‫برکت عمر در کار نیک‬

‫است‬
‫حضرت علی )ع (‬
Respiratory distress in
newborn
Dr.Mahmood Noori-Shadkam
Neonatologist
 Neonatal Respiratory Distress
Signs and symptoms
• Tachypnea (RR > 60/min)
• Nasal flaring
• Retraction
• Grunting
• Delayed or decreased air entry
• +/- Cyanosis
• +/- Desaturation
 score 0 1 2

Respiratory Rate 60 60 – 80 >80 or apnea

(breaths/min)
episode
cyanosis None In room air In40%oxygen

r
e
Retraction None Mild Moderate to
t severe
r
a
c Grunting None Audible with a Audible without a
t
i stethoscope stethoscope
o
n

Crying clear decreased Barely audible

 Neonatal Respiratory Distress
Etiologies
Pulmonary Systemic Anatomic
causes causes causes
- RDS - Infections - Upper airway
- Pneumonia - Metabolic causes obstruction
- TTN - Temperature - Airway
- MAS - Anemia malformation
- Other aspiration Polycythemia - Space occupying
syndrome - Congenital heart lesion
- Air leak syndrome disease - Rib cage
- - Pulmonary anomalies
Lung hemorrhage
hypertension - Phrenic nerve
- Lung hypoplasia injury
- Neuromuscular
- Congenital disorder
malformations

diagnosis : Hx, Phx and L.F

 Neonatal Respiratory Distress
Algorithm
Respiratory
Distress
(tachypnoea, retractions, grunt)

Preterm Term

< 6hrs old > 6hrs old < 6hrs old > 6hrs old
HMD (RDS) Pneumonia TTN Pneumonia
Pneumonia CHD MAS/PPHN CHD
Lung anomaly Pul. Hemorrhage Asphyxia
Lung anomaly
Air leak
Respiratory Distress Syndrome
 Introduction
• The most frequent cause of respiratory
distress in premature infants.
• 60-80% of <28wk GA ; 15-30% of 32-
36wk GA ; 5% of 37wk-term.
• Classic presentation of grunting,
retractions, increasing O2 requirement,
reticulogranular pattern and air
bronchograms on CXR and onset < 6hrs
age
 Pathogenesis
Prematurity Prenatal asphyxia
Reduced surfactant synthesis, storage, release
Increased alveolar surface tension
Progressive atelectasis Diffusion
Uneven V/Q Hypoventilation gradient
Hypoxemia CO2 retention
Acidosis
Pulmonary vasoconstriction Hypoperfusion
Capillary endothelial damage
Plasma leak Fibrin
 Pathology
• Gross : Lung firm, red, liverlike
• Microscopic : Diffuse atelectasis, pink
membrane lining alveoli & alveolar ducts.
Pulmonary arterioles with thick muscular coat,
small lumen. Distended lymphatics
• Electron microscopic : Damage / loss of alveolar
epithelial cells, disappearance of lamellar
inclusion bodies, swelling of capillary endothelial
cells
 Pathology (contd.)
• Biophysical :
– Deficient / absent surfactant
– Abnormal pressure volume curve
Normal
Vol
RDS

Pressure
– Severely reduced arterial bed with blockage near
pulmonary arterioles
 Pathology (contd.)
• Biochemical :
– Diminished surface-active phospholipid
(phosphatidylcholine)
– Diminished apoprotein content ( SP-A, B, C,
D)
 Pathophysiology
• Reduced lung compliance (1/5th -1/10th)
• Poor lung perfusion ( 50-60% not
perfused), decreased capillary blood flow
• R--> L shunting ( 30-60% )
• Alveolar ventilation decreased
• Lung volume reduced
• Increased work of breathing
• Hypoxemia, hypercapnia, acidosis
 Physiologic abnormalities
• Lung compliance 10-20% of norm
• Atelectasis…areas not ventilated
• Areas not perfused
• Decrease alveolar ventilation
• Reduce lung volume
 Risk factor
Prematurity
Acidosis
Hypoxia
Hypercapnia
Hypothermia
C/S
Asphyxia and stress
Male
Familial
DM mother
 signs
• tachypnea
• retraction
• grunting
• Nasal flaring
• apneic episode
• cyanosis
• extremities puffy or swollen
 Chest X-ray

