（体外膜肺ECMO课件）-Neonatal-Diseases.ppt

1、Neonatal DiseasesMODULE EObjectives Identify the key pathophysiologic changes that occur with each disease.Describe the therapeutic intervention needed to treat each of the diseases.Perinatal Diseases and Other Problems with PrematurityRetinopathy of prematurity(ROP)Patent Ductus ArteriosusHypoglyce

2、miaCold StressIntraventricular&Intracerebral hemorrhagingBronchopulmonary dysplasiaWilson Mikity SyndromeApnea of prematurityNecrotizing enterocolitisRDSRetinopathy of Prematurity(ROP)Formerly known as Retrolental Fibroplasia(RLF).Initially described in 1940/1950s following increased incidence of bl

3、indness with babies in incubators.Incidence today:25 to 35%of preemies up to 35 weeksPhysiology 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

4、of the retina.Growth is not complete until 40 weeks.Premature infants dont have complete growth.As the capillary network expands,arteries and veins form in its path.ROP is the failure of this network to develop.Oxygen and ROP In the presence of high PaO2,the retinal vessels constrict.Prolonged expos

5、ure 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.Stages and Zones of ROP 5 stages,with 5 having t

6、he retina completely detached.Three Zones of the eye(zone 1 is the worst)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 hypox

7、emia may result in multiple organ failure.May be associated with PPHN(PFC)or PDA.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 MembraneClinical Signs History

8、 of prematurity f above 60/min Grunting Retractions Flaring of nostrils Cyanosis Severe hypoxemia on blood gases Hypothermia&flaccid muscle toneX-ray Findings Diffuse“White-out”(Radiopaque)Atelectasis Air bronchograms Reticulogranular Pattern“Fishing net”Ground Glass AppearanceTreatment Attempt to a

9、ccelerate lung maturity by pharmacological means.Steroids Tocolysis:Delay labor with b b-Adrenergic Agents(Terbutaline)ThermoregulationTreatment Artificial Surfactant CPAP or mechanical ventilation High Frequency Ventilation ECMORecovery Phase Complications ROP Bronchopulmonary dysplasia Chronic lun

10、g disease(COPD for Neonates)Intraventricular hemorrhage Brain dysfunction Necrotizing Enterocolitis Intrapulmonary Hemorrhage Full Recovery Bronchopulmonary Dysplasia Other Name Neonatal Chronic Lung Disease(NCLD)Progressive chronic lung disease that presents with persistent respiratory problems at

11、28 days or later,radiographic changes and oxygen dependencyBronchopulmonary Dysplasia Criteria Preterm infants Prolonged oxygen concentrations(O2 toxicity)Positive pressure ventilation(barotrauma)Patent ductus arteriosus(PDA)Time exposure to oxygen and positive pressure MalnutritionBronchopulmonary

12、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.Bronchopulmonary Dysplasia Lung Pathology Mucosal hyperplasia of small airways.Destruction of type I cells.Inflammation and destruction of alv

13、eoli and capillary bed.Lungs are cystic in some areas and atelectatic in others.Chest X-Ray Radiology“Honeycomb”appearance Diaphragms are flattened Cystic appear(hyperlucent)Atelectasis(radiopaque)HMD to BPD 3 HourHMD to BPD Day 13HMD to BPD Day 19HMD to BPD 3 MonthsClinical PresentationTachypneaRet

14、ractionsMucous pluggingHyperinflation of chest barrel chestCyanotic spellsPoor ABGWheezingInadequate growthIncreased WOB Increased oxygen consumptionPulmonary hypertension and Cor PulmonaleGoals of Bronchopulmonary Dysplasia Prevention of BPD.Provide enough calories to support growth.Wean slowly off

15、 oxygen.Limit peak inspiratory pressures on ventilator.CPAP or HFV Keep FiO2 levels as low as possible.May need to keep PaO2 levels lower.Complications of Bronchopulmonary Dysplasia Gastroesophageal reflux and feeding intolerance leads to aspiration.Decreased Ca and phosphorus(bone fractures.Loss si

16、ght or hearing(ROP).Chronic infections.Pneumothorax.Cerebral palsy.Limit Fluid intake develop pulmonary edema.Bronchopulmonary Dysplasia Death is usually due to:Cor Pulmonale Infection Sudden DeathDischarge of patients with BPD Home Care Oxygen&CPT Mechanical ventilators Medications Diuretics or car

17、diac meds Special Attention to nutritional needs Frequent re-admissions back into the hospital.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 bact

18、erial invasion.Intestinal ischemia may result in necrosis and gangrene of the intestine.Complication of RDS.Highest incidence in lowest birth weight infants.Necrotizing Enterocolitis(NEC)Intestinal dilation(distended loops of intestine with gas).Gastric ileus(obstruction)Abdominal distention.Rectal

19、bleeding Bloody stool Feeding is difficult.Treatment Stop feedings.Nasogastric Suctioning Hyperalimentation IV.Antibiotics.20%require surgery.Intraventricular Hemorrhage(IVH)Premature infants and low birth weight infants are the greatest risk.Diagnosed by ultrasound or CT scan.Seen with increased in

20、cidence 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.Etiology And History o

21、f IVHGrades of IVHIVH Treatment Prevent Occurrence SupportiveWilson-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 suppor

22、tive.Oxygen and mechanical ventilation.Some question as to whether it is a separate syndrome or not.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

23、 is immediate suctioning&antibiotics.Intubate with endotracheal tube and with a meconium aspirator.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 tub

24、e insertion.Ball-Valve EffectTransient 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.Transi

25、ent 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.Transient Tachypnea of the Newborn ABG

26、show oxygenation problem.Ventilation is usually normal.If ventilation is started,the baby will wean quickly.Process of elimination.Tracheoesophageal Fistula or Atresia is an abnormal communication between two passages or cavities.is the absence or closure of a normal body orifice or tubular passage.

