Extern Conference 30 Aug 07. Case Study A Thai male infant Tachypnea and Dyspnea at 2 hrs after birth.

Extern Conference30 Aug 07

Case Study

A Thai male infant

Tachypnea and Dyspnea at 2 hrs after birth

Historybull Maternal age 35 years

bull G1P0A0 GA 40+2 wks by date

bull Serology negative for anti HIV VDRL and HBsAg

bull Blood group O Rh +

bull Complication during pregnancy

bull GDM A1

bull Hb E trait ( Paternal normal Hb typing )

bull Gestational hypertension on Aldomet (125) 1x3

bull No family history of early neonatal death

Historybull Poor ANC bull Spontaneous ROM 5 hrs Thick meconium bull CS due to CPD and Thick meconium

bull Term AGA male infant (2082550 921am)bull Vigorous babybull ETT suction - Meconium at the tip of ETT bull OG aspiration - Meconium 10 ml

Historybull Resuscitation Oxygen tubing and stimulation

bull Apgar score 8(-color 2) 9(-color 1)

bull Vital signs T 372 oC RR 80min

bull BW 3520 gm HC 35 cm Lt 50 cm

bull Transfered to nursery via incubator with oxygen

hood and oxygen flow 5 LPM due to tachypnea

bull VS T 371 oC HR 163 bpm RR 64min BP 6845 mmHgbull GA active grunting suprasternal retraction

dyspnea tachypnea no cyanosis no jaundice bull CVS normal S1 S2 no murmur bull RS no increase in AP diameter secretion sound both lungs bull Abd soft no abdominal distension active BS

liver and spleen cannot be palpatedbull Neuro symmetrical movementbull Extremities no deformity

bull Genitalia Male type descended testes

Physical examination

Problem list

1Advanced maternal age

2Poor ANC

3Maternal GHT amp GDM A1

4Thick meconium stained amniotic fluid

With evidence of meconium in trachea

5Respiratory distress at 2 hrs after delivery

Differential Diagnosis

Differential Diagnosis

bull Meconium aspiration syndromebull Transient tachypnea of the newborn bull Pneumonia

Differential Diagnosis

Meconium aspiration syndromebull Pro

- Respiratory distress early after delivery - Hx of Thick meconium stained amniotic fluid

- Evidence of meconium in the trachea- Maternal GDM HTN- Secretion sound both lungs

bull Con- Not posterm SGA or depress at birth

- Not increase in chest AP diameter

Differential Diagnosis

Transient tachypnea of the newborn bull Pro

- Mild respiratory distress early within 2 hrs after delivery

- CS- Maternal GDM

bull Con- Not increase in chest AP diameter- Secretion sound both lungs

Differential Diagnosis

Pneumonia bull Pro

- Respiratory distress early after delivery

- Secretion sound both lungs

bull Con- No maternal chorioamnionitis or fever

- No prolonged rupture of the membranes- No hyperthermia- No neonatal depression

Neonatal Respiratory Distress

Neonatal Respiratory Distress Signs and symptoms

bull Tachypnea (RR gt 60min)

bull Retraction

bull Noisy respiration (grunt stridor or moaning)

bull +- Cyanosis

bull +- Desaturation

Neonatal Respiratory Distress Etiologies

Pulmonarycauses

- RDS- Pneumonia- TTNB- MAS- Other aspiration

syndrome- Air leak syndrome- Lung hemorrhage- Lung hypoplasia- Congenital

malformations

Systemiccauses

- Infections- Metabolic causes- Temperature- Anemia

Polycythemia- Congenital heart

disease- Pulmonary

hypertension- Neuromuscular

disorder

Anatomic causes

- Upper airway obstruction

- Airway malformation

- Space occupying lesion

- Rib cage anomalies

- Phrenic nerve injury

Clinical diagnosis clues Hx PE and Ix

Neonatal Respiratory Distress

AlgorithmRespiratory

Distress(tachypnoea retractions grunt)

Preterm Term

lt 6hrs old gt 6hrs old lt 6hrs old gt 6hrs old

HMD (RDS)PneumoniaLung anomalyPDA

PneumoniaCHDPulm Hm

TTNBMASPPHNAsphyxiaLungAnamolyAir leak

PneumoniaCHD

Management amp Progression in this patient

Progression at nursery

bull Hct 64bull CBS 81 mgbull Retained OG tube

meconium 1 ml step feeding via OG

bull On O2 hood 3 LPMand incubatorSpO2 99 FiO2 045SS retraction nasal flaring paradoxical chest movement

bull Portable CXR at 8 hrs

2082550 18238 hr after birth

Meconium Aspiration Syndrome

ndash Nearly all have complete recoveryndash Few have long-term neurologic deficits due to CNS damage

