（体外膜肺ECMO课件）-Respiratory-disease-in-the-newborn.ppt

1、?rial?8ri?r0?0 40?rlai0 a?a?r?0?r?lr?l?r?air?ai?a?80?a0r?.?r?0a0?a8?38.0.?a80?a?aa8air?,?rial 88?a?i lai?ir?,ar?,8r?.?1r0?a10r?ia?ra?r?i?rl 81ri a8air?.?i?8?l?r?lr?a?i lrai?ir?,?a8?rir?0.?r?0r?.?1r0?a10r?lr?a?i lrair?1?ai?a?r?r1?lal?a?i?8?.80a?1?al0a0?.8?89(0?01?rir?r)?rial 0?r?0?8 l?8?0 lr?rial.?8?

2、0?1i?1?8?a?0?35%.ai?a?r1?lal?a?i?8?08r?a?a8?l?r1l0?1?8 60%?0r 8 100%?arra?1?0 90%-88%.r?1r0 lr?a?0?r0?0.?a18?0?pH7.19,pCO2 75,pO2 35,Bic19,BE-6.?r8a1?1?Patch?a?0 a?a?00 lra?lra?a?a?ra1 ala?r?81r 08?a?l.8?r?8r?a?a?ra0a?i?l?r?a81ri I.V.?8 8r?a?ra0r 0r?l?8?8 8r?a?8?i?a8?.?ir?aa?a?rl80?r?a?0 CO2,?O2?i?r

3、?i,lr?8?a8?a1?80?i?r 100%?1?.SatO2?laa?0a0?85%.?r18?la8a?1r0 ECHO 08?i0?a?l,?1i PDA 0?8?a?a?8?8 r PFO.r8?a1?8?r?l?Nitric Oxide?20 ppm?a8?0 SatO2 8 95%?aar l?r1l0?1?8 45%.8?0?8?a8r08 r8a88 8?r?l?Dopamine.?0 8?r?a?al8?,r0?a?a 0?a10r?ir?1?al0a0?8 7?a?a.r?la08 01?0 0r?.Cyanosis Grunting Nasal flaring Re

4、traction Tachypnea Decreased breath sounds with rales and/or rhonchi Pallor Apnea Central or peripheral nervous system hypoventilation:-Birth asphyxia-Intracranial hypertension,hemorrhage-Over sedation(direct or through maternal rout)-Diaphragm palsy-Neuromuscular disease-Seizure Respiratory disease

5、:Upper airway:-Choanal atresia/stenosis-Pier Robin syndrome-Intrinsic airway obstruction (laryngeal/bronchial/tracheal/stenosis)-Extrinsic airway obstruction (bronchogenic cyst,duplication cyst,vascular compression)Respiratory disease:Lower airway:-Respiratory distress syndrome -Transient tachypnea

6、-Meconium aspiration -Pneumonia(sepsis)-Pneumothorax -Congenital diaphragmatic hernia -Pulmonary hypoplasia Cardiac right to left shunt:Abnormal connection(pulmonary blood flow normal or increased):-Transposition of great artery-Total anomalous pulmonary venous return-Truncus arterious -Hypoplastic

7、left heart syndrome -Single ventricle or tricuspid atresia with VSD&without PSCardiac right to left shunt:Obstructed pulmonary blood flow(pulmonary blood flow decreased):-Pulmonic atresia with intact ventricular septum-Tetralogy of Fallot-Tricuspid atresia-Single ventricle with Pulmonic stenosis-Ebs

8、tein malformation of the tricuspid valve-Persistent fetal circulation(PPHN)-Critical Pulmonic Stenosis with PFO or ASDMethemoglobinemia:-congenital(hemoglobin M,methemoglobin reductase deficiency)-Acquired(nitrates,nitrites)Other:-Hypoglycemia-Adrenogenital syndrome -Polycythemia -Blood lossUsually

9、in normal preterm or term vaginal delivery or C/SEarly onset of tachypnea,retraction,cyanosis(O2 V/Q mismatch -air trapping air leaks -persistent pulmonary hypertension -acidosis,hypoxemia,hypercapnea In clinical signs respiratory distress,-tachypnea persistent from few days to several weeks,-hypoxi

10、a and metabolic acidosis.In chest x-ray overdistention,typical patchy infiltrates,coarse streaking of both lung,signs of PPHTherapy supportive care(mechanical ventilation,used of exogenous surfactant,ECMO)Prevention for depressed infant intubations with suction.Occurs in term and post-term infants P

11、redisposition factors:-birth asphyxia,-meconium aspiration pneumonia,-early onset sepsis,-RDS,-hypoglycemia,polycythemia,-maternal use of NSAID(PDA closed)or SSRI,-pulmonary hypoplasia(result of diaphragmatic hernia),-oligohydramnios,-pleural effusion.In pathophysiology this is circulation with feta

