Respiratory Distress Syndrome (Rds)

12,920
-1

Published on

Published in: Health & Medicine
3 Comments
33 Likes
Statistics
Notes
No Downloads
Views
Total Views
12,920
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
3
Likes
33
Embeds 0
No embeds

No notes for slide

Respiratory Distress Syndrome (Rds)

  1. 1. Respiratory distress syndrome (RDS) Mbbs.weebly.com
  2. 2. RDS = HMD RDS: Respiratory distress syndrome HMD: Hyaline membrane disease
  3. 3. Introduction <ul><li>Acute lung disease of the newborn caused by Pulmonary surfactant deficiency. </li></ul><ul><li>Tends to occur in neonates younger than 32 weeks GA </li></ul><ul><li>Outcome of RDS has improved with the increased use of antenatal steroids and early postnatal surfactant therapy </li></ul>
  4. 4. Etiology <ul><li>Prematurity </li></ul><ul><li>Pulmonary surfactant (PS) deficiency </li></ul>
  5. 5. Incidence <ul><li>Increase in incidence with decreasing gestational age </li></ul><ul><li><28wk: 60-80% </li></ul><ul><li>32-34wk: 15-30% </li></ul><ul><li>37wk: 5% </li></ul><ul><li>Infant of diabetic mother (IDM): 5-6 times higher than non-IDM </li></ul>
  6. 6. Constituents of PS
  7. 7. Functions of PS <ul><li>lower surface tension </li></ul><ul><li>maintain alveolar stability </li></ul><ul><li>prevent the collapse of small air spaces at end expiration </li></ul>
  8. 8. Capillary permeability↑ Pulmonary hypertension Hyaline membrane formation R->L shunting
  9. 9. Hyaline membrane
  10. 10. Hyaline membrane
  11. 11. Clinical manifestation <ul><li>symptoms: progressive respiratory distress within 2-6h tachypnea, intermittent expiratory grunting (from partial closure of glottis) </li></ul><ul><li>signs: nasal flaring( 鼻扇 ), cyanosis, subcostal and intercostal retractions ( 三凹征 ), fine rales can be heard, systolic murmur can be heard at left border of sternum in some patients. </li></ul>
  12. 12. Chest retraction
  13. 13. Laboratory examinations 1. foam test (胃液泡沫稳定试验〕 2. measurement of the levels of PS amniotic fluid or tracheal aspirate L / S (lecithin / sphingomyeline)  2  maturity of lungs 3. blood gas : pH  , PaO 2  , PaCO 2  , HCO 3 -  (mixed acidosis)
  14. 14. X-ray of RDS <ul><li>ground glass change </li></ul><ul><li>(fine reticular granularity of the parenchyma) </li></ul><ul><li>air bronchogram </li></ul><ul><li>white lung </li></ul>
  15. 15. Severe RDS- white lung
  16. 16. Echocardiography Color flow Doppler  PDA and PPHN PDA = Patent ductus arteriosus( 动脉导管未闭 ) PPHN = Persistent Pulmonary Hypertension of newborn ( 新生儿持续性肺动脉高压 )
  17. 17. Differential diagnosis <ul><li>wet lung(transient tachypnea of newborn, TTN ) </li></ul><ul><li>group B streptococcal (GBS) pneumonia </li></ul><ul><li>diaphragmatic hernia </li></ul>
  18. 18. X-ray of Wet Lung
  19. 19. Defect in the diaphragm
  20. 20. X-ray of diaphragmatic hernia
  21. 21. Infant of diaphragmatic hernia
  22. 22. Treatment-General therapy I 1. Temperature maintenance: T:36.5  C 2. Monitoring: T, R, HR, S a O 2 ,BP and blood gas 3. Fluid therapy: <ul><li>5%GS 65-75ml/kg/d (D1) </li></ul><ul><li>electrolyte supplement </li></ul><ul><li>start feeding if stable </li></ul><ul><li>parenteral nutrition (肠道外营养〕 when feeding intolerance and poor energy intake </li></ul>
