Ef73 Coclia 86 Neonatal Respiratory Distress

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Ef73 Coclia 86 Neonatal Respiratory Distress

  1. 1. COCLIA: Neonatal Respiratory Distress Carolyn Nguyen April 7, 2008
  2. 2. Terminology <ul><li>Stridor: abnormal or unwanted noise made by turbulent airflow in the airway excluding stertor </li></ul><ul><li>Stertor: snoring type of noise made by nasopharyngeal and oropharyngeal obstruction </li></ul>
  3. 3. Sites of Obstruction <ul><li>Nasal </li></ul><ul><li>Oro/hypopharyngeal </li></ul><ul><li>Supraglottic </li></ul><ul><li>Glottic </li></ul><ul><li>Subglottic </li></ul><ul><li>Tracheobronchial </li></ul>
  4. 4. Nasal Obstruction <ul><li>Initially obligate nasal breathers so causes severe respiratory distress </li></ul><ul><li>Generally no stridor </li></ul><ul><li>Snorting respiration with nasal flaring </li></ul><ul><li>Chest retractions common </li></ul><ul><li>Cyclical cyanosis: cyanotic episodes frequent but interrupted with crying </li></ul><ul><li>Feeding difficulty because of need for mouth breathing </li></ul>
  5. 5. Nasal Differential <ul><li>External </li></ul><ul><ul><li>midline pits or dimples (dermoid) or nasal mass (encephalocele, meningocele, glioma, dermoid, intracranial vascular anomaly) </li></ul></ul><ul><li>Internal </li></ul><ul><ul><li>pyriform aperture, turbinate hypertrophy, nasolacrimal duct cysts, posterior choanae (should pass a 5-6 Fr catheter) and nasopharynx (adenoid, tumor) </li></ul></ul><ul><li>Craniofacial anomalies </li></ul><ul><ul><li>Treacher Collins syndrome (narrowed nares, hypoplastic alar cartilages) </li></ul></ul><ul><ul><li>Apert syndrome (midface hypoplasia) </li></ul></ul>
  6. 6. Oro/hypopharynx Obstruction <ul><li>Coarse inspiratory stridor, worse with sleep, when supine, feeding or agitated </li></ul><ul><li>Normal cry but may be muffled </li></ul><ul><li>Sternal and intercostal retractions common </li></ul><ul><li>Feeding difficulty because of anatomical obstruction </li></ul>
  7. 7. Oro/hypopharyngeal Differential <ul><li>Oral cavity </li></ul><ul><ul><li>macroglossia, glossoptosis, micrognathia </li></ul></ul><ul><li>Pharynx </li></ul><ul><ul><li>lateral pharyngeal wall collapse </li></ul></ul><ul><ul><li>vallecular mass (lingual thyroid, dermoid, vallecular cyst) </li></ul></ul><ul><li>Pierre Robin sequence </li></ul><ul><ul><li>micrognathia, glossoptosis, and cleft palate </li></ul></ul>
  8. 8. Supraglottic Laryngeal Obstruction <ul><li>Muffled cry </li></ul><ul><li>Snorting respirations while asleep </li></ul><ul><li>Coarse inspiratory sounds at rest </li></ul><ul><li>Suprasternal and intercostal retractions </li></ul><ul><li>Feeding difficulty if severe obstruction </li></ul><ul><li>Worse with supine position, feeding, and agitation </li></ul>
  9. 9. Supraglottic Differential <ul><li>Laryngomalacia </li></ul><ul><li>Arytenoid fixation </li></ul>
  10. 10. Glottic Laryngeal Obstruction <ul><li>Hoarse cry or aphonic </li></ul><ul><li>Initially inspiratory stridor becomes biphasic if obstruction increases </li></ul><ul><li>Usually no feeding difficulty (no physical obstruction in pharynx) except hunger for air </li></ul>
  11. 11. Glottic Differential <ul><li>Laryngeal cyst </li></ul><ul><li>Laryngeal web </li></ul><ul><li>Laryngeal atresia </li></ul><ul><li>Laryngeal cleft </li></ul><ul><li>Vocal cord palsy </li></ul>
