Neonatal Diseases
MODULE E
Objectives
• Identify the key pathophysiologic
changes that occur with each disease.
• Describe the therapeutic intervention
needed to treat each of the diseases.
Perinatal Diseases and Other
Problems with Prematurity
•Retinopathy of
prematurity (ROP)
•Patent Ductus
Arteriosus
•Hypoglycemia
•Cold Stress
•Intraventricular &
Intracerebral
hemorrhaging
•Bronchopulmonary
dysplasia
•Wilson Mikity
Syndrome
•Apnea of prematurity
•Necrotizing
enterocolitis
•RDS
Retinopathy of Prematurity (ROP)
• Formerly known as Retrolental
Fibroplasia (RLF).
• Initially described in 1940/1950s
following increased incidence of
blindness with babies in incubators.
• Incidence today:
• 25 to 35% of preemies up to 35 weeks
Physiology of the Developing Eye
• Capillaries of retina begin branching at 16
weeks.
• End of pseudoglandular period.
• Capillaries begin at optic nerve and grow
anteriorly toward the ora serrata which is the
anterior end of the retina.
• Growth is not complete until 40 weeks.
• Premature infants don’t have complete growth.
• As the capillary network expands, arteries
and veins form in its path.
• ROP is the failure of this network to develop.
Oxygen and ROP
• In the presence of high PaO2, the retinal
vessels constrict.
• Prolonged exposure to high PaO2 will lead
to necrosis of the vessels (vasoobliteration).
• The body attempts to correct for this by
over perfusing the “good” arteries, which
leads to hemorrhage in the vitreous.
• This hemorrhage leads to scar tissue
development and blindness.
Stages and Zones of ROP
• 5 stages, with 5 having the retina
completely detached.
• Three Zones of the eye (zone 1 is the
worst)
RDS - Respiratory Distress
Syndrome
• aka: IRDS or Hyaline Membrane Disease
• Associated with lung immaturity and a
deficiency in surfactant production.
• Immaturity of other organ systems.
• Decreased Compliance & increased
WOB.
• Severe hypoxemia may result in multiple
organ failure.
• May be associated with PPHN (PFC) or
PDA.
RDS - Respiratory Distress
Syndrome
• Symptoms worsen for first 48-72 hours.
• Stabilization
• Slow recovery
• With progression of the disease, scar
tissue replaces the normal alveolar
tissue.
• Hyaline Membrane
Clinical Signs
•
•
•
•
•
•
•
•
History of prematurity
f above 60/min
Grunting
Retractions
Flaring of nostrils
Cyanosis
Severe hypoxemia on blood gases
Hypothermia & flaccid muscle tone
X-ray Findings
• Diffuse “White-out” (Radiopaque)
• Atelectasis
• Air bronchograms
• Reticulogranular Pattern
• “Fishing net”
• Ground Glass Appearance
Treatment
• Attempt to accelerate lung maturity by
pharmacological means.
• Steroids
• Tocolysis: Delay labor with bAdrenergic Agents
• (Terbutaline)
• Thermoregulation
Treatment
• Artificial Surfactant
• CPAP or mechanical ventilation
• High Frequency Ventilation
• ECMO
Recovery Phase
• Complications
• ROP
• Bronchopulmonary dysplasia
• Chronic lung disease (COPD for Neonates)
• Intraventricular hemorrhage
• Brain dysfunction
• Necrotizing Enterocolitis
• Intrapulmonary Hemorrhage
• Full Recovery
Bronchopulmonary Dysplasia
• Other Name
• Neonatal Chronic Lung Disease (NCLD)
• Progressive chronic lung disease that
presents with persistent respiratory
problems at 28 days or later, radiographic
changes and oxygen dependency
Bronchopulmonary Dysplasia
• Criteria
• Preterm infants
• Prolonged oxygen concentrations (O2
toxicity)
• Positive pressure ventilation (barotrauma)
• Patent ductus arteriosus (PDA)
• Time exposure to oxygen and positive
pressure
• Malnutrition
Bronchopulmonary Dysplasia
• Not all babies with RDS develop BPD.
