Lecture 5 Pneumonia and Sepsis
Lecture 5 Pneumonia and Sepsis
3 types:
Congenital Pneumonia
Intrapartum Pneumonia
Postnatal Pneumonia
Congenital Pneumonia
An inflammatory condition of the lungs affecting
primarily the microscopic air sacs known as alveoli
Causes:
Most often seen with chorioamnionitis,
prematurity and meconium aspiration
Prematurity
Prolonged rupture of membranes CLINICAL ASSESSMENT
Maternal temp > 38C Gray, pale color
Foul smelling amniotic fluid Lethargy
Rupture of membranes before the onset of labor Temperature instability
Non-reassuring fetal well-being test results Skin rash-petechia
Fetal tachycardia Tachycardia
Meconium in the amniotic fluid Glucose issues Hypoperfusion
Maternal hx of STDs Oliguria
Recurrent maternal UTI PROM> 18 hours
before delivery RESPIRATORY ASSESSMENT
Tachypnea Apnea, irregular breathing pattern
ETIOLOGY Grunting
Congenital pneumonia may be infectious or Retractions
noninfectious Nasal flaring
Group B Streptococcus (GBS) Colorful secretions Rales, rhonchi
Nontypable Haemophilus influenzae Cyanosis
Other gram-negative bacilli
Listeria monocytogenes RADIOLOGICAL INVESTIGATION
Enterococci When considering pneumonia, devote particular
Staphylococcus aureus attention to the following:
Noninfectious pneumonia are a class of diffuse Costophrenic angles
lung diseases. They include: diffuse alveolar Pleural spaces and surfaces
damage, organising pneumonia, nonspecific Diaphragmatic margins
interstitial pneumonia, lymphocytic interstitial Cardiothymic silhouette
pneumonia, desquamative interstitial Pulmonary vasculature
pneumonia aspiration Right major fissure
Transmission of congenital pneumonia usually Air bronchograms overlying the cardiac shadow
occurs via 1 of 3 routes:
Lung expansion
Hematogenous
Patterns of aeration
Ascending
Aspiration
Pneumothorax
PATHOPYSIOLOGY Refers to the presence of air in the pleural space
Causes:
May occur spontaneously or due to trauma to
the lungs or the chest wall
Spontaneous pneumothorax occurs due to the
rupture of pleural blebs
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DR. GERALDINE RAMIREZ RT3 – 2nd SEMESTER
LECTURE – WEEK 5
Iatrogenic injury occurs while performing any
thoracic, cardiac, or any chest wall surgeries
Trauma may be due to gunshot injuries, stab
injuries, blunt trauma over the chest wall
Respiratory Assessment
Tension Pneumothorax
Tachypnea
The communication between the lung and pleural
Nasal flaring
cavity is small and valvular
Grunting
It allows air entry during inspiration but prevents
Retractions it from escaping during expiration
BS absent or decreased Therefore, pleural pressure is more than the
atmospheric pressure
Clinical Assessment
Cyanotic
pale, gray
Heart Rate
o Tachycardia
o Bradycardia
o PEA
Perfusion
o Capillary Refill (CRT)
o Blood Pressure if monitoring Arterial
o Line, narrowing pulse pressure •
Deformities of Chest Wall
o Asymmetry of chest
CHEST X-Ray speaks for itself!!
TYPES
Simple/ Closed pneumothorax
1. The opening in the lung is very small, hence, it heals
rapidly
2.There is no continuous communication between the
lung and the pleural cavity
3. The mean pleural pressure is less than the
atmospheric pressure
Open/Sucking pneumothorax
The ruptured site remains open and there is a
communication between the pleural cavity and the
bronchus forming the broncho-pleural fistula
RADIOLOGICAL FINDINGS
Pleural pressure is equal to the atmospheric Chest X-ray :
pressure Hyper translucency between the lung & thoracic
cage.
Due to broncho-pleural fistula, infection in the Razor sharp border of the collapsed lung.
pleural space is common and hence leads to Shifting of mediastinum on the opposite side of
pyopneumothorax injury.
Chest CT scan:
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DR. GERALDINE RAMIREZ RT3 – 2nd SEMESTER
LECTURE – WEEK 5
Intrapleural gas along with loculated
pneumothoraces.
Pleural effusion, pneumothorax.
Chest Ultrasound:
Smooth horizontal echogenic lines are seen above
and below the pleural lines.
Absence of lung sliding and B-lines
CLINICAL FEATURES
Closed pneumothorax
Reduced chest expansion
Hyper-resonant note on percussion.
Reduced air entry. Pneumothorax
Mediastinal shift to opposite side. Right lateral decubitus view of pneumothorax
Decreased Tactile Vocal Fremitus (TVF).
Decreased Vocal Resonance.
Open pneumothorax :
Crackpot sound on percussion.
Amphoric breath sounds.
Voice and cough sounds may be heard with
metallic echo.
Tension pneumothorax :
Displacement of the mediastinum with
respiration. Pneumopericardium
Dyspnoea
Cyanosis.
