1. Respiratory Problems in the Newborn Infant: Evaluation and Etiology
Dr.AbdulRahman Alnemri , MD
Assistance professor
Head of Neonatal unit
pediatric Department, KKUH

2. Development Embryonic Glandular Canalicular Alveolar At 4 wks

3. Respiratory Distress History, physical examination
Downes' or RDS score - clinical
Arterial blood gases Pulse oximetry - SaO2
Chest x-ray
Serum glucose and calcium; central hematocrit; WBC and differential; platelet count
Maternal vaginal culture
Newborn surface (e.g., ear canal, gastric aspirate) smears, cultures (?); blood culture; urine culture (?); CSF culture (?)

4. Signs and Symptoms Tachypnea - above 60-80/minute
Grunting - prevents alveolar collapse
Retractions - compliant chest wall
Flaring of alae nasi, open mouth - decreases resistance
Cyanosis in room air
PaO2 below 60 mmHg (torr) in FIO2 >0.4
Reduced air entry
Apnea
Stridor

5. Evaluation and Etiology
Medical
Respiratory distress syndrome
Wet lung (transient tachypnea,  
 Aspiration syndromes        (meconium, blood)
 Persistent pulmonary hypertension of the newborn
Pneumonia/sepsis
 Hypoplastic lungs
Cardiac lesions
Central nervous system
Surgical
Diaphragmatic hernia/eventration
Esophageal atresia with or without TE fistula
 Lobar emphysema
Pneumothorax
Pleural effusion
Airway disorders
 Cystic lesions
 Mass lesions
 Phrenic nerve paralysis

6. Respiratory Distress Syndrome
870 gm 28 wks infant , Borne to 27ys old mother
G4 p3. By SVD, Abgar Score 6 , 8
After initial resuscitation
Tachypnea, grunting, Cynosis, IC& SC retraction
Tachycardia
Hypoperfusion
Hypoxia O2 Sat 85% 0n 100% Oxygen
What is (are) D/D ?
How to you manage this infant ?

7. Pathogenesis Inadequate Pulmonary Surfactant
Diffuse alveolar atelectasis
Hypoxia
Hypercapnea
Tachypnea
Grunding
Cynosis
Hypotension
Tachycardia
Mtabolic&Resp.
Acidosis

8. Management
Investigation
Stablization
Step 1
Step2
Treatment
Diagnosis

9. Surfactant Replacement therapy
Timing
Dose

10. Complications Pulmonary Hemorrhage Pneumothorax IVH + PDA + NEC
Infection
ROP
CLD or BPD

11. Wet Lung (TTN) Predisposing factors Cesarean section without labor
Perinatal distress
infants of diabetic mothers
Breech
Delayed cord clamping
Maternal sedation And IV large volumes

12. Signs and symptoms Term or near term male infant
Tachypnea ( breaths per minute)
Mild retraction
Mild Cyanosis
Hyperaeration
Occasional grunting and nasal flaring

13. Chest x-ray Increased markings centrally
Fluid in fissures and costophrenic angles
Hyperaeration may be present

14. Cont. Wet Lung Blood gases, SaO2 Hypoxemia
Acidosis or alkalosis may be present
Resolution one to five days; most improve during the first 24 hours
Management: oxygen, occasionally CPAP/PEEP

15. Pneumonia
Term infant 2.85kg boy, Borne to 34 yeas old mother G6 P4 +1 unbooked
Presented with SROM > 36 hs
Immediately after birth he started to has
Sever respiratory distress , associated with very soft ejection systolic murmur
What is (are) the diagnosis?
How do you manage this infant ?

16. Air leak syndrome
31 wks ,1200gm , admited to NICU with milde RDS, Connected to CMV with good blod gases and oxygen saturation.
2nd day developed sudden deterioration became hypoxic, skin mottling and low BP
What is your diagnosis ?
How do you manage this inbfant?

17. Air Leak Syndrome
Pneumothorax
PIE
Pneumopericardium
Pneumomediastinum

18. Meconium Aspiration
Term boy infant IDM born to 30 ys old mother with prolong second stage, Thick MSAF
How do you resuscitate this infant?
On admission to NICU he showed sever respiratory distress sever hypoxia What is the diagnosis and D/D ?
How do you manage such infant?
What are the complications ?

