The surgical causes for neonatal respiratory distress are life threatening and challenging. Early diagnosis and immediate timely surgical intervention are the key for the final successful outcome.

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Neonatal Respiratory Distress
“Surgical Perspective”
Neonatal Respiratory Distress
“Surgical Perspective”
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Dr.B.SELVARAJ

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Neonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory Distress
“Surgical Perspective”“Surgical Perspective”“Surgical Perspective”“Surgical Perspective”

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Dr.B.SELVARAJ MS;Mch;FICS;
• PEDIATRIC SURGEON
• ASSOCIATE PROFESSOR
• MELAKA MANIPAL MEDICAL COLLEGE
• MELAKA- 75150
• MALAYSIA

5. Neonatal Respiratory Distress
Recognise various conditions
Make early& accurate diagnosis
Prompt Life Saving treatment
Immediate surgical referral4
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Surgical Perspective
Objectives
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6. A NeonateA NeonateA NeonateA Neonate’s request to Surgeons request to Surgeons request to Surgeons request to Surgeon
“Please exercise the greatest gentleness with my
diminutive tissues and try to correct the
deformity at first operation; give me blood and
proper amount of fluid and electrolytes; add
plenty of oxygen to anesthesia, and I will show
you that I can tolerate a terrific amount of
surgery. You will be surprised at the speed of my
recovery, and I shall be grateful to you”
--Dr. Willis Potts
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7. Neonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory Distress—
Surgical CausesSurgical CausesSurgical CausesSurgical Causes
Causes
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D
AEsophageal
Atresia
Diaphragmatic Hernia
Congenital
Lobar
Emphysema
Posterior
Choanal
Atresia
Pierre
Robin
Sequence
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8. Embryology Of Esophageal Atresia
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9. Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia
EA
Challenging&
Fascinating Problem
Team Work
Approach
Post op Ventilator
Care
VACTERL
Anomaly
Incidence 1 in 3500
livebirths
Epitome of Modern Surgery
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia
TypesTypesTypesTypes
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11. Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia----
Associated AnomaliesAssociated AnomaliesAssociated AnomaliesAssociated Anomalies
Vertebral
Anorectal
Cardiac- commonest
Tracheo
Esophageal Fistula
Renal
Limb
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12. Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia
Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features
Clinical
Features
Drooling of salivaMaternal Polyhydramnios
Inability to pass NGT
into Stomach
In atresia with TEF Aspiration
of gastric contents
Chemical Pneumonitis
Feeding Cough,
choking &
Cyanosis
In pure atresia
Gasless Abdomen
Scaphoid Abd
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13. Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia----Drooling of salivaDrooling of salivaDrooling of salivaDrooling of saliva
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14. Physiological Effect of Distal TEF
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• 1. Hyaline membrane disease may
necessitate higher ventilator pressures,
which encourage air to pass through the
distal fistula.
• 2. A distended abdomen elevates and
"splints" the diaphragm.
• 3. Gastric distension may result in
gastric rupture and pneumoperitoneum.
• 4. Passage of air through a distal
tracheoesophageal fistula diminishes the
effective tidal volume.
(B) 1. Aspiration of gastric juices leads to
soiling of the lungs and pneumonia
• 2. Gastroesophageal reflux
• 3. Direction of gastric fluid proximally
through distal fistula.
• 4. Overflow of secretions or inadvertent
feeding may contribute to aspiration and
contamination of the airway.

15. Esophageal Atresia
Imaging Studies
AXR Gasless in pure Atresia
CXR Atelectasis&Pneumonia
Antenatal MRI of Fetus
USG Abd to R/O Urogenital anomaly
Echo to R/O cardiac
anomaly&Rt Aortic
arch
AXR &CXR Curledup NGT in blind upper pouch
Imaging
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Esophageal Atresia
Antenatal MRI
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17. Esophageal Atresia
Clinical Diagnosis
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• . (A) Diagnosis of
esophageal atresia is
confirmed when a 10-
gauge (French)
catheter cannot be
passed beyond 10 cm
from the gums. (B) A
smaller-caliber tube is
not used because it
may curl up in the
upper esophageal
segment, giving a false
impression of
esophageal atresia.