Tachycardia.
Increased respiratory rate.
Decreased blood pressure.
Respiratory failure
SURGICAL MANAGEMENT
Supplemental oxygen:
It is administered to facilitate resorption of
pleural air.
Aspiration:
It is done during thoracocentesis to aspirate the
air in pleural cavity.
Tube thoracostomy:
Chest tube is connected to a water seal device
with or without suction and is kept until the
pneumothorax resolves.
Thoracoscopy:
Video - Assisted Thoracoscopy (VATS) is done
to perform mechanical pleurodesis.
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DR. GERALDINE RAMIREZ RT3 – 2nd SEMESTER
LECTURE – WEEK 5
Lactic Acid
Congenital Abnormalities of the Chest X-ray
Lung and Thorax Congenital Heart Disease - Heart shape and size
(CHD) - PBF
Congenital Diaphragmatic Hernia (CDH) Echocardiogram
Congenital Cystic Adenomatoid - best test - diagnosis
Malformation Cardiac cath for possible intervention
Tracheal Abnormalities
Esophageal Atresia
Pulmonary Hypoplasia Congenital Diaphragmatic Hernia Congenital
Cystic Adenomatoid Malformation
Congenital Heart Disease
Defect present at birth- often picked up on early Ideally diagnosed in utero
ultrasound Develops during pseudoglandular stage, but
Increased risks: CCAM can form up to 35 weeks
o Parents have CHD Normally compromised at delivery
o Siblings have CHD requiring immediate intubation
o Maternal diabetes CDH more commonly found on left side
Exposure to German measles, toxoplasmosis,
or if mother HIV+ Congenital Diaphragmatic Hernia
Alcohol use during pregnancy A diaphragmatic hernia is defined as a communication
Cocaine use during pregnancy between the abdominal and thoracic cavities with or
TWO TYPES OF CHD: without abdominal contents in thorax
Acyanotic-blood returning to right side of
heart passes through lungs-usually defect in Types
heart wall, or obstructed valve or artery Anatomically:
o Pink baby Hiatal (esophageal hiatus)
o Saturations within normal limits Paraesophageal
o Low sats Retrosternal (Morgagni)
Cyanotic- have a mixing of oxygenated blood Posterolateral (Bochdalek)
with venous blood – shunting ductus, PFO,
ASD, VSD ETIOLOGY
o Blue baby
Congenital
Traumatic
RESPIRATORY ASSESSMENT
Respirations EPIDEMIOLOGY
- Normal
Incidence:
- Tachypnea
1/2000-1/5000 live births
Saturations depend upon defect:
M:F-1:2
- Acyanotic lesions sats are more normal
- Cyanotic lesions acceptable sats are low Left side more common (85%)
- 70% is acceptable; ideally on 21% FiO2 Sporadic
Familial (Autosomal recessive, multifactorial)
CLINICAL ASSESSMENT Associated anomalies
HR CNS lesions
- Slow, fast, variable Omphalocele
- Murmur Esophageal atresia
BP Cardiovascular lesion
- Check in all 4 extremities Part of trisomy 21, trisomy 13, trisomy 18
PULSES
CRT
COLOR
- Acyanotic
- Cyanotic
LABS AND TEST
ABGS- dependent upon defect
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LECTURE – WEEK 5
INITIAL MANAGEMENT
RESPIRATORY ASSESSMENT Aggressive respiratory support (rapid
Tachypneic endotracheal intubation, sedation
Retractions NG tube insertion and urinary catheterization
Nasal flaring needed
Grunting Pre- and postductal oxygenation and arterial
Breath Sounds pressure have to be monitored continuously by
o Decreased on the affected side umbilical arterial catheter placement
o May hear bowel sounds in chest with Prolonged Bag and mask contraindicated
125
CLINICAL ASSESSMENT GOAL
Scaphoid Abdomen Pre ductal SaO2>= 85%
o classic sign PIP<25 cm of water
Color Permissive hypercapnia PaCO2 (45-60 mm Hg)
o cyanotic
Heart Rate TREATMENT
o fast, slow or normal Ventilatory Strategies
o shifting of apex beat to contralateral Conventional mechanical ventilation
o side of hernia HFOV
o increased chest wall diameter
ECMO
o delayed presentation
Goal:
o often right
o regurgitation Oxygenation without barotrauma
o vomiting due to intestinal obstruction PIP=<25cmH2O
o incarceration of intestine Rate 30-60 bpm
DIAGNOSIS
Nitric Oxide
Perfusion
- depends upon the severity Selective pulmonary vasodilator
X-Ray- best diagnostic tool ECMO
o bowel, stomach, liver in chest Lower limit of weight required>= 2000
ABGS Can be venoarterial and venovenous
o acidosis, hypoxemia and hypercarbia SURGICAL REPAIR
o prenatal usg at 16-24 week of gestation Mostly after 48 hrs after stabilization and
o polyhydramnios, chest mass, resolution of pulmonary hypertension
mediastinal shift, gastric bubble in Delayed in newborn on HFOV • Most common
