Pediatric emergency medicine trisk 635

priority is evaluating the patient (history and a physical examination) for presence
of a stable airway. Any newborn presenting with a new onset of stridor should be
admitted for a complete evaluation. Bedside fiberoptic laryngoscopy can be
performed, allowing the ENT surgeon to observe the mobility of the vocal cords
and diagnose paralysis in most cases. Supplementary testing such as a modified
barium swallow may be required to look for aspiration in cases with feeding
difficulties. Clinicians should order additional testing in cases where there is
suspicion of underlying conditions. These include cranial MRI or CT scan for
diagnosis of neurologic and brainstem disorders, CT scan of chest and x-ray films
of the neck for mediastinal pathology, or echocardiogram for cardiac disease.

Other Disorders That Produce Neonatal Respiratory Distress
Goals of Treatment
Respiratory distress is one of the most common presenting symptoms for
newborns. Most respiratory conditions (pneumonia, intrathoracic tumors,
congenital lung disorders, chest wall deformities) produce respiratory distress;
however, clinicians must also bear in mind that other extrapulmonary causes
(cardiac disease, neuromuscular disorders, diaphragmatic disorders, anemia,
polycythemia, metabolic acidosis, and neonatal sepsis) can present in this manner.
Classical neonatal respiratory disorders (respiratory distress syndrome, meconium
aspiration syndrome, transient tachypnea of the newborn, persistent pulmonary
hypertension, and congenital pneumonia) usually appear in the first few hours to
days following birth and would generally be treated in the neonatal intensive care
unit. A small group of neonates may present after discharge with pneumonia
(late-onset GBS, chlamydial, respiratory syncytial virus [RSV], and Haemophilus
influenzae ) or exacerbation of bronchopulmonary dysplasia (BPD). These
conditions can present with nonspecific symptoms of poor feeding, hypothermia,
and lethargy. They will be discussed below. Perinatal history (prematurity,
prolonged rupture of membranes, GBS status, mode of delivery, complications
following delivery) should be elicited from the mother. Physical examination will
reveal signs of respiratory distress (nasal flaring, grunting, retractions, head

bobbing, cyanosis, and tachypnea). The neonatal chest wall is very compliant;
small changes in the aeration of the lungs or minor secretions obstructing the
bronchi can cause significant retractions. Other respiratory signs such as
paradoxical motion can be seen in cases with diaphragmatic paralysis.
Asymmetry of chest wall motion could signify pneumothorax or a large effusion.
Care should be taken to auscultate both lungs (rales, wheezing) and examine the
cardiovascular system (murmurs, gallops, distal pulses, and capillary refill). Pulse


oximetry may show desaturation. Blood gas analysis is very useful to detect
hypercarbia and can differentiate between respiratory and metabolic acidosis,
which can inform the next steps in management. Stabilization of the infant with
supplemental oxygen, nasal cannula, or intubation and mechanical ventilation
should be the first priority. Chest x-ray is useful for defining etiology. After
appropriate emergency treatment, infants requiring respiratory support should be
admitted. Additional information can be found in Chapter 71 Respiratory Distress
.
CLINICAL PEARLS AND PITFALLS
Acute exacerbations of BPD spells are characterized by wheezing and
diminished air entry. They can be triggered by mild viral infections,
changes in the weather, or even crying.
Neonates with BPD have long-term scarring and fibrosis. It is important
to compare current chest x-rays with previous ones, if available, to
differentiate chronic lung changes from new pathology.
Neonates normally have a large thymic shadow on CXR. Clinicians can
mistake this for infiltrates.
Ex-premature infants (<32 weeks of life) with BPD are candidates for
RSV prophylaxis with Palivizumab during their first year of life. Ask the
family if they are receiving their monthly shots during RSV season.
Referral to their pediatrician is recommended if they are not up to date

