RESPIRATORY DISTRESS IN NEWBORN PART 3 KIRANJIT KAUR
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- RESPIRATORY DISTRESS IN NEWBORN PART 3 KIRANJIT KAUR
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- PNEUMOTHORAX presence of air or gas in the pleural cavity
between the visceral and parietal pleura, which results in
violation of the pleural space. This causes pressure within the
pulmonary space to exceed extrapleural pressure. It can occur
spontaneously or as a result of infection, meconium aspiration,
lung deformity, or ventilation barotrauma. Frequency : 1-2% in term
births 6% in premature births
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- PATHOPHYSIOLOGY Foreign material is aspirated into the lung
High transpulmonary pressure Rupture of the alveolus occurs with
air escaping
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- SYMPTOMSCyanosisTach y pnea Nasal Flaring
GruntingRetractions
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- EXAMINATION & TESTS breath sounds diminished on side of
pneumothorax. pockets of air will show up as lighter areas
Anteroposterior (AP) and lateral views can reveal the presence of
even small amounts of intrapleural air. Hyperlucency of vascular
and lung markings on the affected side can be seen because of this
air. Atelectasis may also be seen on the affected side, and the
mediastinum and trachea may shift away from the pneumothorax.
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- a.Place light source (otoscope, transilluminator) on infants
chest. Ensure it isnt hot. b.A normal chest will have a small
glowing Halo around the light source. Usually it extends less than
1 cm from the light source and is symmetric. c.If the chest lights
up like a jack-o-lantern or ETs chest (large area of redness that
is often asymmetric), then ptx should be HIGH on your DDx list.
d.You should compare to the other side if you are unsure.
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- MANAGEMENT Observation should be the treatment of choice for
primary spontaneous small closed pneumothoraces without significant
breathlessness, in a spontaneously breathing patient. Inhalation of
high concentrations of oxygen may speed the resolution of a
pneumothorax by reducing the partial pressure of nitrogen in the
pulmonary capillaries. Aspiration Chest tube SpO2 monitoring
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- ASPIRATION Equipment i.Angiocath or butterfly needle (for
neonates) ii.Large syringe (>20mL) iii.3-way stop-cock (to keep
system closed) Procedure i.Locate 2nd or 3rd intercostal space at
the midclavicular line ii.Prep skin with antiseptic and provide
analgesic/anesthetic. iii.Advance needle perpendicularly over
superior border of rib while aspirating. Having saline in syringe
will allow you to detect when youve entered the ptx. iv.When
bubbles are present or you have free movement of the syringe
plunger, evacuate the pneumothorax. v.A 3-way stopcock can be
placed between syringe and butterfly needle, which will allow for
controlled evacuation of pneumothorax.
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- CHEST TUBE
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- PERSISTENT PULMONARY HYPERTENSION OF NEWBORN defined as a
failure of normal pulmonary vasculature relaxation at or shortly
after birth Resulting in impedence to pulmonary blood flow which
exceeds systemic vascular resistance that unoxygenated blood is
shunted to systemic circulation Data suggest that 2-6 cases of PPHN
occur per 1000 live births.
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- PATHOPHYSIOLOGY While a fetus is in the womb, it gets its
oxygen from its mother's placenta through the umbilical cords, so
the lungs need little blood supply. There is high blood pressure in
the lungs, so blood in the pulmonary artery is sent away from the
lungs to the other organs through a fetal blood vessel, called the
ductus arteriosus. When a baby is born and takes its first breaths,
the blood pressure in their lungs falls and there is an increased
blood flow to the lungs, where oxygen and carbon dioxide are
exchanged. The blood is then returned to the heart and pumped back
out to the body. The ductus arteriosus constricts and permanently
closes in the first day of life. However, in babies with PPHN, the
pressure in the lungs remains high and the ductus arterious remains
open, allowing blood to be directed away from the lungs.
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- CAUSES Acute pulmonary vasoconstriction MASRDSPneumonia
Pulmonary hypoplasia Diaphragmatic hernia Idiopathic pulmonary
hypertension HypoxiaCold stressSepsisHypoglycemia
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- Meconium aspiration. Serial radiographs in a newborn with
uncomplicated meconium aspiration. Radiograph obtained shortly
after birth shows ill-defined, predominantly perihilar opacities in
the lungs; these are more severe on the right than on the left. The
lungs are hyperexpanded. The neonate's heart size is within normal
limits. The abnormalities on the initial chest radiograph, aside
from the presence of an endotracheal tube and an umbilical artery
catheter, are identical to those seen in severe cases of transient
tachypnea of the newborn.
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- SIGNS Tachycardia Low O2 levels Heart murmur
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- DIAGNOSIS Chest X-rays may be recommended and can determine if
the baby has lung disease or an enlarged heart. Echocardiogram,
which is an ultrasound of the heart, can show whether the baby has
heart or lung disease and evaluate blood flow in those organs.
Ultrasound of the head may be used to look for bleeding in the
brain. Arterial blood gas (ABG) determines how well oxygen is being
delivered to the body. Complete blood count (CBC) measures the
number of oxygen- carrying red blood cells, white blood cells and
platelets. Serum electrolyte tests evaluate the balance of minerals
in the blood. Pulse oximetry
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- DIFFERENTIAL PPHN Respiratory distress at birth Bradycardia
Blue and restless H/O perinatal hypoxia CONGENITAL CYANOTIC CARDIAC
DISEASE Usually no respiratory distress Usually no bradycardia Blue
but happy
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- TREATMENT Oxygen -- 100 percent supplemental oxygen may be
given to your baby through a mask or plastic hood. Assisted
Ventilation -- During this procedure, a tube is inserted into your
baby's windpipe and a ventilator takes over your baby's breathing
and oxygen is given. Nitric Oxide -- Research has shown that this
gas is effective in treating PPHN because it relaxes contracted
lung blood vessels and improves blood flow to the lungs. It is
given through the ventilator. High Frequency Oscillatory
Ventilation -- This type of ventilation may improve the oxygen
level in the blood if other types of ventilation are not effective.
