Neonatal Pulmonary Diseases Flashcards
Pneumonia
Bacterial or viral infection of the lungs
Pneumonia Categories
-
Early onset or perinatal
- Occurring < 7 days of age
- Can occur in association with amnionitis following PROM
- Often associated with transplacental infection or prolonged delivery
-
Late-onset or post-natal
- Occurring after 7 days of age.
- Typically easier to treat with less sequella
Pneumonia Modes of Transmission
–Intrauterine (transplacental)
–Ascending vertical transmission (extrauterinetransmission, usually during labour
–Postnatal (nosocomial or community acquired)
Early Onset Pneumonia
Bacterial Causes
- Bacterial
- Group B streptococcus (GBS)
- Found in vaginal and cervical area
- Early onset from GBS may progress rapidly to shock or death
- Mortality is 20%-50% regardless of treatment
- E. Coli
- Most common among VLBW infants
- Listeria monocytogenes
- Kelbsiella
- Group D streptococci
- Pneumococci
- Group B streptococcus (GBS)
Early Onset Pneumonia
Group B streptococcus
Will clinically be very similar to RDS and we need a sputum analysis
Spread from maternal cervical and vaginal secretions
ROM >12 hours increases infection risk
Onset of symptoms occurs between hours to days
Occurs most often in low birth weights
Early Onset Pneumonia
Viral
- TORCH Syndrome
- Toxoplasmosis
- Rubella
- Cytomegalovirus
- Herpes simplex virus
Late Onset Pneumonia
–Typically occurs after 7 days of age
–Commonly found in NICU where infants require prolonged intubation
Late Onset Pneumonia
Bacterial
- Bacterial
- Staphylococcus
- Pseudomonas
- Chlamydia trachomatis
- E. Coli
Late Onset Pneumonia
Viral
Respiratory Syncytial Virus (RSV)
Late Onset Pneumonia
Fungi
Candidaalbicans
Pneumonia
Clinical Manifestations
- Early onset
- Lethargy
- Poor feeding
- Irritability
- Cyanosis
- Temp instability
- Progressive Respiratory Distress
- Tachypnea
- Intercostal retractions
- Grunting
Pneumonia
CXR
Patchy asymetrical densities
Hyperinfaltaion
Pleural effusion
Pneumonia
Diagnosis
- Positive blood cultures (bacteria)
- Virus: Possibly elevated serum antibodies
Pneumonia
Antibiotics for Early Onset
Ampicillin or Penicillin G + aminoglycoside
Pneumonia
Antibiotics for Late Onset
Nafcillin+ aminoglycoside
3rd generation cephalosporin
Pneumonia
Candida
Amphotericin B
Pneumonia
Virus Medicine
Ribavirin
Acyclovir
Pneumonia
Management (non-pharmacological)
- Supportive therapies
- Oxygen
- Humidification
- Bronchial Hygiene (coughing, suction in mechanically ventilated)
- Mechanical ventilation
- Physiotherapy
Pulmonary Interstitial Emphysema (PIE)
Air Leak Syndrome- Increase air space distal to the terminal bronchioles.
