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Neonatal

Respiratory
M.Disorders
Khashaba, MD
Professor of Pediatrics

Mansoura University
Introduction
Birth involves changing from the
intrauterine state where the placenta is
the primary organ of respiration, to life
outside the uterus where the lung is
the organ of gas exchange.

M.Khashaba,MD professor of Pediatrics,Mansoura


Respiration involves a system that
includes the lung and other structures,
including the muscles of the diaphragm
and chest.

M.Khashaba,MD professor of Pediatrics,Mansoura


Control of respiration involves the brain
and, specifically, the respiratory center, sensors
that respond to hypoxia and hypercapnia, and
the nerves that conduct impulses to and from
these structures.

M.Khashaba,MD professor of Pediatrics,Mansoura


Neonatal respiratory disease result
from problems with any or all of these
structures.

M.Khashaba,MD professor of Pediatrics,Mansoura


Definition

• Tachypnea > 60 /min

• GFR (Grunting , Flaring & Retraction)

• + cyanosis

M.Khashaba,MD professor of Pediatrics,Mansoura


Causes of respiratory distress
Obstruction of the airway Lung parenchymal disease
1- Choanal atresia 1- Meconium aspiration
2- Congenital stridor 2- Respiratory distress syndrome
3- Tracheal or bronchial stenosis 3- Pneumonia
4- Transient tachypnea of the newborn
(retained lung fluid)
5- Pneumothorax
6- Atelectasis
7- Congenital lobar emphysema
Non-pulmonary causes Miscellaneous
1- Heart failure 1- Disorders of the diaphragm e.g.
2- Intracranial lesions (diaphragmatic hernia)
3- Metabolic acidosis 2- Pulmonary haemorrhage
3- Pulmonary hypoplasia
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
• Transient tachypnea of the newborn (TTN)
• Respiratory Distress Syndrome (RDS)
• Meconium aspiration syndrome (MAS)
• Air leak syndromes
• Pneumonia
• Apnea

M.Khashaba,MD professor of Pediatrics,Mansoura


I - Transient Tachypnea of the
Newborn (TTN)
•Definition:
A benign disease of near-term or term infants who
have respiratory distress shortly after delivery
that resolves within 3-5 days.

•Risk factors:
Cesarean section Male sex
Macrosomia Excessive maternal sedation
Prolonged labor Low Apgar score (<7 at 1 min)

M.Khashaba,MD professor of Pediatrics,Mansoura


•Clinical Presentation

The infant is usually near-term or term


and shortly after delivery has tachypnea
(>80 breaths/min). The infant may also have
grunting, nasal flaring, rib retraction, and
cyanosis. The disease usually does not last
longer than 72 hours.

M.Khashaba,MD professor of Pediatrics,Mansoura


• Investigations:
Laboratory studies: Blood gases
CBC

Radiologic studies:
Chest X-ray: Perihilar streaking, mild
cardiomegaly,
increased lung volume and fluid in the minor
fissure, and perhaps fluid in the pleural space

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
• Management:
A – General: Oxygenation.
Fluid restriction.
Feeding as tachypnea improves.

B – Confirm the diagnosis by excluding other


causes of tachypnea e.g. pneumonia, congenital
heart disease, HMD.

M.Khashaba,MD professor of Pediatrics,Mansoura


•Outcome & prognosis

The disease is self-limited. Respiratory


symptoms improve as intrapulmonary fluid is
mobilized.

M.Khashaba,MD professor of Pediatrics,Mansoura


Hyaline Membrane Disease – 2
((Respiratory Distress Syndrome
•Definition
Hyaline membrane disease (HMD) is also
called respiratory distress syndrome (RDS).
Usually occurs in a preterm newborn with
respiratory difficulty

M.Khashaba,MD professor of Pediatrics,Mansoura


•Incidence

HMD occurs in about 25% of infants born at


32 weeks gestation.
The incidence increases with increasing
prematurity.

M.Khashaba,MD professor of Pediatrics,Mansoura


• Clinical Picture:

 It starts at birth but may appear within first


hours.
 Presents with worsening respiratory distress.
 Tachypnea, grunting on expiration, and
retractions of the chest wall.

