Respiratory Distress

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<ul><li><p>Visual *</p><p>Respiratory Distress</p><p>Julniar M TasliHerman Bermawi</p></li><li><p>ObjectiveTo know the definition of respiratory distressMust be able to obtain a complete maternal and newborn historyCan perform a through physical examination Recognize the common respiratory disordersCan identify those that are life-treatening and rever them to the hospitals that have a NICU subdivison</p></li><li><p>Definiton RD in the newborn is characterized by one or more of thefollowing :- Nasal flaring- Chest restriction : suprasternal subcostal intercostal- Tachypnea- Grunting</p></li><li><p>Visual *EvaluationIs it a life threatening event or illness?</p></li><li><p>Initial AssesmentThe aim of initial assesment of the infant in RD to identify life treatening conditions that require prompt support (alarming for RD) :a. Obstructive airway: - gasping - choking - stridorb. Insufficient breathing : - apnea - poor respiratory effortc. Circulatory collaps : - bradycaria - hipotension - poor perfusiond. Poor oxygenation : - cyanosis</p></li><li><p>Learning Objective 1Visual *Evaluation of RespiratoryDistress Using Downs Score</p><p>Learning Objective 1</p></li><li><p>Learning Objective 1Visual *Evaluation of Respiratory Distress Using Downs ScoreScore &lt; 4No respiratory distress</p><p>Score 4 -7Respiratory distress</p><p>Score &gt; 7 Impending respiratory failure (Blood gases should be obtained)</p><p>Learning Objective 1</p></li><li><p>Visual *Be PreparedResuscitation equipment and/or suppliesInvolve others (team approach)Have staff trainedABCAirway BreathingCirculation</p></li><li><p>Physical examinationInspection : - alarming sign urgent attention - inspiratory stridor upper airway obstruction - asymetric chest + severe distress tension pneumothorax - scaphoid abdomen : congenital diaphragmatic hernia Auscultation : - the symmetry and adequacy of air exchange - abnormal breath sound</p><p>Transilumination of the chest</p></li><li><p>Visual *Conditions Associated with Respiratory Distress History : Maternal Obstertrical Symptom</p></li><li><p>Visual *</p></li><li><p>Differential diagnosis of respiratory distress</p></li><li><p>Visual *InvestigationsChest X-rayArterial blood gasCBC (anemia, polycythemia, sepsis)Glucose check (hypoglycemia)Blood culture (sepsis, pneumonia)</p></li><li><p>Visual *TreatmentAfter stabilization, treat the cause of RDUse CPAPAvoid unnecessary exposure to oxygenAntibiotics until sepsis is ruled out</p></li><li><p>Visual *Common Causes of RDTransient tachypnea of the newborn (TTN)Hyaline membrane disease (HMD)Meconium aspiration syndrome (MAS)Air leak syndromePneumoniaCongenital heart diseases</p></li><li><p>Learning Objective 3Visual *Transient Tachypnea of the Neonate (TTN)</p><p>Definition </p><p>A benign disease of near-term or term neonates who have respiratory distress shortly after delivery that resolves within 3-5 days.</p><p>Learning Objective 3</p></li><li><p>Visual *Pathogenesis of TTNHow is lung fluid formed?What is the function of lung fluids?What happens to lung fluids during labor?Does it matter the type of labor? </p></li><li><p>Learning Objective 3Visual *Transient Tachypnea of the Neonate (TTN) (cont)</p><p>Risk factors </p><p>Cesarean section without laborMacrosomiaMale sexProlonged laborExcessive maternal sedation Low Apgar score (&lt; 7 at 1 minute)</p><p>Learning Objective 3</p></li><li><p>Learning Objective 3Visual *Transient Tachypnea of the Neonate (TTN) (cont)Clinical Presentation of TTN </p><p>The neonate is usually near-term or term, and shortly after delivery has tachypnea (&gt;80 breaths/minute). The neonate may also have grunting, nasal flaring, rib retractions, and cyanosis. The disease usually does not last longer than 72 hours.</p><p>Learning Objective 3</p></li><li><p>Visual *</p></li><li><p>Learning Objective 3Visual *Transient Tachypnea of the Neonate (TTN) (cont)Chest X-ray: Perihilar streaking, mild cardiomegaly, increased lung volume, fluid in the minor fissure, and perhaps fluid in the pleural space are common findings.</p><p>Learning Objective 3</p></li><li><p>Learning Objective 3Visual *Transient Tachypnea of the Neonate (TTN) (cont)Management of TTN</p><p> Judicious use of oxygenFluid restriction Feeding as tachypnea improves Confirm the diagnosis by excluding other causes of tachypnea e.g. pneumonia, congenital heart disease, hyaline membrane disease, and cerebral hyperventilation.</p><p>Learning Objective 3</p></li><li><p>Learning Objective 3Visual *Transient Tachypnea of the Neonate (TTN) (cont)Outcome and Prognosis of TTN</p><p>The disease is self-limited and there is no risk of recurrence or further pulmonary dysfunction. Respiratory symptoms improve as intrapulmonary fluid is mobilized, and this is usually associated with diuresis.</p><p>Learning Objective 3</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) </p><p>DefinitionHyaline membrane disease (HMD) is also called respiratory distress syndrome (RDS). This condition usually occurs in a preterm neonate. Premature lungs are surfactant deficient.