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RESPIRATORY DISTRESS IN NEWBORN final.pptx
- 1. RESPIRATORY DISTRESS IN NEWBORN By : Ashwin Kumar
- 2. B/O Nancy, baby boy born via SVD at 38 weeks with birth weight 3kg Mother is 39 year old, para 4, with anemia in pregnancy She presented with contraction pain and fever 1 day before the delivery, her UFEME showed leucocyte 2+, nitrate negative and she was started on cephalexin for 3 days (TWC 6.51, plt 305), Mothers HVS no growth Subsequently progress into labor and baby born vigorous with good AS (9/10/10) However baby was tachypnea with labile saturation (Spo2 88-90% under room air) at nursery and started on nasal prong at around 2 hours of life and worsening respiratory distress with tachypnea, retractions, and grunting at 4 hours of life and was intubated. Case scenario
- 3. Presumed sepsis Congenital pneumonia Transient tachypnea of newborn (TTN) Persistent pulmonary hypertension of newborn (PPHN) primary or secondary RDS/ hyaline membrane Congenital heart disease Congenital diaphragmatic of hernia Differential diagnosis of respiratory distress in newborn?
- 4. On examination, patient was intubated, tachypnea with recession, good perfusion, other neonatal examinations are normal Lungs clear, equal a/e, CVS DRNM, PA soft BP stable, SPO 100% under low ventilator settings (Pr 18/6, FiO2 30%) FBC normal (TWC 24 (NEU 69.6 %/Lym 15 %)/ HB 20.6/PLT 198/HCT 66.4) ABG : ph. 7.32/Pco2 38/PO2 99 /HCO3 19.6/BE -6.0 CRP : 2.2 Bedside ECHO: TR jet , balanced chamber size, good contractibility Case scenario
- 5. Case scenario ETT Ryle tube 9 ribs Lungs expansion Bilateral lung infiltrates with consolidation mainly in the middle and right lower lobe Left Costophrenic angles - clears 1 2 3 4 5 6 7 8 9 Right costophrenic angles - blunt 1 2 3 4 5 6 7 8 9
- 6. Differential Differential Point support Point against Congenital pneumonia Mother has fever and UTI Respiratory distress CXR Presumed sepsis Mother has fever and UTI Respiratory distress CXR no obvious consolidation Transient tachypnea of newborn Respiratory distress Respiratory distress at 4 hours of life TTN usually right after birth More commonly seen in LSCS CXR not characteristic for TTN Persistent pulmonary hypertension of newborn Respiratory distress Labile Saturation Stable under low ventilator setting ECHO normal Congenital heart disease Respiratory distress Labile Saturation ECHO normal Congenital diaphragmatic of hernia Respiratory distress CXR- no evidence of CDH
- 7. Treated as congenital pneumonia Treatment - Ventilated for 3 days and successfully extubated to nasal prong - Not require inotropes throughout the admission - Completed IV ampicillin and gentamicin for 5 days, blood culture NG - Started feeding at day 1 of life and achieved full feeding Progress
- 9. Objectives Recognize newborn with respiratory distress Understand the differential diagnosis of RDS Learn the pathophysiology, presentation diagnosis and management for the most common causes
- 10. You have called to labour room to review a term baby who is tachypnoea soon after delivery
- 11. Transient tachypnea of newborn (TTN) Congenital pneumonia Respiratory distress syndrome (RDS) Meconium aspiration syndrome (MAS) Persistent pulmonary hypertension of newborn Pneumothorax Congenital heart disease Congenital diaphragmatic of hernia Congenital lung malformation Differential diagnosis
- 12. How old Gestational age (Preterm, term/ post date) Mode of delivery (SVD? LSCS?) Risk factors for sepsis ? Antibiotic given? Antenatal history HVS result? GBS ? Amniotic fluid (Clear? Meconium? CTG, fetal heart rate Take relevant history
- 13. Nasal flaring Tachypnoea, RR > 60 Subcostal, intercostal recession Grunting Cyanosis Lethargy Signs of respiratory distress
- 14. TTN Most common aetiology Impaired clearance of fetal fluid from lungs at birth Infant born via caesarean section Typically present right after birth Treatment: Respiratory support Resolved 48-72 hours (6 hours)
