Author: R. Schumacher, 2009License: Unless otherwise noted, this material is made available under the terms of theCreative...
Citation Key                          for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Ada...
Newborn Respiratory                  Disease             M2 – Respiratory Sequence              Robert Schumacher, M.D.Fal...
M2 Respiratory Sequence 2008: Neonatal Lung Disease•Newborn respiratory distress syndrome ischaracterized by low lung volu...
Review M1• 2 Dead French Guys• 1 Dead Swiss Guy
Laplace Relationship• !P =2"/r• Trans-surface pressure = 2(surface tension) / radius of  curvature                   Sourc...
Von Neergard• Swiss physicist who demonstrated surface tension forces  at work in excised cat lungs. (Air filled v saline ...
•    If this surface film is compressed the phospholipids will    be packed more tightly and more water excluded from    t...
Jean L. Poiseuille                        Poiseuille, Jean Léonard Marie (1799-1869)                        was a French p...
Source Undetermined   Source Undetermined
• Arteriogram:  – Newborn lacks    intra-acinar    arteries  – Lacks    background    “haze” seen in    the adult lung  – ...
THE FIRST BREATH:   Goal #1: Fluid out, Air in.Source Undetermined
Source Undetermined
Source Undetermined
• Starling forces at work to clear lung fluid   Source Undetermined
• Functional                        Residual                        Capacity is                        establishedSource U...
Source Undetermined
Source Undetermined
Goal #2. Blood In• Fetal circulation:   – “right-to-left     shunting” at the     level of the atria     and the ductus   ...
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined                      Source Undetermined
Case: #1• Because “it’s the Holidays” and her mother-in-  law will be in town to “help out”, a scheduled  repeat elective ...
Transient Tachypneaof the Newborn: (TTNB)• Also know as “Wet Lung, Retained Fetal Lung  Fluid”.• Occurs as a consequence o...
Transient Tachypnea of the Newborn• Lung water content (and weight) is high and an  increased respiratory rate is energy e...
Transient Tachypnea of the Newborn          No labor             During labor          30 minutes of life   6 hours of lif...
Source Undetermined
Transient Tachypnea of the Newborn              Source Undetermined (All Images)
Case: #2• A woman delivers premature twins at 25  weeks gestational age. The twins develop  respiratory distress.   – Why ...
Source Undetermined
Hyaline membranesAtelectasis             Source Undetermined (Both Images)
Image ofalveoli without surfactant in   abnormal respiration
Source Undetermined
Newborn Respiratory DistressSyndrome (RDS)• Why does this infant have the following signs:• Tachypnea ?   – Minute ventila...
Newborn Respiratory Distress Syndrome (RDS) • Nasal flaring:    – On inspiration alae diameter increases to lower      air...
Newborn Respiratory Distress Syndrome (RDS)Low lung volumeAir Bronchograms“Ground glass”,“Salt and pepper”  “reticulogranu...
Newborn Respiratory Distress Syndrome (RDS)How would you treat this infant?   Simple things:    Oxygen   Maintain FRC:    ...
• On day 7 one twin deteriorates. You hear a  murmur.  – What is this twin’s problem?               NIH, United States Dep...
Patent Ductus arteriosus       Source Undetermined (Both Images)
Respiratory Distress Syndrome• Occurs as a consequence of a structural  and functional/biochemical immaturity  of a infant...
Case #3: • As a baby shower gift a pregnant woman’s friends   present her with some crack cocaine. Tired of   being pregna...
Case 3# Meconium AspirationSyndrome. Source Undetermined                                             Source Undetermined  ...
Meconium Aspiration Syndrome.    Source Undetermined
Case #3  • After effective resuscitation, the infant is    placed on a ventilator. Shortly thereafter    you note decrease...
Pneumothorax from meconium plug   Source Undetermined                            Source Undetermined     Source Undetermined
• Having fixed this problem you note  persistent cyanosis. You note curiously  that the transcutaneous O2 saturation  moni...
Source Undetermined   Source Undetermined
Source Undetermined (Both Images)
Persistant Pulmonary Hypertension(PPHN)Persistant fetal circulation (PFC)Persistent pulmonary hypertension of the newborn ...
Persistant Pulmonary Hypertension (PPHN)Persistant fetal circulation (PFC)Treatment:• Fix that which is broken.  – Correct...
Persistant Pulmonary Hypertension (PPHN)Persistant fetal circulation (PFC)• Attempt to lower PVR.   – O2, Ventilation, Buf...
Source Undetermined
Additional Source Information                                   for more information see: http://open.umich.edu/wiki/Citat...
