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

Development Embryonic Glandular Canalicular Alveolar At 4 wks

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 (?)

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

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

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 ?

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

Management Investigation Stablization Step 1 Step2 Treatment Diagnosis

Surfactant Replacement therapy Timing Dose

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

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

Signs and symptoms Term or near term male infant Tachypnea (80-120 breaths per minute) Mild retraction Mild Cyanosis Hyperaeration Occasional grunting and nasal flaring

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

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

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 ?

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?

Air Leak Syndrome Pneumothorax PIE Pneumopericardium Pneumomediastinum

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 ?

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 ?

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

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

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)

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 ?

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

. 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

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

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

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)

Signs and symptoms Progressive respiratory distress Wheezing Cyanosis Asymptomatic

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

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

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

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

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

MAS RD HMD CDH Pneumonia

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