RSS

Category Archives: Respiratory Distress Syndrome

Aside

I got an interesting referral from one hospital. It is not really that difficult of a case but it is quite puzzling for the untrained ones, nevertheless interesting.

The mothers’s history is generally unremarkable. She only had some flu-like symptoms during the last trimester of the pregnancy. There was no history of hypertension nor diabetes. Mother’s prenatal visits were timely and regular as this is very much wanted pregnancy. Generally, she never had symptoms. She came to the hospital in labor. She had an ultrasound which stated that the baby is in fine condition, there was adequate fluid. About 12 hours into delivery the bag of waters ruptured. The mom recalled that she noted the fluid to be yellow-stained (normally it should be clear). There was no foul odor.

She gave birth by normal vaginal delivery. The baby was not that big, weighing only 2.6 kgs. There was no difficulty during baby’s delivery. There was no cord loop around the neck (that may have strangulated the baby). The fluid was viscid, thickly saturated with meconium (baby’s first stool). Few minutes thereafter, the baby began to have respiratory distress requiring oxygen support.

Baby had an xray of the chest revealing pneumonia. He was then started on empiric broad spectrum antibiotics. Baby was nursing well from the mother while on oxygen supplementation. There was no progression of the respiratory distress. Despite requirement for oxygen, baby remained comfortable. On the 5th day of life, baby still cant be weaned off from oxygen, breathing was still fast although comfortable. Repeat xray of the chest revealed significant clearing of the pulmonary infiltrates initially seen on the previous xray. An arterial blood gas analysis was done but it was unremarkable. So why then is the baby requiring oxygen despite the comfortable breathing, normal blood gas analysis and clearing of xray picture?

The baby was then referred to me at this time. At first I went with the line of unresolved infection so I suggested shifting of antibiotics as well as determination of c-reactive protein (an indicator of inflammation – often due to infection, that may as well be used to monitor response to treatment).

The CRP was reactive, meaning it indicated presence of an ongoing inflammation/infection, but the value was not congruent with the distress of the baby. So I tried to play along with some of the facts that the baby presented. First, baby was born throught thickly meconium stained amniotic fluid. Second, the baby’s initial xray findings highly suggested pneumonia. Third, the baby remained oxygen dependent despite ample time for antibiotics to have worked, granting this was supposed to be an isolated pneumonia. Fourth, despite improvement of x-ray picture, the baby remained, clinically, unimproved; was still dependent on oxygen support.

With these, I came to rationalize that baby might be having meconium aspiration pneumonia (MAP). (While meconium is supposed to be sterile , meaning it is free of bacteria, antibiotics was a rational modality of treatment as CRP was reactive). But on top of the MAP, I considered that baby might be experiencing as well a complication.

I then requested to obtain blood gas analysis from the right and the left arms, with emphasis on the pulmonary oxygen between the two sites.

pda1

The aorta, the main vessel that arises from the left ventricle (red vessel creating a loop on the above illustration) gives rise to three large vessels that supply the upper part of the human body. The first branch immediately divides into two, one serving as right subclavian artery (that which supplies our right arm) and right carotid artery (that branch supplying to the blood). The second main branch becomes the left carotid artery which also supply our head on the left side whereas the third main branch is the left subclavian artery which supplies our left arm.

There usually is a ductus arteriosus that exists in the fetus and closes permanently about 10 days after the baby is born. It usually arises after the right subclavian and carotid arteries, and before the left subclavian artery. Thus, by origin, the right subclavian artery is usually termed preductal while the left subclavian artery may be, most often, post-ductal. Since preductal vessels include those vessels that send blood supply to the brain, it is also then safe to assume that preductal blood picture also reflects the same blood picture that goes to the brain.

In cases of pathology when the pressure in the right side of the heart is higher than that of the left, and the ductus artery is still patent/open, the unoxygenated blood in the right side may dilute the already oxygenated blood in the left through the ductus arteriosus. In cases therefore involving increased right-sided pressure, the baby tends to be cyanotic from this explanation.

One way of determining whether there is a significant shunting from the right side to the left side via the patent ductus arteriosus is performing a 2-D echocardiography, which exactly measures the pressures between the two sides of the heart. Just compare your obtained pressure from the right side of the heart with the normal values for age and you can immediately say there is elevation of pressure, or simply put pulmonary hypertension. Another way of determination is to obtain blood gas from preductal (right arm) and post ductal (left arm, right foot, left foot) extremities. Then, compare the partial oxygen tension/pressure (pO2). A gradient between right and left of more than 20 mmHg is highly suggestive of right sided pressure, in this case, persistent pulmonary hypertension, of the newborn (also known as persistent fetal circulation).

