Presentation on theme: "TTN vs. TTT (Time to Transport):"— Presentation transcript:
1TTN vs. TTT (Time to Transport): Assessment of Neonatal Respiratory DistressChildren’s/March of Dimes Neonatal ConferenceMay 17, 2010Mark Bergeron, MD, MPHAssociates in Newborn Medicine, PA, St. PaulAssistant Professor, Pediatrics, University of Minnesota Medical School
2DisclosuresI will not be discussing any experimental or off-label uses for any therapies during this presentation.I have no relevant financial relationships to declare.
3ObjectivesFormulate a differential diagnosis for the infant in respiratory distress.Describe initial stabilization measures for the infant in respiratory distress.Describe situations where ongoing respiratory distress requires transfer to a NICU for further management.
5Respiratory distress is a frequent problem in the newborn period. IntroductionRespiratory distress is a frequent problem in the newborn period.Most common indication for evaluation or re-evaluation of the newborn infantAffects as many as 7% of newbornsPotentially life-threateningMust be promptly assessed and managed by an on-site provider in the delivery room or newborn nursery
11Case #13.6-kg term newborn female (20 minutes old) has tachypnea and acrocyanosis. She is 40 weeks EGA delivered by scheduled repeat c-section and Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.Vitals are normal with the exception of a respiratory rate of 84 and exam is notable for slight subcostal retractions but otherwise normal. Over the next several hours, her respiratory rate steadily improves to the 40s and her acrocyanosis resolves.
12Transient Tachypnea of the Newborn (TTN) Most common etiology of newborn respiratory distress.11/1000 live birthsRepresents 40% of cases of newborn respiratory distress.Caused by delayed clearance of fetal lung fluid in both term and preterm infants
13Guglani et al. Pediatrics in Review 2008 TTN Risk FactorsAt birth:Air spaces rapidly clear fluid from lung expansion with airPromoted by:LaborMaternal epinephrine surgeGuglani et al. Pediatrics in Review 2008
14TTN: Clinical Findings History:C/S > NSVDExam:Tachypnea +/-GruntingNasal flaringRetractionsTransient oxygen needLab:Mild respiratory acidosis or normal blood gas
15TTN: Radiographic Findings Chest X-ray:Increased interstitial markings (“wet lung”)Increased fluid in interlobar fissuresImage: Aly H. Pediatrics in Review (2004)
16TTN: Typical CourseUsually benign, self-limitedOccasionally requires therapy:OxygennCPAPMechanical ventilationDiuretics not effectivei.e. LasixTypically resolves by 2 days of ageNo lasting sequalae
17Case #21.2-kg male infant born vaginally at 32 weeks EGAApgars 6, 8Required bulb suctioning, brief PPV.Grunting, retractions, nasal flaring, acrocyanosis immediately after birth.VS: HR 178, RR 79, Mean BP 39 mmHg. O2 sat 74-78% in room air.
18Lab: Case # 2 Continued CBC unremarkable ABG: 7.26/67/58/19CXR: “Prominent reticulogranular pattern uniformly distributed with hypoaeration of lungs. Increased air bronchograms are observed.”emedicine.com
19Respiratory Distress Syndrome (RDS) Also called hyaline membrane disease.Most common cause of respiratory distress in preterm infants.Due to structural and functional immaturity of lungs.Underdeveloped parenchymaSurfactant deficiencyType II pneumatocytesResults in decreased lung compliance, unstable alveoli
20RDS Continued Risk factors Prematurity <28 weeks GA (≈100%) Perinatal depressionMale predominanceMaternal diabetesC-sectionMultiple birth
21Respiratory Distress Syndrome: Clinical Finings Exam:Moderate to severe respiratory distressTachypneaGruntingApneaRetractionsNasal flaringCyanosisLab:Moderate hypoxiaRespiratory acidosisMetabolic acidosis (delayed)X-ray:Low lung volumesDiffuse atelectasis: “ground glass opacities”Air bronchogramsDifficult to distinguish from pneumoniaemedicine.com
22RDS: Typical Course Prevention: Antenatal bethamethasone Arrest of preterm laborTreatmentOxygen supplementationAssisted ventilationnCPAPmechanical ventilationFiO2 > .40Exogenous surfactant replacementFluid restrictionOutcomePeak severity 1-3 daysRecovery coincides with diuresis beginning at 72 hrsSevere cases evolve into bronchopulmonary dysplasia (chronic lung disease)Extreme prematurityProlonged mechanical ventilationSepsis
23Case #34.2-kg female infant is cyanotic and tachypneic at 30 minutes of age following a vaginal delivery through meconium-stained amniotic fluid. Apgar scores were 3 and 6. She had a spontaneous but weak cry at birth and received some positive pressure ventilation followed by suctioning.Vitals signs reveal a pulse of 169, respiratory rate of 115, and a mean BP of 55. Sats are 76% despite 100% O2 by headbox. She is barrel-chested, retracting, grunting, and has diminished coarse breath sounds bilaterally.She is electively intubated, lines placed and labs sent.