  23. 23. Treatment-General therapy II 4.    Correction of acidosis 5.   Closure of PDA 6.    Antibiotics <ul><li>fluid restriction </li></ul><ul><li>diuretics </li></ul><ul><li>Indomethacin, ibuprofen </li></ul><ul><li>surgical ligation </li></ul>
  24. 24. Treatment Oxygen therapy and assist ventilation 1.oxygen therapy <ul><li>nasal cannula, mask or headbox oxygen </li></ul><ul><li>keep PaO 2 50-70mmHg, S a O 2 90-95% </li></ul><ul><li>Prevent alveolar collapse at end expiration </li></ul><ul><li>Indication: FiO 2. > 0.4, PaO 2 < 50 mmHg or S a O 2 < 85% </li></ul><ul><li>Pressure: 4-6 cmH 2 O </li></ul>2. CPAP (continuous positive airway pressure)
  25. 25. CPAP
  26. 26. Treatment - CMV Conventional mechanical ventilation (CMV) 1. Indication <ul><li>CPAP>8cmH 2 O and FiO 2 >0.6,PaO 2 <50mmHg or S a O 2 <85% </li></ul><ul><li>PaCO 2 >60mmHg and PH<7.25 </li></ul><ul><li>Frequent apnea </li></ul><ul><li>Pulmonary air leak (PAL) </li></ul><ul><li>Chronic lung disease (CLD=BPD) </li></ul><ul><li>Retinopathy of prematurity (ROP) </li></ul><ul><li>Ventilator-associated pneumonia (VAP) </li></ul>2. Complications of CMV
  27. 27. Conventional mechanical ventilation
  28. 28. Pulmonary air leak
  29. 29. PS replacement therapy PS
  30. 30. PS replacement therapy 1.Clinical effect 2.natural PS: Survanta synthetic PS: Exosurf 3.method: via endotracheal tube within 2h of life dosing: 2-4 doses <ul><li> RDS mortality </li></ul><ul><li> pneumothorax </li></ul><ul><li> lung compliance and gas exchange </li></ul>
  31. 31. PS treated RDS
  32. 32. Prevention <ul><li>Prevention of prematurity </li></ul><ul><li>Antenatal corticosteroid therapy </li></ul><ul><li>Dexamethasone or betamethasone </li></ul><ul><li> RDS mobidity and mortality </li></ul><ul><li>PS prophylatic therapy </li></ul>
  33. 33.
  34. 34. Hypoxic Ischemic Encephalopathy (HIE)
  35. 35. <ul><li>Definition </li></ul><ul><li>Perinatal asphyxia </li></ul><ul><li> </li></ul><ul><li>hypoxic-ischemic brain injury </li></ul><ul><li> </li></ul><ul><li>significant mortality and long-term morbidity </li></ul><ul><li>permanent neurologic impairment </li></ul><ul><li>(mental retardation, epilepsy and cerebral palsy) </li></ul>
  36. 36. Etiology <ul><li>Hypoxic factors--- perinatal asphyxia, severe respiratory disease </li></ul><ul><li>Ischemic factors---severe heart failure,severe bradycardia </li></ul>
  37. 37. Pathological changes <ul><li>Diffuse cerebral edema, necrosis and hemorrhage </li></ul><ul><li>Term infants: necrosis of cerebral cortex,basal ganglia,thalamic nuclei </li></ul><ul><li>Preterm infants: </li></ul><ul><li>Periventricular hemorrhage (PVH) </li></ul><ul><li>Intraventricular hemorrhage (IVH) </li></ul><ul><li>Periventricular leukomalacia ( PVL, 脑室周围白质软化 ) </li></ul>
  38. 38. Lesions of HIE
  39. 39. Pathogenesis Alteration of cerebral blood flow
  40. 40. Pathogenesis <ul><li>2. Alteration of metabolism of brain tissue </li></ul><ul><li>Hypoxia  anaerobic glycolysis↑  Na–K-ATPase pump insufficiency  cerebral edema </li></ul><ul><li>Free radical formation </li></ul><ul><li>Calcium influx </li></ul><ul><li>Toxic effect of excitatory amino acids </li></ul><ul><li>Neuronal apoptosis and necrosis </li></ul>
