Pulmonary diseases in the newborn period

1、pulmonary diseases in the newborn period ola didrik saugstad department of pediatrics the national hospital, university of oslo student lecture at 9 th semester medical faculty, university of oslo pulmonary diseases in the newborn period 1/13 have breathing problems at birth (7.5%) 1/6 with breathin

2、g problems have infections ga 31 uker: 1/2 have infections boys 9.3%, girls 5.9 % mortality 0.4% (5% 60 per min) cyanosis in room air flare of the nostrils chest retractions grunting pulmonary diseases in the newborn period respiratory distress syndrome(rds) transitoric tachypnoe pneumonia/infection

3、 meconium aspiration air leaks pulmonary hypertension chronic lung disease (cld) pulmonary diseases in the newborn period pulmonary causes common rare rds lung hypoplasia trans tachypne obstr upper airways meconium asp tumours pneumonia pulm hemorrhage pneumothorax malformations cong diaprhagmatic h

4、ernia pulmonary diseases in the newborn period extra-pulmonale causes common rare persist fetal circulat cerebral edema cong card malfor drugs cerebral hemorrhage neuromuscular polycythemia asph, spinal cord hypoglycemia metabolic diseases hypothermia acidosis pulmonary diseases in the newborn perio

5、d work - up extra- pulmonary or pulmonary? if general condition is good and no cyanosis: observe in incubator, ctr respiration and pulse frequency if cyanosis: observe in incubator, give o2, x ray of chest umbilical/periperhal artery line if fio2 0,40 infection work-up (r - l shunt calculation) pulm

6、onary diseases in the newborn period respiratory distress syndrome (rds) surfactant deficiency and immature surfactant lunge compliance reduced to 10-20% reduced lung perfusion (50-60%) increased r- l shunting (30-60%) reduced lungvolum increased work of breathing properties of surfactant rapid adso

7、rption efficient spreading lower surface tension alveoli as bubbles surface tension air liquid surface polar h2o molecules attract laplaces law where: p = pressure t = surface tension r = radius of the bubble p = 2t r p = 2x1= 0.2 10 p = 2x1= 0.4 5 10 5 connected bubbles phospholipids polar heads in

8、soluble tails negative tails monolayer hypophase surfactant action alveolar gas composition 1 2 34 5 6 7 dppc - dipalmitoylphosphatidylcholine 50%* reduces alveolar surface tension pg - phosphatidylglycerol 7%* promotes the spreading of surfactant throughout the lungs apoproteins or surfactant speci

9、fic proteins 2%* 1. serum proteins 8%* 2. other lipids 5%* 3. other phospholipids 3%* 4. phosphatidylinositol 2%* 5. sphingomyelin 2%* 6. phosphatidylethanolamine 4%* 7. unsaturated phosphatidylcholine 17%* * by molecular weight dppc dipalmitoyl phosphatidylcholine water soluble insoluble fatty acid

10、 chains surfactant proteins spa host defence, tubular myelin spd immune activity spb & spc spreading and adsorption stimulus for release gas entering lungs alveolar stretch (inspiration) adrenergic innervation prostaglandins production and release type ll cell alveolar air space hypophase type i cel

11、l basal lamina capillary endothelium monolayer hypophase alveolar gas lmvb golgi rer dmvb type i cell tubular myelin lamellar bodies surfactant cycle type ii cell loss from lungs choline fatty acids lysosomes mvb degradation endoplasmic reticulum golgi synthesis and secretion lamellar bodies recycli

12、ng precursors reuptake catabolic anabolic alveolar transformations alveolusother losses - macrophages - airways - other lung cells surfactant therapy instillation of surfactant into the lungs synthetic surfactant ( almost not in use anymore) natural surfactant (porcine, bovine) prophylactic vs rescu

13、e before surfactant 1 hr after surfactant survival without, with one, and multiple doses of surfactant survival without 1 dose multiple doses of surfactant median duration 40% oxygen without one dose multiple doses surfactant days pulmonary diseases in the newborn period respiratory distress syndrom

14、e 0.5 (-1.0) % of all births increases with decreasing gestational age (ga expiratory grunting retractions (sternal, inter- and subcostal) cyanosis in room air duration 24 hrs pulmonary diseases in the newborn period the natural course of respiratory distress syndrome: maximum after 24 -36 hrs spont

