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Ef73 Coclia 86 Neonatal Respiratory Distress

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  • 1. COCLIA: Neonatal Respiratory Distress Carolyn Nguyen April 7, 2008
  • 2. Terminology
    • Stridor: abnormal or unwanted noise made by turbulent airflow in the airway excluding stertor
    • Stertor: snoring type of noise made by nasopharyngeal and oropharyngeal obstruction
  • 3. Sites of Obstruction
    • Nasal
    • Oro/hypopharyngeal
    • Supraglottic
    • Glottic
    • Subglottic
    • Tracheobronchial
  • 4. Nasal Obstruction
    • Initially obligate nasal breathers so causes severe respiratory distress
    • Generally no stridor
    • Snorting respiration with nasal flaring
    • Chest retractions common
    • Cyclical cyanosis: cyanotic episodes frequent but interrupted with crying
    • Feeding difficulty because of need for mouth breathing
  • 5. Nasal Differential
    • External
      • midline pits or dimples (dermoid) or nasal mass (encephalocele, meningocele, glioma, dermoid, intracranial vascular anomaly)
    • Internal
      • pyriform aperture, turbinate hypertrophy, nasolacrimal duct cysts, posterior choanae (should pass a 5-6 Fr catheter) and nasopharynx (adenoid, tumor)
    • Craniofacial anomalies
      • Treacher Collins syndrome (narrowed nares, hypoplastic alar cartilages)
      • Apert syndrome (midface hypoplasia)
  • 6. Oro/hypopharynx Obstruction
    • Coarse inspiratory stridor, worse with sleep, when supine, feeding or agitated
    • Normal cry but may be muffled
    • Sternal and intercostal retractions common
    • Feeding difficulty because of anatomical obstruction
  • 7. Oro/hypopharyngeal Differential
    • Oral cavity
      • macroglossia, glossoptosis, micrognathia
    • Pharynx
      • lateral pharyngeal wall collapse
      • vallecular mass (lingual thyroid, dermoid, vallecular cyst)
    • Pierre Robin sequence
      • micrognathia, glossoptosis, and cleft palate
  • 8. Supraglottic Laryngeal Obstruction
    • Muffled cry
    • Snorting respirations while asleep
    • Coarse inspiratory sounds at rest
    • Suprasternal and intercostal retractions
    • Feeding difficulty if severe obstruction
    • Worse with supine position, feeding, and agitation
  • 9. Supraglottic Differential
    • Laryngomalacia
    • Arytenoid fixation
  • 10. Glottic Laryngeal Obstruction
    • Hoarse cry or aphonic
    • Initially inspiratory stridor becomes biphasic if obstruction increases
    • Usually no feeding difficulty (no physical obstruction in pharynx) except hunger for air
  • 11. Glottic Differential
    • Laryngeal cyst
    • Laryngeal web
    • Laryngeal atresia
    • Laryngeal cleft
    • Vocal cord palsy
  • 12. Subglottic Laryngeal Obstruction
    • Often normal cry
    • Initially inspiratory stridor becomes expiratory as obstruction increases (then biphasic if severe)
    • Xiphoid retractions
    • Barking type cough
    • Alar flaring
    • Usually feeds normally
  • 13. Subglottic Differential
    • Stenosis
    • Cysts
    • Hemangiomas
  • 14. Tracheobronchial Obstruction
    • Normal cry
    • Characteristic expiratory stridor
    • Wheezing component
    • Retractions uncommon
    • Nasal flaring
    • Brassy cough
    • Normal feeding except air hunger or extrinsic compression
  • 15. Tracheobronchial Differential
    • Tracheal rings
    • Tracheal stenosis or atresia
    • Tracheal cysts
    • Tracheal hemangioma
    • Tracheobronchomalacia
    • Tracheoesophageal fistula
    • Vascular compression
  • 16. Physics
    • Poiseuille’s law: fluid flow through a tube varies with the fourth power of the radius
    • Venturi principle: drop in fluid pressure that results when an incompressible fluid flows through a constricted section of pipe
    • 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
  • 17. Choanal Atresia
    • Occurs in 1 in 5,000-8,000 live births
    • 50% have associated congenital anomalies
    • 30% pure bony, 70% mixed bony-membranous
    • Features: narrow nasal cavity, lateral bony obstruction by the lateral pterygoid plate & medial obstruction due to vomer thickening (endochondral bone formation), membranous obstruction