  12. 12. Subglottic Laryngeal Obstruction <ul><li>Often normal cry </li></ul><ul><li>Initially inspiratory stridor becomes expiratory as obstruction increases (then biphasic if severe) </li></ul><ul><li>Xiphoid retractions </li></ul><ul><li>Barking type cough </li></ul><ul><li>Alar flaring </li></ul><ul><li>Usually feeds normally </li></ul>
  13. 13. Subglottic Differential <ul><li>Stenosis </li></ul><ul><li>Cysts </li></ul><ul><li>Hemangiomas </li></ul>
  14. 14. Tracheobronchial Obstruction <ul><li>Normal cry </li></ul><ul><li>Characteristic expiratory stridor </li></ul><ul><li>Wheezing component </li></ul><ul><li>Retractions uncommon </li></ul><ul><li>Nasal flaring </li></ul><ul><li>Brassy cough </li></ul><ul><li>Normal feeding except air hunger or extrinsic compression </li></ul>
  15. 15. Tracheobronchial Differential <ul><li>Tracheal rings </li></ul><ul><li>Tracheal stenosis or atresia </li></ul><ul><li>Tracheal cysts </li></ul><ul><li>Tracheal hemangioma </li></ul><ul><li>Tracheobronchomalacia </li></ul><ul><li>Tracheoesophageal fistula </li></ul><ul><li>Vascular compression </li></ul>
  16. 16. Physics <ul><li>Poiseuille’s law: fluid flow through a tube varies with the fourth power of the radius </li></ul><ul><li>Venturi principle: drop in fluid pressure that results when an incompressible fluid flows through a constricted section of pipe </li></ul><ul><li>Bernoulli’s principle (conservation of energy): an increase in the speed of the fluid occurs simultaneously with a decrease in pressure or a decrease in the fluid's gravitational potential energy </li></ul>
  17. 17. Choanal Atresia <ul><li>Occurs in 1 in 5,000-8,000 live births </li></ul><ul><li>50% have associated congenital anomalies </li></ul><ul><li>30% pure bony, 70% mixed bony-membranous </li></ul><ul><li>Features: narrow nasal cavity, lateral bony obstruction by the lateral pterygoid plate & medial obstruction due to vomer thickening (endochondral bone formation), membranous obstruction </li></ul>
  18. 18. Choanal Atresia <ul><li>Diagnosis: inability to pass small catheter through the nose into the nasopharynx, rigid or flexible endoscopy </li></ul><ul><li>Imaging: CT </li></ul><ul><li>Nonsurgical management: McGovern nipple, oropharyngeal airway </li></ul><ul><li>Surgical management: removing and shortening posterior bony septum, removal of superior-lateral nasal wall & lateral pterygoid plate, stented 3-6 weeks </li></ul>
  19. 19. Laryngomalacia <ul><li>Most common cause of neonatal stridor </li></ul><ul><li>Develops within first 2 weeks of life </li></ul><ul><li>Usually resolves by 2 years of age </li></ul><ul><li>Inspiratory stridor results from collapse of the supraglottic larynx </li></ul>
  20. 20. Laryngomalacia <ul><li>Anterior prolapse of arytenoid mucosa: laser excision of redundant mucosa </li></ul><ul><li>Short tethered aryepiglottic folds: laser or microscissor supraglottoplasty </li></ul><ul><li>Posterior collapse of the epiglottis: epiglottopexy </li></ul>
  21. 21. Tracheal Vascular Anomalies <ul><li>Innominate artery compression </li></ul><ul><li>Double aortic arch </li></ul><ul><li>Right aortic arch </li></ul><ul><li>Pulmonary artery sling </li></ul><ul><li>Pulmonary artery dilation </li></ul>
  22. 22. Innominate Artery Compression <ul><li>Most common vascular compression </li></ul><ul><li>Artery arises further to left than usual </li></ul><ul><li>Causes anterior tracheal wall compression particularly during expiration and cough </li></ul><ul><li>Treatment: aortopexy </li></ul>