15、aneous breathing in room air in uncomplicated cases deterioration at 3-5 days due to an open ductus arteriosus pulmonary diseases in the newborn period respiratory distress syndrome differentials pneumonia/sepsis transitoric tachypnoe congenital cardiac malformation pneumothorax/airleak primary pulm

16、onary hypertension pulmonary diseases in the newborn period respiratory distress syndrome - therapy reduce prematurity rate antenatal steroids 24 - 168 hrs before birth gives a 50% reduction in the incidens and 40% reduction in mortality surfactant therapy reduces mortality/chronic lung disease 30-4

17、0% general therapy: oxygen, respirator, fluid- electrolytes, nutrition, antibiotics pulmonary diseases in the newborn period classification of neonatal pneumoniae congenital early onset( 48 hrs) pulmonary diseases in the newborn period pneumonia neonatal pneumonia may be an isolated focal infection

18、but usually is a part of a general infection - sepsis. incidence of bacterial pneumonia: 3,7 per 1000 live born (oxford) neonatal pneumonia acquired by the fetus (ascending, transplacental passage, pprom, through intact membranes? gr b streptococci (sepsis develops in 1% of colonized from maternal g

19、enital tract (1- 4/1000 (usa). intrapartum antibiotics as prophylaxis of group b pos mothers recommended aap 1992-1997 . incidence more than halved from 93-98 pulmonary diseases in the newborn period pneumonia - symptoms respiratory distress (tachypnoe, apnoe, cyanosis, retractions) vomiting, hypote

20、nsion poor weigth gain, icterus, hypo/hyperthermia pulmonary hypertensjon and hypoxemia r-l shunting reduced lungfunction (respirator patients) increased tracheal aspirate pulmonary diseases in the newborn period congenital pneumonia rare - high mortality secondary to ascending infections (after pro

21、m) through intact membranes? chorioamnionitis intrauterine asfyxia pulmonary diseases in the newborn period early onset pneumonia 1,8 per 1000 live newborn gr b streptococci (70% in uk) h. influenza s. pneumoniae listeria monocytogenes gram negative enterobakterier (fungi) virus ( rs, adeno, cmv, co

22、xsacki) pulmonary diseases in the newborn period late onset pneumonia usual in preterm on artificial ventilation 10-35% of all on ventilator gram positive gram negative staph areus enterobakter enterocokker e. coli gr b streptokokker klebsiella fungi candida pulmonary diseases in the newborn period

23、pneumonia -other agents ureaplasma urealyticum (in vagina, - pneumonia and lung fibrosis) rs virus (epidemics), more serious if chronic lung disease chlamydia (early onset - may cross intact membranes). in term infants typical debut 3- 4 weeks of age. slow onset. treated with erythromycin pulmonary

24、diseases in the newborn period pneumonia - therapy antibiotics general supportive therapy pulmonary diseases in the newborn period transitoric tachypn (wet lung) a mild respiratory disturbancy in newborn infants occasionally seen after birth unknown etiology increased lung water duration max 5-6 day

25、s pulmonary diseases in the newborn period transitoric tachypnoe boys girls ga 32-42 weeks (average 38 weeks) bw (average) 3200 gr resp rate at 6 hrs age: 80 per min oxygen in 60% of cases incidens 0.37% atle moen student thesis oslo 1990 pulmonary diseases in the newborn period transitoric tachypno

26、e clinic differential diagnosis tachypnoe rds cyanosis in room air pneumonia grunting mekonium aspiration retractions cong heart malformation duration 3 hrs oxygen need not increasing pulmonary diseases in the newborn period transitory tachypnoea - x ray findings x ray: perihilar streaking, patchy i

27、nfiltrates reduced air and/or reticular pattern therapy observation in incubator oxygen if needed antibiotics until infection is excluded pulmonary diseases in the newborn period air leaks pneumothorax/mediastinum 1% of all newborn but only 1/10 are symptomatic increased risk in positive pressure ve

28、ntilation pulmonary diseases in the newborn period primary pulmonary hypertension severe hypoxemia r-l shunting normal heart artificial ventilation no inhalation pulmonary diseases in the newborn period meconium aspiration syndrome (mas) 1:10 - 1:5 meconium stained amniotic fluid 1:1000 - 1:5000 birth develop mas term-post term children inhalation before and during birth plugging the airways (acute effects) inflammation (later effects) inactivates surfactant pulmonary diseases in the newborn period symptoms in meconium aspiration syndrom (mas