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					               ‫برکت عمر در کار نیک است‬
‫حضرت علی (ع)‬
Respiratory distress in
      newborn
Dr.Mahmood Noori-Shadkam
      Neonatologist
        Neonatal Respiratory Distress
         Signs and symptoms
• Tachypnea (RR > 60/min)
• Nasal flaring
• Retraction
• Grunting
• Delayed or decreased air entry
• +/- Cyanosis
• +/- Desaturation
         score          0            1                 2

    Respiratory Rate    60       60 – 80         >80 or apnea
     (breaths/min)
                                                   episode
        cyanosis       None    In room air      In40%oxygen

r   Retraction
e
                       None        Mild          Moderate to
t
r
                                                   severe
a
c   Grunting           None    Audible with a   Audible without a
t                                                 stethoscope
i
                                stethoscope
o
n
         Crying        clear    decreased       Barely audible
          Neonatal Respiratory Distress
                        Etiologies
    Pulmonary               Systemic            Anatomic
     causes                  causes              causes
-   RDS                 - Infections         - Upper airway
-   Pneumonia           - Metabolic causes     obstruction
-   TTN                 - Temperature        - Airway
-   MAS                 - Anemia               malformation
-   Other aspiration      Polycythemia       - Space occupying
    syndrome            - Congenital heart     lesion
-   Air leak syndrome     disease            - Rib cage
-   Lung hemorrhage     - Pulmonary            anomalies
-   Lung hypoplasia       hypertension       - Phrenic nerve
                        - Neuromuscular        injury
-   Congenital            disorder
    malformations

           diagnosis : Hx, Phx and L.F
        Neonatal Respiratory Distress
                     Algorithm
                        Respiratory
                         Distress
                 (tachypnoea, retractions, grunt)

           Preterm                                  Term

  < 6hrs old   > 6hrs old            < 6hrs old        > 6hrs old
HMD (RDS)      Pneumonia       TTN                     Pneumonia
Pneumonia      CHD             MAS/PPHN                CHD
Lung anomaly   Pul. Hemorrhage Asphyxia
                               Lung anomaly
                               Air leak
Respiratory Distress Syndrome
           Introduction
• The most frequent cause of respiratory
  distress in premature infants.
• 60-80% of <28wk GA ; 15-30% of 32-
  36wk GA ; 5% of 37wk-term.
• Classic presentation of grunting,
  retractions, increasing O2 requirement,
  reticulogranular pattern and air
  bronchograms on CXR and onset < 6hrs
  age
               Pathogenesis
Prematurity       Prenatal asphyxia
   Reduced surfactant synthesis, storage, release
     Increased alveolar surface tension
            Progressive atelectasis        Diffusion
     Uneven V/Q         Hypoventilation gradient
     Hypoxemia                 CO2 retention
                  Acidosis
     Pulmonary vasoconstriction        Hypoperfusion
            Capillary endothelial damage
            Plasma leak         Fibrin
               Pathology
• Gross : Lung firm, red, liverlike
• Microscopic : Diffuse atelectasis, pink
  membrane lining alveoli & alveolar ducts.
  Pulmonary arterioles with thick muscular coat,
  small lumen. Distended lymphatics
• Electron microscopic : Damage / loss of alveolar
  epithelial cells, disappearance of lamellar
  inclusion bodies, swelling of capillary endothelial
  cells
          Pathology (contd.)
• Biophysical :
  – Deficient / absent surfactant
  – Abnormal pressure volume curve
                      Normal
  Vol
                      RDS


