CONGENITAL AND ACQUIRED RESPIRATORY DISORDERS IN INFANTS
CONGENITAL AND ACQUIRED RESPIRATORY DISORDERS IN INFANTS
OBJECTIVESOBJECTIVES
Review of Cardio-Pulmonary Development. Review of Cardio-Pulmonary Development. Define changes that occur during transition Define changes that occur during transition
to extra-uterine life with emphasis on to extra-uterine life with emphasis on breathing mechanics.breathing mechanics.
Identify infants at risk for and who have Identify infants at risk for and who have respiratory distressrespiratory distress
Review of common neonatal disease states.Review of common neonatal disease states.
STAGES OF
NORMAL LUNG GROWTH
STAGES OF
NORMAL LUNG GROWTHEmbryonic - first 5 weeks; formation of proximal Embryonic - first 5 weeks; formation of proximal
airwaysairways
Pseudoglandular - 5-16 weeks; formation of Pseudoglandular - 5-16 weeks; formation of conducting airwaysconducting airways
Canalicular - 16-24 weeks; formation of aciniCanalicular - 16-24 weeks; formation of acini
Saccular - 24 - 36 weeks; development of gas-Saccular - 24 - 36 weeks; development of gas-exchange unitsexchange units
Alveolar - 36 weeks and up; expansion of surface Alveolar - 36 weeks and up; expansion of surface areaarea
Pseudoglandular6-16 weeks
Pseudoglandular6-16 weeks
Canalicular Phase16-24 weeks
Canalicular Phase16-24 weeks
Saccular Phase24-34 weeks
Saccular Phase24-34 weeks
PHYSIOLOGIC MATURATION(Surfactant Production)PHYSIOLOGIC MATURATION(Surfactant Production) Type 2 pneumocytes appear at 24-26 weeksType 2 pneumocytes appear at 24-26 weeks
Responsible for reduction of alveolar surface tension.Responsible for reduction of alveolar surface tension. LaPlace’s LawLaPlace’s Law
Lipid profile as indicator of lung maturityLipid profile as indicator of lung maturity L/S RatioL/S Ratio Flourescence Polarization - FLMFlourescence Polarization - FLM
Many other factors influence lung maturationMany other factors influence lung maturation
Maturational FactorsMaturational Factors
StimulationStimulation Glucorticoids, ACTHGlucorticoids, ACTH Thyroid Hormones, Thyroid Hormones,
TRFTRF EGFEGF HeroinHeroin Aminophyline,cAMPAminophyline,cAMP InterferonInterferon EstrogensEstrogens
InhibitionInhibition Diabetes (insulin, Diabetes (insulin,
hyperglycemia, butyric hyperglycemia, butyric acid)acid)
TestosteroneTestosterone TGF-BTGF-B BarbituratesBarbiturates ProlactinProlactin
FETAL CIRCULATIONFETAL CIRCULATION
TRANSITIONTO
EXTRA-UTERINE LIFE
TRANSITIONTO
EXTRA-UTERINE LIFE Fetal BreathingFetal Breathing Instantaneous; liquid filled to air filled lungsInstantaneous; liquid filled to air filled lungs Maintenance of FRCMaintenance of FRC Placental blood flow terminationPlacental blood flow termination Decreased PVRDecreased PVR Closure of fetal shuntsClosure of fetal shunts
MECHANICS OF BREATHINGMECHANICS OF BREATHING
Respiratory Control Center...CNSRespiratory Control Center...CNS Metabolic NeedsMetabolic Needs
Negative pressure breathingNegative pressure breathing Compliance and ResistanceCompliance and Resistance
Inspiratory MusclesInspiratory Muscles Rib Cage Rib Cage
““Compliability becomes a liability”Compliability becomes a liability”
Signs of Respiratory DistressSigns of Respiratory Distress
TachypneaTachypnea Intercostal retractionsIntercostal retractions Nasal FlaringNasal Flaring Grunting Grunting CyanosisCyanosis
When is it abnormal to show signs of respiratory distress?When is it abnormal to show signs of respiratory distress? When tachypnea, retractions, flaring, or When tachypnea, retractions, flaring, or
grunting persist beyond one hour after grunting persist beyond one hour after birth.birth.
When there is worsening tachypnea, When there is worsening tachypnea, retractions, flaring or grunting at any retractions, flaring or grunting at any time.time.
