Neonatal & Pediatric Respiratory Disorders (Part 1)
What is TTN caused by?
Delayed clearance of fetal lung fluid leading to ineffective gas exchange, respiratory distress, and tachypnea. Caused by cesarean sections due to avoidance of thoracic squeeze expelling the fluid in the birth canal.
What is meconium aspiration syndrome (MAS)?
Disorder of term or near term infants that is associated with perinatal depression and asphyxia
What is the last resort treatment of PPHN?
ECMO
Auscultation in RDS
Fine inspiratory crackles
Audible sounds in RDS
Grunting
What is MAS?
Aspiration of fetal feces
How are the five types of lung malformations classified?
By type and size of the cyst
What is the preferred treatment for RDS?
CPAP
Apnea of prematurity
Cessation of breathing by a premature infant that lasts for more than 15 seconds OR it causes cyanosis, pallor, hypotonia, or bradycardia
How do you diagnose RDS?
Chest radiography with diffuse, hazy regiculogranular densities, air bronchospasm, and low lung volumes.
What is BPD?
Chronic problem from alveolar trauma and oxygen toxicity
Mixed apnea
Combination of central and obstructive apnea
congenital diaphragmatic hernia
Combination of lung hypoplasia and abnormal development.
What is PPHN?
Complex syndrome of newborn hypertension
What is the most common lung malformation?
Congenital pulmonary adenomaroid malformation (CPAM)
Congenital abnormalities affecting respiration include:
-Airway Diseases -Lung Malformations -Congenital Diaphragmatic Hernia -Neuromuscular Control
What is the patho physiology of bronchopulmonary dysplasia (BPD)?
-Atelectrauma -Volutrauma -Or a combo of both
What are the treatments for RDS?
-CPAP with nasal prongs (4-6) -MV with PEEP -Surfactant replacement -HFV (Hugh-frequency ventilation)
How do you treat control of breathing (apnea, etc)
-Continuous monitoring of HR and RR -Continued noninvasive monitoring of oxygenation (transcutaneous electrode or pulse oximetry) -"Back to sleep" -CPAP can also be used to manage infant apnea
Treatment of PPHN
-Correct underlying problem (hypoxemia with O2 and surface for RDS) -May require intubation, MV, and sedation -Inhaled INO therapy -Paralysis, HFV, worst cases ECMO may often be required
What are the 5 types of airway disruptions?
-Esophageal atresia with proximal fistula -Esophageal atresia with distal fistula -Esophageal atresia with both proximal and distal fistula -Esophageal her fistula -Intact esophagus with H fistula
Clinical manifestations of MAS include:
-Gasping respiration's, tachypnea, grunting, & retractions -Chest radiograph shows irregular pulmonary densities (atelectasis) and hyperlucent areas with hyperinflation -ABGs show hypoxemia, mixed acidosis due to PPHN
What are 5 events implicated in causing BPD?
-Immaturity -Genetics -Malnutrition -O2 toxicity -Mechanical Ventilation
Treatment for congenital diaphragmatic hernia includes;
-Initially intubation, paralysis, MV, continuous gastric insufflation -Repair delayed for PVR to fall due to adequate VA -Severe cases may require HFV and ECMO
What is the treatment for BPD?
-Minimizing lung damage by preventing atelectrauma and volutrauma is KEY -Use lowest oxygen and MV settings possible -Establish optimal FRC in delivery room -Early use of surfactant -Diuretics to treat pulmonary edema -Antibiotics for pulmonary infections -Chest physiotherapy for retained secretions -Bronchodilator therapy to decrease Raw -Steroids used cautiously
What is the treatment for TTN?
-Oxygen therapy-usually low FiO2 by oxyhood or cannula -CPAP can be used if higher FiO2 is needed -Changing positions to speed lung clearance -May use antibiotics if it seems similar to pneumonia -Need for mechanical ventilation is rare -Moat treatments have a rapid response (24-48 hours)
What 3 problems does MAS involve?
-Pulmonary obstruction due to meconium plugging -Lung damage due to chemical injury -Persistent pulmonary hypertension (PPHN) May also lead to inflammatory responses, cytokine and chemokine activations, complement activation, phospholipase A2 activation.
Characteristics of RDS
-Qualitative surfactant deficiency (due to insufficient amounts of type II cells and poor quality of cells so cannot decrease surface tension) -Decreased alveolar surface area -Increased small airway compliance -Patent ductus arteriosus
Physical findings of Congenital Diaphramatic Hernia
-Scaphoid abdomen -Decreased breath sounds -Displaced heart sounds -Severe cyanosis Similar appearance in respiratory distress and diagnosis is established with chest radiography
What is treatment for MAS?
-Suction applied to ETT (repeat as needed) -CPAP -HFV -Surfactant -INO therapy
Clinical manifestations of PPHN
-Suspect when rapidly changing SpO2 -Detected by performing preductal and postductal SpO2 (preductal > 5% postductal)
Clinical manifestations of TTN include:
-Tachypnea -pH, PaCO2 are normal -Pneumonia like appearance on the chest X-ray, hyperinflation, pleural effusions, and perihilar streaking (lymphatic engorgement)
Clinical manifestations of RDS
-Tachypnea shortly after birth -Worsening refractions, paradoxical breathing, and grunting. (Possible nasal flaring) -Fine inspiratory crackles
What are the three types of PPHN?
