Respiratory Distress Syndrome and Hyaline Membrane Disease.

Characteristics.
Most common in preterm infants because of surfactant deficiency. Higher incidence with maternal diabetes, acute asphyxia, in second twin and meconium aspiration. Prevention and diagnosis of preterm labor is paramount; steroids can be used if delivery is imminent to hasten lung maturity (beta-methasone or dexamethasone 12.5 mg IM Q24h for 48 hours). Resuscitate promptly at delivery.

Clinical findings.
Shortly after birth. Tachypnea (respiratory rate >60), grunting, retractions, and cyanosis, flaring.

bronchograms.

Radiographs. Ground-glass reticulogranular appearance, air Treatment.

Rule out infection; use antibiotics as needed. Respiratory support (endotracheal intubation, mechanical ventilatory support) and metabolic support. Exogenous surfactant (doses differ by preparation) is very effective in treating hyaline membrane disease. Currently recommended drugs include Survanta, 4 cc/kg via endotracheal tube (ETT) Q6h for 4 doses or Exosurf, 5 cc/kg via ETT Q12h for 2-4 doses. Nitric oxide has also been used with some success. Pediatric consult suggested.

Transient Tachypnea of the Newborn.

Characteristics. Diagnosis of exclusion. More common in C-section

deliveries and precipitous deliveries. Pathophysiology is the delayed clearance of lung fluid.

Presentation. Tachypnea, minimal respiratory distress.

changes.

Radiographs. Fluid in fissures, pleural effusion, streaky parenchymal

limited illness that will resolve spontaneously in 24 to 48 hours.

Management. Short-term oxygen supplementation. This is a self-

Meconium Aspiration Syndrome.

Caused by the presence of thick meconium in the distal airways, causing a valvelike mechanism that obstructs air movement. Meconium aspiration can occur in a stressed neonate in utero or at the time of delivery. Deep fetal gasping causes the aspiration of the meconium-mixed amniotic fluid into the lungs.

Characteristics.

Radiographs. Thick infiltrates, air entrapment, pneumothorax. Preventive management. At the delivery of the head, the
airway should be cleared by DeLee suctioning. Tracheal visualization and suctioning should then follow. If meconium is at or below the vocal cords, intubation must be repeatedly performed until suctioning returns clear fluid.

Treatment. Management is complex, and a neonatologist should be

consulted. Treatment requires pulmonary support, as well as management of asphyxia-related effects on CNS, cardiovascular system, renal and GI systems. High-frequency ventilation, nitrous oxide, and ECMO are being used with good results. Small studies suggest that surfactant may also be helpful.

Spontaneous Pneumothorax.
Spontaneous pneumothorax occurs in 1% to 2% of live births. Only symptomatic in 1>1500 live births. When symptoms occur, they include tachypnea, minimal retractions, grunting, nasal flaring, cyanosis. May notice diminished air entry on affected side, shifting of cardiac impulse, muffled heart tones.

Radiographs. Pneumothorax seen on radiograph. Treatment. Supportive, spontaneous resolution is common. If not resolving, consider chest tube or pneumocentesis with a needle.

Bradycardia and Apnea Spells.

Types. Bradycardia may be a primary cardiac event. The following

refers only to noncardiogenic bradycardia and apnea spells. Neonates normally have 3 second pauses in respiratory effort (periodic breathing). Central. No respiratory effort for 15 seconds because of arrest of respiratory drive. May have secondary bradycardia. May be secondary to CNS disorder. Obstructive. Cessation of gas exchange in the lungs because of obstruction to air flow. May be infectious, functional (poor tone or coordination of pharyngeal muscles), or structural.

(choanal atresia), maternal drugs (especially narcotics), infections, metabolic imbalances, temperature instability, seizures, hematologic, cardiovascular, genetic, and CNS disorders. GE reflux or trouble coordinating swallow and palate malformations can all contribute to apnea. In the older child consider breath-holding spells.

Causes. Prematurity, hypoxia, idiopathic, anatomic abnormalities

Clinical characteristics
Document the duration, frequency, state of consciousness, temporal relationship to feeding, sleep, stooling, seizure activity as well as obstetric history (such as maternal fever, meconium). Gestational age is especially important. Apnea and bradycardia from prematurity usually resolves by a corrected gestational age of 35 to 36 week Physical exam should include temperature, BP, gestational age, eye position (as an indication of a CNS disorder), pupillary dilatation, muscle tone, dysmorphic features, respiratory effort, murmur, skin changes.

Lab tests. Blood glucose, electrolytes, differential CBC, drug levels,

T4, TSH, sepsis work-up, CXR, ABGs, head ultrasonogram (for CNS bleed), EEG.

Treatment.

Apnea monitor and addressing underlying factor. Teach CPR to parents and caregivers. Any individual spell will generally resolve with stimulation. Ventilatory support. Consider low flow O2, 3-5 cm of CPAP. For neonatal apnea. Caffeine citrate 20 mg/kg PO or IV (10 mg caffeine/10 mg citrate) followed by 5-7 mg/kg QD started 24 hours after first dose.

Maintain serum levels at 5 to 25 mg/ml. Theophylline has also been used, but caffeine is preferred. Continue treatment for 5-7 days. Observe in hospital off treatment for 5-7 days. If the patient has no further episodes of neonatal apnea, they may be discharged.