• Ground glass appearance

• Reticulogranular
• With air bronchograms
 Treatment
• Surfactant
– Prevention
– rescue
• Supportive
– Thermal
– Fluid and nutrition
– oxygen
• Mechanical ventilation
 complications
• Pneumothorax
• PDA
• Infection
• Line problems
• ROP
• Chronic lung disease
Meconium aspiration
 ‫‪M .A .S‬‬

‫آسپيريشن مايع آمنيوتيك آغشته به مكونيوم‬

‫ممكن است منجر به سندرم آسپيريشن‬
‫مكونيوم گردد كه مربيديتي و مورتاليتي قابل‬
‫ملحظه اي دارد بنابراين مديريت زايمان با‬
‫مايع آمنيوتيك آغشته به مكونيوم براي‬
‫پيشگيري از آسپيراسيون اهميت زيادي دارد‬
 ‫تركيب مكونيوم‬
• Cellular particle
• Bile pigment
• Lango
• Mocus
• Vernix
• Pancreatic secretion
• One gr meconium = one mg Billirubin
 ‫‪Incidence‬‬
‫دفع مكونيوم ‪ 8‬تا ‪ 20‬درصد كل زايمانها ) متوسط‬
‫‪(% 12‬‬

‫مكونيوم آسپيريشن در ‪ 4‬درصد مكونيومي ها‬

‫دیده می شود‬

‫عمدتا‪ Post maturity‬و ‪. SGA‬وجود دارد‬

 ‫فيزيوپاتولوژي‬
‫اگر چه فيزيوپاتولوژي كامل آن و علت دفع‬
‫مكونيوم كامل شناخته نشده اما اين پديده‬
‫بندرت قبل از هفته ‪ 34‬ديده مي شود‬

‫بسياري از مكونيوم دفع كرده ها علمتي دال بر‬

‫مشكل تنفسي يا دپرسيون نداشته اند و عده‬
‫اي هم بعلت آسفيكسي مكونيوم دفع كرده اند‬
 ‫علت دفع مكونيوم‬
‫ي)‪1‬‬
‫تتتك امل عصب‬
‫ت‬ ‫تتيتتزيولوژيك‪:‬‬
‫تتتد يده ف‬
‫پ‬
‫ي‬
‫تتتر يستتل اتيسم روده ا‬
‫ي پ‬ ‫تتتر قرار‬
‫تتتاپ راسمپاتيك و ب‬
‫تتتر م ها و‬
‫تتيتتتوع در ت‬
‫تتتك امل جنين) ش‬
‫ت‬ ‫تتته‬
‫تتتا سخ ب‬‫در پ‬
‫تتو زادان تتان رس(‬
‫تتتو دندر ن‬
‫تتان در ب‬

‫تتتر يستتل اتيسم )‪2‬‬

‫ثافزايش پ‬ ‫تتتا ع‬
‫ب‬ ‫تتتو اند‬
‫ي ت‬ ‫ي م‬‫هيپوكس‪:‬‬
‫تتلابته‬
‫تتوتتتد )‬
‫لش‬ ‫تتتو ن اسفنكترآن ا‬‫تتاتتهش ت‬
‫روده ها و ك‬
‫لآپگار‬‫تتو زادانتتتاب مايع آمنيوتيك مكوني ا‬
‫اكثر ن‬
‫تتد ارند (‬
‫تتتا يينو اسيدوز ن‬
‫پ‬
 Alarm of MAS
1- Thick meconium

2-Fetal tachycardia

3- lack of increase heart rate during

intra partum monitoring
4-Low cord PH
‫پاتوژنز‬
 MAS complication
• Partial obstruction
o
• complete obstruction :

