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Pediatric Surgery

Lim,Kirstyleigh
Limbo, Michael
Lindo, John
Liwag, Conalou
Llamas, Jacqueline
Locaylocay, Charlene
A 6–hour old newborn was
noticed to be in respiratory distress

Physical Exam:
- RR = 65 breaths/min
- (+) intercostal retractions
- (+) alar flaring
Disease of the respiratory system
which invariably alter the exchange
of gases between the air and the
blood

Causes:
(1) Abnormal mechanical function.
(2) Neuromuscular abnormalities
of the respiratory nerves and
muscle.
- alterations in breathing pattern
diaphragmatic breathing pattern
- irregular rate of breathing ( >65/bpm)
- chest wall retractions
- (+) alar flaring
- (+/-) expiratory or inspiratory grunt
- cyanosis
- most common cause of admission to a
neonatal surgical intensive care
- Check for the patients ABC’s
A irway
B reathing
C irculation
- Assess the patients over-all
condition
PE: neck masses, chest and
abdomen
ABG: Respiratory alkalosis
Imaging: CXR
Respiratory distress, (-) breath sounds

Congenital Congenital
Atelectasis Pneumothorax Diaphragmatic Cystic
hernia Adenomatoid
Malformation

Congenital
Lobar
Emphysema
Respiratory distress, (-) breath sounds

Congenital Congenital
Atelectasis Pneumothorax Diaphragmatic Cystic
hernia Adenomatoid
Malformation

Congenital
Lobar
Emphysema
incomplete expansion or complete collapse of lung
tissue

Causes: compression, obstruction, paralysis


Clinical manifestations:
dyspnea
rapid shallow respirations
tachycardia
often, cyanosis
Physical findings:
Flat chest on affected side
Limited or reduced chest excursion
Dull on percussion
Diminished or absent breath sounds
Respiratory distress, (-) breath sounds

Congenital Congenital
Atelectasis Pneumothorax Diaphragmatic Cystic
hernia Adenomatoid
Malformation

Congenital
Lobar
Emphysema
1-2% of neonates

Accumulation of extrapulmonary air within the chest

At birth, due to the high transpulmonary pressure


swings generated by the newborn during first
breaths or during active resuscitation
Clinical manifestations:
Dyspnea, cyanosis

Physical examination:
Retraction
Tympanitic on percussion
Decreased or absent breath sounds on affected lung
Respiratory distress, (-) breath sounds

Congenital Congenital
Atelectasis Pneumothorax Diaphragmatic Cystic
hernia Adenomatoid
Malformation

Congenital
Lobar
Emphysema
a.k.a. infantile lobar emphysema
Over inflation of air spaces with or without alveolar
rupture causing respiratory function to decrease and
air to leak out into the space around the lungs
Often reversible but life threatening cause of RDS in
the neonate
Air can enter but cannot escape
Assoc w/ CHD in 15% (PDA,VSD)
Autosomal dominant
For some it may occur for no apparent reason
Epidemiology
50% - First four weeks of life
75% - in infants <6months old
Male predominance, 3:1
Mortality rate: 10%
almost always one lobe involved
Left upper lobe – 41%
Right middle lobe – 34%
Right upper lobe – 21%
Clinical manifestations
Shortness of breath
Wheezing

Physical Examination
Cyanotic lips and fingernail beds
result of bronchial structures failing
to mature properly at approximately
the fifth or sixth week of gestation,
about the time the lungs begin to
form.
benign mass of abnormal lung tissue
usually located on one lobe of the
lung
caused by overgrowth of abnormal
lung tissue that may form fluid filled
cysts
abnormal tissue will never function
as normal lung tissue.
Clinical Manifestations
most CCAMs either shrink or are small enough not
to cause a problem
“hydrops" or heart failure (large CCAMs)
"pulmonary hypoplasia" or small lungs ( mother
suffering from "polyhydramnios")
babies may have difficulty breathing after birth
and will require oxygen and assistance with
breathing
Physical Examination
decreased breath sounds on the affected area
with mediastinal shift away from the lesion.
Respiratory distress, (-) breath sounds

