Presentation on theme: "Meconium Happens: Meconium Aspiration Syndrome John Salyer RRT-NPS, FAARC, MBA Director Respiratory Therapy Seattle Children’s Hospital and Research Institute."— Presentation transcript:
Meconium Happens: Meconium Aspiration Syndrome John Salyer RRT-NPS, FAARC, MBA Director Respiratory Therapy Seattle Children’s Hospital and Research Institute
What is meconium aspiration? Meconium is the first intestinal discharge of the newborn Epithelial cells, fetal hair, mucus, bile Intrauterine stress may cause in utero passage of meconium Aspirated by the fetus when fetal gasping or deep breathing occurs stimulated by hypoxia and hypercarbia Warning sign of fetal distress
Frequency of meconium stained amniotic fluid = 8-19 % Of MEC stained infants: 30 % depressed at birth 10 % meconium aspiration syndrome (range 5-33 %) Of infants with MEC aspiration syndrome 17 % deliver through thin meconium (range 7-35 %) 35 % need mechanical ventilation (range %) 12 % die (range 5-37 %) Meconium: The Stats
PO 2 L --> R ductus arteriosus shunt Ventilation Remove Placenta Ductus Venosus Closes Systemic Vascular Resistance Umbilical Venous Return IVC Return RA Pressure Pulmonary Venous Return LA Pressure Foramen Ovale Closes Pulmonary Vascular Resistance
Goldsmith JP. J Perinatology 2008:28;S49-S55
Ventilation Strategy for MAS Settings 1.Relatively Rapid Respiratory Rates breaths/min 2.Lowest PIP sufficient for chest excursion Start at 16/5 and institute HFOV for PIP>25 target V T 4-6 mL/kg BW ECLS for mPaw>14 Heavy sedation for gas trapping 3.Short Inspiratory Times s Longer Expiratory Times and lower PEEP for gas trapping 4.Nitric Oxide works well in this population Blood Gases 1.No pulmonary hypertension pCO 2 levels pH > 7.30 Pa Pulmonary hypertension pCO 2 levels pH > 7.35 Pa
Airflow Scalars in a patient with MAS
OHSU Experience: Inborn + Transfers MAS = Meconium aspiration syndrome as primary pulmonary diagnosis No pulmonary hypoplasia or major congenital anomalies MAS+ vent = ventilated with pulmonary diagnosis of MAS or PPHN ECMO = MAS infants transferred for ECMO Died : * 1 infant in each of the years died with a diagnosis of severe HIE
Infant Active Infant Depressed Intrapartum suctioning of mouth, nose, pharynx Intubate and suction trachea Other resuscitation as indicated Observe Meconium in Amniotic Fluid Meconium in Amniotic Fluid
Meconium Aspiration Syndrome Pathophysiology Airway obstruction of large and small airways Inflammation and edema Protein leak Inflammatory Mediators Direct toxicity of meconium constituents = chemical pneumonitis Surfactant dysfunction or inactivation Effects of in utero hypoxemia and acidosis Altered pulmonary vasoreactivity (PPHN)
Meconium Aspiration Syndrome Diagnosis Known exposure to meconium stained amniotic fluid Respiratory symptoms not explained by other cause R/O pneumonia, RDS, spontaneous air leak CXR changes - diffuse, patchy infiltrates, consolidation, atelectasis, air leaks, hyperinflation
Meconium Aspiration Syndrome Treatment Ventilation strategies Avoid air leak, check CXR with acute deterioration Prevent pulmonary hypertension - generous O2 HFOV if unable to maintain on conventional vent Steroids (no human data, controversial) ROS, Antibiotics (ampicillin, gentamicin) Surfactant Inhaled Nitric Oxide ECMO
Other Things to Watch For Hypoxia Acidosis Hypoglycemia Hypocalcemia End-organ damage due to perinatal asphyxia
Fox WW,. Pediatrics 1975; 56: 214–217.
Meconium Aspiration Syndrome Surfactant Treatment Methods < 6 hours old with MAS 20 infants randomized to receive 150 mg/kg surfactant by 20 minute infusion, q6h x4 doses maximum On ventilator - FiO 2 > 50%, MAP > 7, a:A PO 2 < 0.22 Endpoint = improvement in OI and a:A PO 2 No difference in groups Findlay et al. Pediatrics 97 (1): 48, 1996.
Meconium Aspiration Syndrome Surfactant Treatment Results No infant received more than 3 doses Significant improvement in OI, MAP, FiO 2 within 3-6 hours after 2 nd dose of surfactant Significant improvement in a:A PO 2 within 1 hour of 1 st dose of surfactant Findlay et al. Pediatrics 97 (1): 48, 1996.
Meconium Aspiration Syndrome Outcome High incidence long term pulmonary problems At 6 months - 23% MAS with regular bronchodilator therapy* FRC was higher in symptomatic infants IPPV and O2 were not predictors of problems Increased risk of poor neurologic outcome due to perinatal insult - seizures, CP, mental retardation *Yuksel et al. Pediatric Pulmonology 16:358, 1993