Any time there is cyanosisAny time there is cyanosis
Causes of Neonatal Respiratory DistressCauses of Neonatal Respiratory Distress Obstructive/restrictive - mucous, choanal atresia, Obstructive/restrictive - mucous, choanal atresia,
pneumothorax, diaphragmatic hernia.pneumothorax, diaphragmatic hernia. Primary lung problem - Respiratory Distress Primary lung problem - Respiratory Distress
Syndrome (RDS), meconium aspiration, bacterial Syndrome (RDS), meconium aspiration, bacterial pneumonia, transient (TTN).pneumonia, transient (TTN).
NonNon-pulmonary -hypovolemia/hypotension, -pulmonary -hypovolemia/hypotension, congenital heart disease, hypoxia, acidosis, congenital heart disease, hypoxia, acidosis, cold stress, anemia, polycythemiacold stress, anemia, polycythemia
Infants at Risk for Developing Respiratory DistressInfants at Risk for Developing Respiratory Distress Preterm InfantsPreterm Infants Infants with birth asphyxiaInfants with birth asphyxia Infants of Diabetic MothersInfants of Diabetic Mothers Infants born by Cesarean SectionInfants born by Cesarean Section Infants born to mothers with fever, ProlongedInfants born to mothers with fever, Prolonged
ROM, foul-smelling amniotic fluid.ROM, foul-smelling amniotic fluid. Meconium in amniotic fluid.Meconium in amniotic fluid. Other problemsOther problems
Evaluation of Respiratory DistressEvaluation of Respiratory Distress Administer Oxygen and other necessary Administer Oxygen and other necessary
emergency treatmentemergency treatment Vital sign assessmentVital sign assessment Determine cause-- physical exam, Chest Determine cause-- physical exam, Chest
x-ray, ABG, Screening tests: Hematocrit, x-ray, ABG, Screening tests: Hematocrit, blood glucose, CBCblood glucose, CBC
Sepsis work-upSepsis work-up
Principles of TherapyPrinciples of Therapy
Improve oxygen delivery to lungsImprove oxygen delivery to lungs-- supplemental -- supplemental oxygen, CPAP, assisted ventilation, surfactantoxygen, CPAP, assisted ventilation, surfactant
Improve blood flow to lungsImprove blood flow to lungs-- volume expanders, blood -- volume expanders, blood transfusion, partial exchange transfusion for high transfusion, partial exchange transfusion for high hematocrit, correct acidosis (metabolic/respiratory)hematocrit, correct acidosis (metabolic/respiratory)
Minimize oxygen consumptionMinimize oxygen consumption-- neutral thermal -- neutral thermal environment, warming/humidifying oxygen, withhold environment, warming/humidifying oxygen, withhold oral feedings, minimal handlingoral feedings, minimal handling
DISEASE STATESDISEASE STATES
Respiratory Distress SyndromeRespiratory Distress Syndrome Transient Tachypnea of the NewbornTransient Tachypnea of the Newborn Meconium Aspiration SyndromeMeconium Aspiration Syndrome Persistent Hypertension of the NewbornPersistent Hypertension of the Newborn Congenital PneumoniaCongenital Pneumonia Congenital MalformationsCongenital Malformations Acquired ProcessesAcquired Processes
RESPIRATORY DISTRESS SYNDROME
RESPIRATORY DISTRESS SYNDROME
Surfactant DeficiencySurfactant Deficiency
Tidal Volume VentilationTidal Volume Ventilation
Pulmonary Injury SequencePulmonary Injury Sequence
CLINICAL FEATURES OF RDS
CLINICAL FEATURES OF RDS
Tachypnea/ApneaTachypnea/Apnea DyspneaDyspnea Grunting/FlaringGrunting/Flaring HypoxemiaHypoxemia Radiographic FeaturesRadiographic Features Pulmonary Function AbnormalitiesPulmonary Function Abnormalities
Early RDSEarly RDS
Progressive RDSProgressive RDS
Late RDSLate RDS
Hyaline Membrane DiseaseHyaline Membrane Disease
THERAPY FOR RDSTHERAPY FOR RDS
Oxygen - maintain PaO2 > 50 torrOxygen - maintain PaO2 > 50 torr Nasal CPAPNasal CPAP Intermittent Mandatory VentilationIntermittent Mandatory Ventilation Surfactant ReplacementSurfactant Replacement High Frequency VentilationHigh Frequency Ventilation Intercurrent TherapiesIntercurrent Therapies
