COCLIA 86 Neonatal Respiratory Distress

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1 : COCLIA:Neonatal Respiratory Distress Carolyn Nguyen April 7, 2008
2 : Terminology Stridor: abnormal or unwanted noise made by turbulent airflow in the airway excluding stertor Stertor: snoring type of noise made by nasopharyngeal and oropharyngeal obstruction
3 : Sites of Obstruction Nasal Oro/hypopharyngeal Supraglottic Glottic Subglottic Tracheobronchial
4 : Nasal Obstruction Initially obligate nasal breathers so causes severe respiratory distress Generally no stridor Snorting respiration with nasal flaring Chest retractions common Cyclical cyanosis: cyanotic episodes frequent but interrupted with crying Feeding difficulty because of need for mouth breathing
5 : Nasal Differential External midline pits or dimples (dermoid) or nasal mass (encephalocele, meningocele, glioma, dermoid, intracranial vascular anomaly) Internal pyriform aperture, turbinate hypertrophy, nasolacrimal duct cysts, posterior choanae (should pass a 5-6 Fr catheter) and nasopharynx (adenoid, tumor) Craniofacial anomalies Treacher Collins syndrome (narrowed nares, hypoplastic alar cartilages) Apert syndrome (midface hypoplasia)
6 : Oro/hypopharynx Obstruction Coarse inspiratory stridor, worse with sleep, when supine, feeding or agitated Normal cry but may be muffled Sternal and intercostal retractions common Feeding difficulty because of anatomical obstruction
7 : Oro/hypopharyngeal Differential Oral cavity macroglossia, glossoptosis, micrognathia Pharynx lateral pharyngeal wall collapse vallecular mass (lingual thyroid, dermoid, vallecular cyst) Pierre Robin sequence micrognathia, glossoptosis, and cleft palate
8 : Supraglottic Laryngeal Obstruction Muffled cry Snorting respirations while asleep Coarse inspiratory sounds at rest Suprasternal and intercostal retractions Feeding difficulty if severe obstruction Worse with supine position, feeding, and agitation
9 : Supraglottic Differential Laryngomalacia Arytenoid fixation
10 : Glottic Laryngeal Obstruction Hoarse cry or aphonic Initially inspiratory stridor becomes biphasic if obstruction increases Usually no feeding difficulty (no physical obstruction in pharynx) except hunger for air
11 : Glottic Differential Laryngeal cyst Laryngeal web Laryngeal atresia Laryngeal cleft Vocal cord palsy
12 : Subglottic Laryngeal Obstruction Often normal cry Initially inspiratory stridor becomes expiratory as obstruction increases (then biphasic if severe) Xiphoid retractions Barking type cough Alar flaring Usually feeds normally
13 : Subglottic Differential Stenosis Cysts Hemangiomas
14 : Tracheobronchial Obstruction Normal cry Characteristic expiratory stridor Wheezing component Retractions uncommon Nasal flaring Brassy cough Normal feeding except air hunger or extrinsic compression
15 : Tracheobronchial Differential Tracheal rings Tracheal stenosis or atresia Tracheal cysts Tracheal hemangioma Tracheobronchomalacia Tracheoesophageal fistula Vascular compression
16 : Physics Poiseuille’s law: fluid flow through a tube varies with the fourth power of the radius Venturi principle: drop in fluid pressure that results when an incompressible fluid flows through a constricted section of pipe Bernoulli’s principle (conservation of energy): an increase in the speed of the fluid occurs simultaneously with a decrease in pressure or a decrease in the fluid's gravitational potential energy
17 : Choanal Atresia Occurs in 1 in 5,000-8,000 live births 50% have associated congenital anomalies 30% pure bony, 70% mixed bony-membranous Features: narrow nasal cavity, lateral bony obstruction by the lateral pterygoid plate & medial obstruction due to vomer thickening (endochondral bone formation), membranous obstruction
18 : Choanal Atresia Diagnosis: inability to pass small catheter through the nose into the nasopharynx, rigid or flexible endoscopy Imaging: CT Nonsurgical management: McGovern nipple, oropharyngeal airway Surgical management: removing and shortening posterior bony septum, removal of superior-lateral nasal wall & lateral pterygoid plate, stented 3-6 weeks
19 : Laryngomalacia Most common cause of neonatal stridor Develops within first 2 weeks of life Usually resolves by 2 years of age Inspiratory stridor results from collapse of the supraglottic larynx
20 : Laryngomalacia Anterior prolapse of arytenoid mucosa: laser excision of redundant mucosa Short tethered aryepiglottic folds: laser or microscissor supraglottoplasty Posterior collapse of the epiglottis: epiglottopexy
21 : Tracheal Vascular Anomalies Innominate artery compression Double aortic arch Right aortic arch Pulmonary artery sling Pulmonary artery dilation
22 : Innominate Artery Compression Most common vascular compression Artery arises further to left than usual Causes anterior tracheal wall compression particularly during expiration and cough Treatment: aortopexy
23 : Double Aortic Arch “Complete vascular ring” Second most common Derived from persistence of the paired aortic arches Encircles the trachea and esophagus and joins to form the descending aorta Imaging shows posterior esophageal compression Treatment: divide the vascular ring
24 : Neonatal “Stridor” Consult History Time of onset, progression Identify initiating factors Effects of positioning, feeding, or crying History of prematurity, difficult labor/delivery, intubation at birth, cardiac surgery Exam Document quality of stridor and timing with respiration Characterize cry and presence of cough & dysphagia Hoarseness Prolonged exhalation
25 : Congenital Bilateral VC Palsy Second most common cause of neonatal stridor 10% of all congenital laryngeal anomalies Typically presents within first month of life Symptoms: stridor, cyanosis, apnea, feeding difficulty Slight M>F dominance, bilateral>unilateral Causes: neurologic disease, meningomyelocele, trauma, idiopathic
26 : Congenital Bilateral VC Palsy Prognosis: spontaneous recovery is unpredictable Usually within 6 and 36 months Less likely with associated neurologic problem Less common when bilateral Treatment: vocal cord lateralization, arytenoidopexy, posterior cricoid split
27 : Subglottic Hemangioma Caucasian 2:1 female:male 50% affects the head and neck region with subglottis being the most common subsite Can be multiple Peaks at age 6 weeks, before 6 months Most common symptom: initially intermittent stridor, progresses to become constant
28 : Subglottic Hemangioma Diagnosis: direct laryngoscopy Smooth, soft, compressible sessile mass from lateral wall of subglottis Can be biopsied without hemorrhage Natural history: rapid proliferation to 1yr then resolution of airway symptoms 2-3 years (growth of larynx) Treatment: laser excision, systemic steroids, interferon alfa-2a
29 : Endotracheal Tubes & Complications ID (mm) = [age in years + 16] / 4 Prevention! Correct technique and size Complications: lacerations, cricoarytenoid dislocation, nerve injury (lingual, hypoglossal, superior laryngeal, RLN), vocal cord injury Risk of subglottic stenosis from prolonged intubation >7-10 days outweighs the risk of tracheotomy
30 : Cricoid Split Purpose: to decompress the complete cricoid ring and temporarily expand the lumen without stenting One week period of intubation is required Indications: failed extubation from subglottic edema or soft immature stenosis Contraindications: less than 1.5 kg, oxygen requirement >35% from BPD
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