27、TEF is a congenital abnormality resulting in respiratory distress.Most common type is an upper esophageal atresia and a lower tracheal-esophageal fistula.Diagnosis The nurse/physician will try to pass a catheter into the stomach.Bronchoscopy or ultrasound is used to diagnose.May be seen on chest-x-r

28、ay.Clinical Manifestations Constant pooling of oral,nasal and pharyngeal secretions/drooling.Continuous or sporadic respiratory distress.Choking on feedings.Repeated vomiting with or after feedings.Persistent upper lobe pneumonia or atelectasis due to aspiration.Gastric distention.Treatment of TEF S

29、urgical correction is needed.Supportive care until surgery.Aspiration is a major concern.A gastric feeding tube is usually placed in the esophageal pouch to remove secretions.Keep in 30 degree upright position.Infant is fed with a gastrostomy tube until surgery.Choanal Atresia A congenital malformat

30、ion of bone or a membrane causing partial or complete obstruction of one or both of the choana.The obstruction results in asphyxia since infants are nose breathers early in life.Respiratory Distress subsides when the baby cries.Diagnosis A catheter or probe fails to pass through the infants nose.Oft

31、en the nose has a large accumulation of thick secretions.If the obstruction is a membrane,it may be punctured to provide relief of the respiratory distress.Clinical Manifestations Clinical Signs Respiratory distress Cyanosis Retractions Pooling of nasal secretionsTreatment Treatment Insertion of an

32、oral airway to facilitate mouth breathing.If distress continues,then intubate and ventilate.Diaphragmatic Hernia CDH is a congenital condition in which the abdominal organs herniate into the chest cavity through the diaphragm.Life threatening condition.Lung tissue is compressed.Diaphragmatic Hernia

33、Most common defect is in the posterolateral region of the diaphragm in an area called the foramen of Bochdalek.Left side herniation is more frequent(85-90%).Stomach,spleen&intestines can enter the chest.Scaphoid(boat shaped)Abdomen is present.Diaphragmatic Hernia The baby will be in respiratory dist

34、ress at birth.PMI may be shifted.Breath sounds diminished.Bowel sounds can be heard over lung fields.Confirmed with chest x-ray.Lungs are hypoplasitc(underdeveloped).Treatment of Diaphragmatic Hernias Orogastric tube is inserted to remove air.Do not manually ventilate these infants.Overdistension of

35、 stomach will worsen problem.Intubate to prevent air in the stomach and intestines.High Frequency Ventilation,ECMO High mortality rate.Pneumothorax is common.Treatment of Diaphragmatic HerniasPersistent Pulmonary Hypertension of the Newborn(PPHN)Formerly Persistent Fetal Circulation(PFC)Pulmonary hy

36、pertension after birth caused by asphyxia and which prevents the transition of fetal to newborn circulation.It may be a primary disorder or a secondary disorder:RDS TTN Pneumonia Cold Stress Meconium aspiration Diaphragmatic herniaPersistent Pulmonary Hypertension of the Newborn(PPHN)Blood is shunte

37、d Right to Left across the ductus arteriosus.The Apgar is usually 5 or less at 1 and 5 minutes.Signs and Symptoms Tachypnea Retractions Cyanosis Breath sounds are clear if no pulmonary disease is present.Refractory to oxygen therapy(true shunt).Difference in pre&post ductal blood gases.Diagnostic Te

38、sting Hyperoxia Test If PaO2 does not increase with 100%oxygen,suspect a cardiac shunt Not specific for PFC Compare preductal and postductal PaO2 If shunt is present Preductal Postductal.15 to 20 mm Hg and with FiO2 Hyperoxia-Hyperventilation Test Most definitive.Hyperventilate until PaCO2 is 20 25

39、mm Hg Alkalosis will reduce pulmonary hypertension and PaO2 will improve.Echocardiography ultrasound of the heart Cardiac CatheterizationTreatment for PPHN Oxygen therapy to maintain PaO2 greater than 50 60 mm Hg.Mechanical ventilation.Nitric Oxide ECMO,HFV Keep glucose and electrolytes normal.Pneum

40、othorax Cyanosis Tachypnea Grunting Nasal flaring PMI is shifted Diminished or absent breath soundsConfirmation of a Pneumothorax Transillumination Bed Side Chest x-rayTreatment of Pneumothorax Emergency treatment.Needle Aspiration 2nd intercostal space Chest Tube.Given the baby 100%oxygen until che

41、st tube is inserted.Infections Pneumonia infection in the lungs.Septicemia infection in the bloodstream.Meningitis infection/inflammation of the covering of the brain and spinal cord.Urinary Tract Infections Conjunctivitis infection or inflammation of the eye.Omphalitis infection/inflammation of the

42、 umbilical stump.Pneumonia Transplacental Acquired at birth Amniotic fluid.Premature rupture of membranes greater than 12-24 hours(PROM).Postnatal Invasive lines.Respiratory equipment.Hospital Personnel.Pneumonia Premature infants are at greater risk.Group B Beta Hemolytic Streptococci&Escherichia C

43、oli are the most common organisms.PFC is usually a consequence of pneumonia.Diagnosis of Pneumonia Chest x-ray Very difficult to distinguish between Pneumonia,RDS&TTN.Culture and Sensitivity.Postnatally Acquired Pneumonia Klebsiella Pseudomonas Methicillin-Resistant Staphylococcus(MRSA)Resistant to penicillin type drugs.Candida Albicans(fungal).Viruses that affect the Newborns Herpes Virus Respiratory Syncytial Virus (RSV)Rubella Adenovirus Cytomegalovirus Chlamydia