Transcript NEONATAL PNEUMONIA

Respiratory
Distress in Newborn
Eko Sulistijono, Siti Lintang K
Perinatology Division Pediatric
Medical Faculty-Saiful Anwar Hospital
Respiratory Distress in
Newborn
• Normal infants/asphyxia with successful
resuscitation – may have respiratory
distress:
• Infant’s respiratory rate more than 60 times/minute,
may show one or more additional signs of respiratory
problem
• Infant’s respiratory rate less than 30 times/minute
• Infant with central cyanosis (bluish at the tongue and
lips)
• Infant with apnea (breathing stops for more than 20
seconds)
Causes of Respiratory
Distress
• Pulmonary disorders: Pneumonia
• Cardiologic disorders: Congenital Heart Disease,
Myocardium dysfunction
• Central nervous system disorders caused by:
Asphyxia, Cerebral hemorrhage
• Metabolic disorders: Hypoglycemia, Metabolic
acidosis
• Surgical diseases: Pneumothorax, Tracheoesophageal fistula, Diaphragmatic hernia
• Others: Meconeum Aspiration Syndrome, Transient
Tachypnea of the Newborn, Hyaline Membrane
Disease
Causes of Respiratory
Distress
Based on Gestational Age
• In Preterm Infants:
–
–
–
–
Hyaline Membrane Disease
Pneumonia
Asphyxia
Congenital Anomaly or Malformation
• In Aterm Infants:
–
–
–
–
–
Meconeum Aspiration Syndrome
Pneumonia
Transient Tachypnea of the Newborn
Acidosis
Congenital Anomaly or Malformation
Diagnosis of Respiratory
Distress
History taking:
• The Time of Respiratory Distress’s Manifestation
• Gestational Age
• Antenatal Steroid Therapy
• Predisposition Factors: PROM (Premature
Rupture of the Membrane), Fever in mothers
before delivery
• History of Asphyxia and Delivery with
Intervention
• History of Aspiration
Diagnosis of Respiratory
Distress (Cont’d)
Clinical Features of Respiratory Distress
• Clinical Syndrome consisting of these following
symptoms:
– Infant’s respiratory rate more than 60 times/minute or
infant’s respiratory rate less than 30 times/minute and
may show one or more additional signs of respiratory
problem as such:
– Infant with cyanosis (blueness at the tongue and lips)
– Chest wall retraction
– Grunting
– Infant with apnea (breathing stops for more than 20
seconds)
Clinical Classification of
Respiratory Distress
 Severe respiratory distress
 Moderate respiratory distress
 Mild respiratory distress
Table 1. Classification of respiratory distress
Additional signs of respiratory distress
Respiratory rate
Classification
> 60 times/minute
WITH
Central cyanosis AND chest wall retraction OR grunting
during expiration
Severe respiratory distress
OR > 90 times/minute
WITH
Central cyanosis OR chest wall retraction OR grunting
during expiration
OR < 30 times/minute
WITH or
WITHOUT
Other signs of respiratory distress
60-90 times/minute
WITH
Chest wall retraction OR grunting during expiration
but
WITHOUT
Central cyanosis
OR > 90 times/minute
WITHOUT
Chest wall retraction or grunting during expiration or
central cyanosis
60-90 times/minute
WITHOUT
Chest wall retraction or grunting during expiration or
central cyanosis
Mild respiratory distress
60-90 times/minute
WITH
Central cyanosis
Congenital heart disease
but
WITHOUT
Chest wall retraction or grunting
Moderate respiratory
distress
EVALUATION OF RESPIRATORY DISTRESS WITH
DOWN SCORE
0
1
2
Respiratory rate
< 60 x/minute
60-80 x/minute
> 80 x/minute
Retraction
No
Mild
Severe
Cyanosis
No
Disappear with O2
Cyanosis with O2
Air Entry
Positive
Slightly decrease
No
Grunting
No
Audible with
stethoscope
Audible without
tool
Score < 4
Score 4 – 7
Score > 7
be taken)
: No respiratory distress
: Respiratory distress
: Impending respiratory failure (Blood gas analysis must
Test
Public health care is usually not provided
with the facility to perform test, therefore:
improving observation or clinical
examination is the main concern
 Laboratory testing:
 Routine blood test and blood smear to
diagnosis the possibility of infection or
neonatal sepsis
 Blood glucose level
General Management
•
•
•
•
•
•
Obtain intravenous line
If the infant is not dehydrated, administer Dextrose 5% IV
Monitor vital signs
Maintain airway patency
Give oxygen (2-3 liter/minute with nasal catheter)
If the infant has apnea:
– Resuscitate according to the phase needed
– Further evaluate
• If seizure occurs, treat it
• Immediately check blood glucose level (if the facility is
available)
• Administer adequate nutrition
Specific Or Advance
Management
• MODERATE RESPIRATORY DISTRESS:
– Continue oxygenation 2-3 liter/minute with nasal
catheter, if dyspnea persist give O2 4-5
liter/minute with mask
– Do not give fluid to the infant
– Administer antibiotic (ampicillin and gentamicin)
to treat sepsis possibility:
• Axillary temperature < 340C atau > 390C
• Meconeal amniotic fluid
• History of intrauterine infection, suspect severe
infection if fever is present or premature rupture of the
membrane (>18 hours)
 If axillary temperature is 34 – 36,50C or 37,5
– 390C, treat the temperature abnormality
and reevaluate after 2 hours
 If the temperature is still unstable or
respiratory distress is not improving,
administer antibiotic to treat sepsis
possibility
 If the temperature is normal, continue to
observe infant. If the temperature becomes
unstable again, repeat the steps above
• MILD RESPIRATORY DISTRESS:
– Transient Tachypnea of the Newborn (TTN),
• Especially after caesarian surgery, aterm infant
• Usually this condition improves and is alleviated without
treatment
– Observe infant’s breathing every 2 hour for the next 6
hours
– If during observation respiratory distress worsen or other
sepsis symptoms appear, treat for sepsis possibility and
manage the moderate respiratory distress and
immediately refer to Referral Hospital
– Give breast milk if infant could feed. If not, then give
breast milk with one of the fluid administration
alternatives
 Reduce oxygenation periodically when
respiratory distress improves. Stop
oxygenation when respiratory rate is
between 30 – 60 times/minute
 Observe infant for the next 24 hours, when
respiratory rate is stable between 30 – 60
times/minute, no sign of sepsis, and no other
problem needing treatment, infant could be
discharged
 SEVERE RESPIRATORY DISTRESS:




Prepare to refer to Referral Hospital
Stabilize before referring
Refer with resuscitation-skilled personnel
Maintain airway and oxygenation during
transportation
NEONATAL
PNEUMONIA
Introduction
Pneumonia
 is an important cause of neonatal
infection
 Accounts morbidity and mortality
aspecialy in developing country
Pathogenesis
Routes of acquisition: Varies in part with
the time of onset of pneumonia
 Early – onset pneumonia
 Late - onset pneumonia
 Early – onset pneumonia
 Generally within three days of birth
 Aquired from the mother by one of three
routes
 Intra uteri aspiration of infected amniotic fluid
 Transplacental tranmision of organisms from the
mother to the fetus
 Aspiration during or after birth of infected amniotic
fluid or vaginal organisms
 Late - onset pneumonia
 Occures during hospitalization or after
discharge
 Nosocomial acquired from
 Infected individuals
 Contaminated equipment
 Microorganisms can invide through
 injury tracheal
 bronchoia mucosa
 bloodstream
Mechanisms of injury in GBS
pneumonia
 In GBS pneumonia,
 the level of beta – hemolysin expression correlate
directly with the abilility of the organism to injure of
epithelial cell
 Hemolysin act as pore forming cytolysis  alveolar
edema and hemorrhage
 Surfactant phospholipid inhibits beta- hemolysisassociated lung epithelial cell injury  premature
infants more severelly affected
Pathology
(The patologic changes very with type of
organisms)
Bacteria :
 Inflammation of pleura
 infiltration / distruction of
brochopulmonary tissue
 leukocyte and fibrious exudate within
alveoli and bronchi/ bronchioles
 Bacteria are seen within interstitial
spaces, alveoli,bronci/bronchioles
 Virus
 Cause an interstitial pneumonia
 Infiltration of mononuclear cell and
lympocytes  hyalin membrane formation -
interstitial fibrosis and scarring
Microbiology
Cause :





Bacterial
Viral
Spirochetal
Protozoan
Fungal pathogens
Early- onset pneumonia
1. Bacterial infections
1.
2.
3.
4.
5.
6.
Escherichia coli
Group B streptococcus
Kleibsiella spp
Staphylococcus aureus
Streptococcus pneumonia
Mycobacterium tuberculosis
transplacentally
7. Listeria monocytogenes
2. Viral infections
1.
2.
3.
4.
5.
6.
Herpes simplex virus ( HSV)
Adenovirus
Enteroviruses
Mumps
Rubella
Cytomegalovirus
3. Fungal infections
1. Candida sp
4. Other patogens
1. Toxoplasma
2. Syphilis
Late – onset pneumonia
1. Bacterial infections
1.
2.
3.
4.
5.
6.
7.
Staphylococcus
Kleibsiella
Escheichia coli
Enterobacter cloacae
Streptococcus pneumoniae
Pseuodomonas aeroginosa
Serratia marcescens
2. Viral infections
1.
2.
3.
4.
5.
6.
Adenovirus
Parainfluenza virus
Rhinovirus
Enteroviruses
Influenza
RSV
3. Fungal infections
1. Candida sp
Risk factors
 Early – onset pneumonia





PRM > 18 hours
Maternal amnionitis
Premature delevery
Fetal tachycardia
Maternal intrapartum fever
 Late – onset pneumonia
 Assisted ventilation
 Other factors
 Anomaly of the airway (choanal atresia,
tracheoesophageal fistule)
 Severe underlying disease
 Prolonge hospitalization
 Neurologic empairment  aspiration
gastroentestinal contents
 Poor hand washing
 Overcrowding
Clinical manifestation
Early- onset pneumonia
 Respiratory distress beginning at / soon after birth
 May have associated






Lethagy
Apnea
Tachycardia
Poor perfusion
Septic
Shock
 Other sign
 Temperature instability
 Metabolic acidosis
 Abdominal distentions
Late – onset pneumonia
 Respiratory distress
 Apnea
 Tachypnea
 Tachycardia
 Poor feeding
 Abdominal distention
 Jaundice
 Emesis
 Circulatory collapse
Diagnosis
 Sudden onset of respiratory distress or other
sign of illness should be evaluated for
pneumonia / sepsis
 culture: Blood,cerebrospinal fluid, pleural fluid
 Chest radiography
Bilaterall alveolar densities + air bronchograms
Irregular patchy infiltrates
Normal pattern
Treatment
 Early- onset pneumonia
 Ampicillin + gentamycin
 Cephalosphorin
 Late - onset pneumonia
 Vancomycin + aminoglycoside
 viral infection
 Acylovir
Outcome
 Predicted





Severity disease
Gestational age
Underlying medical conditions
Infecting organism
Increased mortality :
 preterm birth
 chronic lung disease
 immune deficiencies