Respiratory Distress in the Newborn, not RDS Dr. Alona Bin-Nun NICU Shaare Zedek

Respiratory Distress in the Newborn – Clinical Presentation Cyanosis Grunting Retractions Tachypnea Nasal flaring Extreme: Apnea, Shock

More Common Causes of Respiratory Distress RDS Pneumonia Meconium Aspiration Transient Tachypnea Hypothermia Hypoglycemia

Acute Life Threatening Emergencies Presenting in Respiratory Distress Choanal Stenosis Meconium Aspiration Tension Pneumothorax Diaphragmatic Hernia

Major Causes of Respiratory Distress in the Newborn: Extrathoracic Developmental –Choanal Atresia –Pierre Robin sequence Infection –Sepsis –Meningitis Metabolic –Hypoglycemia –Hypothermia –Acidosis CNS –Infection –Hemorrhage –Edema Blood –Blood loss, Hypovolemia –Anemia –Polycythemia

Major Causes of Respiratory Distress in the Newborn Intrathoracic Developmental –RDS –Hypoplastic lungs –T-E fistula –Cystic Malformation –Cong. Lobar Emphysema Infection –Pneumonia –Congenital/Acquired viral/bacterial Aspiration –Meconium –Blood –Amniotic Fluid Air Leak –PIE –Pneumothorax –Pneumomediastinum Cardiac –Cong. Heart disease –IDM Misc –Persistent Pulmonary Hypertension of the Newborn (PPHN) –Wet Lungs –Pulm. Hemorrhage

Evaluation of Infant with Respiratory Distress - History Pregnancy- Hydramnios, Diabetes Labor Delivery: C/S or vaginal Evidence of Infection Meconium Apgar Scores Resuscitation

Evaluation of Infant with Respiratory Distress – Physical Examination Degree of respiratory distress Cyanosis Air entry Heart murmur Temperature Scaphoid abdomen Position of PMI

Laboratory Tests O 2 saturation X-ray: AP+lateral. Assess both lungs and heart Blood gas Hct Dextrostix BP Transillumination Hyperoxia test Nasogastric catheter (radio opaque) Evaluate for sepsis

Management of Newborn with Respiratory Distress (1) Clear airway, esp. meconium Oxygen Ventilation –mask bagging → intubation –Cyanosis –CO2 retention –apnea Correct Acidosis

Management of Newborn with Respiratory Distress (2) Arterial Catheter, follow blood gases Correct –Hypoglycemia –Hypothermia –Shock –Anemia or polycythemia Drain Pneumothorax Antibiotics (for unexplained persistent respiratory distress)

Transient Tachypnea Clinical Presentation –Frequently term infant –C/S –Mild respiratory distress –Moderate O 2 requirement –Duration: 2-5 days X-ray –Ill defined hazy central markings –Fade towards periphery –Slight cardiomegaly

Transient Tachypnea Clinical Presentation –Frequently term infant –C/S –Mild respiratory distress –Moderate O 2 requirement –Duration: 2-5 days X-ray –Ill defined hazy central markings –Fade towards periphery –Slight cardiomegaly Pathogenesis –Delayed removal of alveolar fluid Treatment –Supportive Prognosis –Excellent

Pneumonia Bacterial –GBS, E.coli, other Gram negative Viral –CMV, rubella, herpes, RSV Routes of Infection –Ascending (PROM) –Hemtogenous –Aspiration of infected material Time of Infection –Before, during or after delivery X-ray –Focal infiltrates –Can be diffuse –Can be indistinguishable from RDS Evaluation –Tracheal culture –Evaluate for sepsis –Screen for TORCH Treatment –Antibiotics –Supportive

Meconium Aspiration Syndrome (MAS)

Effects of Meconium Aspiration Meconium Aspiration Chemical pneumonitis Bacterial pneumonitis Proximal Airway Occlusion Peripheral Airway Occlusion Extra- alveolar air Partial Atelectasis Intrapulmo nary Shunt Ball valve Complete Hypoxemia and Acidodis PPHN Asphyxia

Treatment of MAS Prevention Oxygen, CPAP Assisted ventilation NO Drain pneumothorax Antibiotics General measures, correct: –hypovolemia –metabolic acidosis –hypoglycemia –hypocalcemia –anemia Further Sequelae –CP –ATN –Anoxic liver + coagulopathy –NEC –Anoxic Myocardial damage

T-E Fistula classification

Esophagial Atresia and T-E Fistula Embryology –Interruption of division of foregut into trachea and esophagus Clinical Picture –Associated with prematurity and hydramnios –Increased salivation –Choking and dyspnea on feeding –Aspiration pneumonia –Other abnormalities (VACTER association) Diagnosis –X-ray: dilated proximal esophageal pouch, curling of NG catheter –Dye studies –Air in abdomen: presence or absence of fistula –Endoscopy

Preoperative Care –Treat Pneumonia –Prevent gastric reflux – upright position –Suctioning of proximal pouch Definitive treatment –Surgery Prognosis –Survival –Depends on birth weight, prematurity, other congenital abnormalities

Diaphragmatic Hernia

Treatment –Intubate and ventilate –Do not mask bag –Gastric tube –Beware of pneumothorax –Surgery Post op: –Ventilation and oxygenation: problematic Outcome –Poor due to lung hypoplasia

Pneumothorax

Accumulation of air in pleural cavity Common cause of respiratory distress. Pathogenesis –Overdistension of alveoli –Rupture of air into interstitial space –Tracking to hilum along periventricular and peripheral sheaths –Air enters mediastinum –Rupture into pleural space –Rupture of subpleural bleb directly into pleural space Results –Decreased lung volume –Decreased cardiac output

Pneumothrax ↑ intrapleural pressure Compression of large intrathoracic veins ↓ lung volumeMediatinum shift ↑ pulm. Vascular resistance ↑ central venous pressure ↓ venous return ↓ cardiac output Mechanisms leading to reduction of CO

Clinical Presentation of Pneumothorax Grunting Tachypnea Apnea Cyanosis Bradycardia Shock Sudden deterioration in ventilated infant Shifting of heart sounds Chest asymmetry Decreased air entry

Pneumothorax: Diagnosis (1) If infant’s life threatened, don’t wait for X- ray, do diagnostic needle aspiration !! Transillumination

Pneumothorax: Diagnosis (2) X-ray –Seperation of lung from chest wall –Absent lung marking peripherally –Shift of mediastinum in tension pneumothorax –Bilateral tension: no shift, small heart –Lateral: air collection beneath sternum

Pneumothorax: Diagnosis (3) Associated with PIE –Pneumomediastinum –Pneumopericardium

Spinnaker sail sign: The thymus, wedge-shaped, extending from the rt. hemidiaphragm to the superior mediastinum (white arrows),is displaced by a collection of gas under pressure (black arrows).

Causes of Pneumothorax Spontaneous RDS CPAP and mechanical ventilation Resuscitation Pulmonary hypoplasis Post thoracotomy

Treatment of Pneumothorax Observe only if: –Minimal respiratory distress –Minimal oxygen requirement –Breathing spontaneously –Maintaining good BP Indications for drainage –Tension pneumothorax –Cyanosis –Apnea –Deteriorating blood gases –Assisted ventilation –Shock