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Esophageal Atresia
CXR
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19. Esophageal Atresia With
TE Fistula- Bronchoscopy
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TE Fistula
Rt Bronchus

20. Esophageal Atresia
Pre op Management
Pre opProximal pouch
Decompression
NPO
If for staged repair
Do Gastrostomy
Head up position
In pure atresia
Stretch proximal pouch
daily
I V AntibioticsS
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21. Esophageal Atresia
Pre op Management
Pre opProximal pouch
Decompression
NPO
If for staged repair
Do Gastrostomy
Head up position
In pure atresia
Stretch proximal pouch
daily
I V AntibioticsS
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22. Esophageal Atresia
Waterston’s Risk Categories
●Birth weight >2.5 Kgs
●No Anomalies
●No Pneumonitis
●Primary Repair 100%survival
●Birth weight 1.8 to 2.5 Kgs
●Non life threatening anomalies
●Mild Pneumonitis
●Delayed Primary Repair 80%survival
●Birth weight < 1.8 Kgs
●Life threatening anomalies
●Severe Pneumonitis
●Staged Repair 40%survival
Risk
Categories
Category
A
Category B
Category C
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23. Esophageal Atresia
Operative Management
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3
Lanman’s Rt posterolateral retropleural
thoracotomy
Ligation & division of Azygos vein
Disconnect TEF; Repair tracheal defect
4 Liberally mobilise the upper pouch for tension
free anastomosis
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24. Esophageal Atresia
Operative Management
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In wide gap Livaditi’s circular myotomies
Never mobilise distal pouch much
Extra pleural drain
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Transanastomotic feeding tube for early gavage
feeding

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Esophageal Atresia
Operative Management
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26. Normal Mediastinum- Rt side
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27. Esophageal Atresia
Immediate Primary Repair
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Esophageal Atresia
VATS Repair
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31. Esophageal atresia
Post op Management in NICU
Gastrograffin swallow on 7th POD; If no leak oral
Feeding & remove chest drain
Feeding through transanastomotic feeding
Tube from 2nd POD
Regular chest Physio&Nasopharyngeal
suction
Otherwise exubate in 1st POD
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Electively paralyse&mechanically ventilate
For 3 to 5 days in tension anastomosis

32. Esophageal Atresia
Complications
LATE
Tracheomalacia
GE Reflux
EARLY
Anastomotic Leakage
Anastomotic Stricture
Recurrent TEF Esophageal Dysmotility
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33. Clinical
Features
Operation
Preop
Trt
•VACTERL
•Maternal Poly Hydramnios
•Drooling of saliva in baby
•Inability to pass NGT into stomach
•NPO
•Headup position
•IV Antibiotics
•Upper pouch suction
Complica
tions
Associ
Anomaly
EA&
TEF
Esophageal Atresia
TE Fistula Recap
Imaging
CXR
•Curledup NGT in blind
upper pouch
•Echo to R/O cardiac
Anomaly
• USG Abd to R/O
Urogenital anomaly
•Immediate primary
Repair
•Delayed primary
Repair
•Staged Repair
•Anastomotic leak
•Anastomotic stricture
•Tracheomalacia
•GE Reflux
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35. Congenital Diaphragmatic Hernia
& Eventration of diaphragm
Herniation of abdominal contents into the thorax
through a defect in diaphragm
In Eventration, diaphragm is replaced by a thin
membrane
Incidence 1 in 4000 live births
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36. Congenital Diaphragmatic Hernia
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37. Congenital Diaphragmatic Hernia
Pathology
Posterolateral Bochdalek Hernia: Commonest;
Lt side 80% Rtside 19% Bilateral 1%
Anteromedial Morgagni’s Hernia: 2%
Hypoplastic ipsilateral lung due to compression
by herniated viscera
Persistent pulmonary hypertension(PPHN) due
to abnormal pulmonary vasculature
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38. Congenital Diaphragmatic Hernia
Associated Anomalies
Neural tube defects
PDA,VSD,Coarctation of Aorta
Midgut Malrotation
Cleft palate
Exomphalos
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39. Congenital Diaphragmatic
Hernia Clinical Features
Respiratory distress Tachypnea,
Cyanosis,Tachycardia,Etc
Scaphoid Abdomen
Mediastinal shift to opposite side
In Lt sided CDH: Pseudodextrocardia
Absence of breath sounds & presence of bowel
sounds in ipsilateral hemithorax
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40. Congenital Diaphragmatic Hernia—
Imaging Studies
Antenatal USG & MRI Chest of the fetus
Postnatal CXR Presence of bowel shadows in the
hemithorax; Mediastinal shift to the opposite
side;Diaphragmatic margin is absent
In Eventration Frontal&lateral CXR show elevated
diaphragm with smooth unbroken outline
Flouroscopy:Paradoxical movement of diaphragm in
eventration
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41. Congenital Diaphragmatic Hernia—
Antenatal Fetal USG Chest

