Neonatal

Respiratory

DisordersM.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 distressObstruction of the airway Lung parenchymal disease

1- Choanal atresia 2- Congenital stridor 3- Tracheal or bronchial stenosis

1- Meconium aspiration 2- Respiratory distress syndrome 3- Pneumonia 4- Transient tachypnea of the newborn

(retained lung fluid) 5- Pneumothorax 6- Atelectasis 7- Congenital lobar emphysema

Non-pulmonary causes Miscellaneous

1- Heart failure 2- Intracranial lesions 3- Metabolic acidosis

1- 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

I - Transient Tachypnea of the Newborn (TTN)

•Definition: 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 Male sexMacrosomia Excessive maternal sedationProlonged labor 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

2 – Hyaline Membrane Disease (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: Blood gas analysis

• Chest X-ray:

– patchy infiltrates

– increased anteroposterior diameter

– flattening of the diaphragm.

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

4 – Air Leak Syndromes

•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 of air leak

according to the type.

M.Khashaba,MD professor of Pediatrics,Mansoura

5 - Pneumonia

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 to bacteria from the environment.

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

•DefinitionCessation 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 Cardiac disease

Hypoglycemia Lung disease

Anemia GE reflux

Hypovolemia Airway Obstruction

Aspiration Infection, Meningitis

NEC / Distension Neurologic disorders

M.Khashaba,MD professor of Pediatrics,Mansoura

2- Apnea of prematurity

• Incidence

50-60% of preterm infants have evidence of apnea.

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 X-

ray, 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

الـطالــــبصفــــــات

العقيدة 1. سليم

العبادة 2. صحيح

الخلق 3. قيم

الفكر 4. مثقف

وقته 5. حريصعلىM.Khashaba,MD professor of Pediatrics,Mansoura

الـطالــــبصفــــــات

شئونه 6. فى منظم

لغيره 7. نافع

البدن 8. صحيح

الكسب 9. على قادر

بأهله 10. بارا6M.Khashaba,MD professor of Pediatrics,Mansoura