M.Khashaba,MD professor of Pediatrics,Mansoura


• Investigations
A- Laboratory studies:
Blood gases: reveal hypoxia, hypercarbia, acidosis.
Complete blood picture to rule out infection.

B- Chest X-ray study:


Ground glass appearance with air bronchogram.

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
• Management
General
• Basic support including thermal regulation and
parenteral fluid .
• Oxygen administration, preferably heated ad
humidified 30-40% O2 by head box.

• Respiratory support is needed if the patient


continues to deteriorate.

M.Khashaba,MD professor of Pediatrics,Mansoura


Respiratory Support
Continuous positive airway pressure (CPAP).

Assisted ventilation.

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
• Specific

* surfactant replacement therapy

• Outcome

* RDS account for 20% of all neonatal


deaths.

M.Khashaba,MD professor of Pediatrics,Mansoura


3 – Meconium Aspiration Syndrome
(MAS)
•Definition

The respiratory distress secondary to


meconium aspiration by the fetus in utero or by
the newborn during labor and delivery.

The aspirated meconium can cause airway


obstruction and an intense inflammatory reaction.

M.Khashaba,MD professor of Pediatrics,Mansoura


• Clinical presentation

 Meconium staining of amniotic fluid


before birth.
 Meconium staining of baby after birth.
 Airway obstruction
 Respiratory distress and increased
anteroposterior diameter of the chest

M.Khashaba,MD professor of Pediatrics,Mansoura


• Investigations

• Laboratory studies: Blood gas analysis


• Chest X-ray:
– patchy infiltrates
– increased anteroposterior diameter
– flattening of the diaphragm.

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
• Management

A-Prenatal management:
– Identification of high-risk pregnancy.
– Monitoring of fetal heart rate during labor.
B-Delivery room management: (if amniotic fluid is
meconium stained)
– Suction of the oropharynx.
– Visualization of vocal cords & tracheal suction
before bagging.

M.Khashaba,MD professor of Pediatrics,Mansoura


C- Management of the newborn in the
neonatal unit:

– General management.
– Respiratory management.
– Cardiovascular management.

M.Khashaba,MD professor of Pediatrics,Mansoura


• General management:
* Empty the stomach contents to avoid further
aspiration.
* Correction of metabolic abnormalities e.g.
hypoxia, acidosis, hypoglycemia, hypocalcemia and
hypothermia
* Surveillance for multi organ hypoxic/ischemic
damage (brain, kidney, heart and liver)

M.Khashaba,MD professor of Pediatrics,Mansoura


• Respiratory management

* Antibiotic coverage.
* Oxygenation (maintain high saturation
>95%)
* Assisted ventilation (avoid hypercarbia and
respiratory acidosis).

M.Khashaba,MD professor of Pediatrics,Mansoura


• Cardiovascular management

* Correct systemic hypotension ( myocardial


dysfunction).
* Treat persistent pulmonary hypertension.
* (Maintain low PCO2 level < 40mmHg & ensure
adequate O2 saturation above 95%).

M.Khashaba,MD professor of Pediatrics,Mansoura


Air Leak Syndromes – 4
•Definition
.Pneumomediastinum, pneumothorax, pulmoanry
interstitial emphysema and pneumopericardium .
. Same pathophysiology.
. Overdistension of alveolar sacs or terminal
airways leads to disruption of airway integrity,
resulting in dissection of air into surrounding
spaces.
M.Khashaba,MD professor of Pediatrics,Mansoura
•Incidence

Most commonly seen in infants with lung


disease who are on ventilatory support and may
occur spontaneously. The more severe the lung
disease, the higher the incidence of pulmonary
air leak.

M.Khashaba,MD professor of Pediatrics,Mansoura


• Risk factors

– Ventilatory support .
– Meconium Aspiration Syndrome.
– Vigorous resuscitation.

M.Khashaba,MD professor of Pediatrics,Mansoura


•Clinical presentation

Respiratory distress or sudden


deterioration of clinical courses with alteration
of vital signs and worsening of blood gases.

* Asymmetry of thorax in unilateral cases.