</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Respiratory difficulties exhibited include:Increasing tachypnea (&gt; 60/min)Chest retractionsCyanosis on room air that persists or progresses over the first 24-48 hours of life.Decreased air entryGrunting</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Incidence HMD occurs in about 25% of neonates born at 32 weeks gestation. The incidence increases with increasing prematurity.</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Risk Factors of HMD</p><p>Increased Risk</p><p>PrematurityMale sexNeonate of diabetic mother</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Risk Factors of HMDDecreased RiskChronic intrauterine stress Prolonged rupture of membranes Maternal hypertensionNarcotic useIntrauterine Growth Retardation (IUGR) or Small for Gestational Age (SGA)Corticosteroids Prenatal</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Investigations for HMD (RDS)Laboratory Studies: Blood gases: hypoxia, hypercarbia, acidosis.CBC and blood culture are required to rule out infection.Serum glucose levels are usually low.Chest X-ray Study:Reveals ground glass appearance with air bronchograms.</p><p>Learning Objective 4</p></li><li><p>Visual *</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Management of HMD (RDS)GeneralThermal regulation Parenteral fluid AntibioticsContinuous monitoring</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Continuous positive airway pressure (CPAP) is tried.If under CPAPPH &lt; 7.2Or PO2 &lt; 40mmHg FiO2 &gt; 60%Or PCO2 &gt; 60mmHBase deficit &gt; -10 Endotracheal intubation and mechanical ventilation.Consider surfactant therapy</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Caution: every 10 days on the ventilator is associated with 20% increased risk for cerebral palsy</p><p>Learning Objective 4</p></li><li><p>Learning Objective 4Visual *Hyaline Membrane Disease (Respiratory Distress Syndrome) (cont)Specific TreatmentSurfactant replacement therapy if tracheal intubation is requiredOutcomeRDS accounts for 20% of all neonatal deathsChronic lung diseases occurs in 29% in VLBW infants</p><p>Learning Objective 4</p></li><li><p>Visual *</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) Definition</p><p>The respiratory distress secondary to meconium aspiration by the fetus in utero or by the neonate during labor and delivery. </p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Pathogenesis: aspiration of meconium can cause:</p><p>Airway obstruction (ball and valve)Severe inflammationPulmonary hypertensionPlatelet activation</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Risk Factors of MAS</p><p>Post-term pregnancyMaternal hypertensionAbnormal fetal heart rateBiophysical profile 6Pre-eclampsiaMaternal diabetes mellitusSGAChorioamnionitis</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Clinical presentation of MAS</p><p>Meconium staining of amniotic fluid before birth.Meconium staining of neonate after birth.Respiratory distress leading to increased anteroposterior diameter of the chest.Persistent pulmonary hypertension of the newborn (PPHN).</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Investigations for MAS</p><p>Laboratory studiesBlood gas analysisBlood culture and CBC</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Investigations for MAS</p><p>Radiologic studiesChest X-ray: findings include patchy infiltrates, coarse streaking of both lung fields, hyperinflation of the lung and flattening of the diaphragm.</p><p>Learning Objective 5</p></li><li><p>Visual *</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Management of MAS</p><p>Prenatal management:Identification of high-risk pregnancy.Monitoring of fetal heart rate during labor.Amnioinfusion (?)</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) cont)Management of MAS</p><p>Delivery room management: (if amniotic fluid is meconium stained)Obstetrical: Suction of the oropharynx by obstetrician before delivery of shoulders.Pediatric: Visualization of vocal cords and tracheal suction if infant is not breathing.</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)General Management of Neonate with MAS</p><p>Empty the stomach contents to avoid further aspiration.Correction of metabolic abnormalities e.g. hypoxia, acidosis, hypoglycemia, hypocalcemia and hypothermia.Surveillance for end organ hypoxic/ischemic damage (brain, kidney, heart and liver).</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Respiratory Management of Neonate with MAS</p><p>Frequent suction and chest vibration.Pulmonary toilet to remove residual meconium if intubated.Antibiotic coverage (ampicillin and gentamicin).Use CPAP.</p><p>Learning Objective 5</p></li><li><p>Learning Objective 5Visual *Meconium Aspiration Syndrome (MAS) (cont)Outcome and Prognosis (MAS)</p><p>Mortality rate may be as high as 50%. Survivors may suffer from bronchopulmonary dysplasia and neurologic sequelae.