Neonatal Pulmonary Diseases

Question 1

Pneumonia

Answer 1

Bacterial or viral infection of the lungs

Question 2

Pneumonia Categories

Answer 2

• Early onset or perinatal
  
  • Occurring < 7 days of age
  • Can occur in association with amnionitis following PROM
  • Often associated with transplacental infection or prolonged delivery
• Late-onset or post-natal
  
  • Occurring after 7 days of age.
  • Typically easier to treat with less sequella

Question 3

Pneumonia Modes of Transmission

Answer 3

–Intrauterine (transplacental)

–Ascending vertical transmission (extrauterinetransmission, usually during labour

–Postnatal (nosocomial or community acquired)

Question 4

Early Onset Pneumonia

Bacterial Causes

Answer 4

• Bacterial
  
  • Group B streptococcus (GBS)
    
    • Found in vaginal and cervical area
    • Early onset from GBS may progress rapidly to shock or death
    • Mortality is 20%-50% regardless of treatment
  • E. Coli
    
    • Most common among VLBW infants
  • Listeria monocytogenes
  • Kelbsiella
  • Group D streptococci
  • Pneumococci

Question 5

Early Onset Pneumonia

Group B streptococcus

Answer 5

Will clinically be very similar to RDS and we need a sputum analysis

Spread from maternal cervical and vaginal secretions

ROM >12 hours increases infection risk

Onset of symptoms occurs between hours to days

Occurs most often in low birth weights

Question 6

Early Onset Pneumonia

Viral

Answer 6

• TORCH Syndrome
  
  • Toxoplasmosis
  • Rubella
  • Cytomegalovirus
  • Herpes simplex virus

Question 7

Late Onset Pneumonia

Answer 7

–Typically occurs after 7 days of age

–Commonly found in NICU where infants require prolonged intubation

Question 8

Late Onset Pneumonia

Bacterial

Answer 8

• Bacterial
  
  • Staphylococcus
  • Pseudomonas
  • Chlamydia trachomatis
  • E. Coli

Question 9

Late Onset Pneumonia

Viral

Answer 9

Respiratory Syncytial Virus (RSV)

Question 10

Late Onset Pneumonia

Fungi

Answer 10

Candidaalbicans

Question 11

Pneumonia

Clinical Manifestations

Answer 11

• Early onset
  
  • Lethargy
  • Poor feeding
  • Irritability
  • Cyanosis
  • Temp instability
• Progressive Respiratory Distress
  
  • Tachypnea
  • Intercostal retractions
  • Grunting

Question 12

Pneumonia

CXR

Answer 12

Patchy asymetrical densities

Hyperinfaltaion

Pleural effusion

Question 13

Pneumonia

Diagnosis

Answer 13

• Positive blood cultures (bacteria)
• Virus: Possibly elevated serum antibodies

Question 14

Pneumonia

Antibiotics for Early Onset

Answer 14

Ampicillin or Penicillin G + aminoglycoside

Question 15

Pneumonia

Antibiotics for Late Onset

Answer 15

Nafcillin+ aminoglycoside

3rd generation cephalosporin

Question 16

Pneumonia

Candida

Answer 16

Amphotericin B

Question 17

Pneumonia

Virus Medicine

Answer 17

Ribavirin

Acyclovir

Question 18

Pneumonia

Management (non-pharmacological)

Answer 18

• Supportive therapies
• Oxygen
• Humidification
• Bronchial Hygiene (coughing, suction in mechanically ventilated)
• Mechanical ventilation
• Physiotherapy

Question 19

Pulmonary Interstitial Emphysema (PIE)

Answer 19

Air Leak Syndrome- Increase air space distal to the terminal bronchioles.

Collection of gases outside of the normal air passages

Iatrogenic-We cause it as it is due to overdistention from mechanical or manual ventilation

Occurs almost exclusively in low birth weight infants

Question 20

PIE

Risk Factors

Answer 20

Prematurity (<32 weeks GA) due to immature lungs and decreased surfactant

VLBW (<1000g)- Inversely related to birth weight meaning the lower the weight the higher the risk

Resuscitation: PPV, Use of increased PIP, Vt, and Ti

Other Disease Processes: RDS, MAS, Amniotic fluid aspiration, Infection, Neonatal sepsis, Pneumonia , Pulmonary Hypoplasia

Question 21

Pulmonary Interstitial Emphysema (PIE)

Pathophysiology

Answer 21

The rupture of the small airways will allow airway into the connective tissue which will compress the vasculature which leads to decreased pulmonary perfusion, increased PVR, and R-L shunt

