case conference
DESCRIPTION
Case Conference. Maria Victoria B. Pertubal M.D. PGY1. Case. 33 weeker preterm male NSVD APGAR 9/9 BW 1990g Admitted to NICU for prematurity and LBW labored breathing. What are your considerations?. Respiratory causes: - PowerPoint PPT PresentationTRANSCRIPT
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Case Conference
Maria Victoria B. Pertubal M.D.PGY1
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Case
• 33 weeker preterm male• NSVD• APGAR 9/9• BW 1990g
• Admitted to NICU for prematurity and LBW
• labored breathing
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What are your considerations?• Respiratory causes:– Respiratory Distress Syndrome (RDS) aka Hyaline
Membrane Disease (HMD)– Transient tachypnea of the Newborn (TTN)– Pneumonia– Air leak / pneumothorax– Persistent pulmonary hypertension– aspiration syndromes (meconium, amniotic fluid), – congenital anomalies such as cystic adenomatoid
malformation, pulmonary lymphangiectasia, diaphragmatic hernia, and lobar emphysema
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Other differential diagnoses?
• Cardiac causes:– Cyanotic congenital heart disease • 5T’s
• Other Systemic disorders:– Hypothermia– Hypoglycemia– Anemia ; polycythemia– Metabolic acidosis
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Initial Work-up
• Chest X-ray• ABG• CBC, Blood culture• BMP, glucose
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CXR
• C
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Hospital course:
• 1st hospital day : NCPAP, FiO2 25-35% – O2 sats 93-95%
• 2nd hospital day: NCPAP, FiO2 35-50%– SC/IC retractions, O2 sats 88-92%– Repeat CXR, ABG
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Respiratory Distress Syndrome
aka. Hyaline Membrane disease (HMD)
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Incidence• primarily in premature infants
• male > females• white infants• inversely related to gestational age and
birthweight. – 60-80% of <28 wk of gestational age– 15-30% of 32 - 36 weekers, – rarely in those >37 wk.
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Other Risk factors
• maternal diabetes• multiple births• cesarean delivery• precipitous delivery• asphyxia, • cold stress• maternal history of previously affected
infants.
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Reduced risk in..
• pregnancies with chronic or pregnancy-associated hypertension
• maternal heroin use• prolonged rupture of membranes• antenatal corticosteroid prophylaxis.
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Etiology and Pathophysiologyof RDS:
Surfactant deficiency (decreased production and secretion)
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SurFactant Facts
Nelson Pediatrics Figure 95-2 (From Jobe AH: Fetal lung development, tests for maturation, induction of maturation, and treatment. In Creasy RK, Resnick R, editors: Maternal-fetal medicine: principles and practice, ed 3, Philadelphia, 1994, WB Saunders.)
• 90% Lipids (Phospholipids)• 10% Proteins (4 Surfactant specific)
-A,-B,-C,-D
• produced by type 2 alveolar cells
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The Premature Lung
• Both decreased in quantity and quality of surfactant
• LESS QUALITY due to:– Less protein content –PhosphatidylINOsitol > PhosphatidylGLYcerol
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Figure 95-4 Nelson pediatrics
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Clinical Manifestations
• Tachypnea• Nasal flaring, • Expiratory grunting• Intercostal, subxiphoid, and subcostal retractions, • Cyanosis or pallor• breath sounds are decreased • diminished peripheral pulses. • urine output often low in the first 24 to 48 hours
and peripheral edema
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CXR: diffuse reticulogranular ground-glass appearance with airbronchogram
A. Severe RDS B. Moderate RDS
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Other Laboratory findings
• Arterial blood gas – hypoxemia that responds to supplemental
oxygen.– PCO2 initially is normal or slightly elevated, but
may increases as the disease worsens.
• hyponatremia
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Management1. DELIVERY ROOM: Provide warmth, position
head, clear air, stimulate baby.
2. Assisted ventilation (MV, CPAP, NIPPV)
3. Surfactant therapy
4. Inhaled NO
5. Glucocorticoid (post-natal)
6. Other supportive care - Fluid status monitoring- Early nutrition
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Surfactant therapy
• Types available- Survanta (Bovine); Curosurf(porcine); Infrasurf (Calf); Exosurf(synth)
• Indications: – Prophylactic therapy – immediately after birth– Early-rescue therapy – during the 1st few hours after
birth. • AAP recommends to give when the diagnosis of RDS is
established; – Continued therapy - clinical evidence of persistent
disease
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Ventilatory support• to improve oxygenation and elimination of CO2 w/o
causing pulmonary injury/toxicity
• Criteria for mechanical ventilation – Respiratory acidosis- pH <7.20, PaCO2 >60 mm Hg– Hypoxia- PaO2 <60 mm Hg oxygen, O2sats <85%
despite supplementation of 70 % on nasal CPAP– Severe apnea
• CPAP, HFV, NIPPV- alternative to mechanical ventilation
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Other treatment options: (controversial)
• Inhaled Nitric oxide– Mosty benefits or late preterm infants with
persistent pulmonary hypertension through: • reduced lung inflammation, • improved surfactant function, • Slows down hyperoxic lung injury, • promotes lung growth
– Not commonly used due to cost
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• Postnatal glucocorticoids– given in the first day of life– improves pulmonary and circulatory function and
decreases the incidence of BPD– Limitations of use:• short-term complications: intestinal perforation,
metabolic instability; • long-term abnormal neurodevelopmental outcomes
Other treatment options: (controversial)
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Prevention
• Avoidance of unnecessary or poorly timed cesarean section,
• appropriate management of high-risk pregnancy and labor
• Antenatal corticosteroids for all women in preterm labor (24-34 wk of gestation) who are likely to deliver a fetus within 1 wk
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Complications of RDS:
• Endotracheal tube complications• Bronchopulmonary dysplasia (BPD)• Pulmonary air leak – Pneumothorax– Pneumomediastinum– Pulmonary interstitial emphysema (PIE)
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pneumothorax
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Pneumothorax, Left
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case
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pneumomediastinum
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pneumomediastinum
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Pulmonary interstitial emphysema
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Pulm Interstitial empysema PneumomediastinumpneumopericardiumSubcutaneous emphysema
Courtesy of Gerardo Cabrera-Meza, MD
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References:• Carlo, W. Respiratory Distress Syndrome (Hyaline Membrane
Disease) Nelson Textbook of Pediatrics. 2011• Welty, Stephen. Treatment and complications of respiratory
distress syndrome in preterm infants. Uptodate may2011– http://www.uptodate.com.elibrary.einstein.yu.edu/contents/treatment-and-complications-of-
respiratory-distress-syndrome-in-preterm-infants?source=see_link#H17
• Fernandes, Caraciolo. Pulmonary Air Leak in the Newborn. Uptodate. May 2011
<http://www.uptodate.com.elibrary.einstein.yu.edu/contents/treatment-and-complications-of-respiratory-distress-syndrome-in-preterm-infants?source=see_link#H25>
• <http://www.vanuatumed.net/MODULES/07_WomensChildrens/_N+P_WomensChildrens/139_Jackson/ISSUES/139_LI4_files/image001.jpg>
• Staporn Maung-In, M.D <http://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-42/case42.HTM>