respiratory distress in neonate

Rerespiratory distress in neonateDr. Bassam kh.Al-AbbasiConsultant pediatric surgeon

Differential diagnosis surgical aspect
A. Air way obstruction 1. Nose Bilateral coanal Atresia 2. Pharynx a. Nasopharyngeal mass(haemangioma,lymphangioma)  b.pierre Robin syndrome (cleft palate, micrognathia and macroglossia) c. mass at Base of tongue (lingual thyroid)

3. Larynx a. Laryngomalacia(inspiratory stridor) b. webs , Atresia . c.Neoplasm(haemangioma,lymphangioma) 4. Tracheobronchial tree  a. Tracheomalacia(expiratory stridor)  b. Esophageal Atresia & TEF c. Forgut cyst,esophageal duplication cyst (as mediastinal mass) d. Pulmonary sequestration (abnormal lung tissue not comunicates with broncheal tree)and its 2 typs: -intralober:within lung tissue. -extralober :isolated liver like mass out side lung tissues.

B- Compression of lung tissue by air , fluid and blood . -pneumoyhorax. -haemothorax. -chylothorax.  C- Anatomic Defect in the Diaphragm . -congenital diaphragmatic hernia.D. Intrinsic pulmonary Lesions. * Congenital lung cysts * Congenital lobar emphysema * pulmonary Sequestration* lung Agenesis , or lung hypoplasia * cystic Adenomatoid malformation of the lung

Esophageal atresia and tracheoesophageal fistula

-complet interruption of the esophagus -blind upper esophageal pouch &lower sigment that usually communicates with trachea

Classifications

87.5%
7.5%
3.5%
0.5%
1%

pathophysiology

-saliva (or milk) accumulate in the blind pouch &spill over the trachea choking and cyanosis. -gastric content aspirate through distal fistula Atelactasis and pneumonia(chemical pneumonitis) -abdominal distention (gastric)splint diaphragm inadequit ventilation

Diagnosis

-Antinatally: ultrasonography show: 1-polyhydramnios. 2-small stomach. 3-abnormal esophageal contractions. -Early diagnosis postnatally very important and confirmed by failure of orogastric tube to pass to stomach. -signs &symtoms: 1-excessive droling of saliva. 2-respiratory distress. 3-frothy white bubbles from nose and mouth(excessive salivation. 4-chocking at feeding causing aspiration pneumonitis.

Associated anomalies

1-Cardiac . 2- gasrointestinal(Anorectal). 3-Vertebral\skeletal(Limb). 4-Renal. 5-chromosomal (usualy trisomy 18 &21) 6-sometimes all are present together and called V A C T E R L

Investigations

1-x-ray of the cheast &abdomen provides informations about the followings: a-coiling of NGT and level of obstruction. b-prescence of air in the stomach which indicates fistula. c- states of the lungs. d-vertebral &ribs anomalies. e- evidence of right aortic arche. 2-Echocardiography:to identify the type of associated congenital heart disease &aright aortic arche 3- renal ultrasonography:to assess renal anomalies spcialy bilateral renal agenesis.

Ttreatment

-pre operative: 1-frequent oral suction to keep the upper pouch empty and prevent aspiration 2-incubator to avoid heat loss. 3-intravenous fluid &antibiotics . 4- vitamin K .(1 mg I M). 5-Time of surgery : within 12 hrs of admission to hospital. 6- Surgery : -right posterolateral extrapleural thoracotomy. -azygous vein ligated. -fistula identified and closed . -upper blind pouch identified with end to end anastomosis over a NGT and chest drain. -sometimes ventilator is used specially in diseased lung. -oral feeding can be commenced 3 to 4 days post operativly. -sometimes thoracoscopic repair can be done.

Esophageal Atresia without fistula

-no connection to respiratory system. -no gas below diaphragm(gasless abdomin) on initial x-ray(also in prox. Fistula) . -big gap primary anastomos is impossible. - Gastrostomy to allow entral feeding. -frequent suction of upper pouch. -6 week later primary anastomosis done, if failed esophageal replacement is required.(using either stomach,colon,or small bowel)

H-fistula

-the esophagus is intact . -ther is abnormal fistulous communication at level of C7 or T1. -clinically : in first week of life episod of coughing . cyanosis during feeding. pulmonary complications. later on requrrent pulmonary infection . abdominal distention mimmic bowel obstruction.