42. Congenital Diaphragmatic Hernia—
Antenatal Fetal MRI

43. Congenital Diaphragmatic Hernia—
Imaging Studies

44. Congenital Diaphragmatic Hernia—
Imaging Studies

45. Diaphragmatic Hernia
Pre op Management
In Utero transfer to a maternity unit close to Pediatric surgical
centre Electively deliver, promptly resuscitate & operate
NGT aspiration to decompress GIT
ET tube ventilation; “No face mask ventilation”
“EXIT” Extrauterine Intrapartum Treatment
Correct acidosis with NaHCO3 & Tromethamine
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46. Diaphragmatic Hernia
Pre op Management
Delayed Repair after preop stabilisation aimed at
correcting hypoxia, hypoperfusion& PPHN
Correct PPHN with Tolazoline or Nitric oxide
Pre&post ductal O2 saturation to assess the
degree of arterial oxygenation &ductal shunting
In intractable PPHN ECMO may be tried
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47. Diaphragmatic Hernia
Bad Prognostic Indicators
Infants born to mothers with Polyhydramnios
Stomach in thorax
Lung Head ratio: LHR < 1
Presentation within first 6Hrs of birth
Very low blood pH & high pCo2
Rt sided hernia
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48. Diaphragmatic Hernia
Prognostic Indicators
Alveolar-arterial O2 tension difference (AaDo2)
:If>500mmHg bad prognosis
Ventilatory Index: VI=RRxMAPxPaco2;When
Paco2 is <40mmHg & VI is <1000 all babies
survive
O2Index:OI=MAPXFiO2X100/Pao2
OI<6 Survival rate 98%
OI>17 No Survivors
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49. Diaphragmatic Hernia
Operative Management

50. Diaphragmatic Hernia
Operative Management

51. Eventration of Diaphragm
Plication

52. Diaphragmatic Hernia
Post op Management in NICU
Ventilatory support to maintain postductal Po2 80 to
100mmHg;Pco2 < 30mmHg & pH > 7.4
This can be achieved by high frequency ventilation
with low airway pressures & low tidal volume
Weaning from ventilator should be meticulous &
slow as small variation in pH, Po2& Pco2 will lead to
PPHN
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53. CDH is a congenital anomaly with a high mortality.
Usually associated with pulmonary hypoplasia and
pulmonary hypertension.
Surgical repair is the only treatment. Delayed surgery
until the patient is stable is associated with better
outcomes.
Congenital cardiac and renal diseases, hypoxemia and
hypercapnia increases mortality.
HFOV, ECMO, iNO has improved the survival of CDH.
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Congenital Diaphragmatic Hernia
Recap

54. Permissive hypercapnia with acceptable pO2 has
shown to improve survival.
Long term follow up is necessary to detect
complications.
Tracheal occlusion in utero, keeps lung expanded
but it is an abnormal lung.
Primary repair if small defect, patch if large defect,
to prevent tension
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Congenital Diaphragmatic Hernia
Recap

56. Congenital Lobar Emphysema
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•Congenital lobar overinflation
–Normal architecture with overdistension of the alveoli
–In true emphysema permanent distension of airspaces distal to terminal bronchiole with
destruction of their walls
•Etiology
–Not found in up to 50%
–Bronchial obstruction found in ~25%
•Allows collapse on exhalation (ball-valve mechanism)
•Air trapping leads to alveolar overinflation
•Intrinsic obstruction (more common)
–Intramural: Defect in the bronchial wall
•Defective quantity or quality of cartilage
–Intraluminal: Lesion in the lumen of the bronchus
•Redundant bronchial folds, mucous plugs
•Extrinsic obstruction
–Compression of the bronchus from a lesion outside the bronchial wall
•Cardiovascular: PDA, vascular sling
•Mass: Lymph node, bronchogenic cyst, oncologic mass

57. Congenital Lobar Emphysema
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•Males:Females= 3:1
•Upper lobes are predominantly involved
–LUL: 42%
–RML: 35%
–RUL: 21%
–Lower lobes: <1%
–Bilateral involvement: <20%
•Associated congenital malformations: 14-21%
–Congenital heart disease
•PDA
•VSD
–Of those with CHD, >10% have additional anomalies
•Rib cage defects
•Renal defects

58. Congenital Lobar Emphysema
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•Presentation
–Age
•At birth: 33%
•By 1 m.o.: 50%
•After 6 m.o.: 5%
–Symptoms (in order of decreasing frequency)
•Moderate respiratory distress (most)
•Cyanosis (half)
•Mild respiratory distress (less than half)
•Asymptomatic (infrequent)
•Severe life-threatening distress (least common)

