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Neonatology > Respiratory Distress > Flashcards

Respiratory Distress Flashcards

1
Q

What are the cardinal signs of respiratory distress?

A
  • Persistent tachypnea (>60 breaths per minute)
  • Central cyanosis in room air
  • sternocostal recession
  • expiratory grunting
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2
Q

What are predisposing factors to respiratory distress?

A
  1. Preterm delivery
  2. Underweight for gestational age or wasting
  3. Fetal distress or failure to breathe well at birth
  4. Complicated labour
  5. Clinical chorioamnionitis in the mother
  6. Elective Caesarian section
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3
Q

What are the respiratory causes of respiratory distress?

A
  • hyaline membrane disease
  • wet lung syndrome
  • meconium aspiration
  • pneumonia
  • chronic lung disease
  • pneumothorax
  • lung hypoplasia
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4
Q

What are the non- respiratory causes of respiratory distress?

A 
Hypothermia 
Metabolic acidosis 
Anaemia or polycythemia 
Patent ductus arteriosus
Congenital heart disease 
Diaphragmatic hernia
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5
Q

What are the two types of infants most at risk for hyaline membrane disease?

A

Pre term infants and term infants born to poorly controlled diabetic mothers

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6
Q

What 3 factors further inhibit surfactant synthesis?

A

Hypoxia, hypothermia and metabolic acidosis

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7
Q

What are the clinical signs of hyaline membrane disease?

A
  • features of respiratory distress are apparent at or soon after birth and get worse for 72 hours before improving. Infant is inactive and tends to lie in a frog position
  • chest X-ray typically shows an under expanded chest with a fine reticule- granular appearance over both lung fields
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8
Q

What is the dosage of betamethasone to prevent hyaline membrane disease?

A

2 doses of bethamethasone 12 mg

24 hours apart

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9
Q

What are the aims of management for hyaline membrane disease?

A
  • prevent progressive alveolar collapse
  • maintain oxygen says at 86-92%
  • keep body temperature and blood glucose concentration within normal limits
  • provide adequate nutrition
  • maintain paO2 between 7 and 10 kPa
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10
Q

What is hypoxia treated with in hyaline membrane disease? And what needs to be measured when administering this?

A

Nasal prong CPAP
Arterial oxygen tension and saturation
The inspired oxygen concentration

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11
Q

What is the management of hyaline membrane disease once respiratory distress deteriorates after CPAP is given?
How long does respiratory distress usually take to resolve?

A
  • give surfactant by in- and- out enndotracheal intubation
  • intermittent positive pressure ventilation or high frequency oscillation

Usually the respiratory distress had resolved by a week

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12
Q

How do you treat respiratory and metabolic acidosis associated with hyaline membrane disease?

A

Mild respiratory acidosis is well tolerated and is not an indication for ventilation.

Metabolic acidosis Will usually improve with adequate oxygenation and hydration. severe metabolic acidosis May need correction with 4% sodium bicarbonate given IV very slowly according to the formula: mmol bicarbonate = base deficit x weight x 0.6

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13
Q

What are the complications associated with HMD?

A 
Early: 
Pneumothorax 
Periventricular haemorrhage 
Heart failure due to persistent PDA
Pneumonia

Late:
Chronic lung disease (bronchopulmonary dysplasia)

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14
Q

Who is most at risk for wet lung syndrome? What is the pathogenisis?

A

Infants delivered by elective Caesarian section. It’s attributed to delayed clearing of the fetal lung fluid into pulmonary capillaries and lymphatics after birth.

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15
Q

What are the clinical signs of wet lung syndrome?

A

Within an hour or two of birth there are features of respiratory distress and the chest is hyperinflated.
Chest X-ray shows increased vascular markings with hilar streaking.

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16
Q

What is the management of wet lung syndrome?

A

Additional oxygen via nasal catheter or head box is required but usually does not exceed 40%. Most infants improve in 12 - 24 hours. Tachypnea may persist for several days. Does not require admission to intensive care unit

17
Q

Which infants are at risk for meconium aspiration

A

It usually follows fetal distress during labour. It is limited to term or post-term infants especially if they are wasted or underweight for gestational age

18
Q

What is the clinical presentation of meconium aspiration

A

Inhaled meconium produces areas of emphysema and atelectasis throughout the lungs. The chest is hyperinflated and there is a risk of pneumothorax and pneumomediastinum. A pneumonitis may be caused by chemical irritation of inhaled meconium or by secondary bacterial infection. At birth meconium is present in the mouth and pharynx and may stain the skin, nails, cord and placenta. Poor breathing after delivery is common

19
Q

What is the treatment of meconium aspiration?

