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Neonatal Diseases

Neonatal Diseases. MODULE E. Objectives. Identify the key pathophysiologic changes that occur with each disease. Describe the therapeutic intervention needed to treat each of the diseases. Retinopathy of prematurity (ROP) Patent Ductus Arteriosus Hypoglycemia Cold Stress

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Neonatal Diseases

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  1. Neonatal Diseases MODULE E

  2. Objectives • Identify the key pathophysiologic changes that occur with each disease. • Describe the therapeutic intervention needed to treat each of the diseases.

  3. Retinopathy of prematurity (ROP) Patent Ductus Arteriosus Hypoglycemia Cold Stress Intraventricular & Intracerebral hemorrhaging Bronchopulmonary dysplasia Wilson Mikity Syndrome Apnea of prematurity Necrotizing enterocolitis RDS Perinatal Diseases and Other Problems with Prematurity

  4. Retinopathy of Prematurity (ROP) • Formerly known as Retrolental Fibroplasia (RLF). • Initially described in 1940/1950s following increased incidence of blindness with babies in incubators. • Incidence today: • 25 to 35% of preemies up to 35 weeks

  5. Physiology of the Developing Eye • Capillaries of retina begin branching at 16 weeks. • End of pseudoglandular period. • Capillaries begin at optic nerve and grow anteriorly toward the ora serrata which is the anterior end of the retina. • Growth is not complete until 40 weeks. • Premature infants don’t have complete growth. • As the capillary network expands, arteries and veins form in its path. • ROP is the failure of this network to develop.

  6. Oxygen and ROP • In the presence of high PaO2, the retinal vessels constrict. • Prolonged exposure to high PaO2 will lead to necrosis of the vessels (vaso-obliteration). • The body attempts to correct for this by over perfusing the “good” arteries, which leads to hemorrhage in the vitreous. • This hemorrhage leads to scar tissue development and blindness.

  7. Stages and Zones of ROP • 5 stages, with 5 having the retina completely detached. • Three Zones of the eye (zone 1 is the worst)

  8. RDS - Respiratory Distress Syndrome • aka: IRDS or Hyaline Membrane Disease • Associated with lung immaturity and a deficiency in surfactant production. • Immaturity of other organ systems. • Decreased Compliance & increased WOB. • Severe hypoxemia may result in multiple organ failure. • May be associated with PPHN (PFC) or PDA.

  9. RDS - Respiratory Distress Syndrome • Symptoms worsen for first 48-72 hours. • Stabilization • Slow recovery • With progression of the disease, scar tissue replaces the normal alveolar tissue. • Hyaline Membrane

  10. Clinical Signs • History of prematurity • f above 60/min • Grunting • Retractions • Flaring of nostrils • Cyanosis • Severe hypoxemia on blood gases • Hypothermia & flaccid muscle tone

  11. X-ray Findings • Diffuse “White-out” (Radiopaque) • Atelectasis • Air bronchograms • Reticulogranular Pattern • “Fishing net” • Ground Glass Appearance

  12. Treatment • Attempt to accelerate lung maturity by pharmacological means. • Steroids • Tocolysis: Delay labor with b-Adrenergic Agents • (Terbutaline) • Thermoregulation

  13. Treatment • Artificial Surfactant • CPAP or mechanical ventilation • High Frequency Ventilation • ECMO

  14. Recovery Phase • Complications • ROP • Bronchopulmonary dysplasia • Chronic lung disease (COPD for Neonates) • Intraventricular hemorrhage • Brain dysfunction • Necrotizing Enterocolitis • Intrapulmonary Hemorrhage • Full Recovery

  15. Bronchopulmonary Dysplasia • Other Name • Neonatal Chronic Lung Disease (NCLD) • Progressive chronic lung disease that presents with persistent respiratory problems at 28 days or later, radiographicchanges and oxygen dependency

  16. Bronchopulmonary Dysplasia • Criteria • Preterm infants • Prolonged oxygen concentrations (O2 toxicity) • Positive pressure ventilation (barotrauma) • Patent ductus arteriosus (PDA) • Time exposure to oxygen and positive pressure • Malnutrition

  17. Bronchopulmonary Dysplasia • Not all babies with RDS develop BPD. • Pattern begins to unfold within the first 3-4 days of life that places a neonate at high risk of developing BPD.

  18. Bronchopulmonary Dysplasia • Lung Pathology • Mucosal hyperplasia of small airways. • Destruction of type I cells. • Inflammation and destruction of alveoli and capillary bed. • Lungs are cystic in some areas and atelectatic in others.