The pathogenesi

s of MAS

Risk factors

bull Post-term pregnancybull Preeclampsiabull Maternal diabetesbull Maternal hypertensionbull Difficult deliverybull Fetal distressbull Intra-uterine hypoxia a condition in which a

fetus receives a decreased amount of oxygen while still in the uterus

Most common symptoms

bull Rapid or labored breathingbull Retractions pulling in of the chest wallbull Grunting sounds with breathingbull Bluish skin color called cyanosisbull Low Apgar score -- the Apgar test is given to

infants just after birth to quickly evaluate their color heartbeat reflexes muscle tone and respiration

bull The body appearing limp

Investigation

bull Acid-base statusbull Serum electrolytesbull CBCbull Imaging Studies

ndash A chest radiographndash Later in the course of MAS when the infant is

stable imaging procedures of the brain such as MRI CT scan or cranial ultrasound

bull Other Tests ndash Echocardiogram for RO PPHN

Meconium Aspiration Syndrome

Meconium Aspiration Syndrome

Progression at nurserybull Feeding intolerance

and hyperthermia(T374 c) at 15 hrs

bull On O2 hood 5 LPM FiO2 045SpO2 98 active RR 80min

SS retraction nasal flaring paradoxical chest movementbull FU CXR at 24 Hrsbull CBC

ndash Hb 145 gdl Hct 41ndash WBC 27020mm3 (N63

L19 Band 13 IT = 012)ndash PLT 270000mm3

bull Transfer to intermediatenewborn care (for RO pneumonia)

2182550 100824 hr after birth

Progression at Intermediate newborn care

bull Respiratory distressbull MAS RO secondary pneumonia

bull On O2 hood 5 LPM FiO2 045

bull SpO2 98 RR 80min SS retraction nasal flaring paradoxical chest movement

bull Start Ampicillin 150 mgkgdose Gentamicin 4 mgkgdose at 2nd DOL

bull 4th DOL wean off O2 hood SpO2 RA 96-99 no dyspnea

bull HC no growth

bull Nutritionbull 2nd DOL NPO iv fluid GPR 47

bull 3rd DOL Step feeding via OG tube gt Try cup gt Try spoon

bull No feeding intolerance Wean off iv at 6th DOL

Complications

bull Persistent pulmonary hypertension bull Air leak

bull pneumomediastinum pneumothorax cystic lung disease bull Pulmonary haemorrhage bull Complications of asphyxia

bull encephalopathy seizures oliguria coagulopathy and thrombocytopenia

bull Chronic lung diseasebull Infections

Management1 Prevention

bull Monitor fetal status bull Amnioinfusionbull Suctioning +- intubation and immediate

suctioning bull Avoid harmful techniques

2 Interventionbull Optimal thermal environment amp minimal handlingbull Respiratory care Oxygen therapy amp ECMObull Surfactant therapybull Keep stable VS

PPHN prevention1 Avoid vasoconstriction

bull Acidosisbull Hypoxiabull Metabolic disturbance - Hypocalcemia

- Hypercalcemia- Hyperglycemia- Hypoglycemia

2 Prevent right to left shunt

Management Discussion

Guidelines of the baby exposed to meconium

Vigorous

Immediate tracheal suction

Meconium No meconium

reintubate and suction

PPV and suction again later

Clear secretions and meconiuminitial resuscitation steps

HRgt100 HRlt100

No Yes

The American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee management guidelines of the baby exposed to meconium

EET suction indication

bull Only in non vigorous baby- depressed respirations

- decreased muscle tone - heart rate lt 100 beats per minute

bull Pharyngeal suctioning of an infant before delivery of the shouldersbull Removal of meconium from hypopharynx and larynx by large-bore catheterbull Endotracheal intubation for removal of meconium in the lower airwaybull Meconium aspirator attached to wall suction

Steroid therapy for meconium aspiration syndrome in newborn infants

bull The Cochrane Database of Systematic Reviews 2007 Issue 3 The Cochrane Library (ISSN 1464-780X

bull Conclusions

At present there is insufficient evidence to assess the effects of steroid therapy in the management of meconium aspiration syndrome

(no significant reduction in mortality duration of hospital stay Duration of mechanical ventilation incidence of air leakincrease in duration of oxygen therapy was seen with the use of steroids)

Role of antibiotics in meconium aspiration syndromebull Ann Trop Paediatr 2007 Jun27(2)107-13 bull Basu S Kumar A Bhatia BDbull Division of Neonatology Department of Paediatrics Institute of