                Pressure
  – Severely reduced arterial bed with blockage
    near pulmonary arterioles
          Pathology (contd.)
• Biochemical :
  – Diminished surface-active phospholipid
    (phosphatidylcholine)
  – Diminished apoprotein content ( SP-A, B, C,
    D)
        Pathophysiology
• Reduced lung compliance (1/5th -1/10th)
• Poor lung perfusion ( 50-60% not
  perfused), decreased capillary blood flow
• R--> L shunting ( 30-60% )
• Alveolar ventilation decreased
• Lung volume reduced
• Increased work of breathing
• Hypoxemia, hypercapnia, acidosis
      Physiologic abnormalities
•   Lung compliance 10-20% of norm
•   Atelectasis…areas not ventilated
•   Areas not perfused
•   Decrease alveolar ventilation
•   Reduce lung volume
                Risk factor
Prematurity
Acidosis
Hypoxia
Hypercapnia
Hypothermia
C/S
Asphyxia and stress
Male
Familial
DM mother
                     signs
•   tachypnea
•   retraction
•   grunting
•   Nasal flaring
•   apneic episode
•   cyanosis
•   extremities puffy or swollen
        Chest X-ray


• Ground glass appearance
• Reticulogranular
• With air bronchograms
                 Treatment
• Surfactant
  – Prevention
  – rescue
• Supportive
  – Thermal
  – Fluid and nutrition
  – oxygen
• Mechanical ventilation
              complications
•   Pneumothorax
•   PDA
•   Infection
•   Line problems
•   ROP
•   Chronic lung disease
Meconium aspiration
                   ‫‪M .A .S‬‬

‫آسپيريشن مايع آمنيوتيك آغشته به مكونيوم ممكن است منجر‬
        ‫به سندرم آسپيريشن مكونيوم گردد كه مربيديتي و‬
  ‫مورتاليتي قابل مالحظه اي دارد بنابراين مديريت زايمان‬
      ‫با مايع آمنيوتيك آغشته به مكونيوم براي پيشگيري از‬
                          ‫آسپيراسيون اهميت زيادي دارد‬
               ‫تركيب مكونيوم‬
•   Cellular particle
•   Bile pigment
•   Lango
•   Mocus
•   Vernix
•   Pancreatic secretion
•   One gr meconium = one mg Billirubin
                 ‫‪Incidence‬‬
 ‫دفع مكونيوم 8 تا 02 درصد كل زايمانها ( متوسط 21 %)‬

‫مكونيوم آسپيريشن در 4 درصد مكونيومي ها ديده می شود‬

            ‫عمدتا‪ Post maturity‬و ‪ SGA‬وجود دارد.‬
                ‫فيزيوپاتولوژي‬
‫اگر چه فيزيوپاتولوژي كامل آن و علت دفع مكونيوم كامال‬
    ‫شناخته نشده اما اين پديده بندرت قبل از هفته 43 ديده‬
                                                ‫مي شود‬

  ‫بسياري از مكونيوم دفع كرده ها عالمتي دال بر مشكل‬
‫تنفسي يا دپرسيون نداشته اند و عده اي هم بعلت آسفيكسي‬
                                 ‫مكونيوم دفع كرده اند‬
                ‫علت دفع مكونيوم‬
     ‫1) پديده فيزيولوژيك : تكامل عصبي پاراسمپاتيك و‬
   ‫برقراري پريستالتيسم روده اي در پاسخ به تكامل جنين‬
        ‫(شيوع در ترم ها و نادر بودن در نوزادان نارس )‬

‫2) هيپوكسي : مي تواند باعث افزايش پريستالتيسم روده ها‬
  ‫و كاهش تو ن اسفنكترآنال شود (البته اكثر نوزادان با مايع‬
            ‫آمنيوتيك مكونيال آپگار پايين و اسيدوز ندارند )‬
            Alarm of MAS
1- Thick meconium

2-Fetal tachycardia

3- lack of increase heart rate during
  intra partum monitoring
4-Low cord PH
‫پاتوژنز‬
                MAS complication
• Partial obstruction

  o
• complete obstruction       :

• Surfactant destruction

• Chemical pneumonitis &Bacterial pneumonia

• Asphyxia

• PPHN
              Clinical sign
• Classic sign :Post maturity
  nail, skin , umblical cord are heavily
  stained with a yellowish pigment
• Early sign (resp . Distress) : grunting &
  cyanosis & nasal flaring & retraction &
  marked tachypnea
• Characteristic sign : chest overinflation
  and Rale
       Radiography of M.A.S