M.Khashaba,MD professor of Pediatrics,Mansoura


•Investigations

The definitive diagnosis of all air leak


syndromes is made radiographically. An A-P
chest X-ray film along with a lateral film.

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
• Management

General: Oxygenation
Prevention: Judicious use of ventilatory
support.

Specific: Decompression of air leak


according to the type.

M.Khashaba,MD professor of Pediatrics,Mansoura


Pneumonia - 5
1.Congenital Pneumonia :

Aspiration of bacteria in amniotic fluid


lead to congenital pneumonia or
Systemic bacterial infection blood born
from the mother

M.Khashaba,MD professor of Pediatrics,Mansoura


Manifestations
– prior to delivery (fetal distress,
tachycardia),
– delivery (perinatal asphyxia), or
– after a latent period of a few hours
(respiratory distress, shock).

M.Khashaba,MD professor of Pediatrics,Mansoura


2.Acquired pneumonia

Exposure to bacteria from the


environment.

M.Khashaba,MD professor of Pediatrics,Mansoura


•Clinical picture

Onset 1-2 days after delivery

Moderate to severe respiratory distress in


presence of one or more risk factors for
infection.

M.Khashaba,MD professor of Pediatrics,Mansoura


Investigation

•Chest X-ray
•.Blood gases.
•Bacterial cultures

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
• Treatment
• Antibiotics better according to culture and
sensitivity if positive.
• Management of respiratory distress (02 and
ventillation).

M.Khashaba,MD professor of Pediatrics,Mansoura


6 - Apnea

•Definition
Cessation of respiration accompanied by
bradycardia and/or cyanosis for more than
20 seconds.

M.Khashaba,MD professor of Pediatrics,Mansoura


• Causes of neonatal apnea
1- Pathological apnea:
Hypothermia Cardiac disease
Hypoglycemia Lung disease
Anemia GE reflux
Hypovolemia Airway Obstruction
Aspiration Infection, Meningitis
NEC / Distension Neurologic disorders
M.Khashaba,MD professor of Pediatrics,Mansoura
2- Apnea of prematurity

• Incidence

50-60% of preterm infants have


evidence of apnea.

M.Khashaba,MD professor of Pediatrics,Mansoura


A. Apnea within 24 hrs. after delivery: It is
usually not simple apnea of prematurity.

B. Apnea after the first 3 days of life: If not


associated with other pathologic conditions,
may be classified as apnea of prematurity.

M.Khashaba,MD professor of Pediatrics,Mansoura


Management
• Monitoring of infants at risk less than 32 weeks.
• Evaluate for a possible underlying cause.
• Laboratory studies: CBC, blood gases, serum
glucose, electrolyte and calcium levels.
• Radiologic studies: Chest X-ray, abdominal X-
ray, cranial sonar and C.T. (infants with definite
signs of neurologic disease)

M.Khashaba,MD professor of Pediatrics,Mansoura


Treatment
• General
– Tactile stimulation.
– CPAP or assisted ventilation in recurrent apnea
– Theophylline in apnea of prematurity.
• Specific
– Treatment of the case if identified e.g. treatment
of sepsis, hypoglycemia, anemia and electrolyte
abnormalities

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
Transposition of Great Arteries

M.Khashaba,MD professor of Pediatrics,Mansoura


Atrial Septal Defect

M.Khashaba,MD professor of Pediatrics,Mansoura


M.Khashaba,MD professor of Pediatrics,Mansoura
‫صفــــــاتالـطالــــب‬
‫‪‬‬

‫‪ .1‬سليم العقيدة‬
‫‪ .2‬صحيح العبادة‬
‫‪ .3‬قيم الخلق‬
‫‪ .4‬مثقف الفكر‬
‫‪ .5‬حريص على وقته‬
‫‪M.Khashaba,MD professor of Pediatrics,Mansoura‬‬
‫صفــــــاتالـطالــــب‬
‫‪‬‬
‫‪ .1‬منظم فى شئونه‬
‫‪ .2‬نافع لغيره‬
‫‪ .3‬صحيح البدن‬
‫‪ .4‬قادر على الكسب‬
‫‪ .5‬باراً بأهله‬
‫‪M.Khashaba,MD professor of Pediatrics,Mansoura‬‬