• Pattern begins to unfold within the first
3-4 days of life that places a neonate at
high risk of developing BPD.
Bronchopulmonary Dysplasia
• Lung Pathology
• Mucosal hyperplasia of small airways.
• Destruction of type I cells.
• Inflammation and destruction of alveoli and
capillary bed.
• Lungs are cystic in some areas and
atelectatic in others.
Chest X-Ray
• Radiology
•
•
•
•
“Honeycomb” appearance
Diaphragms are flattened
Cystic appear (hyperlucent)
Atelectasis (radiopaque)
HMD to BPD – 3 Hour
HMD to BPD – Day 13
HMD to BPD – Day 19
HMD to BPD – 3 Months
Clinical Presentation
•Tachypnea
•Retractions
•Mucous plugging
•Hyperinflation of
chest – barrel chest
•Cyanotic spells
•Poor ABG
•Wheezing
•Inadequate growth
•Increased WOB
•Increased oxygen
consumption
•Pulmonary
hypertension and Cor
Pulmonale
Goals of Bronchopulmonary
Dysplasia
• Prevention of BPD.
• Provide enough calories to support
growth.
• Wean slowly off oxygen.
• Limit peak inspiratory pressures on
ventilator.
• CPAP or HFV
• Keep FiO2 levels as low as possible.
• May need to keep PaO2 levels lower.
Complications of
Bronchopulmonary Dysplasia
• Gastroesophageal reflux and feeding
intolerance leads to aspiration.
• Decreased Ca and phosphorus (bone
fractures.
• Loss sight or hearing (ROP).
• Chronic infections.
• Pneumothorax.
• Cerebral palsy.
• Limit Fluid intake – develop pulmonary
edema.
Bronchopulmonary Dysplasia
• Death is usually due to:
• Cor Pulmonale
• Infection
• Sudden Death
Discharge of patients with BPD
• Home Care
• Oxygen & CPT
• Mechanical ventilators
• Medications
• Diuretics or cardiac meds
• Special Attention to nutritional needs
• Frequent re-admissions back into the
hospital.
Necrotizing Enterocolitis (NEC)
• Injury to the intestinal mucosa due to
hypoperfusion, hypoxia or hyperosmolar
feedings.
• The mucosa cannot secrete the protective
layer of mucus and it becomes vulnerable
to bacterial invasion.
• Intestinal ischemia may result in necrosis
and gangrene of the intestine.
• Complication of RDS.
• Highest incidence in lowest birth weight
infants.
Necrotizing Enterocolitis (NEC)
• Intestinal dilation (distended loops of
intestine with gas).
• Gastric ileus (obstruction)
• Abdominal distention.
• Rectal bleeding
• Bloody stool
• Feeding is difficult.
Treatment
•
•
•
•
•
Stop feedings.
Nasogastric Suctioning
Hyperalimentation IV.
Antibiotics.
20% require surgery.
Intraventricular Hemorrhage (IVH)
• Premature infants and low birth weight infants
are the greatest risk.
• Diagnosed by ultrasound or CT scan.
• Seen with increased incidence in children of
alcoholic mothers.
• 4 grades of IVH.
• Grade 1 - Bleeding occurs just in a small area of the
ventricles.
• Grade 2 - Bleeding also occurs inside the ventricles.
• Grade 3 - Ventricles are enlarged by the blood.
• Grade 4 - Bleeding into the brain tissues around the
ventricles.
Etiology And History of IVH
Grades of IVH
IVH Treatment
• Prevent Occurrence
• Supportive
Wilson-Mikity Syndrome
• Seen in premature and LBW infants.
• Less than 1500 grams at birth.
• “Emphysema” of little babies.
• Lung immaturity with rupture of the
alveolar septa.
• Similar to BPD except babies have
not been ventilated.
• Treatment is supportive.
• Oxygen and mechanical ventilation.
• Some question as to whether it is a
separate syndrome or not.
Meconium Aspiration
• Disease of term or post term neonates.