24Case # 3 Continued Lab: CXR: CBC: NL ABG: 7.19/72/36 Image: Aly H. Pediatrics in Review (2004)
25Meconium Aspiration Syndrome (MAS) Meconium staining of amniotic fluid complicates nearly 15% of all deliveries.Fetal distressPrimarily term and post-termMeconium can be aspirated before, during or after delivery.Once aspirated, meconium causesChemical pneumonitisMechanical obstruction (“ball-valve”) with severe air-trappingPneumothoraces (10-20%)Surfactant inactivationSevere hypoxemia and hypoventilationV/Q mismatch
26Meconium Aspiration Syndrome: Clinical Presentation Exam:Air trapping with barrel chestModerate to severe respiratory distressRales and/or rhonchiHypoxia with cyanosisHypoperfusionLab:AcidosisRespiratory and metabolicCXR:Hyperinflation/overdistensionDiffuse, patchy intraparenchymal opacities
27Meconium Aspiration Syndrome: Typical Course ComplicationsSepsis/pneumoniaAirleaksPneumothorax/pneumopericardiumPersistent pulmonary hypertension (PPHN)Treated with inhaled Nitric Oxide (iNO)ECMOResolutionDays to weeksMortality 10-12%Prevention?NRPTreatment:OxygenMechanical ventilationHigh-FrequencyJetOscillatorSurfactant replacement
28Case #43.9-kg male infant develops poor feeding, tachypnea and mild oxygen need at 14 hrs of life.Exam: equal and clear breath sounds with tachypnea. Otherwise unremarkable.Labs: WBC 4.3 x 103, ABG NL, electrolytes and glucose acceptable.CXR:indyrad.iupi.edu
29Congenital Pneumonia: Clinical Presentation Most common neonatal infectionWide variety of presenting signsVarying degree of respiratory distressLethargy, poor feedingApneaTemperature instabilityHigh or lowCXR: “Can look like anything!”Mild focal opacitiesPleural effusion(s)Complete white-outNormal
30Pneumonia: Epidemiology Hematogenous vs. aspiration acquisitionAntenatal, perinatal, or postnatally acquiredCommon organisms:Antenatal: rubella, CMV, HSV, adenovirus, Toxoplasma gondii, Treponema pallidum, Mycobacterium tuberculosis, Listeria monocytogenes, Varicella zoster and othersPerinatal: GBS, E. coli, Klebsiella, Chlamydia trachomatisPostnatal: adenovirus, RSV, Streptococcus, Staphylococcus, gram negative enterics
31Congenital Pneumonia: Typical Course Transient oxygen needGradual resolution of tachypneaAntibiotic (ampicillin, gentamicin) therapy 5-7 days unless complicated by sepsis or for specific organism requiring longer courses of therapy
37Other Pulmonary Causes of Respiratory Distress PneumothoraxNeopix (pedialink.org)
38Non-Pulmonary Causes of Respiratory Distress: Congenital Heart Disease
39Congenital Heart Disease CyanoticTransposition of the great arteriesTotal anomalous pulmonary venous returnTricuspid atresiaTetralogy of FallotTruncus arteriosusPulmonary atresiaSevere CHFEbstein’s anomalyDouble outlet right ventricleAcyanoticHypoplastic left heart syndromeInterrupted aortic archCritical aortic stenosisPatent ductus arteriosusVSD/ASDAV canal defectCoarctation of the aorta*Valvular defects* May present as cyanotic or acyanotic
41Differentiating CHD from Pulmonary Disease Aly H. Pediatrics in Review (2004)
42Management of the Newborn with Respiratory Distress
43Initial Assessment: “ABCs” Next:StabilizeGather dataGenerate DDxFinally:Consult?Manage or TransferFirst:AirwayBreathingCirculation
44Initial Assessment, continued Identify life-threatening conditions that require prompt supportInadequate or obstructed airwayGaspingChokingStridorInadequate oxygenationCyanosisCentral vs. peripheralInadequate ventilationTachypneaGruntingNasal flaringRetractionsInadequate perfusionPallorCapillary refill
45Prolonged maternal rupture of membranes? Maternal GBS status? Clues from the History?Prolonged maternal rupture of membranes?Maternal GBS status?Maternal fever?Fetal distress?Meconium?Onset of respiratory distress?Immediate?Delayed?
47Management Supplemental oxygen: Blow by Head box Nasal cannula Face maskMonitoringHR, RRPulse oxHow long?2 hrs?4 hrs?Longer?NPO
48Hermansen CL, Lorah KN. American Family Physician. 2007.
49Unclear risk factors or presentation? ManagementInfants with TTN and no sepsis risk factors likely just need support and observation.Infants with possible meconium aspiration, RDS, sepsis or pneumonia require a sepsis evaluation with blood culture, cbc and IV antibiotics x 48hrs and repeat CXR(s).Unclear risk factors or presentation?Undertake sepsis evaluation
50So when to transport?! It depends… Failure to resolve in 2-4 hrs Worsening conditionPerfusionOxygen needsDistressStaff ability/comfort/availabilityIV accessAirwayAny suspicion of cardiac disease
51Respiratory distress is common! Most do well with little intervention. Take-Home PointsRespiratory distress is common!Most do well with little intervention.Short differential dxWhen to transport is up to you!Every situation is uniqueHelp is just a phone call away!
52How to Arrange Transport? Neonatologist on-call (In-house 24/7)St. Paul NICU:(800)(651)Minneapolis NICU:(800)(612)Transport teamCentralized Children’s Neonatal Transport Team in 2010AirHelicopterFixed-wing planeGround
53ReferencesAly H. Respiratory disorders in the newborn: Identification and diagnosis. Pediatrics in Review 2004;25:Guglani L, Lakshminrusimha S, Ryan RM. Transient tachypnea of the newborn. Pediatrics in Review 2008;29:e59-e65.Hermansen CL, Lorah KN. Respiratory distress in the newborn. American Family Physician 2007;76:Additional suggested reading:Fidel-Rimon O, Shinwell ES. Respiratory distress in the term and near-term infant. NeoReviews 2005;6:e289-e296.Suggested resources:NRP Program, AAP/AHAS.T.A.B.L.E. Program