Infant Lung Disease and Associated Complications

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Infant Lung Disease and Associated Complications

• Mary P. Martinasek, BS, RRT
• Director of Clinical Education
• Hillsborough Community College

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Respiratory Distress Syndrome

• RDS , formerly called Hyaline Membrane disease
  (HMD)
• Primary cause of respiratory disorders
• 70 preterm deaths, 30 neonatal deaths
• Etiology - deficiency in surfactant
• Premature pulmonary system

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Risk Factors associated with RDS

• Less than 35 weeks gestation
• Maternal diabetes
• Hx of RDS in sibling
• White male
• PFC (Persistent Fetal Circulation)
• Prenatal maternal complication
• Abnormal placental conditions
• Umbilical cord disorders

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Pathophysiology of RDS

• Decreased surfactant

Wide spread atelectasis
?
?
?
Worsening V/Q

__ Surface Tension
_FRC
?
?
??
__ PaO2 __ PaCO2
_WOB
__ Compliance
?
?
Respiratory Acidosis
Stiffer Lungs
?
Capillary damage Alveolar Necrosis

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Clinical Signs of RDS

• Respiratory Rate gt 60 bpm
• Grunting
• Retracting
• Nasal flaring
• Cyanosis
• Hypothermia
• CXR underaeration, opaque, ground glass
  appearance

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Treatment of RDS

• Maternal steroids
• Artificial surfactant therapy
• Adequate hydration
• Thermoregulation
• Goal support the patients respiratory system
  while minimizing complications

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Complication of RDS

• ICH occurs in 40 of lt 1500 grams
• Barotrauma pulmonary air leaks
• Infection
• PDA

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Airleak Identification
100 points!!!
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ICH - Grade 1
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Reverse Jeopardy

• For 100 points!!!
• Exactly how many grams equal 1 pound?

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Clinical Scenario

• 1500 gram infant born at 28 weeks gestation.
  Exhibiting signs of respiratory distress.
• ABG 7.20 60 (CO2) 45 (02) -6 (BE)
• Select an appropriate mode initial of therapy
• N.C. _at_ 2 LPM
• Head Hood at 35
• Nasal cpap 4 Fio240

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BPD

• Chronic infant who was exposed to long term
  oxygen and high pressures
• Infant on supplemental oxygen for gt 30 days
  exhibiting the classic x-ray findings

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Pathophysiology of BPD

• Oxygen toxicity
• Barotrauma
• Presence of PDA

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CXR in BPD

• Stage I
• First 3 days of life
• Ground glass appearance on x-ray
• Stage II
• 3 - 10 days
• Opaque, obscure cardiac markings
• Stage III
• 10 - 20 days
• Cyst formations
• Stage IV
• 28 days
• Increased lung density, larger cysts

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Stage 1
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Stage 2
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Stage 3
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Stage 4
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Treatment of BPD

• Avoidance of factors that lead to development
• Adequate ventilatory humidification
• CPT and bronchodilators
• Fluid management
• Nutrition

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100 Points!!
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Persistent Pulmonary Hypertension

• PPHN
• Formerly called Persistent fetal circulation
• (PFC)
• R/O Congenital heart disease
• Hyperoxia test
• Hyperoxia-Hyperventilation test ??
• Echocardiogram

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Treatment of PPHN

• Nitric Oxide (NO)
• Hyperventilation
• Tolazoline
• Dopamine
• ECMO (extracorporeal membrane oxygenation
• High frequency ventilation

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Reverse Jeopardy

• What color tank is NO?
• What color tank is NO2?
• 100 points

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Transient Tachypnea of the Newborn

• TTN
• Aka RDS II
• Term infants delivered via cesarean section
• Signs of RDS
• CXR - streaky infiltrates
• R/O pneumonia
• Treatment
• O2, Cpap if necessary

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TTN x-ray
6 hours
2 days
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Meconium Aspiration Syndrome

• Term and Postterm infants
• Asphyxia in utero ? blood shifts to vital organs
  ? relaxation of anal sphincter
• Gasping respirations ? meconium aspirated
• Ball valve effect - air trapping
• Furthers hypoxemia and hypercarbia
• Air leak
• Inflammation
• Persistent pulmonary hypertension

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Diagnosis and Treatment

• Aspiration of meconium
• Classic sign of RDS
• Irregular densities on CXR
• Treatment
• Suction meconium
• Peep
• Low peak pressures
• Antibiotics
• amnioinfusion

