Respiratory Problems in the Newborn Infant:

Evaluation and Etiology

Dr.AbdulRahman Alnemri , MD

Assistance professor

Head of Neonatal unit

pediatric Department, KKUH

Development

At 4 wks

12– 16 wks

16-24 wk

–24 wk

Embryonic

Glandular

Canalicular

Alveolar

Respiratory Distress

History, physical examination Downes' or RDS score - clinical Arterial blood gases Pulse oximetry - SaO2 Chest x-ray Serum glucose and calcium; central hematocrit; WBC and differential; platelet count Maternal vaginal culture Newborn surface (e.g., ear canal, gastric aspirate) smears, cultures (?); blood culture; urine culture (?); CSF culture (?)

Signs and Symptoms

• Tachypnea - above 60-80/minute • Grunting - prevents alveolar collapse • Retractions - compliant chest wall • Flaring of alae nasi, open mouth - decreases resistance • Cyanosis in room air • PaO2 below 60 mmHg (torr) in FIO2 >0.4 • Reduced air entry • Apnea • Stridor

Evaluation and Etiology

Medical• Respiratory distress syndrome• Wet lung (transient tachypnea,  •  Aspiration syndromes 

      (meconium, blood)•  Persistent pulmonary hypertension

of the newborn• Pneumonia/sepsis•  Hypoplastic lungs• Cardiac lesions• Central nervous system

Surgical Diaphragmatic

hernia/eventration Esophageal atresia with or

without TE fistula  Lobar emphysema Pneumothorax Pleural effusion Airway disorders  Cystic lesions  Mass lesions  Phrenic nerve paralysis

Respiratory Distress Syndrome

870 gm 28 wks infant , Borne to 27ys old mother G4 p3. By SVD, Abgar Score 6 , 8After initial resuscitation Tachypnea, grunting, Cynosis, IC& SC retractionTachycardiaHypoperfusionHypoxia O2 Sat 85% 0n 100% Oxygen

What is (are) D/D? How to you manage this infant?

Pathogenesis

Inadequate Pulmonary Surfactant

Diffuse alveolar atelectasis HypoxiaHypercapnea

Mtabolic&Resp.Acidosis

TachypneaGrundingCynosis

HypotensionTachycardia

Management

Step 1Stablization Investigation

Treatment

Step2

Diagnosis

Surfactant Replacement therapy

TimingTiming Dose

Complications

Pulmonary Hemorrhage Pneumothorax

IVH + PDA + NEC

ROP

CLD or BPD

Infection

Wet Lung (TTN)

• Predisposing factors • Cesarean section without labor• Perinatal distress • infants of diabetic mothers • Breech • Delayed cord clamping• Maternal sedation And IV large volumes

Signs and symptoms

• Term or near term male infant• Tachypnea (80-120 breaths per minute) • Mild retraction• Mild Cyanosis • Hyperaeration • Occasional grunting and nasal flaring

Chest x-ray

• Increased markings centrally • Fluid in fissures and costophrenic angles • Hyperaeration may be present

Cont. Wet Lung

• Blood gases, SaO2 • Hypoxemia • Acidosis or alkalosis may be present • Resolution one to five days; most improve

during the first 24 hours • Management: oxygen, occasionally

CPAP/PEEP

Pneumonia

Term infant 2.85kg boy, Borne to 34 yeas old mother G6 P4 +1 unbookedPresented with SROM > 36 hsImmediately after birth he started to hasSever respiratory distress , associated with very soft ejection systolic murmurWhat is (are) the diagnosis?How do you manage this infant?

Air leak syndrome

• 31 wks ,1200gm , admited to NICU with milde RDS, Connected to CMV with good blod gases and oxygen saturation.

• 2nd day developed sudden deterioration became hypoxic, skin mottling and low BP

• What is your diagnosis ?• How do you manage this inbfant?

Air Leak Syndrome

Pneumothorax PIE

Pneumomediastinum Pneumopericardium

Meconium Aspiration

Term boy infant IDM born to 30 ys old mother with prolong second stage, Thick MSAFHow do you resuscitate this infant?