It can occur naturally when babies have very low surfactant

There will be an increased airway resistance due to the decrease in the lumen of the bronchioles

Question 22

Pulmonary Interstitial Emphysema (PIE)

CXR

Answer 22

The tiny black little dots are the PIE in the lungs

This disease is a mix of atelectasis and hyperinflation

Question 23

Pulmonary Interstitial Emphysema (PIE)

Clinical Manifestation

Answer 23

Progressive respiratory deterioration

Deteriorating ABG’s,

Decreased compliance

Increasing SOB

Increasing ventilatory requirements due to decreased compliance and increasing airway resistance

Disease course of mild PIE is approx. 5 days

Excess air continues to accumulation which can lead to the rupture of the mediastinum (pneumomediastinum) which is a very severe stage of the disease

There can also result in subcutaneous emphysema

Question 24

Pulmonary Interstitial Emphysema (PIE)

Management

Answer 24

Decrease barotrauma, minimal vent support and PPV

Prone positioning or positioning the affected side down

Selective intubation of “good” lung to rest affected lung

In severe cases-HFOV and pneumonectomy/lobectomy

Question 25

PIE Prevention

Answer 25

The best treatment for PIE is prevention In the past this was very common now it is not common and is causethrough a severe case of another disease or mismanagement of the vent We try to keep down PIP and Peak pressure in order to help prevent/worsen PIE

Question 26

PIE Prognosis

Answer 26

Poor if evident within 24 hours of birth. The faster that someone develops PIE the less likely the chance of survival

Question 27

Pneumothorax Pathophysiology

Answer 27

Occurs spontaneously due to high inspiratory effort or secondary to the use of positive pressure ventilation Rupture of alveoli allowing air leak causes air accumulation in the pleural space this may be asymptomatic or symptomatic Symptomatic - enough air leak to cause respiratory distress If the air accumulation is large enough and under pressure = a tension pneumothorax = can be life-threatening PIE can lea to a pneumothorax

Question 28

Pneumothorax Primary and Secondary

Answer 28

Primary-When there is no underlying disease Secondary- Caused by an underlying disease

Question 29

Pneumothorax Spontaneous Pneumothorax

Answer 29

Neonates with spontaneous pneumothorax tend to be asymptomatic and they tend to be small and may only need a small amount of oxygen. The problem is when they develop there is a chance that the pneumothorax can get bigger

Question 30

Pneumothorax Clinical Manifestations

Answer 30

* •Ranges depending on severity –asymptomatic to respiratory distress with: * Cyanosis, * Hypoxia, * Tachypnea, * Grunting-Kin to pursed lip breathing and will increase FRC * Asymmetrical chest * Decreased breath sounds on the affected side * A shift of the mediastinum away from the affected side * Breath sounds will also be decreased on the affected side * **Remember that even a significant pneumothorax may not be detectable with auscultation**

Question 31

Pneumothorax Diagnosis

Answer 31

CXR-Large left pneumothorax appears black and outlines the partially collapsed left lung and left cardiac border (arrow). ## Footnote Transluminationis a quick way to identify a pneumothorax without a chest x ray One of the main problem with PIE is that they will have a decrease SA for gas exchange and also when it heals it can lead to fibrosis If you have a left penumoyour mediastinum will pull to the other side If you have ataelctasisyou mediastinum will pull to the affected side

Question 32

Pneumothorax Management

Answer 32

* In spontaneous breathing infant with a small pneumothorax – observe or consider 100% oxygen (wash out nitrogen) – * Not really used anymore and is controversial (wash out nitrogen * Consider observation if infant is premature to prevent oxygen toxicity/RDS/ROP * Patient in severe respiratory distress requiring ventilation will most likely need chest tube or needle aspiration * Needle aspiration - mid-clavicular line above the third rib with angiocathto immediately evacuate air

Question 33

Pneumothorax Prognosis

Answer 33

Good with intervention

Question 34

What are the Pre-Term (\<35 week) pathologies

Answer 34

RDS BPD

Question 35

Pre Term (\>35 Weeks) Pathologies

Answer 35

ACP Pneumonia

Question 36

Term (40 Weeks) Disorders

Answer 36

TTN (C-Section) PPHN MAS Pneumonia

Question 37

Congenital Abnormalities Typically Term

Answer 37

CDH Tracheoesophageal Fistula Pierre Robin Choanal Atresia Tracheomalacia/Stenosis

Question 38

Air Leak Syndrome

Answer 38

PIE Pneumothorax