Teachings

Question 1

What is the most common reason for admission to NICU?

Answer 1

Respiratory distress

Question 2

What are the causes of respiratory distress in a newborn?

Answer 2

Respiratory 
Cardiac 
Sepsis 
Surgical 
Metabolic

Question 3

What is the clinical presentation of respiratory distress?

Answer 3

Cyanosis 
Grunting 
Tachypnoea 
Nasal flaring 
Head bobbing 
Recessions 
Use of accessory muscles 
Poor feeding and lethargy 
Poor blood O2 sats 
Hypercapnia and hypoxaemia on blood gas 
CXR changes

Question 4

What are the respiratory causes of distress?

Answer 4

Resp distress syndrome 
Meconium aspiration syndrome 
Congenital pneumonia (bacterial/viral) 
Pneumothorax 
Persistent pulmonary hypertension 
Transient tachypnoea of newborn 
Delayed postnatal adaptation

Question 5

What are the cardiovascular causes of respiratory distress?

Answer 5

Patent ductus arteriosus
Congenital cardiac anomaly (heart failure/ coarctation)
Anaemia
Hypotension

Question 6

What are the congenital malformations that cause resp distress?

Answer 6

Choanal atresia 
Pierre Robin Syndrome 
Laryngobronchomalacia 
Subglottic stenosis 
Diaphragmatic hernia 
Tracheo eosophageal fistula 
Congenital lung malformation (congenital cystic adenomatoid malformation, lobar emphysema, bronchogenic cyst)
Pulmonary hypoplasia

Question 7

What is the other name for respiratory distress syndrome?

Answer 7

Hyaline membrane disease

Question 8

What is the most common cause of respiratory distress syndrome in preterm and low birthweight neonates?

Answer 8

Incomplete lung development
Deficiency of surfactant
Correlates with structural and functional immaturity

Question 9

What is the rate of RDS in different ages/gender?

Answer 9

50% of infants born before 28 weeks have RDS
30% of infants between 28 and 34 have RDS
5% of infants in more than 34 weeks

More common in boys
Incidence is 6x higher in mothers with diabetes due to a delayed pulmonary maturation.

Question 10

What is the pathophysiology of respiratory distress syndrome?

Answer 10

Immature type 2 pneumocytes produce less surfactant

Increase in surface tension and decrease in compliance

Results in atelectasis with pulmonary vascular constriction, hypoperfusion abd lung tissue ischaemja

Hyaline membrane forms through a comb of sloughed epithelium, protein and oedema.

Question 11

What would you see on xray of respiratory distress syndrome?

Answer 11

Air bronchograms

Ground glass appearance

Question 12

What is the treatment of respiratory distress syndrome?

Answer 12

They are lacking surfactant
Positive pressure ventilation, especially provision of PEEP
Gentle ventilation (this is to prevent barotrauma and volutrauma

Question 13

How can you decrease the number of neonates with respiratory distress syndrome?

Answer 13

Antenatal steroids
Careful decisions regarding early delivery
Early recruitment of the lungs by the appropriate sue of PEEP during resuscitation and gentler ventilation
Early use of surfactant and repeat doses depending on need
Supportive treatment- management of fluid balance, PDA and nutrition

Question 14

What is the pathophysiology behind meconium aspiration syndrome?

Answer 14

Meconium passage may represent inutero hypoxia or fetal distress

When aspirated the meconium can induce hypoxia a number of ways...m
. Airway obstruction 
. Surfactant dysfunction 
. Chemical pneumonitis 
. Persistent pulmonary hypertension

Question 15

How does meconium aspiration lead to perinatal infection?

Answer 15

Meconium alters the amniotic fluid, reducing its antibacterial activity and therefore subsequently increasing the perinatal infection risk.

Question 16

What is the presentation of meconium aspiration?

Answer 16

Infants can be very sick needing extensive resuscitation at birth, intubation and ventilation

They can be asymptomatic at birth and then become symptomatic after several hours

May have yellow green staining of the skin, umbilical cord and nails

Respiratory symptoms

Question 17

What would you see on a CXR of meconium aspiration?

Answer 17

Bilateral homogenous air space shadowing
Areas of atelectasis
Areas of air trapping

Question 18

What is the treatment of meconium aspiration?

Answer 18

The neonatal team should be present at the time of the delivery

If the baby is vigorous with normal heart rate and breathing…
Then the meconium is nor causing airway obstruction and therefore there will be no advantage of suctioning, meconium observation should take place

If the baby is not vigorous…
the oropharynx and trachea should be suctioned under direct vision
And also it is important to remove the mechanical obstruction

Baby should recieve optimal ventilation, administratuon of surfactant, management of persistent pulmonary hypertension (with Nitric oxide, high flow oxygen ventilation), hypotension, fluid balance
ABX administration

Question 19

What is the most common causes of respiratory distress in the newborn and who is it more common in?

Answer 19

Transient tachypnoea of newborn
It constitutes 40% of the cases
Infants are usually full term or near term
More common in:
Male infants
Infants born after precipitous delivery or by caesarean
Macrosomic infant of diabetic mothers

Question 20

What is the pathophysiology behind transient tachypnoea of the newborn?

Answer 20

It is a benign condition caused by residual fluid in the neonatal lung tissue after birth.

Prostaglandins released during and after delivery help to dilate the lymphatic vessels which remove lung fluid as baby takes the first few breaths.

Question 21

What is the clinical picture of transient tachypnoea of the newborn?

Answer 21

Respiratory distress in a term/near term infant which starts immediately after birth or within two hours
The baby will have no risk factors for sepsis, no history of meconium stained liquor and normal antenatal scans

The distress usually lasts for 24-48 hours with gradual improvement in symptoms

Question 22

What is the treatment for transient tachypnoea?

Answer 22

Supportive and close observation
Self limiting disease
Low flow oxygen may be needed
Antenatal administration of steroids 48 hours before elective c section decreases the risk of TTN

Its important to rule out other causes of resp distress and it is a diagnosis of exclusion

Question 23

What are the causes of pneumonia?

Answer 23

Congenital pneumonia- haematogenous spread from mother, ascending infection, in utero aspiraton

Intrapartum pneumonia

Postnatal pneumonia
Colonisation of the respiratory tract with pathogen of maternal or environmental origin

Ventilated neonates

Question 24

When do respiratory symptoms usually start in pneumonia?

Answer 24

Usually start within 24-72 hours

There can be a delayed onset

Question 25

What is the treatment of oneumonia?

Answer 25

Prompt diagnosis
Treatment is either with antibiotics or antivirals
Look for disseminated infection to other sites (blood and CSF).