</p><p>Learning Objective 5</p></li><li><p>Learning Objective 6Visual *Air Leak SyndromesDefinitionThe air leaks syndromes (pneumomediastinum, pneumothorax, pulmonary interstitial emphysema and pneumopericardium) comprise a spectrum of diseases with the same underlying pathophysiology. Overdistension of alveolar sacs or terminal airways leads to disruption of airway integrity, resulting in dissection of air into surrounding spaces.</p><p>Learning Objective 6</p></li><li><p>Learning Objective 6Visual *Air Leak Syndromes (cont)Incidence</p><p>Most commonly seen in neonates with lung disease who are on ventilatory support but can also occur spontaneously. The more severe the lung disease, the higher the incidence of pulmonary air leak.</p><p>Learning Objective 6</p></li><li><p>Learning Objective 6Visual *Air Leak Syndromes (cont)Risk Factors for Air Leak Syndromes</p><p>Spontaneous 0.5%Ventilatory support 15-20%CPAP 5% Meconium staining / aspirationSurfactant therapyVigorous resuscitation (bag ventilation)</p><p>Learning Objective 6</p></li><li><p>Visual *</p></li><li><p>Visual *</p></li><li><p>Learning Objective 6Visual *Air Leak Syndromes (cont)Clinical Presentation of Neonates with Air Leak Syndromes</p><p>Respiratory distress or sudden deterioration of clinical course with alteration of vital signs and worsening of blood gases.Asymmetry of thorax is present in unilateral cases.</p><p>Learning Objective 6</p></li><li><p>Learning Objective 6Visual *Air Leak Syndromes (cont)Investigations for Air Leak Syndromes</p><p>The definitive diagnosis of all air leak syndromes is made radiographically by an A-P chest X-ray film and a lateral film.</p><p>Learning Objective 6</p></li><li><p>Visual *</p></li><li><p>Learning Objective 6Visual *Air Leak Syndromes (cont)Management of Air Leak Syndromes</p><p>GeneralAvoid ventilatorsCareful use of manual bag ventilation SpecificDecompression of air leak according to the type.Do not needle the chest</p><p>Learning Objective 6</p></li><li><p>Learning Objective 7Visual *ApneaDefinitionCessation of respiration accompanied by bradycardia and/or cyanosis for more than 20 seconds.Incidence50-60% of preterm neonates have evidence of apnea (35% with central apnea, 5-10% with obstructive apnea, and 15-20% with mixed apnea).</p><p>Learning Objective 7</p></li><li><p>Learning Objective 7Visual *Apnea (cont)Risk Factors of Neonatal ApneaPathological apneaHypothermiaHypoglycemiaAnemiaHypovolemiaAspirationNEC / DistensionCardiac diseaseLung diseaseGastro intestinal refluxAirway obstructionInfection, meningitisNeurological disorders</p><p>Learning Objective 7</p></li><li><p>Learning Objective 7Visual *Apnea (cont)InvestigationsMonitoring at-risk neonates less than 32 weeks gestational age.Evaluate for a possible underlying cause.Laboratory studies should include a CBC, blood gas analysis, serum glucose, electrolyte, and calcium levels.Radiologic studies if chest disease is suspected</p><p>Learning Objective 7</p></li><li><p>Learning Objective 7Visual *Apnea (cont)Management of ApneaGeneral Therapy Perform tactile stimulation.CPAP in recurrent and prolonged apnea. Pharmacological therapy (caffeine or theophylline) may be required.Monitor levels.</p><p>Learning Objective 7</p></li><li><p>Learning Objective 7Visual *Apnea (cont)Management of Apnea</p><p>Specific TherapyTreatment of the cause, if identified, eg. treatment of sepsis, hypoglycemia, anemia, and electrolyte abnormalities.</p><p>Learning Objective 7</p></li><li><p>Learning Objective 7Visual *Apnea (cont)Outcome and Prognosis</p><p>In most neonates apnea resolves without the occurrence of long-term deficiencies.</p><p>Learning Objective 7</p></li><li><p>Learning ObjectivesVisual *Summary: Learning Objectives1. Evaluate the severity of respiratory distress using the Down's Score.2. Identify common neonatal respiratory disorders, including:Transient Tachypnea of the Newborn (TTN)Respiratory Distress Syndrome (RDS)Meconium Aspiration Syndrome (MAS)Air leak syndromesApneaPneumonia</p><p>Learning Objectives</p></li><li><p>Learning ObjectivesVisual *Summary: Learning Objectives (cont)3. Identify the risk factors, clinical presentation, required laboratory and radiological investigations, and management of TTN.4. Identify the incidence, risk factors, required laboratory and radiological investigations, and management of RDS.</p><p>Learning Objectives</p></li><li><p>Learning ObjectivesVisual *Summary: Learning Objectives (cont)5. Identify the risk factors, clinical presentation, required laboratory and radiological investigations, management of MAS.6. Identify the incidence, risk factors, clinical presentations, required radiological investigations, and management of air leak syndromes.</p><p>Learning Objectives</p></li><li><p>Learning ObjectivesVisual *Summary: Learning Objectives (cont)7. Identify the incidence, risk factors, causes, required investigations, and management of apnea.8. Identify the etiology, clinical presentation, required investigations, and management of pneumonia....</p></li></ul>