  • 18. Choanal Atresia
    • Diagnosis: inability to pass small catheter through the nose into the nasopharynx, rigid or flexible endoscopy
    • Imaging: CT
    • Nonsurgical management: McGovern nipple, oropharyngeal airway
    • Surgical management: removing and shortening posterior bony septum, removal of superior-lateral nasal wall & lateral pterygoid plate, stented 3-6 weeks
  • 19. Laryngomalacia
    • Most common cause of neonatal stridor
    • Develops within first 2 weeks of life
    • Usually resolves by 2 years of age
    • Inspiratory stridor results from collapse of the supraglottic larynx
  • 20. Laryngomalacia
    • Anterior prolapse of arytenoid mucosa: laser excision of redundant mucosa
    • Short tethered aryepiglottic folds: laser or microscissor supraglottoplasty
    • Posterior collapse of the epiglottis: epiglottopexy
  • 21. Tracheal Vascular Anomalies
    • Innominate artery compression
    • Double aortic arch
    • Right aortic arch
    • Pulmonary artery sling
    • Pulmonary artery dilation
  • 22. Innominate Artery Compression
    • Most common vascular compression
    • Artery arises further to left than usual
    • Causes anterior tracheal wall compression particularly during expiration and cough
    • Treatment: aortopexy
  • 23. Double Aortic Arch
    • “ Complete vascular ring”
    • Second most common
    • Derived from persistence of the paired aortic arches
    • Encircles the trachea and esophagus and joins to form the descending aorta
    • Imaging shows posterior esophageal compression
    • Treatment: divide the vascular ring
  • 24. Neonatal “Stridor” Consult
    • History
      • Time of onset, progression
      • Identify initiating factors
      • Effects of positioning, feeding, or crying
      • History of prematurity, difficult labor/delivery, intubation at birth, cardiac surgery
    • Exam
      • Document quality of stridor and timing with respiration
      • Characterize cry and presence of cough & dysphagia
      • Hoarseness
      • Prolonged exhalation
  • 25. Congenital Bilateral VC Palsy
    • Second most common cause of neonatal stridor
    • 10% of all congenital laryngeal anomalies
    • Typically presents within first month of life
    • Symptoms: stridor, cyanosis, apnea, feeding difficulty
    • Slight M>F dominance, bilateral>unilateral
    • Causes: neurologic disease, meningomyelocele, trauma, idiopathic
  • 26. Congenital Bilateral VC Palsy
    • Prognosis: spontaneous recovery is unpredictable
      • Usually within 6 and 36 months
      • Less likely with associated neurologic problem
      • Less common when bilateral
    • Treatment: vocal cord lateralization, arytenoidopexy, posterior cricoid split
  • 27. Subglottic Hemangioma
    • Caucasian
    • 2:1 female:male
    • 50% affects the head and neck region with subglottis being the most common subsite
    • Can be multiple
    • Peaks at age 6 weeks, before 6 months
    • Most common symptom: initially intermittent stridor, progresses to become constant
  • 28. Subglottic Hemangioma
    • Diagnosis: direct laryngoscopy
    • Smooth, soft, compressible sessile mass from lateral wall of subglottis
    • Can be biopsied without hemorrhage
    • Natural history: rapid proliferation to 1yr then resolution of airway symptoms 2-3 years (growth of larynx)
    • Treatment: laser excision, systemic steroids, interferon alfa-2a
  • 29. Endotracheal Tubes & Complications
    • ID (mm) = [age in years + 16] / 4
    • Prevention! Correct technique and size
    • Complications: lacerations, cricoarytenoid dislocation, nerve injury (lingual, hypoglossal, superior laryngeal, RLN), vocal cord injury
    • Risk of subglottic stenosis from prolonged intubation >7-10 days outweighs the risk of tracheotomy
  • 30. Cricoid Split
    • Purpose: to decompress the complete cricoid ring and temporarily expand the lumen without stenting
    • One week period of intubation is required
    • Indications: failed extubation from subglottic edema or soft immature stenosis
    • Contraindications: less than 1.5 kg, oxygen requirement >35% from BPD
  • 31.