Medical Sciences Banaras Hindu University Varanasi India drsriparnabasurediffmailcom

bull CONCLUSION

Routine antibiotic therapy is not necessary for managing MAS No significant difference

ndash period of oxygen dependency (58 vs 59 days)

ndash day of starting feeds (40 vs 42)

ndash day of achievement of full feeds (94 vs 93)

ndash clearance of chest radiograph (117 vs 129 days)

ndash duration of hospital stay (137 vs 135 days)

Surfactant for meconium aspiration syndrome in full termnear term infants

bull Cochrane Database Syst Rev 2007 Jul 18(3)CD002054 bull El Shahed A Dargaville P Ohlsson A Soll R

bull CONCLUSIONS In infants with MAS surfactant administration may reduce the severity of respiratory illness and decrease the number of infants with progressive respiratory failure requiring support with ECMO The relative efficacy of surfactant therapy compared to or in conjunction with other approaches to treatment including inhaled nitric oxide liquid ventilation surfactant lavage and high frequency ventilation remains to be tested

Reference1 Cyanosis (The Diagnostic Approach to Symptoms and Signs in

Pediatrics) httpwwwwrongdiagnosiscomsymptomscyanosisbook-causes-15ahtm

2 Overview of neonatal respiratory distress Dsorder of transient Up to date

3 Neonatal Respiratory Distress Radiologic Approach Simon CS Kao MDhttpwwwradiologyuiowaeduRadshortclerkshipRadShortClkshipLectureNotesKaohtm

4 Management of Respiratory Distress in the Newborn Surg Cdr SS Mathai Col U Raju MJAFI 2007 63 269-272

5 The epidemiology of meconium aspiration syndrome incidence risk factors therapies and outcome Dargaville PA Copnell B Australian and New Zealand Neonatal Network Pediatrics 2006 May117(5)1712-21

6 Role of antibiotics in meconium aspiration syndromeBasu S Kumar A Bhatia BD Ann Trop Paediatr 2007 Jun27(2)107-13

7 Inflammatory markers in meconium induced lung injury in neonates and effect of steroids on their levels a randomized controlled trialTripathi S Saili A Dutta R Indian J Med Microbiol 2007 Apr25(2)103-7

Reference1 Role of Steroids on the Clinical Course and Outcome of Meconium

Aspiration Syndrome--A Randomized Controlled Trial Basu S Kumar A Bhatia BD Satya K Singh TB J Trop Pediatr 2007 May 29 [Epub ahead of print

2 The effect of steroids on the clinical course and outcome of neonates with meconium aspiration syndrome Tripathi S Saili A J Trop Pediatr 2007 Feb53(1)8-12 Epub 2006 May 16

3 Surfactant for meconium aspiration syndrome in full termnear term infants El Shahed A Dargaville P Ohlsson A Soll R Cochrane Database Syst Rev 2007 Jul 18(3)CD002054

4 Surfactant replacement therapy Stevens TP Sinkin RA Chest 2007 May131(5)1577-82

5 ECMO for meconium aspiration syndrome support for relaxed entry criteria Radhakrishnan RS Lally PA Lally KP Cox CS Jr ASAIO J 2007 Jul-Aug53(4)489-91

6 Therapeutic lung lavage in meconium aspiration syndrome a preliminary report Dargaville PA Mills JF Copnell B Loughnan PM McDougall PN Morley CJ J Paediatr Child Health 2007 Jul-Aug43(7-8)539-45

Reference1 Bronchoalveolar lavage with diluted porcine surfactant in

mechanically ventilated term infants with meconium aspiration syndrome Lista G Bianchi S Castoldi F Fontana P Cavigioli F Clin Drug Investig 200626(1)13-9

2 Inhaled nitric oxide treatment inhibits neuronal injury after meconium aspiration in piglets Aaltonen M Soukka H Halkola L Jalonen J Kalimo H Holopainen IE Kaumlaumlpauml PO Early Hum Dev 2007 Feb83(2)77-85 Epub 2006 Jun 21

3 Morphological alterations of exogenous surfactant inhibited by meconium can be prevented by dextran Ochs M Schuumlttler M Stichtenoth G Herting E Respir Res 2006 Jun 6786

4 Intrapartum amnioinfusion for meconium-stained amniotic fluid a systematic review of randomised controlled trials Xu H Hofmeyr J Roy C Fraser WD BJOG 2007 Apr114(4)383-90

5 ACOG Committee Opinion Number 346 October 2006 amnioninfusion does not prevent meconium aspiration syndrome ACOG Committee Obstetric Practice Obstet Gynecol 2006 Oct108(4)1053

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