PIEPIE
PIE PathologyPIE Pathology
PIE HistologyPIE Histology
Pneumothorax/PIEPneumothorax/PIE
PneumothoraxPneumothorax
PneumopericardiumPneumopericardium
TRANSIENT TACHYPNEA OF THE NEWBORN
TRANSIENT TACHYPNEA OF THE NEWBORN
Delayed Fluid ResorptionDelayed Fluid Resorption Hard to differentiate early on from RDS Hard to differentiate early on from RDS
both clinicaly and radiographicaly both clinicaly and radiographicaly especially in the premature infantespecially in the premature infant
Initial therapy similar to RDS, but hospital Initial therapy similar to RDS, but hospital course is quite differentcourse is quite different
Wet LungWet Lung
MECONIUM ASPIRATION SYNDROME
MECONIUM ASPIRATION SYNDROME
Chemical PneumonitisChemical Pneumonitis Surfactant InactivationSurfactant Inactivation Potential for InfectionPotential for Infection Potential for Pulmonary HypertensionPotential for Pulmonary Hypertension Management varies on severityManagement varies on severity
Meconium AspirationMeconium Aspiration
PERSISTENT PULMONARY HYPERTENSION
PERSISTENT PULMONARY HYPERTENSION
Usually secondary to primary pulmonary Usually secondary to primary pulmonary disease statedisease state
Pulmonary Vascular LabilityPulmonary Vascular Lability Treat the underlying problemTreat the underlying problem Maintain normo-oxygenationMaintain normo-oxygenation Selective Pulmonary VasodilatorsSelective Pulmonary Vasodilators Pray for good luckPray for good luck
PPHNPPHN
CONGENITAL PNEUMONIACONGENITAL PNEUMONIA
Infectious; primarily GBSInfectious; primarily GBS Amniotic Fluid aspirationAmniotic Fluid aspiration Viral etiologyViral etiology Surfactant inactivationSurfactant inactivation
GBS PneumoniaGBS Pneumonia
CONGENITAL MALFORMATIONSCONGENITAL MALFORMATIONS
Choanal AtresiaChoanal Atresia Tracheal Atresia/stenosisTracheal Atresia/stenosis Chest MassChest Mass
Diaphragmatic herniaDiaphragmatic hernia CCAMCCAM SequestrationSequestration Lobar emphysemaLobar emphysema
CCAMCCAM
Lobar EmphysemaLobar Emphysema
Diaphragmatic HerniaDiaphragmatic Hernia
ChylothoraxChylothorax
Phrenic Nerve ParalysisPhrenic Nerve Paralysis
ACQUIRED DISEASESACQUIRED DISEASES
InfectionsInfections Bronchopulmonary DysplasiaBronchopulmonary Dysplasia Sub-glottic stenosisSub-glottic stenosis Apnea of PrematurityApnea of Prematurity
Early BPDEarly BPD
Progressive BPDProgressive BPD
Late BPDLate BPD
APNEAAPNEA
Definition: cessation of breathing Definition: cessation of breathing for longer than a 15 second period for longer than a 15 second period or for a shorter time if there is or for a shorter time if there is bradycardia or cyanosisbradycardia or cyanosis
Babies at Risk for ApneaBabies at Risk for Apnea
PretermPreterm Respiratory DistressRespiratory Distress Metabolic DisordersMetabolic Disorders InfectionsInfections Cold-stressed babies who are being warmedCold-stressed babies who are being warmed CNS disordersCNS disorders Low Blood volume or low HematocritLow Blood volume or low Hematocrit Perinatal CompromisePerinatal Compromise Maternal drugs in laborMaternal drugs in labor
Anticipation and DetectionAnticipation and Detection
Place at-risk infants on cardio-Place at-risk infants on cardio-respiratory monitorrespiratory monitor
Low heart rate limit (80-100)Low heart rate limit (80-100) Respiratory alarm (15-20 seconds)Respiratory alarm (15-20 seconds)
Treatment Treatment
Determine cause:Determine cause: x-rayx-ray blood sugarblood sugar body and environmental temperaturebody and environmental temperature hematocrithematocrit sepsis work upsepsis work up electrolyteselectrolytes cardiac work upcardiac work up r/o seizurer/o seizure
TreatmentTreatment
CPAPCPAP Theophylline/Caffeine therapyTheophylline/Caffeine therapy Mechanical ventilationMechanical ventilation Apnea monitorApnea monitor