19. Congenital Diaphragmatic hernia
Term baby presented with cyanosis at birth
Physical exam refealed respiratory distress, a scaphoid abdomen, decrease breath sound on the left side.
What is the diagnosis ?
What is the immediate treatment ?
What is the long term management ?

20. ECHOC . Surgical Repair CDH Itubation N.G suction Oxygenation
Alkalosis
Inotrope support
Nitric Oxide
Surfactant
Sedation
Antibiotic
IV Nutrition
. Surgical
Repair
ECMO

21. Persistent Pulmonary Hypertension (persistent fetal circulation)
Secondary to another disorder (e.g., respiratory distress syndrome, aspiration, pneumonia, diaphragmatic hernia)
Affects primarily near-, full- and post-term infants
Increased pulmonary vascular resistance --> intracardiac right-to-left shunt (PDA, foramen ovale) --> hypoxemia, acidosis --> increased resistance --> increased shunt

22. Etiology
Acute pulmonary vasoconstriction (e.g., acidosis, hypoxia, RDS, pneumonia; hyperviscosity)
Increased pulmonary vascular smooth muscle with its extension (e.g., perinatal distress, aspiration ?) to arterioles surrounding alveoli
Decreased number of pulmonary blood vessels with excessive muscle (e.g., diaphragmatic hernia, other thoracic space-occupying lesions)

23. Esophageal Atresia withTEF
Term female newborn 3kg, presented with vomiting and abdominal distension
O/E Mild respiratory distress no dismorphic featurs had exseisve salivation
What is (are) the D/D ?
What is the line of management ?

24. Esophageal Atresia withTEF
General
Esophageal atresia with distal (TE) fistula (85%)
Esophageal atresia (10%)
H-type fistula (4-6%)

25. . Signs and symptoms Maternal polyhydramnios in 30-70% of patients
Excessive secretions and drooling after birth
Choking, coughing and cyanosis with feedings
Inability to pass an orogastric tube to the stomach
Respiratory distress
Congenital anomalies (50%) -VACTERL or VATER

26. X-ray Dilated proximal pouch in the mediastinum
Right upper lobe pneumonia or atelectasis (overflow of secretions)
Gastric dilatation and excessive air in the bowel loops if a fistula is present
No air in abdomen if a fistula is absent

27. Initial management
Intermittent suction or aspiration of the upper pouch, nasopharynx
Head and chest elevated 45 degrees from the horizontal
Prevent excessive crying
Antibiotics
Surgery when stable - gastrostomy should be done early

28. Congenital lobar emphysema
Location is usually left upper lobe, right middle lobe or right upper lobe, unless due to an aberrant vessel related to congenital heart disease
Partial obstruction of the airway on expiration leads to overdistention of the lobe; there is often abnormal bronchial cartilage
Intraluminal obstruction
Extraluminal compression, often associated with congenital heart disease (lower lobes)

29. Signs and symptoms Progressive respiratory distress Wheezing Cyanosis
Asymptomatic

30. . Chest x-ray Overdistention of the lobe
Compression of surrounding lobes
Mediastinal shift
Radiolucent lobe

31. Differential diagnosis
Lung cyst
Tension pneumothorax
Compensatory emphysema due to contralateral atelectasis
Pneumatocele

32. Initial management Ventilatory support with 100% oxygen Alkalosis
Good lung uppermost
Surgery

33. Pleural effusion (bilateral or unilateral)
Etiology
Chylothorax
Hydrops fetalis (immunologic or nonimmunologic)
Pneumonia
Turner syndrome
Wet lung
Congestive heart failure
Hemothorax
Parenteral nutrition or fluid extravasation

34. Airway Obstruction Foreign material Congenital subglottic stenosis
Choanal atresia
Micrognathia (Peirre Robin syndromes )
Macroglossia ( Trisomy 21 )
Laryngeal web, Laryngeal spasm
Vocal cord paralysis
Tracheo/laryngomalacia

35. MAS RD
HMD
CDH
Pneumonia

36. Thanks