The baby’s right arm blood pO2 was 81.7mmHg, whereas the left arm pO2 was 42.16mmHg. There was a gradient between right and left arm of 39.1mmHg, way higher than 20mmHg cut off, clearly suggesting that the baby has a pulmonary hypertension. Pulmonary hypertension usually arises when the small supposedly thin capillaries in the lungs that carry blood for oxygenation thickens. With thick pulmonary vessels, the transit of oxygen from lung alveoli to the blood vessels is rendered more difficult and hence the slow or lack of oxygenation of the blood that returns to the heart, making the baby a little bluish. And if the pulmonary hypertension is severe, this “resists” the incoming blood from the heart and is shunted directly into the aorta via the ductus arteriosus, unoxygenated, already diluting the blood that may have successfully went into the lungs for oxygenation (but not sufficiently). This can turn into vicious cycle until the baby’s demise.

In cases however of pulmonary hypertension, where the wall between the right and left atrium has a large communication known as patent foramen ovale, since at the level of atrium there is already mixing of blood between right (unoxygenated) and left (oxgenated) sides of the heart, there may not be an appreciable gradient of pO2 between preductal and postductal blood gas analyses.

Respiratory Distress?

Advertisements
 

Tags: , , , , , , , , , ,

Service or Martyrdom?

Service or Martyrdom?.

 

Tags: , , , , , ,

Service or Martyrdom?

This is a retro-blog.

I remember one patient who was referred to me for neonatal care. It was about 4 years ago. A mother had to deliver prematurely by cesarean section because of premature rupture of membrane and uncontrolled uterine contractions.. Baby was 28 weeks gestational age. There was no more room for control of labor, and preparing the baby’s lungs for eventual delivery; the cesarean section had to be done outright. Both parents were employed at that time, so I thought there was no problem about financial resources.

Again, as for all babies being born prematurely, he needed to be administered surfactant. It was night time, banks were closed so there’s no way the father can tender cash at that time. I told him to go to another hospital, secure surfactant with my name as guarantor and sign a waiver for them to pay for the drug in 24 hours. The medicine was released to him and thus I was able to administer it immediately.

(Image courtesy of www.nhlbi.nih.gov/health/health-topics/topics/pda/)

Baby was already being weaned from the respirator, when a new problem arose, a patent ductus arteriosus. This posed a threat as it increased the volume of blood that goes to the lungs for oxygenation and predisposing to a chronic problem: bronchopulmonary dysplasia. Oral medication given via tube to treat the problem. Then another problem set in: persistent pulmonary hypertension and renal insufficiency bordering renal failure, plus signs of systemic infection showing. I did some double volume blood exchange transfusion here besides giving respective medicines.

Baby’s persistent pulmonary hypertension responded to sildenafil. After the exchange transfusion, baby started urinating. Then the murmur disappeared. However, it took a some time to wean the baby off from the respirator because of one problem: baby developed bronchopulmonary dysplasia. I had to give cocktail of medications. Finally baby was weaned off from the respirator and was extubated but still dependent on oxygen support. There were even times when after extubation and when his BPD would exacerbate, it would require some hourly aerosolization to open up his distal airways.

When baby was almost two months, he was then discharged from the hospital, free from oxygen support, feeding well, and gaining weight daily. Due to big hospital bill, they asked if it is okay for them to sign a promisory note for their payment of my professional fee. Should I say no? I never proposed any condition at all. I just called the hospital to give my approval. They also partially paid their hospital bill.

One week from discharge, they followed up at the clinic. Few days after that, the hospital declared bankruptcy and closed. Then, my fear came true. They disappeared and never came back. They never at least had the courtesy to tell me that they can’t pay my professional fee. Nada! Boom! Ba-bye! I had their number. Sometimes I ask my secretary to remind them, but then they just say they will come to no avail. Then I recall how was I attending to that baby before, I had no car then. I would wait for a cab to visit the baby. Then during early mornings, I had to walk for about 10-15 minutes going to the main road to hail a cab to go back home. And then this is what I deserve.

The perks of a neonatologist. Other colleagues surely do have their own stories and could be worse than this.

 

Tags: , , , , ,

Beinte-Cinco: Quatro

Beinte-Cinco: Quatro.

 

Tags: , , , , , , , , , , , ,

Beinte-Cinco: Quatro

For the past few days, I have been plagued by extremely premature babies for the first time, all 25 weeks gestational age, with different stories embracing each…

UNO…

Parents are well-to-do. They have a business, requiring husband to be out of town. Allegedly, the current pregnancy is not of the husband’s… Mother came in to the labor room, in active phase of labor, meaning, baby is already about to come out. Based on limited data gathered by my resident, mother is about 25 weeks pregnant, had been having diarrhea few hours prior to abdominal pain.

Baby was born, I immediately provided his needs – intubation, mechanical ventilator support, umbilical vascular catheterization. Despite full support, baby’s oxygenation status was never better. Chest x-ray showed collapsed lungs due to sequelae of prematurity. Husband is out of town, the mother’s companions are her employees, who cannot help me with legalities and decision-making.