Extracorporeal Membrane Oxygenation -- In addition, an
extracorporeal membrane oxygenation (ECMO) machine may be used for
patients who are experiencing serious heart or lung failure. It
delivers oxygen to the brain and body as temporary support while
the PPHN resolves. ECMO is similar to a heart-lung bypass machine,
which takes over your baby's heart and lung functions with an
external pump and oxygenator. Blood is drained from the patient to
an artificial lung, where oxygen is added and carbon dioxide is
removed, and then the blood is pumped back into your child.
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- 1. Blood is drained out of the body through a vein into the
ECMO machine, which removes carbon dioxide and adds oxygen allowing
the heart and lungs to rest 2. Blood is warmed before being
returned to the heart - flow of blood out of the body is steadily
reduced as patient recovers
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- Inotropic drugs-dopamine, dobutamine, and/or milrinone is
frequently helpful in maintaining adequate cardiac output and
systemic blood pressure while avoiding excessive volume
administration. Surfactant administration Acidosis and alkalosis
correction Treating hypothermia,hypocalcemia, hypoglycemia
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- PROGNOSIS Periods of inadequate oxygenation can have long-term
effects on infants who survive PPHN, such as bronchopulmonary
dysplasia (a chronic lung disease associated with scarred,
stiffened lungs) and breathing difficulties. Seizure disorders,
developmental delay, and neurological deficits may also be seen.
Medical treatments such as high frequency ventilation, nitric
oxide, and ECMO have significantly decreased the percentage of
children who die from PPHN. Fifteen years ago, almost half of
infants diagnosed with PPHN died; today, less than 20% of infants
with PPHN die, and only about one fifth of surviving infants
experience long-term physical or developmental complications.
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- CONGENITAL DIAPHRAGMATIC HERNIA is when there is an absence of
a child's diaphragm, or a hole in the diaphragm. This can occur on
either the left or right side, but is most common on the left. The
contents the child's abdomen, including stomach, intestines, liver
and spleen may go through the hole and into the chest. This
prevents the normal development of the lung on that side, and may
affect the growth of the other lung.
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- TYPES There are 3 types of diaphragmatic hernia: Bochdalek
hernia: This type involves an opening on the back side of the
diaphragm. The stomach, intestines and liver or spleen usually move
up into the chest cavity. (left-sided hernia is the most common).
occurs in approximately 1 per 3000 live births, more commonly in
males Morgagni hernia: This type is rare and involves an opening in
the front of the diaphragm, just behind the breastbone (right-sided
hernias, only the liver and a portion of the large bowel tend to
herniate.) Bilateral hernias are uncommon and usually fatal
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- Chest radiography revealed an enlarged right mediastinum with
air content on the right side (Panel A, arrow; and Panel B, lateral
view). Thoracic computed tomographic (CT) scans showed a Morgagni's
hernia, characterized by an anteromedial diaphragmatic defect, with
herniation of the transverse colon and part of the omentum into the
thorax (Panels C and D).
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- PATHOPHYSIOLOGY A failure of the diaphragm to completely close
during development Herniation of the abdominal contents into the
chest Pulmonary hypoplasia
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- SIGNS & SYMPTOMS Symptoms (of a Bochdalek diaphragmatic
hernia): difficulty breathing tachypnea tachycardia cyanosis
abnormal chest development, with one side being larger than the
other abdomen that appears caved in(scaphoid) In left-sided
posterolateral hernia, auscultation of the lungs reveals poor air
entry on the left, with a shift of cardiac sounds over the right
chest. Associated anomalies occur in a relatively high percentage
of infants. Dysmorphisms such as craniofacial, extremity
abnormalities, or spinal dysraphism A baby born with a Morgagni
hernia may or may not show any symptoms.
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- Scaphoid abdomen, one of the clinical finding in a newborn with
diaphragmatic hernia
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- DIAGNOSIS 1)During pregnancy : During routine prenatal care at
around 18 weeks, an ultrasound may reveal the existence of a
diaphragmatic hernia, or what is suspected to be CDH. 2) After
birth : After birth, your baby's physician will perform a physical
examination. The following tests may also be done: a)A chest x-ray
is done to look at the abnormalities of the lungs, diaphragm and
intestine. b)Arterial blood gas is often performed to evaluate the
baby's breathing ability. c)A blood test for chromosomes helps
determine if there is a genetic problem. d)An ultrasound of the
heart (echocardiogram) provides further details about the child's
condition.
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- TREATMENT In the delivery room, if the infant is known or
suspected to have congenital diaphragmatic hernia, immediately
place a vented orogastric tube and connect it to continuous suction
to prevent bowel distension and further lung compression. avoid
mask ventilation and immediately intubate the trachea. Mechanical
ventilation strategies are targeted at avoiding high peak
inspiratory pressures and synchronizing ventilation with the
infant's respiratory effort. ECMO is a heart and lung bypass system
that does the job that the heart and lungs would be doing; ECMO may
be used temporarily while the baby's condition stabilizes and
improves. Surgery - When the baby's condition has improved, the
diaphragmatic hernia will be repaired with an operation. The
stomach, intestine and other abdominal organs are moved from the
chest cavity back to the abdominal cavity. The hole in the
diaphragm is repaired, or if the diaphragm is absent, an artificial
diaphragm will be constructed.
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- Thank you for your attention! No questions right