  41. 41. Clinical manifestation <ul><li>Altered level of consciousness </li></ul><ul><li>Irritability– somnolence (嗜睡〕 -- lethargy (昏睡〕 -- coma </li></ul><ul><li>Muscle tone--- hypotonic or flaccid (肌力松软〕 </li></ul><ul><li>Primary reflex--- diminish or disappear </li></ul><ul><li>Seizures </li></ul><ul><li>Increased intracranial pressure </li></ul>
  42. 42. Clinical manifestation
  43. 43. Diagnosis <ul><li>History: perinatal asphyxia </li></ul><ul><li>Profound metabolic or mixed acidemia (pH <7) in an umbilical artery blood sample </li></ul><ul><li>Persistence of an Apgar score of 0-3 for longer than 5 minutes </li></ul><ul><li>Clinical manifestation </li></ul><ul><li>Neonatal neurologic sequelae (eg, seizures, coma, hypotonia) </li></ul>
  44. 44. Diagnosis <ul><li>Laboratory examination </li></ul><ul><li>Cranial ultrasound </li></ul><ul><li>CT scanning (decrease of tissue attenuation) </li></ul><ul><li>MRI </li></ul><ul><li>EEG abnormalities </li></ul><ul><li>Biochemical markers (serum CK-BB and plasma NSE  ) </li></ul>
  45. 45. CT scanning of HIE
  46. 46. Treatment-I <ul><li>Supportive care </li></ul><ul><li>Maintain adequate ventilation PaO 2 50-70mmHg PaCO 2 <40mmHg </li></ul><ul><li>maintain adequate tissue perfusion (normal HR,BP) </li></ul><ul><li>correction of electrolyte and acid-base disorder </li></ul><ul><li>correction of hypoglycemia </li></ul><ul><li>correction of hypotension Dopamine and Dobutamine </li></ul><ul><li>fluid therapy 60-80ml/kg/d </li></ul>
  47. 47. Treatment-II <ul><li>2.Control seizures </li></ul><ul><li>Sodium luminal (first choice) </li></ul><ul><li>loading dose 15-20mg/kg IV </li></ul><ul><li>maintenance dose 3-5mg/kg/d </li></ul><ul><li>Diazepam (安定〕 </li></ul><ul><li>Chloral hydrate </li></ul>
  48. 48. Treatment-III <ul><li>3.Treatment of cerebral edema </li></ul><ul><li>Frusemide (first choice) </li></ul><ul><li>Albumin </li></ul><ul><li>Mannitol </li></ul>
  49. 49. Intracranial hemorrhage of the newborn
  50. 50. <ul><li>remains a significant cause of both morbidity and mortality in infants born prematurely. </li></ul><ul><li>Sequelae include life-long neurological deficits, such as cerebral palsy, developmental delay, and seizures. </li></ul><ul><li>PVH-IVH remains a serious problem for preterm infant </li></ul>Intracranial hemorrhage of the newborn
  51. 51. Etiology and pathogenesis <ul><li>Vascular factor </li></ul><ul><li>< 32wk premature infant </li></ul><ul><li> </li></ul><ul><li>immature blood vessels in germinal matrix </li></ul><ul><li>(subependymal region) </li></ul><ul><li> </li></ul><ul><li>perinatal hypoxia and blood pressure fluctuations </li></ul><ul><li> </li></ul><ul><li>subependymal hemorrhage(SEH) </li></ul><ul><li> </li></ul><ul><li>periventricular – intraventricular hemorrhage </li></ul><ul><li>(PVH-IVH) </li></ul>
  52. 52. Where is germinal matrix ?
  53. 53. Etiology and pathogenesis <ul><li>2.Pressure factor </li></ul><ul><li>Hypoxia, acidosis, wide fluctuation of cerebral blood flow velocity </li></ul><ul><li> </li></ul><ul><li>impairment of vascular auto-regulation </li></ul><ul><li> </li></ul><ul><ul><li>“ pressure passive circulatory state” </li></ul></ul><ul><li> </li></ul><ul><li>capillary injury </li></ul>