Collection of gases outside of the normal air passages
Iatrogenic-We cause it as it is due to overdistention from mechanical or manual ventilation
Occurs almost exclusively in low birth weight infants
PIE
Risk Factors
Prematurity (<32 weeks GA) due to immature lungs and decreased surfactant
VLBW (<1000g)- Inversely related to birth weight meaning the lower the weight the higher the risk
Resuscitation: PPV, Use of increased PIP, Vt, and Ti
Other Disease Processes: RDS, MAS, Amniotic fluid aspiration, Infection, Neonatal sepsis, Pneumonia , Pulmonary Hypoplasia
Pulmonary Interstitial Emphysema (PIE)
Pathophysiology
The rupture of the small airways will allow airway into the connective tissue which will compress the vasculature which leads to decreased pulmonary perfusion, increased PVR, and R-L shunt
It can occur naturally when babies have very low surfactant
There will be an increased airway resistance due to the decrease in the lumen of the bronchioles
Pulmonary Interstitial Emphysema (PIE)
CXR
The tiny black little dots are the PIE in the lungs
This disease is a mix of atelectasis and hyperinflation
Pulmonary Interstitial Emphysema (PIE)
Clinical Manifestation
Progressive respiratory deterioration
Deteriorating ABG’s,
Decreased compliance
Increasing SOB
Increasing ventilatory requirements due to decreased compliance and increasing airway resistance
Disease course of mild PIE is approx. 5 days
Excess air continues to accumulation which can lead to the rupture of the mediastinum (pneumomediastinum) which is a very severe stage of the disease
There can also result in subcutaneous emphysema
Pulmonary Interstitial Emphysema (PIE)
Management
Decrease barotrauma, minimal vent support and PPV
Prone positioning or positioning the affected side down
Selective intubation of “good” lung to rest affected lung
In severe cases-HFOV and pneumonectomy/lobectomy
PIE Prevention
The best treatment for PIE is prevention
In the past this was very common now it is not common and is causethrough a severe case of another disease or mismanagement of the vent
We try to keep down PIP and Peak pressure in order to help prevent/worsen PIE
PIE Prognosis
Poor if evident within 24 hours of birth.
The faster that someone develops PIE the less likely the chance of survival
Pneumothorax
Pathophysiology
Occurs spontaneously due to high inspiratory effort or secondary to the use of positive pressure ventilation
Rupture of alveoli allowing air leak causes air accumulation in the pleural space this may be asymptomatic or symptomatic
Symptomatic - enough air leak to cause respiratory distress
If the air accumulation is large enough and under pressure = a tension pneumothorax = can be life-threatening
PIE can lea to a pneumothorax
Pneumothorax
Primary and Secondary
Primary-When there is no underlying disease
Secondary- Caused by an underlying disease
Pneumothorax
Spontaneous Pneumothorax
Neonates with spontaneous pneumothorax tend to be asymptomatic and they tend to be small and may only need a small amount of oxygen. The problem is when they develop there is a chance that the pneumothorax can get bigger
Pneumothorax
Clinical Manifestations
- •Ranges depending on severity –asymptomatic to respiratory distress with:
- Cyanosis,
- Hypoxia,
- Tachypnea,
- Grunting-Kin to pursed lip breathing and will increase FRC
- Asymmetrical chest
- Decreased breath sounds on the affected side
- A shift of the mediastinum away from the affected side
- Breath sounds will also be decreased on the affected side
- Remember that even a significant pneumothorax may not be detectable with auscultation
Pneumothorax
Diagnosis
CXR-Large left pneumothorax appears black and outlines the partially collapsed left lung and left cardiac border (arrow).
Transluminationis a quick way to identify a pneumothorax without a chest x ray
One of the main problem with PIE is that they will have a decrease SA for gas exchange and also when it heals it can lead to fibrosis
If you have a left penumoyour mediastinum will pull to the other side
If you have ataelctasisyou mediastinum will pull to the affected side
Pneumothorax
Management
- In spontaneous breathing infant with a small pneumothorax – observe or consider 100% oxygen (wash out nitrogen) –
- Not really used anymore and is controversial (wash out nitrogen
- Consider observation if infant is premature to prevent oxygen toxicity/RDS/ROP
- Patient in severe respiratory distress requiring ventilation will most likely need chest tube or needle aspiration
- Needle aspiration - mid-clavicular line above the third rib with angiocathto immediately evacuate air
Pneumothorax
Prognosis
Good with intervention
What are the Pre-Term (<35 week) pathologies
RDS
BPD
Pre Term (>35 Weeks) Pathologies
ACP
Pneumonia
Term (40 Weeks) Disorders
TTN (C-Section)
PPHN
MAS
Pneumonia
Congenital Abnormalities
Typically Term
CDH
Tracheoesophageal Fistula
Pierre Robin
Choanal Atresia
Tracheomalacia/Stenosis
Air Leak Syndrome
PIE
Pneumothorax