• Coarse , nodular , irregular pulmonary
  densities with areas of diminished aeration
  or consolidation.
• Hyperinflation of the chest .
• Atelectasis
• Flattening of diaphragm
• Cardiomegally
(manifestation of the underlying prenatal
  hypoxia)
Chest.X.Ray
Meconium Aspiration Syndrome
Meconium Aspiration Syndrome
           ‫‪ABG‬‬             ‫‪in‬‬       ‫‪M.A.S‬‬
‫.1‬   ‫شواهدي از يك آلكالوز تنفسي‬
‫.2‬   ‫هيپوكسي‬
‫.3‬   ‫در مواقع شديد اسيدوز تنفسي و اسيدوز متابوليك‬
‫.4‬   ‫شواهدي از شنت راست به چپ‬
   ‫‪Management of‬‬                      ‫‪M.A.S‬‬
  ‫حضور مكونيوم در مايع آمنيوتيك دليل برديسترس جنينی‬
 ‫نيست وچنانچه ضربان قلب جنين و پی-اچ بند ناف طبيعي‬
                            ‫باشد پيش آگهي خوب است‬

‫آميخته شدن مكونيوم با مايع آمنيوتيك باضافه ضربان قلب نا‬
                 ‫مناسب نويد دهنده يك آسفيكسي مي باشد‬
               ‫‪Intra partum‬‬
‫در اين گونه مواقع وقتي سر بيرون آمد در روي پرينه بايد‬
   ‫ساكشن دهان وبيني و فارنكس با كاتتر نمره 21 يا 41‬
      ‫انجام شود (قبل از اينكه توراكس بيرون بيايد و نوزاد‬
                                        ‫بخواهد تنفس كند )‬
                          ‫اولين ارزيابي نوزاد متولد شده :‬
                             ‫‪vigorous or depress‬‬
         Criteria of vigorous
1) Heart rate greater than 100 beat /min
2) Good muscle tone
3) regular breathing
                 Guidelines of the baby
                 exposed to meconium
                                 Vigorous
                  No                                 Yes

         Immediate tracheal                      Clear secretions and
         suction                                 meconium
                                                 initial resuscitation
                                                 steps
   Meconium              No meconium

HR>100                  HR<100


   reintubate            PPV and suction
   and suction           again later

 The American Academy of Pediatrics Neonatal Resuscitation Program Steering
 Committee management guidelines of the baby exposed to meconium:
          ET suction indication
• Only in non vigorous baby
      - depressed respirations
      - decreased muscle tone
      - heart rate < 100 beats per minute

