presentation
Respiratory distress or sudden deterioration of clinical courses with alteration of vital signs and worsening of blood gases. * Asymmetry of thorax in unilateral cases.

M.Khashaba,MD professor of Pediatrics,Mansoura

•Investigations
The definitive diagnosis of all air leak

syndromes is made radiographically. An A-P chest X-ray film along with a lateral film.

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• Management
General: Oxygenation Prevention: Judicious use of ventilatory support. Specific: Decompression according to the type. of air leak

M.Khashaba,MD professor of Pediatrics,Mansoura

Pneumonia - 5
1.Congenital Pneumonia :

Aspiration of bacteria in amniotic fluid lead to congenital pneumonia or Systemic bacterial infection blood born from the mother

M.Khashaba,MD professor of Pediatrics,Mansoura

Manifestations
– prior

to

delivery

(fetal

distress,

tachycardia), – delivery (perinatal asphyxia), or – after a latent period of a few hours (respiratory distress, shock).
M.Khashaba,MD professor of Pediatrics,Mansoura

2.Acquired pneumonia
Exposure environment. to bacteria from the

M.Khashaba,MD professor of Pediatrics,Mansoura

•Clinical picture
Onset 1-2 days after delivery Moderate to severe respiratory distress in presence of one or more risk factors for infection.

M.Khashaba,MD professor of Pediatrics,Mansoura

Investigation
•Chest X-ray •.Blood gases. •Bacterial cultures

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

• Treatment
• Antibiotics better according to culture and sensitivity if positive. • Management of respiratory distress (02 and ventillation).

M.Khashaba,MD professor of Pediatrics,Mansoura

6 - Apnea
•Definition
Cessation of respiration accompanied by bradycardia and/or cyanosis for more than 20 seconds.

M.Khashaba,MD professor of Pediatrics,Mansoura

• Causes of neonatal apnea
1- Pathological apnea: Hypothermia Hypoglycemia Anemia Hypovolemia Aspiration NEC / Distension Cardiac disease Lung disease GE reflux Airway Obstruction Infection, Meningitis Neurologic disorders

M.Khashaba,MD professor of Pediatrics,Mansoura

2- Apnea of prematurity • Incidence 50-60% of preterm evidence of apnea. infants have

M.Khashaba,MD professor of Pediatrics,Mansoura

A. Apnea within 24 hrs. after delivery: It is usually not simple apnea of prematurity. B. Apnea after the first 3 days of life: If not associated with other pathologic conditions, may be classified as apnea of prematurity.

M.Khashaba,MD professor of Pediatrics,Mansoura

Management
• Monitoring of infants at risk less than 32 weeks. • Evaluate for a possible underlying cause. • Laboratory studies: CBC, blood gases, serum glucose, electrolyte and calcium levels. • Radiologic studies: Chest X-ray, abdominal Xray, cranial sonar and C.T. (infants with definite signs of neurologic disease)

M.Khashaba,MD professor of Pediatrics,Mansoura

Treatment
• General
– Tactile stimulation. – CPAP or assisted ventilation in recurrent apnea – Theophylline in apnea of prematurity.

• Specific
– Treatment of the case if identified e.g. treatment of sepsis, hypoglycemia, anemia and electrolyte abnormalities
M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

Transposition of Great Arteries

M.Khashaba,MD professor of Pediatrics,Mansoura

Atrial Septal Defect

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

‫صفــــــاتالـطالــــب‬ ‫‪‬‬
‫1. سليم العقيدة‬ ‫2. صحيح العبادة‬ ‫3. قيم الخلق‬ ‫4. مثقف الفكر‬ ‫5. حريص على وقته‬
‫‪M.Khashaba,MD professor of Pediatrics,Mansoura‬‬

‫صفــــــاتالـطالــــب‬ ‫‪‬‬
‫1. منظم فى شئونه‬ ‫2. نافع لغيره‬ ‫3. صحيح البدن‬ ‫4. قادر على الكسب‬ ‫5. بارً بأهله‬ ‫ا‬
‫‪M.Khashaba,MD professor of Pediatrics,Mansoura‬‬

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