PEDIATRIC RESPIRATORY DISORDERS

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"><U><B>Febrile Seizures </B></U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="dvlp bis"><U><B>dvlp bis</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="DEVELOPMENTAL NEUROLOGIC DISEASES"><U><B>DEVELOPMENTAL NEUROLOGIC DISEASES</B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="GENETIC DISEASES "><U><B>GENETIC DISEASES </B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="angelman syndrome"><U><B>angelman syndrome</B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="TAYSACHS DISEASE"><U><B>TAY-SACHS DISEASE</B></U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="krabbes disease"><U><B>krabbe's disease</B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="Refsums Disease"><U><B>Refsum's Disease</B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="meningitis"><U><B>meningitis</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> </td> <td valign="top" height=355 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> PEDIATRIC RESPIRATORY DISORDERS</div> <bR> <div> see also my usmle 2 med 6 for acute epiglotitis</div> <bR> <bR> <div> Aspiration<FONT SIZE="5" COLOR="#808080" FACE="times new roman" > </FONT></div> <div> <B>Definition</B>: the inhalation of fluid (gastric contents, amniotic fluids or liquids) or solid objects into the tracheobronchial system. Mostly right mainstem because of the straight pathway. </div> <div> <B>Etiology</B> </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="669" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Impaired gag reflex or swallowing, tubes in the epiglottis, communication between esophagus and trachea tracheoesophageal fistula </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP><NOBR><div> High risk: young children who can<FONT SIZE="3" COLOR="#000000" FACE="WP TypographicSymbols" >=</FONT>t adequately chew and unconscious patients </div> </NOBR></tD> </tR> </TABLE></div> <div> <B>Pathology</B> </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="669" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Normally the epiglottis protects the trachea from foreign objects. Depending on the content aspirated, there may be only trauma, irritation or inflammation. </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Chemicals can erode and destroy the trachea or lung tissue. </div> </tD> </tR> </TABLE></div> <div> <B>Manifestations</B> </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="669" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Wheezing, coughing, retractions, stridor </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Hypoxemia/Hypoxia </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Respiratory distress; Respiratory arrest </div> </tD> </tR> </TABLE></div> <div> <B>Management</B> </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="669" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Infants: Prevention is best management </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Suction baby<FONT SIZE="3" COLOR="#000000" FACE="WP TypographicSymbols" >=</FONT>s airway when the head is delivered </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Control use of baby powder </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Avoid overfeeding </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Cut toddlers food in small pieces </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="622"><div> Avoid toys with small pieces </div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 56 WIDTH="40"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="56" ALIGN="bottom" WIDTH="40" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP><NOBR><div> Remove object by suction bronchoscopy, or obstructed airway maneuver (Heimlich) </div> <bR> <bR> </NOBR></tD> </tR> </TABLE></div> <div> Sudden Infant Death Syndrome (SIDS)<FONT SIZE="5" COLOR="#808080" FACE="times new roman" > </FONT></div> <div> This is the<B> </B>greatest cause of death between 1 week and 1 year.</div> <div> 7000 thousand infants die yearly. However this has decreased since parents are now encouraged to lay their infant on his/her back.</div> <div> <B>Etiology</B>: Exact cause is unknown. Sudden death theories.</div> <div> 1. Brain stem abnormality preventing effective cardiorespiratory control.</div> <div> 2. Abnormal T lymphocyte mediated inflammatory response in the lungs which causes edema, obstruction and hypoxia.</div> <div> <B>Risk factors:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mothers under 20 years with poor economic status </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Low birth weight babies </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prematurity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Multiple birth babies </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Siblings of children who have died from SIDS </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prenatal influences </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Smoking </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lack of prenatal care </div> <div> <B>Treatment:</B></div> <div> No treatment since this is sudden death.</div> <div> Home monitoring of high risk infants for respiratory and cardiovascular functioning has been successful for prevention of the near misses.</div> <bR> <bR> <bR> <div> Respiratory Distress Syndrome (Hyaline Membrane Disease)</div> <div> <B>Incidence:</B></div> <div> Usually a complication of prematurity.</div> <div> <B>Etiology:</B></div> <div> 1. Decreased surfactant production</div> <div> 2. Immature lung tissue</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At 24 weeks gestation there are very small amounts of surfactant and few developed terminal air sacs, plus under-developed vascularity causes little chance for survival. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At 26-28 weeks, there is usually sufficient surfactant and lung development to permit survival. </div> <div> <B>Pathophysiology:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Alveoli unable to expand due to decreased surfactant (this reduces surface tension and allows the alveoli to expand). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Unable to exchange oxygen and carbon dioxide (<I>atelectasis</I>) which leads to <I>respiratory acidosis</I>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Decreased pulmonary blood flow (may be due to ductus arrteriosus remaining open and decreased vascular development). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4. Alveoli are small and have a difficult time expanding. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5. Can develop <I>metabolic acidosis</I> related to increased lactic acid and anaerobic metabolism. </div> <div> <B>Manifestations:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased respirations, intercostal retractions, labored breathing -- expiratory grunting, nasal flaring </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Decreased pH, increased pCO2, deceased pO2 (resp. acidosis) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chest X-ray shows atelectasis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Central cyanosis </div> <div> <B>Management:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dexamethasone to mothers in premature labor and having an imminent delivery (helps to mature lungs) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Artificial surfactant to infant (via endotracheal tube) after delivery </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Positive pressure ventilation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Correct the acid/base balance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Provide calories </div> <bR> <bR> <div> Bronchopulmonary Dysplasia</div> <div> <B>Incidence:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most common in newborn infants who remain O2 dependent for more than 28 days; severity and mortality rate of BPD decreased since advent of artificial surfactant for RDS. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Associated with chronic lung disease in infants and children. </div> <div> <B>Etiology:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Premature birth, RDS, prolonged mechanical ventilation, O2 toxicity. </div> <div> <B>Pathology:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mechanical ventilation with oxygen acts as an irritant to lung tissue. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endotracheal tube causes irritation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Scarring and stiffening of the lung tissue. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alveoli fail to multiply. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic inflammation results in increased mucus and plugging of the alveoli and shunt unit. </div> <div> <B>Manifestations:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tachycardia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Retractions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Barrel chest </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Shallow breathing </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypoxemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Compensated respiratory acidosis (decreased pH, increased CO2) </div> <div> <B>Management:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mechanical ventilation, oxygenation (with gradual weaning of both). Infant may go home on the ventilator. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adequate nutrition and calories. </div> <div> <B>Prognosis:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rapid lung development occurs during the first year of life and lung function usually improves. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These children usually have some degree of respiratory dysfunction as they age as a result of BPD (increased respiratory infections, asthma). </div> <bR> <bR> <div> UPPER RESPIRATORY INFECTIONS</div> <div> Croup</div> <div> Syndrome of clinical manifestations in the upper airway resulting in narrowing of the airway.</div> <div> <B>Incidence:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Viral origin: 85% of cases (3 months to 5 years usually). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bacterial origin: rare (usually in children 3-7 years). </div> <div> <B>Pathophysiology:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inflammation of trachea, epiglottis, larynx, or pharynx causes narrowing of airway. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stridor caused by turbulent airflow over inflamed vocal cords on inspiration. (Wheezing is from obstructed lower airways on expiration) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Spasms. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased mucous production. </div> <div> <B>Manifestations:</B></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="998" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#000066 > <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="60"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="60" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="179"><div> <B>Acute</B><B> Laryngotracheobronchitis</B></div> </tD> <tD VALIGN=CENTER WIDTH="292"><div> <B>Epiglotitis</B></div> </tD> <tD VALIGN=CENTER WIDTH="266"><div> <B>Spasmodic Croup</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>Bronchiolitis - RSV</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="60"><div> <B>Agent</B></div> </tD> <tD VALIGN=CENTER WIDTH="179"><div> Virus</div> </tD> <tD VALIGN=CENTER><NOBR><div> Hemophilus Influenza Bacteria</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="266"><div> Virus</div> </tD> <tD VALIGN=CENTER WIDTH="171"><div> Respiratory Syncytial Virus</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="60"><div> <B>Age</B></div> </tD> <tD VALIGN=CENTER><NOBR><div> 6 months to 3 years</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="292"><div> 2-7 years</div> </tD> <tD VALIGN=CENTER WIDTH="266"><div> 3 months to 5 years</div> </tD> <tD VALIGN=CENTER WIDTH="171"><div> Less than 2 years</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 112 WIDTH="60"><div> <B>S/S</B></div> </tD> <tD VALIGN=CENTER WIDTH="179"><div> Croupy cough,</div> <div>  stridor, </div> <div> low grade fever, </div> <div> pale retractions,</div> <div>  worse at night</div> </tD> <tD VALIGN=CENTER WIDTH="292"><div> Respiratory distress, </div> <div> stridor, agitation,</div> <div>  retractions,</div> <div>  drooling, </div> <div> m<FONT SIZE="3" COLOR="#FFFF00" FACE="Arial" >uffled voice,</FONT></div> <div>  a f<FONT SIZE="3" COLOR="#FFFF00" FACE="arial" >rog-sitting position</FONT></div> </tD> <tD VALIGN=CENTER WIDTH="266"><div> Stridor,</div> <div>  wet barky