Congenital Congenital
Atelectasis Pneumothorax Diaphragmatic Cystic
hernia Adenomatoid
Malformation

Congenital
Lobar
Emphysema
Herniation of abdominal contents into the thoracic
cavity, commonly through the posterolateral
foramen of Bochdalek
1 in 5,000 live births
Predominantly on the left (70-85%)
Trisomy 21, 13 & 18
Associated anomalies (20-30%)
CNS lesions
Esophageal atresia
Omphalocoele
CV lesions
Etiology
8th wk of gestation: separation of the developing thoracic &
abdominal cavity is accomplished by closure of the
posterolateral foramen (Bochdalek)

Failure of pleuroperitoneal canal to close results to CDH

Primary problem is pulmonary hypoplasia with 2° diaphragm


maldevelopment
surfactants is absent

Alveolar growth and pulmonary vasculature are linked, so


there is an abnormal pulmonary vasculature
Clinical manifestations:
Signs of RDS either at birth or first few hours of life
Retractions, cyanosis, grunting respirations
Scaphoid abdomen, barrel shaped chest
20-25% has congenital heart disease
Physical Examination
Absent or decreased breath sounds
shift of cardiac sounds over the
contralateral CDH
Bowel sounds heard in the thorax
Congenital Diaphragmatic Hernia
Respiratory distress, (-) breath sounds

CHEST X-RAY

Congenital Congenital
Atelectasis Pneumothorax Diaphragmatic Cystic
hernia Adenomatoid
Malformation

Congenital
Lobar
Emphysema
Radiographic findings:
Opacity of the
atelectatic lung
Deviation of mediastinal
structures and heart
towards the involved
lung
Radiologic findings:
Hyperlucency of involved lung
Shift of mediastinal structures away from the affected side
A frontal radiograph of the chest Lateral chest radiograph shows
in a neonate shows marked anterior herniation of the right
overdistention of the left upper middle lobe.
lobe with mediastinal shift to the
right.
On the Left side
opaque mass is
seen
Radiographic findings:
“bubble bowel” in the chest
Prenatal Mgt
Medical Therapy
Fetal Surgical Therapy
Postnatal Mgt
Surgical Mgt
Ventilatory Strategy
initial mgt; GOAL: adequate O2 delivery and to
mainatain acceptable arterial pH
Minimize barotrauma by use of pressure limited
vent, tolerance of high PaCO2, min sedation
and avoidance of paralysis
High Frequency Oscillation
Avoids high inspiratory pressures while
providing effective ventilation; GOAL: adequate
gas exchange
Recently used as a second line therapy
Extacorporeal Membrane Oxygenation
(ECMO)
Most patients who are treated had
ventilator-induced lung injury
>90% of CDH px who are treated w/ ECMO
are now placed on ECMO prior to repair
CRITERIA for use:
Clinically detoriorating
Req level of ventilation that has a high risk of
lung injury (peak inspiratory pressure
>25mmHg)
Timing of Operation
Ideal time to repair CDH is unknown
Some repair 24 hrs after stabilization, but
7-10 days delay is often tolerable
Some if normal pulmonary artery pressure
maintained for at least 24-48 hrs based on
ECG
Operative Approach
Long Term Follow-Up
Subcostal incision – most common
Transthoracic approach
chest incision; very useful in a large right-
sided defects
e.g. reduction of the liver is easier
Transabdominal approach
mostly used on the left side
Patch repair
Polytetrafluoroethylene is the most widely
used
Recurrence rate is high in large hernias
Repair of diaphragmatic defect often worsen
pulmonary compliance by reducing elasticity of the
chest wall and increasing abdominal pressure
COMPLICATIONS:
Chylothorax
known complication after repair
Due to injury o the thoracic duct during repair but
possible there is an abnormality in the chyle
drainage
Late bowel obstruction
Wound hernias