1. Combined meeting
2015/7/2
R2 潘妤玟

2. Patient Informations Name:蔡X祺 Age: 3 month 16 day old Gender: Male
Admission Date: 2015/3/16
Chief Problem:
Respiratory distress after birth

3. Present Illness Maternal history: Birth history:
Prenatal care at 婦兒安 and 新樓: unremarkable.
Birth history:
G3P1A2, GA 36+5 weeks BBW: 2878g
Apgar score: 7->9
FHB poor variation at 新樓H.
Emergent C/S then
Delay of initial crying s/p ambu bagging
Poor activity admitted to NICU+NCPAP
Blood gas: pH 7.188, CO2 59.7, HCO3 22.2, BE -7
Intubation done and transferred to our NICU

4. Physical Examination T/P/R: 36.8/163/44, BP: 70/47mmHg
General appearance:
Pink appearance, fair activity
HEENT:
Conjunctiva: not pale
Sclera: anicteric
Neck: supple,
No JVE, no LAP
Chest:
Symmetric expansion, retraction(+)
Slightly decreased right lower BS, no bowel sound could be heard
Skin: no edema, petechiae or ecchymosis
Heart: regular heart beat, no murmur
Abdomen: flat and soft, normoactive bowel sound
Tenderness (-)
Rebound tenderness (-)
Muscle guarding (-)
Flank pain(-)
Extremities: warm, pitting edema (-)

6. Hospital course 2015/3/17 1033: 2015/3/17-3/18 2015/3/17 1033:
Echo: liver parenchyma in right thoracic cavity
Consult CS arrange surgery
2015/3/17-3/18
Aggitation and fighting ventilator desaturation
Sedation
Cardiac echo: PPHN、TR iNO but poor response
Suspect Right& left pul. artery hypoplasia
FiO2 65%
pH=7.204 ，pCO2=62.8，HCO ，BE=-3.8
2015/3/ :
Echo: liver parenchyma in right thoracic cavity
Cardiac echo: PDA R->L shunt
FiO2 35%
Consult CS arrange surgery
2015/3/ :
Frequent bradycardia
CXR: no pneumothorax
↑Stroke volume
2015/3/18
Aggitation and fighting ventilator desaturation
Sedation
Cardiac echo: PPHN、TR iNO but poor response
Right& left pul. artery atrophy
FiO2 65%
pH=7.204 ，pCO2=62.8，HCO ，BE=-3.8
Adjust stroke volume

7. Hospital course 2015/3/19 surgery:
Right side diaphragm eventration without diaphragm herniation
Perform diaphragm plication

9. Admission course
2015/3/21
HFOV shift to IMV mode
3/20, 3/21, 3/23

10. Admission course 2015/3/26 Extubation + NIV NAVA support
Diaphragm elevation gradually
3/26, 3/29, 4/3

11. Hospital course 4/3 Tachypnea + sputum 4/5 frequent ABD  Intubation
Consult CS surgeon
for re-eventration
4/5 frequent ABD
 Intubation
(NIV NAVA x 9 days)

12. Hospital course 4/11 Sputum culture Antibiotics Unasyn use
Klebsiella pneumoniae
Antibiotics Unasyn use
Blood culture: negative
4/11
Fever + Frequent ABD
CRP: 25.666.989.8
Blood culture:
Shift to Fortum use

13. Hospital course 4/10 chest CT 4/16 Extubation  NIV NAVA support
hypoplasia of
RML, RLL
PDA
4/16 Extubation
 NIV NAVA support

14. Hospital course 5/4 Intubation due to CO2 retention
Apnea/bradycardia/desaturation when agitation
Chlohydrate prn use for sedation

15. Hospital course 6/12 Extubation  NIV NAVA support Cardiac echo:
BiPAP tried but failed
Still CO2 retention
Cardiac echo:
 Add Viagra
6/24 Intubation

16. Lung perfusion scan
Diffusely lower lung perfusion in the right lung

17. Hospital course 3/16 Admission 3/18 Diaphragm plication
3/ Extubation
4/ Intubation due to frequent ABD
CXR: Re-eventration + RUL collaspe
4/ Chest CT
4/ K.P. Bacteremia
4/ Extubation
FiO2 around 25-30%, CO2 around 45-55mmHg
FiO2 around 30-40%, CO2 around 60-70mmHg

18. Hospital course 5/4 Intubation due to progressive CO2↑
ABD while agitation, bagging prn
6/ Lung perfusion scan
6/ Extubation
Cardiac echo: pulmonary hypertension
Add Viagra
6/ Intubation
FiO2 around 40-50%, CO2 around 70-80mmHg
Currently,
FiO2 around 50-60%, CO2 around 70-80mmHg

19. Next step? Surgery again? Lung hypoplasia? Tracheostomy?
Younger children (under 1 year of age) had a higher complication rate than older cases.
Lung transplantation?
Complications
Early
Emphysema
Pneumomediastinum
pneumothorax
Wound complications
Bleeding
Late
Granulations/laryngeal stenosis/tracheal stenosis

20. Prognosis
Severe pulmonary hypoplasia was a major contributing factor to mortality in this series.
Pulmonary hypoplasia similar to that associated with diaphragmatic hernias (CDH) also occurs in CDE, albeit more rarely and to a lesser degree [4, 12, 17].

21. Thank you!