cough,</div> <div>  usually at night, </div> <div> relieved by cold moist air</div> </tD> <tD VALIGN=CENTER WIDTH="171"><div> Breathlessness, </div> <div> rapid shallow breaths, cough, </div> <div> wheezing retractions</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="60"><div> <B>Onset</B></div> </tD> <tD VALIGN=CENTER WIDTH="179"><div> Gradual</div> </tD> <tD VALIGN=CENTER WIDTH="292"><div> Sudden (life threat)</div> </tD> <tD VALIGN=CENTER WIDTH="266"><div> Sudden at night</div> </tD> <tD VALIGN=CENTER WIDTH="171"><div> Gradual</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 ><NOBR><div> <B>Managed</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="179"><div> Hydration, humidity, oxygen</div> </tD> <tD VALIGN=CENTER WIDTH="292"><div> Hospitalized, intubation or tracheotomy, antibiotics</div> </tD> <tD VALIGN=CENTER><NOBR><div> Mist tent, vaporizer, oxygen</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="171"><div> Supportive, oxygen, hydration</div> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> CYSTIC FIBROSIS</div> <div> An autosomal recessive (chromosome 7) exocrine gland disorder resulting in excessive, thick mucous production which results in obstruction of the respiratory and pancreatic ducts.</div> <div> <B>Incidence:</B></div> <div> Affects about 1 out of 2,500 white children -- most common chronic lung disease in children; 2-5% of whites are carriers. Rare in African Blacks and Asians.</div> <div> <B>Pathology:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Production and stasis of thick tenacious mucous. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pancreatic exocrine deficiency of trypsin, amylase and lipase. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic respiratory disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elevated sweat sodium chloride due to ineffective chloride out of the cell and high reabsorption of sodium into the cells. </div> <div> <B>Respiratory system:</B></div> <div> Accumulations of thick mucous in bronchi results in obstruction, inflammatory response, air trapping and atelectasis.</div> <div> <B>Respiratory manifestations:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Recurrent infections, chronic rhinitis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rales, rhonchi </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clubbing of fingers </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypoxia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cyanosis </div> <div> <B>Secondary respiratory manifestations:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Barrel chest </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Kyphosis </div> <div> <B>Management for respiratory problems:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antibiotics </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Steroids </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bronchodilators </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mucolytic agents </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chest percussion </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lung transplants </div> <div> <B>GI Manifestations:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pancreatic deficiency in 80-90% of the cases </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Newborn infants with a meconium ileus are at high risk </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malabsorption problems </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Failure to thrive </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gall bladder problems </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Steatorrhea </div> <div> <B>Management for GI problems:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pancreatic enzyme replacement </div> <div> <B>Diagnosis:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sweat chloride elevated sweat test </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infants with a meconium ileus </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood testing in newborns for elevated immunoreactive trypsin </div> <bR> <bR> <div> <B><U>RESPIRATORY DISTRESS</U></B><B><U> </U></B></div> <bR> <bR> <div>  <A NAME="1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Predisposing Factors:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preterm delivery (especially if born by Caesarean section or if mother is diabetic) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Underweight for gestational age or wasting (especially if covered in meconium) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fetal distress or asphyxia at birth </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complicated labour e.g. prolonged rupture of membranes or vacuum extraction </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">clinical chorioamnionitis in the mother </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="16" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Cardinal Signs:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tachypnoea (> 60 per minute) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">recession </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">central cyanosis (tongue) in room air </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">expiratory grunting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="16" ALIGN="bottom" HSPACE="0" VSPACE="0">Respiratory distress is diagnosed if 2 or more cardinal signs are present. </div> <div>  <A NAME="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> <B>Causes:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="4"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Respiratory</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hyaline membrane disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">wet lung syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">meconium aspiration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pneumonia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pneumothorax </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diaphragmatic hernia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="5"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Metabolic</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hypothermia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acidosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="6"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Rarer causes</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">patent ductus arteriosus </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">congenital heart disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lung hypoplasia </div> <bR> <bR> <div> A chest x-ray and examination of the gastric aspirate for lung maturity (shake test), pus cells and bacteria will aid in the diagnosis. </div> <bR> <bR> <div>  <A NAME="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Shake Test</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Place 0.5 ml gastric aspirate in a clean, dry test tube. Add 0.5 ml normal saline and replace cap.