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MAS x-ray
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Asphyxia

• Major complication is hypoxic-ischemic
  encephalopathy
• Periventricular leukomalacia
• Tubular necrosis of kidneys and GI effects
• Liver damage
• Lung damage
• ? PVR, surfactant disruption ? RDS

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PVL
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Wilson- Mikity Syndrome

• AKA - Pulmonary dysmaturity
• BPD lung changes in unventilated infant
• Signs
• Hyperpnea, cyanosis, retractions, hypercarbia,
  respiratory acidosis
• Treatment
• Supportive
• Ventilated to treat apnea
• O2 to treat hypoxemia

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Air leak syndrome

• Increased incidence in RDS, MAS, TTN
• Mostly caused by mechanical ventilation
• Pneumothorax
• Spontaneous vs. tension
• ? HR, cyanosis, apnea, ?BP
• Transillumination, CXR
• Pneumomediastinum
• Pneumopericardium
• PIE (pulmonary interstitial emphysema)
• Peep, high PIP, prolonged I times

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PIE x-ray
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Apnea

• Cessation of breathing leading to bradycardia
  and/or cyanosis
• Nonobstructive apnea (Central) absence of
  airflow and ventilatory effort
• Obstructive apnea absence of airflow despite
  ventilatory effort

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Central or Nonobstructive Apnea

• Apnea of prematurity
• Chemoreceptor sensitivity
• Arousal response
• Stimulation of airway reflexes
• Dysfunction of the respiratory centers
• Dysfunction of the ventilatory muscles
• Dysfunction of the peripheral nervous system
• Treatment caffeine or theophylline

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Obstructive apnea

• Anatomic abnormalities
• Pierre Robin Syndrome (micronathia)
• choanal atresia, laryngeal webs, vocal cord
  paralysis, enlarged tonsils and adenoids
• Treatment pharmacologic agents, surgery

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100 points
What is choanal atresia and what is the classic
sign?
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Pierre Robin Syndrome
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100 points
What is this x-ray terminology for this condition?
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Retinopathy of Prematurity

• AKA ROP
• Formerly known as RLF (Retrolental Fibroplasia)
• Scar formation behind lens of eye
• Factors
• Immature retinovascularity
• Oxygen administration

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Pathophysiology

• Capillaries begin branching at 16 weeks
• Begin at optic nerve and grow toward the ora
  serrata (anterior end of retina)
• Reach ora serrata at 40 weeks
• In the presence of high PaO2 vessels constrict ?
  vaso-obliteration (necrosis)

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1 Partial vascularization with distinct
demarcation line 2 Ridge develops at
demarcation line, stopping normal vascular
development 3 Blood vessels within ridge grow
wildly toward center of eye, and scar tissue
develops. 4 Scar tissue pulls the retina,
causing partial detachment
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Treatment of ROP

• Cryotherapy -20 degrees C. Nitrous Oxide behind
  the eye and freeze the avascular portion of
  vessel
• Complications - scarring, cell destruction,
  retinal detachment
• Laser therapy - photocoagulation
• Complication - scarring, choroidal hemorrhage,
  pain

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Intracranial/Intraventricular Hemorrhage

• ICH and IVH
• Majority of hemorrhages in neonate are
  periventricular/ Intraventricular (IVH)
• Preterm and Infants lt1500 grams high risk
• Germinal matrix most common

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IVH

• Fluctuations in blood flow and immaturity of
  cerebral vascular system to regulate flow leads
  to bleeds
• Triggering factors
• Shock
• Acidosis
• Hypernatremia, transfusion of blood
• Seizures
• Rapid expansion of blood volume
• Ventilator
• Trendelenburg position
• Maternal alcohol intake

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Signs of germinal matrix bleeding

• Apnea
• Hypotension
• Drop in Hct
• Flaccidity
• Bulging fontanelles
• Tonic posturing

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IVH Classifications

• Grade O - No bleeding
• Grade I - bleeding in germinal matrix only
• Grade II - germinal matrix ventricles
• Grade III - ventricles dilated
• Grade IV - extend to parenchyma

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Complications/ Treatment of IVH

• Post hemorrhagic hydrocephalus (PHH)
• Obstructed CSF outflow/impairment of CSF
  resorption
• Lumbar puncture and shunts
• Cerebral palsy, vision loss, hearing loss,
  epilepsy, mental retardation
• Treatment
• Avoid factors that lead to occurrence
• supportive

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