On admission to NICU he showed sever respiratory distress sever hypoxia

What is the diagnosis and D/D? How do you manage such infant?What are the complications?

Congenital Diaphragmatic hernia

• Term baby presented with cyanosis at birth• Physical exam refealed respiratory distress,

a scaphoid abdomen, decrease breath sound on the left side.

• What is the diagnosis ?• What is the immediate treatment ?• What is the long term management ?

ItubationN.G suction

ECHOCOxygenation

AlkalosisInotrope support

Nitric OxideSurfactantSedation

AntibioticIV Nutrition

.Surgical Repair

CDH

ECMO

Persistent Pulmonary Hypertension (persistent fetal circulation)

• Secondary to another disorder (e.g., respiratory distress syndrome, aspiration, pneumonia, diaphragmatic hernia)

• Affects primarily near-, full- and post-term infants • Increased pulmonary vascular resistance -->

intracardiac right-to-left shunt (PDA, foramen ovale) --> hypoxemia, acidosis --> increased resistance --> increased shunt

•Etiology

• Acute pulmonary vasoconstriction (e.g., acidosis, hypoxia, RDS, pneumonia; hyperviscosity)

• Increased pulmonary vascular smooth muscle with its extension (e.g., perinatal distress, aspiration ?) to arterioles surrounding alveoli

• Decreased number of pulmonary blood vessels with excessive muscle (e.g., diaphragmatic hernia, other thoracic space-occupying lesions)

Esophageal Atresia withTEF

Term female newborn 3kg, presented with vomiting and abdominal distension

O/E Mild respiratory distress no dismorphic featurs had exseisve salivation

What is (are) the D/D?

What is the line of management?

Esophageal Atresia withTEF

• General • Esophageal atresia with distal (TE)

fistula (85%) • Esophageal atresia (10%) • H-type fistula (4-6%)

.Signs and symptoms

• Maternal polyhydramnios in 30-70% of patients

• Excessive secretions and drooling after birth • Choking, coughing and cyanosis with feedings • Inability to pass an orogastric tube to the

stomach • Respiratory distress • Congenital anomalies (50%) -VACTERL or

VATER

X-ray

• Dilated proximal pouch in the mediastinum • Right upper lobe pneumonia or atelectasis

(overflow of secretions) • Gastric dilatation and excessive air in the

bowel loops if a fistula is present • No air in abdomen if a fistula is absent

Initial management

• Intermittent suction or aspiration of the upper pouch, nasopharynx

• Head and chest elevated 45 degrees from the horizontal

• Prevent excessive crying • Antibiotics • Surgery when stable - gastrostomy should

be done early

Congenital lobar emphysema

• Location is usually left upper lobe, right middle lobe or right upper lobe, unless due to an aberrant vessel related to congenital heart disease

• Partial obstruction of the airway on expiration leads to overdistention of the lobe; there is often abnormal bronchial cartilage

• Intraluminal obstruction • Extraluminal compression, often associated with

congenital heart disease (lower lobes)

Signs and symptoms

• Progressive respiratory distress • Wheezing • Cyanosis • Asymptomatic

.Chest x-ray

• Overdistention of the lobe • Compression of surrounding lobes • Mediastinal shift • Radiolucent lobe

Differential diagnosis

• Lung cyst • Tension pneumothorax • Compensatory emphysema due to

contralateral atelectasis • Pneumatocele

Initial management

• Ventilatory support with 100% oxygen • Alkalosis • Good lung uppermost • Surgery

Pleural effusion (bilateral or unilateral)

Etiology • Chylothorax • Hydrops fetalis (immunologic or nonimmunologic) • Pneumonia • Turner syndrome • Wet lung • Congestive heart failure • Hemothorax • Parenteral nutrition or fluid extravasation

Airway Obstruction

• Foreign material• Congenital subglottic stenosis• Choanal atresia• Micrognathia (Peirre Robin syndromes )• Macroglossia ( Trisomy 21 )• Laryngeal web, Laryngeal spasm• Vocal cord paralysis• Tracheo/laryngomalacia

RDRD HMD

MAS

CDH

Pneumonia

Thanks