• Surfactant destruction

• Chemical pneumonitis &Bacterial pneumonia

• Asphyxia

• PPHN
 Clinical sign
• Classic sign: Post maturity
nail, skin , umblical cord are heavily
stained with a yellowish pigment
• Early sign (resp . Distress) : grunting &
cyanosis & nasal flaring & retraction &
marked tachypnea
• Characteristic sign : chest overinflation
and Rale
 Radiography of M.A.S

• Coarse , nodular , irregular pulmonary

densities with areas of diminished aeration
or consolidation.
• Hyperinflation of the chest .
• Atelectasis
• Flattening of diaphragm
• Cardiomegally
(manifestation of the underlying prenatal
hypoxia)
Chest.X.Ray
Meconium Aspiration Syndrome
Meconium Aspiration Syndrome
 ‫‪ABG‬‬ ‫‪in‬‬ ‫‪M.A.S‬‬
‫شواهدي از يك آلكالوز تنفسي ‪1.‬‬
‫هيپوكسي ‪2.‬‬
‫در مواقع شديد اسيدوز تنفسي و اسيدوز ‪3.‬‬
‫متابوليك‬
‫شواهدي از شنت راست به چپ ‪4.‬‬
 ‫‪Management of‬‬ ‫‪M.A.S‬‬
‫حضور مكونيوم در مايع آمنيوتيك دليل‬
‫بردیسترس جنینی نيست وچنانچه ضربان قلب‬
‫جنین و پی‪-‬اچ بند ناف طبيعي باشد پيش آگهي‬
‫خوب است‬

‫آميخته شدن مكونيوم با مايع آمنيوتيك باضافه‬

‫ضربان قلب نا مناسب نويد دهنده يك‬
‫آسفيكسي مي باشد‬
 ‫‪Intra partum‬‬
‫در اين گونه مواقع وقتي سر بيرون آمد در روي‬
‫پرينه بايد ساكشن دهان وبيني و فارنكس با‬
‫كاتتر نمره ‪ 12‬يا ‪ 14‬انجام شود )قبل از اينكه‬
‫توراكس بيرون بيايد و نوزاد بخواهد تنفس‬
‫كند (‬
‫‪ :‬اولين ارزيابي نوزاد متولد شده‬
‫‪vigorous or depress‬‬
 Criteria of vigorous
1) Heart rate greater than 100 beat /min

2) Good muscle tone

3) regular breathing
 Guidelines of the baby
exposed to meconium
Vigorous
No Yes

Immediate tracheal Clear secretions and

suction meconium
initial resuscitation
steps
Meconium No meconium

HR>100 HR<100

reintubate PPV and suction

and suction again later

The American Academy of Pediatrics Neonatal Resuscitation Program Steering

Committee management guidelines of the baby exposed to meconium:
Meconium
 ET suction indication
• Only in non vigorous baby
- depressed respirations
- decreased muscle tone
- heart rate < 100 beats per minute

• Pharyngeal suctioning of an infant before delivery of the shoulders.