thoracic cavity approach: subcostal approach Laparoscopic
o after delivery: cxr with a nasogastric and thoracoscopic repair Native tissue vs
tube patch(GORE-TEX, porous
o barium study Relative indicators for stability
o echocardiography Requirement of conventional ventilation
o amniocentesis Only
Low PIP
Left Congenital Diaphragmatic Hernia
FiO2<50%
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DR. GERALDINE RAMIREZ RT3 – 2nd SEMESTER
LECTURE – WEEK 5
Liquid ventilation: Tracheal installation of
perfluorocarbon (PFC) to replace as a carriage
for oxygen and carbon dioxide
Fetal surgery: Human tracheal occlusion
(fetoscopic endoluminal tracheal occlusion)
COMPLICATION
GERD (50%)
Intestinal Obstruction (20%)
Recurrent diaphragmatic hernia (5-20%)
Delayed growth in 1st 2 years of life
Neurocognitive defect (more common in
infants requiring ECMO)
Pectus excavatum
Scoliosis
PROGNOSIS
Overall survival of CDH 67%
Spontaneous fetal demise: 7-10%
POOR PROGNOSIS
Associated major anomalies
Symptoms before 24 hrs of age
Severe pulmonary hypoplasia
Need for ECMO
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LECTURE – WEEK 5
2. Increased volume of pulmonary blood flow returning Foetal:
to left atrium→ Increases left atrial volume and 1. Birth asphyxia-prolonged hypoxemia leads to release
pressure→ Closure of foramen ovale (functionally) of humoral factors which cause vasoconstriction and
→Becomes Fossa Ovalis. remodelling of pulmonary vasculature
(abnormal muscularization of arterial wall with >>
CLOSURE OF: medial thickness) →decreased cross sectional area of
Foramen ovale : the vessels >> PVR.
Functional Closure: 3rd month of life. 2.Parenchymal lung diseases like pneumonia,
Anatomical closure of septum primum & surfactant deficiency, meconium aspiration-reversible
septum secundum by 1 year of age. due to vasospasm.
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DR. GERALDINE RAMIREZ RT3 – 2nd SEMESTER
LECTURE – WEEK 5
o PaO2 > 100 is lung disease Requires immediate intervention to reverse
o PaO2 = 50 to 100 is either lung or heart hypoxemia, improve pulmonary and systemic
o disease perfusion, preserve end organ function
o PaO2 <50 is fixed right to left shunt Supplemental oxygen (postductal SaO2 is
>90% and < 98%)
BREATH SOUNDS Intubation, mechanical ventilation (persisting
-Depend on cause hypoxemia, hypercapnea, acido is)
Pre and Post-ductal saturations to monitor In the absence of pulmonary disease
shunting- best indicator if ECHO not available mechanical ventilation with rapid,low pressure
If fixed R to L shunt is suspected Obtain pre and and short inspiratory time
post ductal Pa02 PPHN + parenchymal lung disease -> High
Difference < 15 torr, no ductal shunting frequency oscillatory ventilation/High
Difference > 15 torr, ductal shunting frequency jet ventilation (MAS,air leak)
disease PaO2 <50 is fixed right to left shunt
Sildenafil
CLINICAL ASSESSMENT PDE-5 inhibitor
Color Inhibits metabolism of NO
o Blue/gray >> available NO
X-Ray Dose: 0.4mg/kg/dose IV over 3hrs followed by
o Depends on cause a continuous infusion of 1.6mg/kg/24hrs for up
o Usually with decreased blood flow, minimal to 7 days
lung markings
DIAGNOSIS
Presents within 18 hours of birth
Respiratory distress
Marked cyanosis
Differential cyanosis between regions perfused
by preductal and postductal vasculature
Lab
o Dependent on cause
o Many present with abnormal
Platelets/PT/ Fibrinogen
ABG
o Respiratory and metabolic acidosis
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DR. GERALDINE RAMIREZ RT3 – 2nd SEMESTER
LECTURE – WEEK 5
Sedation and analgesia with fentanyl/morphine
(prevents release of catecholamines which
activate
pulmonary adrenergic receptors) Muscle
relaxants like pancuronium
Correct polycythemia, hyperviscosity (partial
exchange transfusion with normal saline to
maintain HCT between 50-55%)
Other therapies: Magnesium sulfate,
adenosine, tolazoline, calcium channel
blockers, inhaled prostacyclin, inhaled ethyl
nitrite
PROGNOSIS
Neurodevelopmental sequelae in 15-20%
Hyperventilation reduces cerebral perfusion,
leads to sensorineural hearing loss
Prolonged ventilation leads to development of
chronic lung disease 20% risk of
rehospitalization within 1 year of discharge
Bronchopulmonary Dysplasia
Abbreviated as BPD
Obstructive disease
Definition-02 usage, 28 days post partum
Causitive factors:
o 02
o Airway Pressure
o Time of exposure
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