Then the obstetrician revealed, (as she has the rapport with the mother), that the mother attempted to abort the baby by ingesting some abortifacient. About six hours from birth, the father arrived, but even if he wanted to be aggressive, the baby couldn’t respond anymore to treatment. They then signed a DO NOT RESUSCITATION order. Baby expired after about 12 hours from birth.

DOS…

Both parents are young and unemployed. Mother is 18 years old, father is 22. She came in too to the hospital because of abdominal pain. When at the emergency room, baby’s head was already presenting so she was rushed to the delivery room. I was called in after the baby was delivered so I rushed like an ambulance driver to the hospital. Baby’s urgent needs were provided and then I talked to the father about baby’s condition, what he needs. Unfortunately, even after he has called all possible resources, he wasn’t able to provide the medication baby badly needed.

Baby was only relying on the mechanical ventilatory support. However on the 30th hour of life, he started showing signs of deterioration. His mechanical ventilatory settings were unusually high that eventually led to rupture of both lungs (just as when I left the hospital). I had to rush back to possibly rescue baby. His x-ray revealed rupture of both lungs, with air escaping out but still within chest cavity, thus compressing both the lungs, and the heart. If this were not addressed, baby will die in a few minutes..

I called in a pediatric surgeon to insert tube to drain the air, while I only deed a rescue needle thoracentesis. Alas, after our attempts to rescue baby, he didn’t make it. He expired at about 38 hours from birth.

TRES…

I was informed that there is a pregnant mother, on her 28th week gestational age, for control of labor, but if she will deliver, I will attend to the baby. At least, the baby was older this time (and so I thought)… I instructed then the NICU staff to prepare equipment that baby will need upon delivery. Only two hours after the referral, the phone rang again, calling me now to the delivery room as the baby’s head was already almost out. At least this time, I was already able to have dinner.

I rushed to the hospital and in less than 10 minutes, baby came out. But baby wasn’t looking normal, he was deformed. His head and face were deformed, the abdomen was as large as the head (normally, for a preterm, the head is larger, abdomen and chest are almost the same in diameter), the feet are compressed, looking like club foot. When I was asked what the gender of baby was, I couldn’t commit whether baby is a boy or girl. It seemed like there are scrotal sacs, but empty (which is expected at this gestational age), there was a protrusion that is hard to discern if its penis or clitoris. (In cases where genitalia is ambiguous, we are not obliged to assign a gender until we were able to document it by chromosome (DNA) analysis, so as to avoid mistake in gender assignment). Baby’s skin were also showing red spots highly suggestive that baby has congenital infection, probably german measles or cytomegalovirus. The large abdomen suggests that liver or kidney is enlarged. Whether it is a tumor or a reaction to maternal infection during the course of pregnancy, I could not be certain. Physical assessment also revealed that baby is only 25 weeks, and not 28 weeks as thought of by the mother.

Upon birth also, heart beat was already less than normal, and he was already gasping (an ominous sign of arrest). I already knew that resuscitative efforts in this kind of situation will be otiose. So, I immediately called in the grandmother (as the husband is abroad) and explained how futile resuscitating baby is. We provided comfort care, had baby baptized, and waited for baby to expire.

In retrospect, I learned that at 5 months gestational age, baby’s ultrasound revealed that there was polyhydramnios (excessive amount of amniotic fluid). The placenta was large too, heavier than the baby, also substantiating my suspicion that mother had a lethal form of asymptomatic infection that grossly affected the baby.

After 58 minutes from birth, baby expired.

QUATRO…

It was a Sunday, it was supposed to be lazy day, rest day for me, but for some crazy reason, the world does not want me to fully enjoy my rest days, this day included. I was called in for emergency cesarean delivery at a hospital for the birth of yet again 25 weeks old baby. Baby had to be delivered as the hand is already coming out of the vagina.

Upon arrival at the hospital, the obstetrician and her assistant was already operating on the mother so I barely had time to prepare. Baby came out in few minutes and needed resuscitation as he was not spontaneously crying and breathing. We had to provide bag-mask ventilation but the equipment was dysfunctional. Also, many equipment that baby needs is not available in that hospital so I had to immediately transfer baby to a higher center. The baby is the 2nd child, the 1st child being 13 years old already and parents want the baby to live. What am I to do but to stress myself thus? (evil-grin) 

The ambulance and I rushed to the other hospital in convoy. Again, his needs were provided. This time, I or perhaps the baby was lucky because the father was able to provide that much needed surfactant. Also, the baby’s lungs are not that collapsed compared to the other ones I previously mentioned.

It seemed that the mother has uterine infection as the bag of waters broke one day before she had labor pains. Usually infections at this week of gestation is lethal/deadly to the premature baby.

The baby is currently stable at present, although still requiring mechanical ventilatory support.

 

Tags: , , , , , , , , , , , , , ,

A Gush Of Air

A Gush Of Air.

 

Tags: , , , , , , , , , ,