Investigations

1-barium swallow: done in 2 ways: a –the baby swallow the barium by a pacifier, it should be done in prone position with head elevation and it will show passage of the barium from mid esophagus to the trachea down, giving the appearance of H shape or N shape fistula. b- mid esophageal contrast study by putting a nasogastric tube till reaching mid esophagus and then push the barium. 2-bronchoscopy: it’s the best way for diagnosis and give direct visualization of the fistula which can be catheterized by small size tube and will help in identifying the fistula at time of surgery.

Treatment

-cervical approach. -right cervical incision. -identification of the fistula &division with tissue interposition to prevent recurrence.

Complication of surgery

1-anastomotic leak:2 types a-minor common &treated conservatively. - stop feeding, parantral neutrition, antibiotics, keep the NGT ,and chest tube drainage waiting for spontaneous closure. b-major leak mediastinitis&empyema.more dangerious and usualy need surgerical closure . 2-stricture anastamosis or secondary to GERD 3- recurrent TEF due to reconnection between the anastamosis and the site of the previous fistula and treated by surgery(thoracotomy).

Any question

Congenital diaphragmatic hernia
The diaphragm develops largely from three structures: 1- the pleuroperitoneal membrane; 2- the septum transversum; 3- the marginal ingrowths from the muscles of the body wall. Congenital diaphragmatic hernia results from failure of formation or fusion of the components of the diaphragm, such that abdominal contents can move through a defect into the chest. Sometimes, failure of muscularisation may produce a thin, weak diaphragm, referred to as an eventration of the diaphragm.

Types of diaphragmatic hernia 1- The Bochdalek type (posterior)is the most common. 2- Morgagni hernia (anterior) or (retrosternal) is rare, and results from a defect in the anterior midline, just behind the sternum . It usually contains part of the colon or small bowel, and less commonly, part of the liver. mostly hernias are symptomless unless strangulation occurs. Very rarely the hernia may protrude into the pericardial cavity rather than into the inferior mediastinum and cause cardiac tamponade, presenting as cardiorespiratory distress in the neonatal period.


Anterior diaphragmatic (Morgagni) hernias are often diagnosed on an incidental x-ray of the chest in a symptomless patient. but repair is still advisable because of the risk of strangulation of the bowel that protrudes through the defect. This is usually performed as open or a laparoscopic Procedure The results are excellent. 3-hiatal hernia Oesophageal hiatal hernias also occur and usually produce symptoms of gastro-oesophageal reflux.

The Bochdalek type is the most common. Left sided (85%)affected more than right side(12%) and only 3% bilateral During intra-uterine development, the small bowel, stomach, spleen and left lobe of the liver pass through the defect in the diaphragm into the chest, limiting the space available for the developing lung. This causes lung hypoplasia.

Antenatal diagnosis;- -ultrasonography by finding the stomach in the chest. Postnatal diagnosis:- A-Clinically 1-cyanosed with severe respiratory distress within minutes of birth(pulmonary hypoplasia is severe). 2-tachypnoea, increased respiratory effort. 3-hyperinfl ated chest and scaphoid abdomen. 4-heart sounds are on the right side. 5-The most common serious abnormalities are heart defects.

B-Investigation

1-chest x-ray. 2-Alternatively, a barium study will show bowel within the thoracic cavity when there is a diaphragmatic hernia.

Treatment

1-intensive cardiorespiratory resuscitations andsupport and insertion of a nasogastric tube to prevent bowel dilatation within the chest.2-avoid hyperinflation and barotrauma of the small hypoplastic lungs.3-Ventilation with a face mask (‘bagging’) should be avoided 4-Vigorous endotracheal ventilation should also be avoided because of the risk of causing barotrauma and a tension pneumothorax

Sudden deterioration is usually caused by tension pneumothorax. The management of the infant with severe hypoplastic lungs is difficult and may involve high frequency oscillatory ventillator with nitric oxid(pulmonary vasodilators) or extracorporeal membrane oxygenation. The major cause of death remains pulmonary hypoplasia and pulmonary hypertension.


Surgery to return the bowel to the abdominal cavity and to repair the defect in the diaphragm is performed when the infant’s condition is stable. This may be anywhere between 12 h and 7 or more days after birth (not emergency). In left-sided defects, a left transverse or subcostal abdominal incision is used.