This document discusses two case studies of neonatal respiratory distress. The first case involves a preterm infant with respiratory distress syndrome that was not resolving with treatment. Imaging revealed a right-sided diaphragmatic hernia. The second case involves a term infant with respiratory distress found to have a congenital cystic adenomatoid malformation of the right middle lobe on prenatal ultrasound and CT scan. In both cases, imaging was key to diagnosis and surgical intervention helped resolve the respiratory distress.
1. Respiratory Distress In Neonates
⢠Case 1
By Dr. Randeep Singh
Resident Paediatrics
NKP SIMS and LMH, Nagpur
2. ⢠Preterm 32 weeks gestation unbooked case delivered by normal
vaginal delivery
⢠Didnât cried after birth
⢠Cried after bag and mask ventilation
⢠Shifted in NICU for prematurity, low birth weight, grunt(RDS 4)
8. ⢠USG thorax â
Bilateral lung parenchyma shows heterogenous echotexture
with interspread sonographic air bronchograms which suggest
possibility of consolidation.
Also possibility of Right sided diaphragmatic hernia.
10. Congenital Diaphragmatic Hernia
⢠Prevalenceď 1:2000 to 1:5000
⢠Male : female ď equal
⢠Right sided(20%) common in males
⢠80% is left sided
16. MANAGEMENT
⢠Stabilize blood pressure (dopamine,dobutamine,
milrinone)
⢠Circulating volume
⢠Correct hypoxemia(Nitric Oxide)
⢠Pulmonary distress
⢠ECMO(conventional medical therapy are failing)
17. ⢠Fetal surgical intervention
ď Fetal repair
ď Fetal tracheal occlusion
⢠Postnatal
ď reduction of herniated viscera and closure of diaphragmatic defect
ď chest tube drainage ď tension pneumothorax
Ideal time for surgery is unknown(24 hours of stabilisation delays upto
7-10 days)
18. Prognosis
Poor prognostic indicators-
1. Early symptoms(symptoms after 24 hrs good prognosis)
2. Preterm
3. LBW
ABG-
Paco2ď 40mmHg, Pao2ď 100mmHg
Oxygen Index
Compliance of lung
ECHOď PPHN
Size of the diaphragm defect
19. Case 2
By Dr. Shyam kartikey Dwivedi
Resident Paediatrics
NKP SIMS and LMH, Nagpur
20. Case
⢠Term, Female baby/ AGA with Bwt. 3.420 kg , delivered by
Elective cesarean section (I/V/O previous scar)
⢠Booked case- Antenatal scan showed cystic lesion in right side
of chest
⢠Baby cried immediately after birth.
⢠APGAR score was 8/10 and 9/10 at 1 min and 5 min
respectively.
21. ⢠Baby had respiratory distress (tachyponea, subcostal
indrawing and not maintaining saturation at room
air) & shifted to NICU for same.
⢠There is no H/O PROM and foul smelling liquor
22. ⢠Examination:-
Vitals-
Normothermic
AF at level
HR- 146/min
RR- 72/min
Spo2-76% ORA
RDS- 4
CRT- <2 sec
GPE
B/L femoral well felt
No Pallor ,No icterus, acro
cyanosis present
No oedema,No dysmorphic
faces
No evidence of any congenital
anamoly
Genitals are normal
23. ⢠S/E-
RS - chest b/l symmetrical, decreased air entry on right side of the
chest, subcostal indrawing present
CVS - S1 S2 normal, No murmur
P/A - Soft , normal shaped, no organomegaly, bowel sounds heard
adequately in all quadrants.
CNS - Cry, tone, activity good
good NNR
24. Chest X âray after birth
Investigation
Septic Screen
CBC
Hb 16.5gm/dl
TLC 17000
DLC
N 72%,
L 20%,
E 02%,
M 03%
BAND CELL 03%(IT ratio-4%)
CRP â 0.1
26. ⢠Management:-
Baby immediately shifted to NICU
Feed withhold
IV access done and fluid started
O2 by nasal prone at 2ltr
Spo2 improved but distress still present
RDS 2
28. ⢠Immediately call to paediatric surgeon, advised
surgery.
⢠Right middle lobectomy (lesion was confined to Rt.
middle lobe) was done.
⢠After 45mins of surgery, the respiratory distress was
decreased to minimal and baby was kept on oxygen
by hood.
32. Congenital Cystic Adenematoid
Malformation
⢠Incidence : 1-4 in 1 lakh
Histological classification
⢠Type 0: Acinar dysplasia, < 3% , poor prognosis
⢠Type 1: Macrocystic (usually cyst 2-8cm), 60%
Psuedostratified
localised only one part of one lobe
good prognosis
33. ⢠Type 2 : Micro cystic, 20%
Multiple small cyst(<2cm)
Psuedo stratified epithelium
associated with other congenital
anomalies(renal,cardiac,diaphragmatic
hernia)
poor prognosis
34. Type 3(10%) : mixture of microcyst +
solid tissue
Cuboidal ciliated epithelium
Poor prognosis
TYPE 4(10%): Macrocystic (lack with mucus cells)
Associated with malignancy like
pleuropulmonary blastoma
35. ⢠DIAGNOSIS : MADE IN UTERO by USG at 21 weeks (as early as
16 weeks)
⢠CT scan: Gives accurate diagnosis.
Clinical Feature:
Respiratory distress
Recurrent respiratory infection
Pneumothorax
Decrease breath sounds on effected side
Mediastinal shift on physical examination
Multiloculated cystic lesion in right hemithorax with mediastinal shift to the left. However there is no evidence of obvious defect noted in the right dome of diaphragm. Shift of the mediastinum away from the lesion There is air-trapping in the cysts leads to rapid enlargement.
There is a large multiloculated cystic lesion centered in the right lower lobe. The multiloculations are typical for a congenital cystic adenomatoid malformation. The periphery of the lesion shows some wall thickening and ill-defined infiltration into the surrounding parenchyma. I believe the lesion arises largely in the apical segment of the right lower lobe.
The radioopacity and cystic areas noted in the previous x ray is not seen in the current x ray.
Both the lungs show normal aeration and improvement following excision of the affected lobe.
The treatment of choice is excision of the affected lobe. The prognosis is favorable in the absence of pulmonary hypoplasia, fetal hydrops, or associated congenital anomalies