Case 13 - breathing difficulties

Question 1

Best option for treatment for pre-term baby for surfactant deficiency

Answer 1

• Antenatal steroids
• Infusion of magnesium during labour - improve neurodevelopmental outcomes

Question 2

Clnical signs of respiratory distress in newborn

Answer 2

• Tachypnoea - over 60
• Intercostal, sternal and subcostal recessions
• Nasal flaring
• Expiratory grunting (attempt to create positive airway pressure during expiration to maintain FRC)
• Tracheal tug
• Cyanosis

Question 3

Normal saturations at birth

Answer 3

Can take up to 10 mins to achieve adult levels
eg 91% at 1 minute is normal

Question 4

Causes of respiratory distress in newborn

Answer 4

• Congenital cystic adenomatoid malformation of lung
• Infantile surfactant deficient respiratory distress syndrome
• Neonatal chronic lung disease (broncho-pulmonary dysplasia)
• Sepsis
• Transient tachypnoea of newborn

Question 5

What is congenital cystic adenomatoid malformation of lung?

Answer 5

• Rare benign lung lesion
• Abnormal lung tissue
• Arises from error in lung development - does not function properly but grows
• Often diagnosed antenatally via scans

Question 6

Infantile surfactnant deficient RDS - what is it

Answer 6

• RDS is caused by lack of surfactant
• More common if premature - more if before 28 weeks as surfactant starts to be produced at 24-28 weeks
• = alveolar collapse, impaired exchange
• Can occur in term babies from diabetic mothers

Question 7

What is neonatal chronic lung disease?

Answer 7

• AKA broncho-pulmonary dysplasia
• Refers to babies with persisting O2 requirement up until 36 weeks corrected gestation

Question 8

Most common cause of resp distress in newborn

Answer 8

• Transient tachypnoea of newborn
• = delay in clearance of foetal lung fluid
• More common post C section, uncommon in premature

Question 9

Best intervention for respiratory support in newborn if needed

Answer 9

• CPAP
• If started early it improves outcomes
• Gives pressure support

Question 10

What is shwon in image?

Answer 10

• L sided pneumothorax
• Mediastinal shift to R
• = tension pneumothorax

Question 11

Prognosis of neurodisability in premature babies

Answer 11

• Chance of neurodisability increases as gestation falls
• Even at 22-23 weeks 1 in 3 have serious disability now
• Hyperactivity is common in ex preterm - 10-20% depending on gestation

Question 12

3 classes of prematurity

Answer 12

• Under 28 weeks- extreme
• 28-32 - very
• 32-37 - moderate to late preterm

Question 13

Associations of prematurity

Answer 13

• Social deprivation
• Smoking
• Alcohol
• Drugs
• Over/underweight mother
• Maternal co-morbids
• Twins
• Personal/FH of prematurity

Question 14

Who is managed as higher risk of preterm?

Answer 14

• History of preterm birth
• Cervical length on US 25mm or less before 24 weeks gestation

Question 15

Management in women who are higher risk of preterm delivery

Answer 15

• Prophylactic vaginal progesterone - suppository
• Prophylactic cervical cerclage - suture into cervix to hold it closed

Question 16

What is management when preterm labour is confirmed/suspected?

Answer 16

• Tocolysis with nifedipine
• Maternal steroids - if before 35 weeks
• IV magnesium sulfate - if before 34 weeks to protect brain
• Delayed cord clamping or cord milking - increase blood volume and Hb in baby

Question 17

Issues in early life premature babys are at risk of

Answer 17

• Respiratory distress syndrome
• Hypothermia
• Hypoglycaemia
• Poor feeding
• Intraventricular haemorrhage
• Retinopathy of prematurity
• Necrotising enterocolitis
• Immature immune system + infection

Question 18

Long term effects of prematurity

Answer 18

• Chronic lung disease of prematurity - CLDP
• Learning and behavioural difficulties
• Susceptibility for infection - esp resp
• Hearing and visual impairement
• Cerebral palsy

Question 19

What is apnoea of preamaturity?

Answer 19

• Due to immature autonomic nervous system
• Breathing stops for more than 20s
• Very common in premature neonates

Question 20

What can apnoea be a sign of?

Answer 20

• Infection
• Anaemia
• Airway obstruction
• CNS pathology
• GORD
• Neonatal abstinence

Question 21

Management of apnoea

Answer 21

• Apnoea monitors - these make a sound when apnoea occurs - tactile stimuli to wake up
• IV caffeine can also be used to prevent apnoea and bradycardia

Question 22

Cause of retinopathy of prematurity

Answer 22

• Retinal blood vessels start developing at 16 weeks
• Complete by 37-40
• Grow from middle outwards
• Stimulated by hypoxia - normal in pregnancy
• When retina exposed to higher O2 levels in preterm, stimulant for development is removed
• –> hypoxia occurs = neovasculiration, scar tissue –> retinal detachment

Question 23

Assessment of retinopathy of prematurity - zones

Answer 23

• Zone 1 - optic nerve and macula
• Zone 2 - edge of zone 1 to ora serrata (pigmented border between retina and ciliary body)
• Zone 3 - outside ora serrata

Described as stages as if retina is clock face

Question 24

What is plus disease?

Answer 24

• Additional abnormal findings = tortuous vessels
• Hazy vitreous humour

Question 25

Screening for retinoapthy of prematurity - who?

Answer 25

* Babies born before 32 weeks * Or under 1.5kg

Question 26

When do we screen for ROP in at risk babies?

Answer 26

* 30-31 weeks gestational age - babies before 27 weeks * 4-5 weeks of age in babies born after 27 weeks * Screen every 2 weeks, cease once vessels enter zone 3 (usually 36 weeks)

Question 27

Management of ROP

Answer 27

* Transpupillary laser photocoagulation - halt and reverse neovascularisation * Others - cryotherapy, intravitreal VEGF inhibitors * Surgery if retinal detachment

Question 28

Reducing risk of BPD

Answer 28

* CPAP rather than intubation * Caffeine - stimulate resp effort * Not over oxygenating

Question 29

Management of BPD

Answer 29

* Overnight oximetry study - record O2 sats during sleep, diagnose and guide management * Low dose home O2 (0.1L/min) and wean * Montly palivizumab for RSV protection for bronchiolitis

Question 30

What is necrotising enterocolitis?

Answer 30

* Affects premature neonates * Bowel --> necrotic = life threatening * --> perforation, peritonitis, shock

Question 31

RF for NEC

Answer 31

* Very LBW or very premature * Formula feeds * Resp distress + assisted ventilation * Sepsis * Patient PDA + other congenital HD

Question 32

Presentation of NEC

Answer 32

* Intolerance to feeds * Vomiting - esp green bile * Generally unwell * Distended, tender abdo * Absent bowel sounds * Blood stools

Question 33

X-ray findings for NEC

Answer 33

* Dilated loops bowel * Bowel wall oedema - thumb printing * Pneumatosis intestinalis - gas in bowel wall * Pneumoperitoneum - free gas in peritoneal cavity = perf - riglers sign or football sign * Gas in portal veins

Question 34

Riglers sign

Answer 34

* Air on both sides of bowel wall = outline of bowel is very clear

Question 35

Football sign

Answer 35

* Outlining of falciform ligament - whole abdomen is outlined by gas

Question 36

Management of NEC

Answer 36

* NBM * IV fluids * TPN * Antibiotics * NG tube can be used to drain fluid and gas from stomach * Surgical emergency - immediate referral to neonate surgical team