A
  • Remove meconium from the upper airways before the infant starts to breathe
  • Nasal CPAP helps to expand the collapsed alveoli and gives better distribution of air in the lungs
  • gastric lavage using 2% sodium bicarbonate solution to treat gastritis
  • antibiotics only if secondary bacterial infection develops
  • steroids are not helpful and may increase the risk of secondary pneumonia
20
Q

Which organisms are responsible for the majority of early onset bacterial pneumonia?

A

E. coli and group B haemolytic streptococcus. Chronic fetal infections (syphillis) may cause early onset (congenital) pneumonia

21
Q

What is pneumonia on day one a result of?

A

Chorioamnionitis.

22
Q

Which organisms usually cause nosocomial pneumonia?

A

Staph aureus, klebsiella, pseudomonas

23
Q

How does a newborn with pneumonia present?

A

Poor breathing after delivery, apnoeic spells or features of respiratory distress.

24
Q

How is a diagnosis of pneumonia confirmed?

A

It is confirmed by chest X-ray (reticulo-granular appearance over both lung fields). The causative agent may be cultured from the trachea or the blood. In early onset pneumonia due to chorioamnionitis the gastric aspirate at birth contains bacteria and pus cells on gram stain

25
Q

What are common causes of pneumothorax?

A
  • meconium aspiration
  • vigorous resuscitation after birth
  • hyaline membrane disease, especially if on positive pressure ventilation or CPAP
26
Q

What are the clinical signs of a severe pneumothorax?

A
  • the infant is increasingly dyspnoeic or apnoeic and is often shocked or cyanosed.
  • affected side: hyper- resonant to percussion and breath sounds are diminished. Affected side will also transilluminate with a bright light source such as a fibrescope
  • a chest X-ray will confirm the diagnosis by showing absent lung markings and a collapsed lung on the affected side
  • tension pneumothorax is confirmed by a mediastinal shift
27
Q

What is the treatment for a pneumothorax?

A

Mild degrees of pneumothorax may resolve spontaneously. These infants are not distressed and can be managed with supplemental oxygen. Severe cases will need an urgent underwater chest drain to remove the free air. Do not wait for a confirmatory chest X-ray in severe cases

28
Q

What is persistent pulmonary hypertension of the newborn?

A

It is the failure of the normally high pulmonary artery pressures of the fetus to fall rapidly after birth

29
Q

How does an infant with persistent pulmonary hypertension present

A

They present with respiratory distress and hypoxia soon after birth due to pulmonary underperfusion and right to left shunting. There is usually a history of intrapartum hypoxia with meconium staining and poor breathing at delivery

30
Q

How is the diagnosis of persistent pulmonary hypertension confirmed?

A

It is confirmed on cardiac ultrasonography which shows a normal heart structure but raised pulmonary artery pressure with a ductal shunt. Chest X-ray may be clear or show features of Vernix or meconium aspiration

31
Q

What is the treatment for persistent pulmonary hypertension?

A

Supplementary oxygen or ventilation may be needed. Sedate the infant and maintain normal systemic blood pressure with inotropes to reduce the shunting. Sildenafil or nitric oxide may be needed in severe cases to dilate the pulmonary arteries.

32
Q

How does a diaphragmatic hernia present?

A

Infant presents at birth with severe respiratory distress, cyanosis and a shift of the mediastinum and interference with lung function.

The main diagnostic clues are: polyhydramnios, shift of the maximal heart sounds to the right and scaphoid appearance of the abdomen. Bowel sounds may be heard in the chest

33
Q

How should infants with diaphragmatic hernia be resuscitated? Why can’t mask ventilation be used?

A

The infant should be intubated at delivery. Do not give mask ventilation as this expands the gut and worsens the respiratory distress

34
Q

What is the cause of chronic lung disease in preterm infants?

A

Preterm infants who require intubation and ventilation for respiratory distress may develop chronic lung disease due to barotrauma in immature lungs

35
Q

When should the diagnosis of chronic lung disease (bronchopulmonary dysplasia) be suspected?

A

If infants with HMD still red ventilation after 10 days

36
Q

What does the X-ray of an infant suffering from chronic lung disease look like?

A

Chest X-rays shows hyperinflation, streaky fibrosis and a bubbly appearance

37
Q

What can prevent chronic lung disease?

A

Antenatal steroids and surfactant therapy with early CPAP reduces the risk of HMD needing ventilation and therefore prevents many cases of chronic lung disease.
Whenever possible CPAP should be used images of assisted ventilation especially in very small infants

38
Q

What are the indications for ventilation ?

A
  • failure to maintain adequate oxygenation with other forms of respiratory support
  • respiratory acidosis
  • high paCO2
  • apnoea

Neonatology (9 decks)

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