  23. 23. Double Aortic Arch <ul><li>“ Complete vascular ring” </li></ul><ul><li>Second most common </li></ul><ul><li>Derived from persistence of the paired aortic arches </li></ul><ul><li>Encircles the trachea and esophagus and joins to form the descending aorta </li></ul><ul><li>Imaging shows posterior esophageal compression </li></ul><ul><li>Treatment: divide the vascular ring </li></ul>
  24. 24. Neonatal “Stridor” Consult <ul><li>History </li></ul><ul><ul><li>Time of onset, progression </li></ul></ul><ul><ul><li>Identify initiating factors </li></ul></ul><ul><ul><li>Effects of positioning, feeding, or crying </li></ul></ul><ul><ul><li>History of prematurity, difficult labor/delivery, intubation at birth, cardiac surgery </li></ul></ul><ul><li>Exam </li></ul><ul><ul><li>Document quality of stridor and timing with respiration </li></ul></ul><ul><ul><li>Characterize cry and presence of cough & dysphagia </li></ul></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Prolonged exhalation </li></ul></ul>
  25. 25. Congenital Bilateral VC Palsy <ul><li>Second most common cause of neonatal stridor </li></ul><ul><li>10% of all congenital laryngeal anomalies </li></ul><ul><li>Typically presents within first month of life </li></ul><ul><li>Symptoms: stridor, cyanosis, apnea, feeding difficulty </li></ul><ul><li>Slight M>F dominance, bilateral>unilateral </li></ul><ul><li>Causes: neurologic disease, meningomyelocele, trauma, idiopathic </li></ul>
  26. 26. Congenital Bilateral VC Palsy <ul><li>Prognosis: spontaneous recovery is unpredictable </li></ul><ul><ul><li>Usually within 6 and 36 months </li></ul></ul><ul><ul><li>Less likely with associated neurologic problem </li></ul></ul><ul><ul><li>Less common when bilateral </li></ul></ul><ul><li>Treatment: vocal cord lateralization, arytenoidopexy, posterior cricoid split </li></ul>
  27. 27. Subglottic Hemangioma <ul><li>Caucasian </li></ul><ul><li>2:1 female:male </li></ul><ul><li>50% affects the head and neck region with subglottis being the most common subsite </li></ul><ul><li>Can be multiple </li></ul><ul><li>Peaks at age 6 weeks, before 6 months </li></ul><ul><li>Most common symptom: initially intermittent stridor, progresses to become constant </li></ul>
  28. 28. Subglottic Hemangioma <ul><li>Diagnosis: direct laryngoscopy </li></ul><ul><li>Smooth, soft, compressible sessile mass from lateral wall of subglottis </li></ul><ul><li>Can be biopsied without hemorrhage </li></ul><ul><li>Natural history: rapid proliferation to 1yr then resolution of airway symptoms 2-3 years (growth of larynx) </li></ul><ul><li>Treatment: laser excision, systemic steroids, interferon alfa-2a </li></ul>
  29. 29. Endotracheal Tubes & Complications <ul><li>ID (mm) = [age in years + 16] / 4 </li></ul><ul><li>Prevention! Correct technique and size </li></ul><ul><li>Complications: lacerations, cricoarytenoid dislocation, nerve injury (lingual, hypoglossal, superior laryngeal, RLN), vocal cord injury </li></ul><ul><li>Risk of subglottic stenosis from prolonged intubation >7-10 days outweighs the risk of tracheotomy </li></ul>
  30. 30. Cricoid Split <ul><li>Purpose: to decompress the complete cricoid ring and temporarily expand the lumen without stenting </li></ul><ul><li>One week period of intubation is required </li></ul><ul><li>Indications: failed extubation from subglottic edema or soft immature stenosis </li></ul><ul><li>Contraindications: less than 1.5 kg, oxygen requirement >35% from BPD </li></ul>

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