  54. 54. Etiology and pathogenesis 3. Birth trauma Laceration of tentorium cerebelli,falx cerebri and cerebral superficial vein  Rupture of cerebral vein  Subdural hemorrhage(SDH)
  55. 55. Subdural hemorrhage ( SDH)
  56. 56. Etiology and pathogenesis <ul><li>4. Other factors </li></ul><ul><li>Vit k deficiency, coagulopathy </li></ul><ul><li>Maternal ITP </li></ul><ul><li>Maternal medication (phenytoin, phenobarbital, rifampicin) </li></ul><ul><li>Infusion of hyperosmotic solution </li></ul>
  57. 57. Clinical manifestation-I <ul><li>Non-specific features </li></ul><ul><li>Hypothermia </li></ul><ul><li>Anemia </li></ul><ul><li>Jaundice </li></ul><ul><li>Frequent apnea, </li></ul><ul><li>Hypovolemia shock </li></ul>
  58. 58. Clinical manifestation-II <ul><li>Neurologic dysfunction </li></ul><ul><li>Increased intracranial pressure </li></ul><ul><li>bulging anterior fontanel, BP  ,seizures, </li></ul><ul><li>opisthotonus( 角弓反张 ),high pitched shrill cry </li></ul><ul><li>Abnormal respiration </li></ul><ul><li>Altered level of consciousness </li></ul><ul><li>irritability, somnolence( 嗜睡 ) , lethargy( 昏睡 ) , coma </li></ul>
  59. 59. Clinical manifestation-III <ul><li>Neurologic dysfunction </li></ul><ul><li>Abnormal eye signs </li></ul><ul><li>gaze, limitation of upward gaze, nystagmus (眼球震颤〕 </li></ul><ul><li>Pupil : dilated and poorly reactive pupil </li></ul><ul><li>Primary reflex (rooting, sucking, grasp, Moro) diminish or disappear </li></ul><ul><li>Muscle tone </li></ul>
  60. 60. Periventricular- Intraventricular Hemorrhage <ul><li>Grading based on cranial ultrasound or CT scan </li></ul><ul><li>Grade I: GMH (confined to GM- subependymal region) </li></ul><ul><li>Grade II: Intraventricular hemorrhage( IVH) </li></ul><ul><li>Grade III: Grade II + dilated ventricles </li></ul><ul><li>Grade IV: Grade III + intraparenchymal hemorrhage </li></ul>
  61. 61. Periventricular- Intraventricular Hemorrhage CT ultrasound PVH IVH PVH-IVH
  62. 62. Primary Subarachnoid Hemorrhage(SAH) <ul><li>Associated with birth trauma </li></ul><ul><li>Post hemorrhage hydrocephalus (communicating or obstructive hydrocephalus) </li></ul>
  63. 63. Intraparenchymal Hemorrhagel (IPH) hemorrhage  liquefied  cyst formation  porencephalic cysts ( 脑穿通性囊肿 )
  64. 64. Treatment-I <ul><li>Supportive care </li></ul><ul><li>minimal handling </li></ul><ul><li>fluid therapy </li></ul><ul><li>maintain blood pressure ,temperature </li></ul><ul><li>Hemostasis </li></ul><ul><li>fresh frozen plasma (FFP), </li></ul><ul><li>Vit k 1, ethamsylate, reptilase </li></ul>
  65. 65. Treatment-II <ul><li>Control seizures </li></ul><ul><li>sodium luminal </li></ul><ul><li>Diazepam </li></ul><ul><li>Decrease of intracranial pressure </li></ul><ul><li>frusemide </li></ul><ul><li>low dose mannitol </li></ul>
  66. 66. Treatment-III <ul><li>Management of hydrocephalus </li></ul><ul><li>Pharmacologic: acetazolamide </li></ul><ul><li>serial lumbar punctures </li></ul><ul><li>permanent ventricular –peritoneal shunt </li></ul>
  67. 67. Prevention <ul><li>Avoidance of premature birth </li></ul><ul><li>Prevention of perinatal asphyxia </li></ul><ul><li>Avoidence of wide fluctuation of BP </li></ul><ul><li>Prophylatic therapy </li></ul><ul><li>Antenatal steroid </li></ul>
  68. 68. Questions?
  69. 69. Thank You!

×