  19. Chest X-Ray • Radiology • “Honeycomb” appearance • Diaphragms are flattened • Cystic appear (hyperlucent) • Atelectasis (radiopaque)

  20. HMD to BPD – 3 Hour

  21. HMD to BPD – Day 13

  22. HMD to BPD – Day 19

  23. HMD to BPD – 3 Months

  24. Tachypnea Retractions Mucous plugging Hyperinflation of chest – barrel chest Cyanotic spells Poor ABG Wheezing Inadequate growth Increased WOB Increased oxygen consumption Pulmonary hypertension and Cor Pulmonale Clinical Presentation

  25. Goals of Bronchopulmonary Dysplasia • Prevention of BPD. • Provide enough calories to support growth. • Wean slowly off oxygen. • Limit peak inspiratory pressures on ventilator. • CPAP or HFV • Keep FiO2 levels as low as possible. • May need to keep PaO2 levels lower.

  26. Complications of Bronchopulmonary Dysplasia • Gastroesophageal reflux and feeding intolerance leads to aspiration. • Decreased Ca and phosphorus (bone fractures. • Loss sight or hearing (ROP). • Chronic infections. • Pneumothorax. • Cerebral palsy. • Limit Fluid intake – develop pulmonary edema.

  27. Bronchopulmonary Dysplasia • Death is usually due to: • Cor Pulmonale • Infection • Sudden Death

  28. Discharge of patients with BPD • Home Care • Oxygen & CPT • Mechanical ventilators • Medications • Diuretics or cardiac meds • Special Attention to nutritional needs • Frequent re-admissions back into the hospital.

  29. Necrotizing Enterocolitis (NEC) • Injury to the intestinal mucosa due to hypoperfusion, hypoxia or hyperosmolar feedings. • The mucosa cannot secrete the protective layer of mucus and it becomes vulnerable to bacterial invasion. • Intestinal ischemia may result in necrosis and gangrene of the intestine. • Complication of RDS. • Highest incidence in lowest birth weight infants.

  30. Necrotizing Enterocolitis (NEC) • Intestinal dilation (distended loops of intestine with gas). • Gastric ileus (obstruction) • Abdominal distention. • Rectal bleeding • Bloody stool • Feeding is difficult.

  31. Treatment • Stop feedings. • Nasogastric Suctioning • Hyperalimentation IV. • Antibiotics. • 20% require surgery.

  32. Intraventricular Hemorrhage (IVH) • Premature infants and low birth weight infants are the greatest risk. • Diagnosed by ultrasound or CT scan. • Seen with increased incidence in children of alcoholic mothers. • 4 grades of IVH. • Grade 1 - Bleeding occurs just in a small area of the ventricles. • Grade 2 - Bleeding also occurs inside the ventricles. • Grade 3 - Ventricles are enlarged by the blood. • Grade 4 - Bleeding into the brain tissues around the ventricles.

  33. Etiology And History of IVH

  34. Grades of IVH

  35. IVH Treatment • Prevent Occurrence • Supportive

  36. Wilson-Mikity Syndrome • Seen in premature and LBW infants. • Less than 1500 grams at birth. • “Emphysema” of little babies. • Lung immaturity with rupture of the alveolar septa. • Similar to BPD except babies have not been ventilated. • Treatment is supportive. • Oxygen and mechanical ventilation. • Some question as to whether it is a separate syndrome or not.

  37. Meconium Aspiration • Disease of term or post term neonates. • Asphyxia occurs before, during or after the onset of labor. • Relaxation of the anal sphincter with release of the meconium (first stool). • Treatment is immediate suctioning & antibiotics. • Intubate with endotracheal tube and with a meconium aspirator.

  38. Meconium Aspiration • Usually associated with PFC and infection. • Pneumothorax may result from the hyperinflation. • An emergency tension pneumothorax is treated with a needle aspiration followed by chest tube insertion.

  39. Ball-Valve Effect

  40. Transient Tachypnea of the Newborn (TTN) • RDS type II. • Occurs in term or near term infants born by cesarean section. • Caused by the retention of lung fluid following birth. • Baby is born with respiratory distress and rapid f (80 – 100/min or higher). • Evaporation of lung fluid.

  41. Transient Tachypnea of the Newborn • X-ray findings are similar for RDS, TTN, and pneumonia. • Pleural effusions may be present. • May be started on broad spectrum antibiotics. • Lung maturity is found. • Usually good APGAR scores. • Frequent turning is helpful to eliminate lung fluid.

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