• Removal of meconium from hypopharynx and larynx by large-bore catheter.
• Meconium aspirator attached to wall suction.
• Endotracheal intubation for removal of meconium in the lower airway.
 Management
1. Prevention
• Monitor fetal status
• Amnioinfusion
• Suctioning +/- intubation and immediate
suctioning
• Avoid harmful techniques
2. Intervention
• Optimal thermal environment & minimal handling
• Respiratory care, Oxygen therapy & ECMO
• Keep stable V/S
• Surfactant therapy
Steroid therapy for meconium aspiration
syndrome in newborn infants
• The Cochrane Database of Systematic Reviews 2007 Issue 3,
The Cochrane Library (ISSN 1464-780X
• Conclusions:
At present, there is insufficient evidence to assess
the effects of steroid therapy in the management of
meconium aspiration syndrome
(no significant reduction in mortality, duration of hospital
stay, Duration of mechanical ventilation, incidence of air
leak,increase in duration of oxygen therapy was seen
with the use of steroids)
Role of antibiotics in
meconium aspiration syndrome
• Ann Trop Paediatr. 2007 Jun;27(2):107-13.
• Basu S, Kumar A, Bhatia BD.
• Division of Neonatology, Department of Paediatrics, Institute of
Medical Sciences, Banaras Hindu University, Varanasi, India.
drsriparnabasu@rediffmail.com
• CONCLUSION:
Routine antibiotic therapy is not necessary for managing
MAS. No significant difference
– period of oxygen dependency (5.8 vs 5.9 days)
– day of starting feeds (4.0 vs 4.2)
– day of achievement of full feeds (9.4 vs 9.3)
– clearance of chest radiograph (11.7 vs 12.9 days)
– duration of hospital stay (13.7 vs 13.5 days)
Surfactant for meconium aspiration
syndrome in full term/near term infants
• Cochrane Database Syst Rev. 2007 Jul 18;(3):CD002054
• El Shahed A, Dargaville P, Ohlsson A, Soll R.
• CONCLUSIONS: In infants with MAS, surfactant
administration may reduce the severity of respiratory
illness and decrease the number of infants with
progressive respiratory failure requiring support with
ECMO. The relative efficacy of surfactant therapy
compared to, or in conjunction with, other approaches to
treatment including inhaled nitric oxide, liquid ventilation,
surfactant lavage and high frequency ventilation remains
to be tested.
 PPHN prevention
1. Avoid vasoconstriction
• Acidosis
• Hypoxia
• Metabolic disturbance - Hypocalcemia
- Hypercalcemia
- Hyperglycemia
- Hypoglycemia
2. Prevent right to left shunt
Infections
 Infections
• Pneumonia & Sepsis have various
manifestations including typical signs of
distress as well as temperature instability.
• Common pathogen- Group B
Streptococcus, Staph aureus,
Streptococcus Pneumonia,Gm neg. rods
 Infections con..
• Risk factors- prolonged rupture of
membranes, prematurity,& maternal fever.
• CXR- bilateral infiltrates suggesting in
utero infection.
 Congenital pneumonia
• Sepsis risk factors
– PROM
– Prematurity
– Maternal fever, discharge, abdominal pain,
leukocytosis
– Colonization with GBS
• Same signs of RDS
• X-ray
 Transient Tachypnea of
Newborn
• Most common cause of respiratory
distress.
• Residual fluid in fetal lung tissues.
• Risk factors- maternal asthma, c- section,
male sex, macrosomia, maternal diabetes
 TTN
• Tachypnea immediately after birth or
within two hours, with other predictable
signs of respiratory distress.
• Symptoms can last few hours to two
days.
• Chest radiography shows diffuse
parenchymal infiltrates, a “ wet
silhouette” around heart, or intralobar
fluid accumulation
 X-ray

Fluid in the
fissure
Transient tachypnea of newborn
• Term
• Cesarian delivery
• Usually tachypnea without O2 requirment
• Resolve in 48-72 houres
• Lung fluid
• X-ray
 Other causes-
• Congenital malformations-Pulmonary
hypoplasia, congenital emphysema,
esophageal atresia & diaphragmatic
hernia.
• Neurological causes- hydrocephalus &
intracranial hemorrhage.
• Metabolic derangements-hypoglycemia,
hypocalcemia, polycythemia.
 Congenital Heart disease
Cyanotic Heart Disease-
• Tetralogy of fallot- ( VSD, Pulmonary
stenosis, overriding aorta, RVH)
• Tricuspid atresia
• Transposition of great vessel
• Total anomalous pul. venous return
• Truncus arteriosus.
 Hyperoxia Test
• Obtain ABG–> Then place the
patient on 100% O2 for 10 minutes
then repeat ABG , If the cyanosis
is pulmonary , the PaO2 should be
increased by 30 mm of Hg. If the
cause is cardiac , there will be
minimal improvement in PaO2.
‫با تشکراز‬
‫همکاران‬
‫گرامی‬