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09.23.08: Newborn Respiratory Disease

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09.23.08: Newborn Respiratory Disease

  1. 1. Author: R. Schumacher, 2009License: Unless otherwise noted, this material is made available under the terms of theCreative Commons Attribution – Non-Commercial – Share Alike 3.0 License:http://creativecommons.org/licenses/by-nc-sa/3.0/We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share,and adapt it. The citation key on the following slide provides information about how you may share and adapt this material.Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, orclarification regarding the use of content.For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medicalevaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medicalcondition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (USC 17 § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (USC 17 § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (USC 17 § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Newborn Respiratory Disease M2 – Respiratory Sequence Robert Schumacher, M.D.Fall, 2009
  4. 4. M2 Respiratory Sequence 2008: Neonatal Lung Disease•Newborn respiratory distress syndrome ischaracterized by low lung volumes. Contributingfactors to the low FRC in such patients include:” a. decreased lung compliance b. surfactant deficiency c. increased chest wall compliance d. hey, babies are small e. All of the above*
  5. 5. Review M1• 2 Dead French Guys• 1 Dead Swiss Guy
  6. 6. Laplace Relationship• !P =2"/r• Trans-surface pressure = 2(surface tension) / radius of curvature Source Undetermined
  7. 7. Von Neergard• Swiss physicist who demonstrated surface tension forces at work in excised cat lungs. (Air filled v saline filled cat lungs) Laplace relationship holds for alveoli. Source Undetermined
  8. 8. • If this surface film is compressed the phospholipids will be packed more tightly and more water excluded from the surface. This is ideal: the smaller the radius of curvature the more important surface tension forces become (LaPlace), the smaller the radius of curvature the tighter the surfactant molecular pack and the greater the reduction in surface tension forces. Source Undetermined
  9. 9. Jean L. Poiseuille Poiseuille, Jean Léonard Marie (1799-1869) was a French physiologist who made a key contribution to our knowledge of the circulation of blood in the arteries. Source UndeterminedPoiseuilles Law of The Flow of Liquids Through a Tube:Where:l = the length of the tube in cmr = the radius of the tube in cmp = the difference in pressure of the two ends of the tube in dynes per cm2c = the coefficient of Viscosity in poises (dyne-seconds per cm2)v = volume in cm3 per secondThen: v = r 4 p/8cl
  10. 10. Source Undetermined Source Undetermined
  11. 11. • Arteriogram: – Newborn lacks intra-acinar arteries – Lacks background “haze” seen in the adult lung – So resistance is high Source Undetermined
  12. 12. THE FIRST BREATH: Goal #1: Fluid out, Air in.Source Undetermined
  13. 13. Source Undetermined
  14. 14. Source Undetermined
  15. 15. • Starling forces at work to clear lung fluid Source Undetermined
  16. 16. • Functional Residual Capacity is establishedSource Undetermined
  17. 17. Source Undetermined
  18. 18. Source Undetermined
  19. 19. Goal #2. Blood In• Fetal circulation: – “right-to-left shunting” at the level of the atria and the ductus arteriosus. Source Undetermined
  20. 20. Source Undetermined
  21. 21. Source Undetermined
  22. 22. Source Undetermined
  23. 23. Source Undetermined Source Undetermined
  24. 24. Case: #1• Because “it’s the Holidays” and her mother-in- law will be in town to “help out”, a scheduled repeat elective cesarean section is performed on a woman at 37 weeks gestational age. When this baby is born he is tachypneic.• List as many reasons as you can for the lack of clearance of lung fluid.• How would you treat this problem?
  25. 25. Transient Tachypneaof the Newborn: (TTNB)• Also know as “Wet Lung, Retained Fetal Lung Fluid”.• Occurs as a consequence of delayed or incomplete clearance of fetal lung fluid.• Predisposing/ causative factors: – No labor, c-section, hypoventilation, low colloid oncotic pressure, low pulmonary blood flow
  26. 26. Transient Tachypnea of the Newborn• Lung water content (and weight) is high and an increased respiratory rate is energy efficient.• Signs in infant – tachypnea• ABGs: – usually normal• Clinical course: – usually benign / self limiting.• Treatment (usual) : – none or O2.
  27. 27. Transient Tachypnea of the Newborn No labor During labor 30 minutes of life 6 hours of life Source Undetermined
  28. 28. Source Undetermined
  29. 29. Transient Tachypnea of the Newborn Source Undetermined (All Images)
  30. 30. Case: #2• A woman delivers premature twins at 25 weeks gestational age. The twins develop respiratory distress. – Why is lung volume low in these infants? • Small baby • Compliant chest wall • Non-Compliant lungs (surfactant deficiency)
  31. 31. Source Undetermined
  32. 32. Hyaline membranesAtelectasis Source Undetermined (Both Images)
  33. 33. Image ofalveoli without surfactant in abnormal respiration
  34. 34. Source Undetermined
  35. 35. Newborn Respiratory DistressSyndrome (RDS)• Why does this infant have the following signs:• Tachypnea ? – Minute ventilation is RR x TV. With a compliant chest wall increasing RR is more efficient than taking deeper breaths (increasing TV).• Grunting ? – Exhaling against a partially closed glottis provides positive end expiratory pressure -maintains lung volume (FRC).