12、l pattern of right to left shunting through the PDA and Foramen Ovale after birth.PPHN is often idiopathic.Some infants have low plasma arginine and nitric oxide metabolite concentration and polymorphisms of the carbamoyl phosphate synthase gene defect NO production.Incidence:1/500 1/1500 live birth

13、.Survival varies with underline diagnosis.In clinical picture:-infant become ill in the delivery room or within first 12 hr -initial signs may be minimal Diagnosis:-hypoxia unresponsive to 100%of oxygen -gradient pO2 between preductal and postductal site of blood sampling 20 mmHg or SatO2 5%by pulse

14、 oxymetry.-by ECHO right to left shunt,tricuspid regurgitation.-x-ray chest D.D.cyanotic heart disease.Treatment:-Correcting predisposition disease -Oxygen administration-Talazoline non selective alpha-adrenergic antagonist -Hyperventilation(pCO2=25 mmHg with pH 7.50-7.55)-Sedation(Fentanyl)-paralyt

15、ic drugs controversial -Inotropic therapy -Nitric Oxide ET inhalation(reduce ECMO by 40%)-Prostacyclin(PGI 2)I.V.-Extracorporeal Membrane Oxygenation(ECMO)is form of cardiopulmonary bypass that augments systemic perfusion and provides gas exchange.Criteria:-Oxygenation Index:(MAP*FiO2*100)/PaO2 (35-

16、60)-Alveolar Arterial Oxygen Gradient:FiO2(P-47)PaO2 PaCO2 FiO2+(1-FiO2)/R P barometric pressure(760),R respiratory quotient(0.8)(605-620)-PaO2:40 mmHg -Acidosis and Shock:pH7.25 or+hypotension May be due to defective formation of the pleuroperitoneal membrane.Associated with pulmonary hypoplasia.In

17、cidence of CDH 1/2000 1/5000 live birth Female:Male=2:1 Defect more common left(85%)Most common sporadic.Associated anomalies in 30%(CNS lesion,Esophageal Artesia,omphalocele,CVS lesion)Initial management aggressive respiratory support with immediately intubation.Surfactant therapy commonly use,but

18、no study for that is beneficial.Bacterial infection is possible cause of neonatal respiratory distress.Common pathogens include:-group B streptococci(GBS),-Staphylococcus aureus,-Streptococcus pneumoniae,-gram-negative enteric rods.Pneumonia and sepsis have various manifestations,including the typic

19、al signs of distress as well as temperature instability.Risk factors for pneumonia include:-prolonged rupture of membranes,-prematurity,-maternal fever.Prevention of GBS infection through screening and antepartum treatment reduces rates of early-onset disease including pneumonia and sepsis,by 80 per

20、cent.Intrapartum antibiotics at least four hours before delivery.Chest radiography helps in the diagnosis,with bilateral infiltrates suggesting in utero infection.Pleural effusions are present in 2/3 of cases.Serial blood cultures may be obtained to later identify an infecting organism.Pneumothorax,

21、defined as air in the pleural space,can be a cause of neonatal respiratory distress when pressure within the pulmonary space exceeds extrapleural pressure.It can occur spontaneously or as a result of infection,meconium aspiration,lung deformity,or ventilation barotrauma.The incidence of spontaneous

22、pneumothorax is 1 to 2 percent in term births,but it increases to about 6 percent in premature births.Pneumomediastinum occurs in at least 25%of patients with pneumothorax Usually asymptomatic Subcutaneous emphysema often asymptomatic and pathognomonic of pneumomediastinum If trapped air is great ne

23、ck veins are distended and -blood pressure is low its result of tamponade of the systemic and pulmonary vein.Pulmonary interstitial emphysema(PIE)may:-precede the development of a pneumothorax -occur independently In pathogenesis:-increased alveolar-arterial oxygen gradient -increased intrapulmonary

24、 shunting -progressive enlargement of blebs of air may result in cystic dilatation.In therapy with oxygen and high frequency ventilation Central cyanosis Lack or minimal respiratory distress signs Systolic murmur Evaluation by ECHO Chest x-ray Hyperoxic test TGATARVR Placing in 100%oxygen concentrat

25、ion During for 5 to 10 minutes Sampling arterial gas or monitoring oxygenation non invasively If PaO2 level higher than 100 mmHg-good If PaO2 level above 40-50 mmHg sign to right to left shunting Anamnesis Clinical signs and symptoms Oxygen therapy Blood gas measurement CBC and blood culture Chest x-ray ECG if need NPO Fluid intravenously Stomach decompression Mechanical ventilation if need