• Asphyxia occurs before, during or after
the onset of labor.
• Relaxation of the anal sphincter with
release of the meconium (first stool).
• Treatment is immediate suctioning &
antibiotics.
• Intubate with endotracheal
tube and with a meconium
aspirator.
Meconium Aspiration
• Usually associated with PFC and
infection.
• Pneumothorax may result from the
hyperinflation.
• An emergency tension pneumothorax is
treated with a needle aspiration followed by
chest tube insertion.
Ball-Valve Effect
Transient Tachypnea of the
Newborn (TTN)
• RDS type II.
• Occurs in term or near term infants born
by cesarean section.
• Caused by the retention of lung fluid
following birth.
• Baby is born with respiratory distress
and rapid f (80 – 100/min or higher).
• Evaporation of lung fluid.
Transient Tachypnea of the
Newborn
• X-ray findings are similar for RDS,
TTN, and pneumonia.
• Pleural effusions may be present.
• May be started on broad spectrum
antibiotics.
• Lung maturity is found.
• Usually good APGAR scores.
• Frequent turning is helpful to
eliminate lung fluid.
Transient Tachypnea of the
Newborn
• ABG show oxygenation problem.
• Ventilation is usually normal.
• If ventilation is started, the baby will wean
quickly.
• Process of elimination.
Tracheoesophageal Fistula or
Atresia
•
•
•
•
Fistula is an abnormal communication
between two passages or cavities.
Atresia is the absence or closure of a
normal body orifice or tubular
passage.
TEF is a congenital abnormality
resulting in respiratory distress.
Most common type is an upper
esophageal atresia and a lower
tracheal-esophageal fistula.
Diagnosis
• The nurse/physician will try to pass a
catheter into the stomach.
• Bronchoscopy or ultrasound is used to
diagnose.
• May be seen on chest-x-ray.
Clinical Manifestations
• Constant pooling of oral, nasal and
pharyngeal secretions/drooling.
• Continuous or sporadic respiratory
distress.
• Choking on feedings.
• Repeated vomiting with or after
feedings.
• Persistent upper lobe pneumonia or
atelectasis due to aspiration.
• Gastric distention.
Treatment of TEF
• Surgical correction is needed.
• Supportive care until surgery.
• Aspiration is a major concern.
• A gastric feeding tube is usually placed
in the esophageal pouch to remove
secretions.
• Keep in 30 degree upright position.
• Infant is fed with a gastrostomy tube until
surgery.
Choanal Atresia
• A congenital malformation of bone or a
membrane causing partial or complete
obstruction of one or both of the
choana.
• The obstruction results in asphyxia
since infants are nose breathers early in
life.
• Respiratory Distress subsides when the
baby cries.
Diagnosis
• A catheter or probe
fails to pass through
the infant’s nose.
Often the nose has a
large accumulation
of thick secretions.
• If the obstruction is
a membrane, it may
be punctured to
provide relief of the
respiratory distress.
Clinical Manifestations
• Clinical Signs
•
•
•
•
Respiratory distress
Cyanosis
Retractions
Pooling of nasal secretions
Treatment
• Treatment
• Insertion of an oral airway to facilitate
mouth breathing.
• If distress continues, then intubate and
ventilate.
Diaphragmatic Hernia
• CDH is a congenital condition in which
the abdominal organs herniate into the
chest cavity through the diaphragm.
• Life threatening condition.
• Lung tissue is compressed.
Diaphragmatic Hernia
• Most common defect is in the
posterolateral region of the diaphragm
in an area called the foramen of
Bochdalek.
• Left side herniation is more frequent (8590%).
• Stomach, spleen & intestines can enter the
chest.
• Scaphoid (boat shaped) Abdomen is
present.
Diaphragmatic Hernia
• The baby will be in respiratory distress
at birth.
• PMI may be shifted.
• Breath sounds diminished.
• Bowel sounds can be heard over lung
fields.
• Confirmed with chest x-ray.
• Lungs are hypoplasitc (underdeveloped).