-Vascular spasm (triggered by hypoxemia or pain) -Increased muscle wall thickness (chronic) -Decreased cross sectional area of vasculature
Symptoms of CPAM
-Volume Loss -As mass expands, normal surround lung is compressed
Clinical manifestations of BPD include:
-progressive respiratory distress at 2-3 weeks of life -Chest radiograph shows diffused areas of atelectasis, emphysema, and fibrosis -ABGs show hypoxemia and hypercapnia
Where is placement of pulse oximeters preferred in infants with PDA?
1 On the right arm and another on either of the infants legs. (use 2 in order to find a substantial gradient (>5%) between the preductal and post duct O2 saturation that is usually present in these infants who have a significant shunt through the ductus arteriosus.)
Identify the six infant characteristics often seen near the time of death in infants with SIDS
1. Age younger than 6 months (peak between 1-3 months) 2. Winter Season 3. Asleep at night 4. Mile illness in week before death 5. History of apparent life threatening event or mother smokes cigarettes 6. Prone sleep position
What are the two types of congenital diaphragmatic hernia?
1. Bochdalek hernia (lateral and posterior defect, usually on the left) 2. Morgagni hernia (medial and anterior, May be on either side)
What are the three mechanisms of airway diseases?
1. Internal obstruction (is; stridor, wheezing, tracheal stenosis) 2. Airway disruptions (tracheoesophageal fistula) 3. External obstruction (neck or thoracic mass)
List the four defects seen in tetralogy of Fallot:
1. Obstruction of right ventricular outflow (pulmonary stenosis) 2. Ventricular septal defect ( a hole between the left and right ventricles) 3. Dexotropisition of the aorta 4. Right ventricular hypertrophy
What 4 lung parenchyma diseases exist today?
1. Respiratory Distress Syndrome (RDS) 2. Transient Tachypnea of the Newborn (TTN) 3. Meconium Aspiration Syndrome 4. Bronchopulmonary Dysplasia (BPD)
Respiratory rate is RDS
Abnormally fast, tachypnea
What is bronchiolitis?
Acute infection of the lower airways
What is periodic breathing?
An abnormal pattern of respiration characterized by alternating periods of apnea and deep rapid breathing. Compromises sequential so short apnea episodes of 5-10 seconds followed by 10-15 seconds of rapid respiration.
What is abnormal apneic spells?
Any period of apnea that lasts longer than 15 seconds in length or if the apnea spells are associated with cyanosis, pallor, hypotonia, or bradycardia.
What factors contribute to BPD?
Immaturity, genetics, malnutrition, oxygen toxicity, hypoxia, and mechanical ventilation.
What is SIDS?
Leading cause of death in infants < 1 year old
What is epiglottitis?
Life threatening upper airway infection
List two respiratory treatments for TTN
Low FiO2 via infant O2 hood or nasal cannula. CPAP (if requiring higher FiO2)
Central apnea
No respiratory effort during apnea
How do you treat PDA?
Pharmacologic (indomethacin) or surgical (ligation)
What is TTN?
Poor clearance of lung fluids
What is the pathophysiology of PPHN?
Pulmonary blood flow is low due to right to left shunt through patent for amen ovals or ductus arteriosus
What is PDA?
Pulmonary ductus arterioles is a disease of immature, preterm infants in which factors altering pressure gradients or affecting the smooth muscle contraction can cause the ductus not to close or to reopen after it has been closed resulting in a left or right shunt.
What is atelectrauma?
Repeated alveolar collapse and expansion causing lung injury
What is GERD?
Stomach problem associated with asthma
What is RDS?
Surfactant deficiency in preemies
Lung prematurity in RDS causes what?
Surfactant deficiency, alveolar instability and collapse, increased WOB, Draws fluid into alveoli, impaired oxygenation with hypoxemia, acidosis leading to increased PVR, increased right to left shunt, all ultimately leading to an overall downward spiral.
Treatment of CPAM
Surgical resection of affected love and cardiopulmonary compromise occurs in severe cases.
What age group does TTN most often occur in?
Term babies
Persistent Pulmonary Hypertension of the Newborn (PPHN)
The failure of the normal circulatory transition that occurs after birth due to increased PVR
What is volutrauma?
The local overdistention of normal alveoli injuring the airways and lung parenchyma
What is another name for Type II RDS?
Transient tachypnea of the newborn (TTN)
What is the immediate treatment of MAS?
Upon delivery: ETT insertion and suction should be applied directly to the ETT. Repeat until: No further meconium is aspirated or until two to four aspirations have been performed. If the condition worsens: CPAP or mechanical ventilation may be indicated to correct possible hypoxemia and or respiratory acidosis.
What is croup?
Virus induced subglottic swelling
Breathing pattern in RDS
Worsening retractions and paradoxical breathing pattern
Respiratory Distress Syndrome is also known as what?
hyaline membrane disease
Obstructive apnea
respiratory effort but no flow