- 15. TTN Fluid in the fissure Hyperexpanded lungs Flattened diaphragms Streaky infiltrates Fluffy densities (alveolar oedema)
- 16. Congenital pneumonia Tend to be more sick (poor feeding, apnoea, poor perfusion, tachycardia) Present of risk factor: Infant of GBS carrier mother, maternal chorioamnionitis, maternal pyrexia, leaking > 18 hours Investigations: raised TWC, Low plt, raised CRP Treatment: respiratory support, antibiotic, nutrition
- 17. Congenital pneumonia Consolidation with air bronchograms Poor lungs expansion
- 18. RDS Most commonly seen in premature baby Surfactant deficiency in immature lung (Surfactant decrease alveolar surface tension which helps with alveolar expansion and decrease risk of atelectasis. Risk: Extreme premature, no/incomplete antenatal steroid
- 19. RDS Low lung volumes Poor lungs expansion Ground glass appearance Treatment: respiratory support, surfactant, antibiotics, nutrition
- 20. Meconium aspiration syndrome Risk factor: Post date, sepsis, stress (any cause of fetal hypoxia) Aspiration of meconium into the lungs Obstruction of airways air trapping alveolar rupture Deactivation and decrease synthesis of surfactant Risk of develop PPHN
- 21. MAS Hyperinflation Flattened diaphragms Diffuse, patchy opacities Treatment: Respiratory support
- 22. Quiz 1 Congenital pneumonia TTN MAS Pneumothorax Congenital heart disease (TGA) CDH RDS Congenital lung malformation
- 23. Quiz 2 You receive another call from O&G to review a newborn in the labour room with tachypnoea.
- 24. Quiz 2 What history you would like to know? Describe what you see What is your differential diagnosis ? What is your management?
- 25. Quiz 3 1 2 3 4 5 Stridor Wheezing Grunting in respiratory distress infant Infant making constipated grunting sounds. Infant grunting while pooping
- 26. Summary Identify the high risk group (Prem delivery, MMSL/TMSL, maternal risk of sepsis etc) Recognize signs and symptoms of respiratory distress NRP Always call for help Early Respiratory support Other treatment will depend on the respective pathologies
- 27. REFERENCES 1. Nelson Textbook Of Paediatrics 2. https://emedicine.medscape.com/article/976914-overview#a7 3. Ncbi: Respiratory Distress of Newborn 4. American Academy of Family Physicians: Respiratory Distress in the Newborn 5. Michael D. Nissen, Congenital and neonatal pneumonia, Paediatric Respiratory Reviews, Volume 8, Issue 3, 2007, Pages 195-203, ISSN 1526-0542, https://doi.org/10.1016/j.prrv.2007.07.001. 6. Pediatric Protocol 7. OPENPediatrics
Editor's Notes
- #4: Ask the floor to name at least 7 of the differential
- #7: Quite obvious for this case The baby has congenital pneumonia With the history of mother having fever and UTI Lets look at other differential diagnosis Basically all will present with respiratory distress With that Im going to talk about the RDS in newborn
- #11: While on your way to labour room, you should have some differential in your mind as you are dealing with a newborn with respiratory distress Whats the differential in your mind?
- #14: Describe what can see from this video
- #15: Describe what can see from this video
- #16: Describe what can see from this video
- #18: CXR as mentioned earlier
- #19: Surfactant decrease alveolar surface tension Helps with alveolar expansion And decrease risk of atestasis.
- #20: Surfactant decrease alveolar surface tension Helps with alveolar expansion And decrease risk of atestasis.
- #21: Surfactant decrease alveolar surface tension Helps with alveolar expansion And decrease risk of atestasis.
- #22: Surfactant decrease alveolar surface tension Helps with alveolar expansion And decrease risk of atestasis.
- #25: SVD 38 week EFW 3kg ANC fever, tachycardic high TWX, cover with triple antibiotic , 3doses and progress into labour HVS GBS Liquor clear AS 9/9 , CTG normal prior to deliver
- #26: Try to appreciate this sound and interpret the sound
- #27: Surfactant decrease alveolar surface tension Helps with alveolar expansion And decrease risk of atestasis.