Treatment of Diaphragmatic
Hernias
• Orogastric tube is inserted to remove air.
• Do not manually ventilate these infants.
• Overdistension of stomach will worsen
problem.
• Intubate to prevent air in the stomach
and intestines.
• High Frequency Ventilation, ECMO
• High mortality rate.
• Pneumothorax is common.
Treatment of Diaphragmatic
Hernias
•Prenatal ultrasound can
accurately diagnose a CDH in
utero (in utero repair has been
successfully accomplished)!!
Persistent Pulmonary Hypertension of
the Newborn (PPHN)
• Formerly Persistent Fetal Circulation (PFC)
• Pulmonary hypertension after birth caused by
asphyxia and which prevents the transition of
fetal to newborn circulation.
• It may be a primary disorder or a secondary
disorder:
•
•
•
•
•
•
RDS
TTN
Pneumonia
Cold Stress
Meconium aspiration
Diaphragmatic hernia
Persistent Pulmonary Hypertension of
the Newborn (PPHN)
• Blood is shunted Right to Left across
the ductus arteriosus.
• The Apgar is usually 5 or less at 1 and 5
minutes.
Signs and Symptoms
•
•
•
•
Tachypnea
Retractions
Cyanosis
Breath sounds are clear if no pulmonary
disease is present.
• Refractory to oxygen therapy (true
shunt).
• Difference in pre & post ductal blood
gases.
Diagnostic Testing
• Hyperoxia Test
• If PaO2 does not increase with 100% oxygen,
suspect a cardiac shunt
• Not specific for PFC
• Compare preductal and postductal PaO2
• If shunt is present Preductal > Postductal.
• 15 to 20 mm Hg and with FiO2
• Hyperoxia-Hyperventilation Test
• Most definitive.
• Hyperventilate until PaCO2 is 20 – 25 mm Hg
• Alkalosis will reduce pulmonary hypertension
and PaO2 will improve.
• Echocardiography – ultrasound of the heart
• Cardiac Catheterization
Treatment for PPHN
• Oxygen therapy to maintain PaO2
greater than 50 – 60 mm Hg.
• Mechanical ventilation.
• Nitric Oxide
• ECMO, HFV
• Keep glucose and electrolytes normal.
Pneumothorax
•
•
•
•
•
•
Cyanosis
Tachypnea
Grunting
Nasal flaring
PMI is shifted
Diminished or absent breath sounds
Confirmation of a Pneumothorax
• Transillumination
• Bed Side
• Chest x-ray
Treatment of Pneumothorax
• Emergency treatment .
• Needle Aspiration
• 2nd intercostal space
• Chest Tube.
• Given the baby 100% oxygen until chest
tube is inserted.
Infections
• Pneumonia – infection in the lungs.
• Septicemia – infection in the
bloodstream.
• Meningitis – infection/inflammation of
the covering of the brain and spinal
cord.
• Urinary Tract Infections
• Conjunctivitis – infection or
inflammation of the eye.
• Omphalitis – infection/inflammation of
the umbilical stump.
Pneumonia
• Transplacental
• Acquired at birth
• Amniotic fluid.
• Premature rupture of membranes
greater than 12-24 hours (PROM).
• Postnatal
• Invasive lines.
• Respiratory equipment.
• Hospital Personnel.
Pneumonia
• Premature infants are at greater risk.
• Group B Beta Hemolytic Streptococci &
Escherichia Coli are the most common
organisms.
• PFC is usually a consequence of
pneumonia.
Diagnosis of Pneumonia
• Chest x-ray
• Very difficult to distinguish between
Pneumonia, RDS & TTN.
• Culture and Sensitivity.
Postnatally Acquired Pneumonia
• Klebsiella
• Pseudomonas
• Methicillin-Resistant Staphylococcus
(MRSA)
• Resistant to penicillin type drugs.
• Candida Albicans (fungal).
Viruses that affect the Newborns
•
•
•
•
•
•
Herpes Virus
Respiratory Syncytial Virus (RSV)
Rubella
Adenovirus
Cytomegalovirus
Chlamydia