59. Congenital Lobar Emphysema
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•Radiographic evaluation
–CXR: PA and lateral
•Large, space-occupying air-filled lobe
•Collapse of ipsilateral lung
•Mediastinal shift
•Atelectasis of contralateral lung
•Clear anterior mediastinum
–CT
•May identify point of obstruction, intraluminal or extrinsic
–Ventilation-Perfusion scan
•Decreased perfusion of affected lobe (secondary to vessel
compression)
•Increased perfusion of unaffected lobe (secondary to shunting)

60. Congenital Lobar Emphysema
Imaging Studies

61. Congenital Lobar Emphysema
Segmental
Resection
Lobectomy
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63. Pierre-Robin Sequence
Micrognathia/ Retrognathia
Glossoptosis
High arched Palate and/or Cleft Palate
Occur sporadic or syndromic Stickler’s &
Velocardiofacial syndromes
Respiratory distress aggravated during feeding
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64. Pierre-Robin Sequence- Grading
Grade1: Eats & breaths well in supine
position
Grade 2: Breaths well but obstructs
when fed by mouth
Grade 3: Cannot breathe or eat without
obstruction and desaturation
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65. Pierre-Robin Sequence
Most neonates responds to 2-3 months of
conservative treatment
Nursing the baby in prone position with head
tilted to one side prevent tongue fall back
Feeding the baby in lateral position with jaw
pushed forward
Rarely in severe cases may require anterior
fixation of the tongue Anterior Glossopexy
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66. Pierre-Robin Sequence
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68. Posterior Choanal Atresia
Absence of posterior nasal openings; Atresia can be a
membrane or bony overgrowth
Common in Rt nostril
Neonates are obligatory nasal breathers; in bilateral
cases “ Cyclical Cyanosis”relieved by crying
Respiratory distress aggravated during feeding
Difficulty in feeding & failure to thrive
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69. Posterior Choanal Atresia
Failure to pass NGT through nostrils
CT Skull Reveal bony block unilateral or bilateral
Respiration is not a problem in unilateral cases but it
is in bilateral cases oral airway
Feeding by a spoon or a long nipple directly into the
pharynx
Transpalatal or transnasal surgical correction
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70. Posterior Choanal Atresia
Associaed Anomaly
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Coloboma and/or CNS abnormalities
Heart abnormality
Atresia choanae
Retardation of growth
Genital defects (males)
Ear anomalies/deafness

71. Posterior Choanal Atresia

72. Posterior Choanal Atresia

73. Posterior Choanal Atresia

74. Posterior Choanal Atresia
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With the advent of miniaturized endoscopic
equipment and powered instrumentation, the most
popular and successful method over the past
decade has been the endoscopic transnasal
technique.

76. NEONATAL RESPIRATORY
DISTRESS Surgical Perspective
Sl No Symptoms Signs Workup Diagnosis Treatment
1
Attacks of
choking,
coughing and
cyanosis during
feeding
Drooling of
saliva
Failure to pass
NGT into the
stomach
CXR:Curled
up NGT in
upper
esophagus
AXR:Gasless
abdomen in
pure atresia
Esophageal
Atresia with or
without TEF
•Primary
repair
•Delayed
Primary repair
•Staged repair
2
Tachypnea
Tachycardia
Cyanosis
Scaphoid
abdomen
Mediastinal
shift
Bowel sound in
the hemithorax
CXR:Bowel
loops in
hemithorax
Mediastinal
shift
Congenital
diaphragmatic
hernia/
Eventration
Repair/
Plication of
Diaphragm

77. NEONATAL RESPIRATORY
DISTRESS Surgical Perspective
Sl No Symptoms Signs Workup Diagnosis Treatment
3
Cough,
tachypnea and
breathlessness
Shift of trachea/
Mediastinum
Area of hyper
resonance
Decreased
breath sounds
CXR:Mediastin
al shift
Hyperlucent
area of lung
Adjacent
normal lung
Congenital
Lobar
Emphysema
Bronchoscopy
if needed
Lobectomy/
Segmental
resection
4
Respiratory
distress
aggravated
during feeding
Micronathia
Glossoptosis
Cleft palate -----
Pierre-Robin
sequence
Nurse baby in
prone position
Anterior
glossopexy

78. NEONATAL RESPIRATORY
DISTRESS Surgical Perspective
Sl No Symptoms Signs Workup Diagnosis Treatment
5
Respiratory
distress
aggravated
during feeding
“ Cyclical
cyanosis”
Failure to pass
a catheter
through the
nostril
CT Skull
Bony block
unilateral or
bilateral
Posterior
Choanal
Atresia
Surgical
correction
Transnasal or
Transpalatal
approach

79. “ Practice without theory is blind”
“Theory without practice is sterile”

80. CARRY HOME MESSAGE
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“EYES CANNOT SEE WHAT
THE MIND DOES NOT KNOW”

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