  36. 36. Newborn Respiratory Distress Syndrome (RDS) • Nasal flaring: – On inspiration alae diameter increases to lower airway resistance. • Paradoxical breathing: (On inspiration the abdomen pops-up, the chest wall sinks) – Use of diaphragm with compliant chest wall produces negative intra-thoracic pressure, positive abdominal pressure, a costly way to breathe. • Retractions: – increased use of muscles of respiration = very costly, and hence a “late” sign
  37. 37. Newborn Respiratory Distress Syndrome (RDS)Low lung volumeAir Bronchograms“Ground glass”,“Salt and pepper” “reticulogranular lungs Source Undetermined Source Undetermined
  38. 38. Newborn Respiratory Distress Syndrome (RDS)How would you treat this infant? Simple things: Oxygen Maintain FRC: Positive end expiratory pressure Positive pressure ventilation, Treat the Cause: Artificial surfactant
  39. 39. • On day 7 one twin deteriorates. You hear a murmur. – What is this twin’s problem? NIH, United States Department of Health and Human Services
  40. 40. Patent Ductus arteriosus Source Undetermined (Both Images)
  41. 41. Respiratory Distress Syndrome• Occurs as a consequence of a structural and functional/biochemical immaturity of a infants lung including: – a relative lack of surfactant production. – a compliant chest wall – a variable degree of L to R shunting through a patent ductus arteriosus.
  42. 42. Case #3: • As a baby shower gift a pregnant woman’s friends present her with some crack cocaine. Tired of being pregnant the woman tries to induce labor by using the crack. Subsequent severe abdominal pain prompts her to seek medical attention. An emergency c-section is planned. At rupture of membranes there is blood and thick chunky pea- soup like material seen. The infant is born floppy, pale with no spontaneous respirations. • Think about why and when this baby may have problems……..
  43. 43. Case 3# Meconium AspirationSyndrome. Source Undetermined Source Undetermined Cornell University Medical College, 1995
  44. 44. Meconium Aspiration Syndrome. Source Undetermined
  45. 45. Case #3 • After effective resuscitation, the infant is placed on a ventilator. Shortly thereafter you note decreased breath sounds, a shift of the PMI, hypotension and profound cyanosis. • What has happened? What should you do?
  46. 46. Pneumothorax from meconium plug Source Undetermined Source Undetermined Source Undetermined
  47. 47. • Having fixed this problem you note persistent cyanosis. You note curiously that the transcutaneous O2 saturation monitor gives different readings on the hands vs feet.• What is happening? What can you do?
  48. 48. Source Undetermined Source Undetermined
  49. 49. Source Undetermined (Both Images)
  50. 50. Persistant Pulmonary Hypertension(PPHN)Persistant fetal circulation (PFC)Persistent pulmonary hypertension of the newborn (PPHN) is the result of elevated pulmonary vascular resistance to the point that venous blood is diverted to some degree through fetal channels (i. e. the ductus arteriosus and foramen ovale) into the systemic circulation and bypassing the lungs, resulting in systemic arterial hypoxemia.
  51. 51. Persistant Pulmonary Hypertension (PPHN)Persistant fetal circulation (PFC)Treatment:• Fix that which is broken. – Correct the cause of hypoxia, hypercarbia, acidosis.• If it hurts when you go like that, then don’t go like that. – Avoid over distention of lungs, – Barotrauma
  52. 52. Persistant Pulmonary Hypertension (PPHN)Persistant fetal circulation (PFC)• Attempt to lower PVR. – O2, Ventilation, Buffer – Inhaled Nitric Oxide• Attempt to raise SVR (and output) – Volume expansion for preload – Vasoconstrictors? – Inotropic support
  53. 53. Source Undetermined
  54. 54. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicySlide 6: Source UndeterminedSlide 7: Source UndeterminedSlide 8: Source UndeterminedSlide 9: Source UndeterminedSlide 10: Source Undetermined; Source UndeterminedSlide 11: Source UndeterminedSlide 12: Source UndeterminedSlide 13: Source UndeterminedSlide 14: Source UndeterminedSlide 15: Source UndeterminedSlide 16: Source UndeterminedSlide 17: Source UndeterminedSlide 18: Source UndeterminedSlide 19: Source UndeterminedSlide 20: Source UndeterminedSlide 21: Source UndeterminedSlide 22: Source UndeterminedSlide 23: Source Undetermined; Source UndeterminedSlide 27: Source UndeterminedSlide 28: Source UndeterminedSlide 29: Source Undetermined (All Images)Slide 31: Source UndeterminedSlide 32: Source Undetermined (Both Images)Slide 34: Source UndeterminedSlide 37: Source Undetermined; Source UndeterminedSlide 39: NIH, United States Department of Health and Human ServicesSlide 40: Source Undetermined (Both Images)Slide 43: Source Undetermined; Cornell University Medical College, 1995; Source UndeterminedSlide 44: Source UndeterminedSlide 46: Source Undetermined; Source Undetermined; Source UndeterminedSlide 48: Source Undetermined; Source UndeterminedSlide 49: Source UndeterminedSlide 53: Source Undetermined

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