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Shake well for 15 seconds. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Add 1 ml 95% alcohol to the 1 ml mixture of gastric aspirate and saline. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Again replace cap, shake well for 15 seconds and read at 15 minutes.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> If no bubbles are present the test is negative. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If an incomplete ring of bubbles is seen the test is intermediate. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A complete ring of bubbles with or without extension of bubbles over the surface indicates a positive test. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infants with a positive test are very unlikely to develop hyaline membrane disease. </div> <bR> <bR> <bR> <div>  <A NAME="8"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>HYALINE MEMBRANE DISEASE (HMD):</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is the most important cause of neonatal respiratory distress (RD).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is virtually confined to preterm infants in whom it is the major cause of death. It is due to a deficiency of surfactant in the infant's lungs.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Sufactant lowers the surface tension in the alveoli in mature infants and allows respiration with minimal physical effort. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lack of adequate amounts of surfactant leads to progressive alveolar collapse. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Synthesis of surfactant is inhibited by hypoxia, acidosis and cold. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thus the more asphyxiated or shocked the infant, the more severe the hyaline membrane disease is likely to be. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With preterm infants every effort must be made to avoid these factors. </div> <bR> <div>  <A NAME="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Clinical Signs:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The features of respiratory distress (tachypnoea, recession, grunting, cyanosis) are usually apparent within hours of birth.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> On auscultation the air entry is reduced and there may be crepitations.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The baby is inactive and tends to lie in the frog position. Moderate generalized oedema is usually present.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The chest X-ray typically shows an under-expanded chest with a fine reticulo-granular appearance over both lung fields, "air-bronchograms" extend beyond the borders of the heart and thymus and the outline to the cardiothymic shadow is indistinct. </div> <bR> <div>  <A NAME="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Management:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preterm delivery should be prevented if possible. Antenatal steroids should be given to all women at high risk of preterm delivery to accelerate fetal lung maturity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Whenever possible, delivery should be delayed for 48 hours while two doses of betamethasone 12 mg are given intramuscularly 24 hours apart. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The use of antenatal steroids does not always prevent hyaline membrane disease but decreases the severity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The basic aim of treatment in the newborn infant is to maintain oxygenation of the blood at a safe level, keep body temperature and biochemical status within normal limits and provide adequate nutrition.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The sick infant should be handled as little as possible while regular and frequent observations (skin temperature, colour, heart rate, and respiration) are recorded. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most infants starts to replenish lung surfactant and recover after 72 hours</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Usually the respiratory distress has resolved by a week. Infants with hyaline membrane disease should be transferred as soon as possible to an intensive care unit. </div> <bR> <div>  <A NAME="11"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Relief of hypoxia</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> is the most important aspect of treatment. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adequate oxygenation may be achieved by increasing the concentration of oxygen in the inspired air using a perspex head-box.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Too much oxygen is as dangerous as too little and can damage the eyes (retinopathy of prematurity) and lungs. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thus when administering oxygen one must have adequate facilities for measuring the inspired oxygen concentration (FiO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>) and the arterial oxygen tension (PaO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>) or transcutaneous oxygen saturation (Sa O<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood samples are obtained by radial artery puncture or from an indwelling umbilical artery catheter. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The aim is to maintain PaO<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT> between 7 and 10 k Pa (50-80 mmHg).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The Sa O<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT> must be kept between 85 and 90%. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe cases of HMD may require other means of achieving sufficient oxygenation such as continuous positive airway pressure (CPAP) via nasal prongs or intermittent positive pressure ventilation (IPPV) via an endotracheal tube. </div> <bR> <bR> <div>  <A NAME="12"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Correction of acidosis:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Respiratory acidosis due to a high PaCO2 can be corrected by improving ventilation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Metabolic acidosis will improve with adequate oxygenation but may need correction with 4% sodium bicarbonate given intravenously very slowly according to the formula: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mmol bicarbonate = base deficit x wt in kg x 0.6 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="16" ALIGN="bottom" HSPACE="0" VSPACE="0">It is wise to give only half the calculated amount initially and then to reassess the situation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="16" ALIGN="bottom" HSPACE="0" VSPACE="0">Do not use 8% sodium bicarbonate. It has a very high osmolality. </div> <div>  <A NAME="13"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Temperature control:</B> </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prevent hypothermia by nursing baby under a radiant heat source or in an incubator with the temperature controlled (between 31°C and 34°C) to maintain the neutral thermal environment. </div> <bR> <bR> <div>  <A NAME="14"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Nutrition:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fluid, electrolyte and energy requirements should be supplied by intravenous infusion at first. Milk feeds by nasogastric tube should be started as soon as possible provided the infant does not vomit. </div> <bR> <bR> <div>  <A NAME="15"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Additional treatment</B> may include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">blood transfusion for anaemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">phototherapy for jaundice </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">antibiotics for infection </div> <bR> <div>  <A NAME="16"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Surfactant replacement therapy:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="16" ALIGN="bottom" HSPACE="0" VSPACE="0">Both natural and artificial surfactant can placed down an endotracheal tube to either prevent or treat hyaline membrane disease. As the price is extremely high it is usually only given to infants requiring intubation and ventilation. Hopefully early or prophylactic treatment will become affordable in future. Surfactant therapy is most effective if antenatal steroids have been given. </div> <bR> <bR> <div>  <A NAME="17"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Complications:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most important are: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Early </div> <bR> <div> pneumothorax </div> <div> periventricular haemorrhage </div> <div> heart failure due to a persistent patent ductus arteriosus </div> <div> pneumonia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Late </div> <bR> <div> chronic lung disease (bronchopulmonary dysplasia) </div> <div>  <A NAME="18"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> <B>WET LUNG SYNDROME</B> [see usmle med 6 on usmle 2 web page for details and graphic]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is the commonest cause if respiratory distress. It is a condition which may affect both preterm and term infants, particularly if delivered by caesarian section.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is attributed to delayed clearing of the fetal lung fluid into the vessels and lymphatics after birth. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The condition is not due to surfactant deficiency and the shake test is usually positive. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Within an hour or two of birth there are features of respiratory distress and the chest is hyperinflated. X-ray chest shows increased vascular markings with prominent hilar streaking.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Additional oxygen is required but usually does not exceed 40%.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Most infants improve within twelve to twenty four hours though tachypnoea may persist for several days.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is important to differentiate wet lung syndrome from hyaline membrane disease as the former do not require refereral to an intensive care unit. </div> <bR> <bR> <bR> <div>  <A NAME="19"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>MECONIUM ASPIRATION</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is due to the inhalation of meconium during or immediately after delivery. It usually follows on fetal distress during labour. It is limited to mature or wasted infants since preterm infants rarely pass meconium in utero. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The inhaled meconium produces areas of emphysema and atelectasis throughout the lungs. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is considerable risk of pneumothorax and pneumomediastinum. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A pneumonitis may be caused by chemical irritation or secondary bacterial infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Many infants with severe meconium aspiraton die or suffer severe lung damage. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At birth the meconium is present in the mouth and pharynx and may stain the skin, nails, cord and placenta.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Birth asphyxia is common and signs of severe respiratory distress are often noted after resuscitation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Air trapping causes over-distension of the chest and there are often wide-spread rhonchi and crepitations. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">On x-ray the lungs look over-expanded and contain multiple areas of atelectasis.