• Pharyngeal suctioning of an infant before delivery of the shoulders.
• Removal of meconium from hypopharynx and larynx by large-bore catheter.
• Meconium aspirator attached to wall suction.
• Endotracheal intubation for removal of meconium in the lower airway.
               Management
1. Prevention
       • Monitor fetal status
       • Amnioinfusion
       • Suctioning +/- intubation and immediate
         suctioning
       • Avoid harmful techniques
2. Intervention
       • Optimal thermal environment & minimal handling
       • Respiratory care, Oxygen therapy & ECMO
       • Keep stable V/S
       • Surfactant therapy
Steroid therapy for meconium aspiration
syndrome in newborn infants
 • The Cochrane Database of Systematic Reviews 2007 Issue 3, The
   Cochrane Library (ISSN 1464-780X
 • Conclusions:
   At present, there is insufficient evidence to assess
   the effects of steroid therapy in the management of
   meconium aspiration syndrome
   (no significant reduction in mortality, duration of hospital
   stay, Duration of mechanical ventilation, incidence of air
   leak,increase in duration of oxygen therapy was seen
   with the use of steroids)
Role of antibiotics in
meconium aspiration syndrome
• Ann Trop Paediatr. 2007 Jun;27(2):107-13.
• Basu S, Kumar A, Bhatia BD.
• Division of Neonatology, Department of Paediatrics, Institute of
  Medical Sciences, Banaras Hindu University, Varanasi, India.
  drsriparnabasu@rediffmail.com
• CONCLUSION:
  Routine antibiotic therapy is not necessary for managing
  MAS. No significant difference
    – period of oxygen dependency (5.8 vs 5.9 days)
    – day of starting feeds (4.0 vs 4.2)
    – day of achievement of full feeds (9.4 vs 9.3)
    – clearance of chest radiograph (11.7 vs 12.9 days)
    – duration of hospital stay (13.7 vs 13.5 days)
Surfactant for meconium aspiration
syndrome in full term/near term infants
• Cochrane Database Syst Rev. 2007 Jul 18;(3):CD002054
• El Shahed A, Dargaville P, Ohlsson A, Soll R.
• CONCLUSIONS: In infants with MAS, surfactant
  administration may reduce the severity of respiratory
  illness and decrease the number of infants with
  progressive respiratory failure requiring support with
  ECMO. The relative efficacy of surfactant therapy
  compared to, or in conjunction with, other approaches to
  treatment including inhaled nitric oxide, liquid ventilation,
  surfactant lavage and high frequency ventilation remains
  to be tested.
            PPHN prevention
1. Avoid vasoconstriction
         • Acidosis
         • Hypoxia
         • Metabolic disturbance   - Hypocalcemia
                                   - Hypercalcemia
                                   - Hyperglycemia
                                   - Hypoglycemia
2. Prevent right to left shunt
Infections
                Infections
• Pneumonia & Sepsis have various
  manifestations including typical signs of
  distress as well as temperature instability.
• Common pathogen- Group B
  Streptococcus, Staph aureus,
  Streptococcus Pneumonia,Gm neg. rods
            Infections con..
• Risk factors- prolonged rupture of
  membranes, prematurity,& maternal
  fever.
• CXR- bilateral infiltrates suggesting in
  utero infection.
       Congenital pneumonia
• Sepsis risk factors
  – PROM
  – Prematurity
  – Maternal fever, discharge, abdominal pain,
    leukocytosis
  – Colonization with GBS
• Same signs of RDS
• X-ray
      Transient Tachypnea of
             Newborn
• Most common cause of respiratory
  distress.
• Residual fluid in fetal lung tissues.
• Risk factors- maternal asthma, c- section,
  male sex, macrosomia, maternal diabetes
                 TTN
• Tachypnea immediately after birth or
  within two hours, with other
  predictable signs of respiratory
  distress.
• Symptoms can last few hours to two
  days.
• Chest radiography shows diffuse
  parenchymal infiltrates, a “ wet
  silhouette” around heart, or intralobar
  fluid accumulation
               X-ray




Fluid in the
fissure
Transient tachypnea of newborn
•   Term
•   Cesarian delivery
•   Usually tachypnea without O2 requirment
•   Resolve in 48-72 houres
•   Lung fluid
•   X-ray
           Other causes-
• Congenital malformations-Pulmonary
  hypoplasia, congenital emphysema,
  esophageal atresia & diaphragmatic
  hernia.
• Neurological causes- hydrocephalus &
  intracranial hemorrhage.
• Metabolic derangements-hypoglycemia,
  hypocalcemia, polycythemia.
    Congenital Heart disease
Cyanotic Heart Disease-
• Tetralogy of fallot- ( VSD, Pulmonary
  stenosis, overriding aorta, RVH)
• Tricuspid atresia
• Transposition of great vessel
• Total anomalous pul. venous return
• Truncus arteriosus.
         Hyperoxia Test
• Obtain ABG–> Then place the
  patient on 100% O2 for 10
  minutes then repeat ABG , If the
  cyanosis is pulmonary , the PaO2
  should be increased by 30 mm of
  Hg. If the cause is cardiac , there
  will be minimal improvement in
  PaO2.
‫با تشکراز همکاران‬
     ‫گرامی‬

				
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