on prophylaxis.
Chronic Lung Disease or Bronchopulmonary Dysplasia
BPD, or chronic lung disease, occurs when the lungs of premature infants are
exposed to mechanical ventilation for prolonged periods of time. It is defined as
the presence of an oxygen requirement beyond 28 days of life or >36 weeks
corrected gestational age (gestational age plus weeks postnatal). The original
disease was described by Northway in 1967 as chronic respiratory failure
(hypoxia and hypercarbia) in preterm newborns following prolonged highpressure mechanical ventilation (mechanical trauma) and oxygen toxicity with
distinct chest x-ray changes (severe fibrosis and alternating areas of atelectasis
and hyperinflation). Respiratory distress syndrome, infection, increased
circulation in the lung, and increase in fluid from a patent DA are thought to be
contributing factors. With the widespread use of CPAP and surfactant therapy and
improvements in mechanical ventilators, the incidence of BPD has decreased


(25% to 42% in infants born less than 1.5 kg). Smaller, sicker premature
newborns are more prone to the disease. Changes in neonatal ventilation and care
have produced the “new BPD.” This is a milder form with chest x-ray (CXR)
showing diffuse haziness instead of the severe cystic form ( Fig. 96.36 ). The
pathologic destruction of lung tissue decreases lung compliance and increases
airway resistance. Changes in pulmonary function may persist well into
adolescence.
Infants with BPD can present in the ED with acute exacerbations due to
respiratory infections, resulting in catastrophic respiratory failure. Viral illnesses
(e.g., viral upper respiratory infections, RSV bronchiolitis) are common during
the first year of life; but respiratory tract infections caused by bacteria and fungi
can also occur with similar consequences. Infection will trigger more
inflammation, increased airway reactivity, plugging by secretions, and acute
airway obstruction. Respiratory distress, apnea, and desaturations can be
presenting symptoms. History of prematurity with prolonged ventilation and

discharge on supplemental oxygen or tracheostomy with mechanical ventilation
can be elicited from the parents. Coarse breath sounds, crackles, and wheezing
may be heard on auscultation. Often decreased airflow into the chest can occur
during episodes termed “BPD spells.” Spells can be triggered by the slightest
agitation such as stooling or secretions, particularly when the baby is sick. Pulse
oximetry reveals desaturations and hypoxemia, often requiring an increase in
FiO2 above baseline. Asking the parents about the baby’s baseline requirements
under normal conditions will help determine if the baby is currently requiring
more oxygen supplementation. Arterial blood gas may show chronic respiratory
insufficiency (chronic CO2 retention) with hypoxia if the baby is desaturating.
Chest x-ray of a neonate with severe BPD may show extensive scarring and
fibrosis of the lung ( Fig. 96.37 ). Care must be taken to compare the current film
with the previous films to determine if any new lesions have developed. It can be
very challenging for a clinician or radiologist to make that decision without
looking at older films. Neonates normally have a large thymic shadow on CXR.
Care should be taken not to mistake this with infiltrates. An echocardiogram will
help determine the extent of pulmonary hypertension. Management is targeted at
stabilizing the infant’s cardiorespiratory status, giving oxygen supplementation
and escalating respiratory support as needed. Bronchodilators (albuterol,
ipratropium) may relieve reactive airway component in BPD. Occasionally
steroids may be helpful. BPD patients are extremely sensitive to fluid overload.
Be cautious when giving intravenous boluses in this population. Clinicians should
also check and correct any underlying anemia to maximize oxygen delivery. Any


infant with BPD with acute exacerbation should be admitted to an intensive care
unit for continuous monitoring.

FIGURE 96.36 Bronchopulmonary dysplasia. Typical bubbly appearance with bubbles of
various sizes is seen in advanced bronchopulmonary dysplasia. A clip is also apparent on the

film where the patent ductus arteriosus (PDA) has been ligated. (Reprinted with permission
from Brant WE, Helms CA. Brant and Helms Solution . Philadelphia, PA: Lippincott Williams
& Wilkins; 2006.)