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The heart size may be increased and pneumothorax or pneumomediastinum may be seen. </div> <bR> <bR> <div>  <A NAME="20"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Treatment:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prevention: eliminate fetal hypoxia at all times </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Suck meconium from mouth, pharynx as soon as the head is delivered and before breathing starts. Use a large, end hole catheter. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Manage in the same way as severe respiratory distress </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gastric lavage using 2% sodium bicarbonate solution </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antibiotic (Penicillin and Gentamicin) if secondary bacterial infection develops. Steroids are not indicated. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="16" ALIGN="bottom" HSPACE="0" VSPACE="0">Every effort must be made to prevent meconium aspiration by a strict policy of suctioning the upper airways before delivery of the head whenever the liquor is meconium stained. If the infant fails to breathe well after birth, direct suctioning down an endotracheal tube must be done before starting ventilation. </div> <bR> <bR> <div>  <A NAME="21"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>PNEUMONIA</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infection acquired before or during passage through the birth canal may cause pneumonia which is often difficult to distinguish clinically from other causes of respiratory distress<B>. E.coli and the group B haemolytic Streptococcus are responsible for the majority of infections.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The latter may cause a picture indistinguishable from that of <B>hyaline membrane disease. Staph aureus, Klebsiella, Pseudomonas, etc may also give rise to serious infection. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pneumonia on day 1 results from chorioamnionitis caused by an ascending spread of bacterial from the cervix with or without prolonged rupture of the membranes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The mother usually has no clinical signs of infection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The newborn with pneumonia may present with birth asphyxia, apnoeic spells or features of respiratory distress. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fine crackles may be heard. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The diagnosis is confirmed by chest x-ray. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The causative organism may be cultured from the trachea or blood. In congenital pneumonia due to chorioamnionitis the gastric aspirate at birth contains bacteria and pus cells on Gram stain. </div> <bR> <bR> <div>  <A NAME="22"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Treatment:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">general measures as for respiratory distress </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">specific therapy with appropriate antibiotics </div> <bR> <bR> <div>  <A NAME="23"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>PNEUMOTHORAX</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Common causes:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">meconium aspiration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vigorous resuscitation after birth </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hyaline membrane disease, especially if on positive pressure ventilation or CPAP </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A small pneumothorax may have few clinical signs. In more severe cases, especially those with tension pneumothorax, there is a rapid deterioration in condition. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The infant becomes increasingly dyspnoeic or apnoeic and is often pale or cyanosed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The affected side will tend to be hyper-resonant to percussion and breath sounds are diminished. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The affected side will also transilluminate with a bright light source. A chest x-ray will confirm the diagnosis. </div> <bR> <bR> <div>  <A NAME="24"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Treatment:</B> </div> <div> Mild degrees of pneumothorax may resolve spontaneously. In some cases the rate of resorption of the pneumothorax in term infants can be accelerated by letting the baby breathe a high oxygen concentration. More severe cases will need an under water chest drain. </div> <bR> <bR> <bR> <div>  <A NAME="25"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>DIAPHRAGMATIC HERNIA</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Herniation of abdominal viscera through the diaphragm (usually on the left side) usually presents at birth with severe respiratory distress, cyanosis and a shift of the mediastinum and interference with lung function. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The main diagnostic clues are maternal polyhydramnios, shift of the maximal heart sounds to the right and a scaphoid appearance of the abdomen. Bowel sounds may be heard in the chest.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Many cases are detected by routine antenatal ultrasonography. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">X-ray immediately confirms the diagnosis - the condition must be regarded as a surgical emergency for early surgery may be life-saving. </div> <bR> <bR> <div>  <A NAME="26"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>CHRONIC LUNG DISEASE(Bronchopulmonary dysplasia)</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preterm infants who require intubation and ventilation for respiratory distress may develop chronic lung disease (bronchopulmonary dysplasia). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They have respiratory distress and need additional oxygen for weeks to months. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some may also need prolonged ventilation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Chest X-ray shows hyperinflation, streaky fibrosis and a bubbly appearance</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Steroids may help wean these infants off a ventilator and hasten recovery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe cases die of respiratory failure or secondary pneumonia.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Antenatal steroids and possibly surfactant therapy reduces the risk of chronic lung disease</div> <bR> </td> </tr></table></body>