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1、新生儿呼吸困难陈 超复旦大学儿科医院新生儿科 一位31岁孕妇，G2P1，怀孕已29周，孕期检查正常，今天上午感觉开始宫缩，住院检查，宫口开3cm，约每20分钟一次宫缩，已破膜， 并有低热， 37.9OC。产科医师请新生儿科医师会诊，这位孕妇可能要早产，怎么处理？各位医师有什么建议？ Actions: Attempt to delay delivery Tocolysis at discretion of obstetrician Ensure culture and therapy for possible chorioamnionitis Antenatal corticosteroids
2、The single most important neonatal intervention Ensure that adequate neonatal resuscitation is available Cooperation between pediatricians and obstetricians is essential!A single dose of antenatal corticosteroids is administered, along with antibiotic therapy and indomethacin tocolysis. However, lab
3、our continues to progress, the mother delivers a male infant weighing 1100 grams.A neonatal resuscitation team is present at the delivery. Heart rate at delivery was 80 per minute and the infant initially is apneic. What actions should the neonatal team take? Actions: Suction, drying, stimulation. I
4、f apneic, bag mask ventilation If no response, intubation (3.0 ETT) Administer oxygen If persistently bradycardic despite adequate ventilation cardiac compressions If no response, epinephrine per ETT Immediate, skilled resuscitation is essential to optimize outcomes.The infant begins to breath regul
5、arly in response to stimulation, the heart rate is now 156.but he is persistently mildly cyanotic, with mild intercostal chest retractions and mild grunting respirations.What actions should the neonatal team take now?What are the likely diagnoses? Differential Diagnosis: NRDS Neonatal sepsis with pn
6、eumonia Pneumothorax secondary to resuscitation Retained fetal lung fluid / transitional respirations Actions: Begin monitoring of oxygen saturations Maintain oxygen saturations 88 92% Keep NPO and place intravenous line Draw blood culture and begin antibiotic therapy Assess blood pressure, blood su
7、gar etc Observe for 1 2 hours as long as symptoms remain mild and oxygen 60 FiO2 in preterm infant 60% Diagnosis of moderate RDS with availability of surfactant Place umbilical arterial lineThe infant is intubated uneventfully with a 3.0 ETT. He is receiving bag mask ventilation in 100% O2 and has s
8、aturations of 99%.Several mechanical ventilators are available, including models with intermittent mandatory ventilation, patient triggered ventilation, and high frequency oscillatory ventilation.What ventilatory settings and parameters will you prescribe?Which ventilator will you select?Actions: Be
9、gin with intermittent mandatory ventilation Evidence inadequate for elective high frequency oscillation and there is a risk of intraventricular hemorrhage or PVL Patient triggered modes are an option, but not necessary for the current clinical situation IMV settings: PIP to move chest (usually 15 25
10、 cm H2O) PEEP 4 to 6 cm H2O (never less in RDS!) Rate 40 to 60 breaths per minute Ti (inspiratory time) 0.4 to 0.5 seconds Oxygen to maintain SaO2 88 92 %The infant is placed on IMV, PIP 28 (to achieve adequate chest excursion), PEEP 5, Rate 60, Ti 0.4. Saturations are 88% on 0.70 FiO2. The initial
11、pressure-volume curve is shown in the slide.What is your next step?VolumePressureVolumePressureActions: Exogenous surfactant (early rescue)O2 requirement 40% with radiological evidence surfactant deficiencyOr, gestational age 29 weeks and respiratory distressUse Survanta 4 ml/kg or Exosurf 5 ml/kgFo
12、llowing surfactant administration, the infant initially improves clinically. Six hours later, IMV settings are PIP 26, PEEP 5, Rate 60, Ti 0.4, FiO2 35%. There is excellent chest movement and breath sounds are equal on auscultation, with scattered coarse crackles.The pressure-volume loop is shown on
13、 the next slide, and a repeat blood gas shows the following:Do you want to make any changes, or continue with the current plan?Arterial blood gas in 0.30:pH 7.58PaCO226 mm HgPaO275 mm HgHCO322 mmol Assessment: Hyperventilation/overdistention Excessive chest movement, hypocarbia Risk of acute or chro
14、nic lung injury Actions: Reduce PIP until chest rises gently but not excessively Follow changes on P-V curve Reduce rate by 10 then by increments of 5 to maintain PaCO2 45 to 55 cm H2O Repeat blood gas4 hours later, IMV settings are PIP 19, PEEP 4, Rate 35, Ti 0.4, FiO2 55%. The infant has gradually
15、 become very active. and breathing irregularly over and through the ventilator breaths.The flow volume and pressure volume loops are shown on the next slide.Do you want to make any changes? Assessment: New diagnosis Pneumothorax, abdominal pathology, intracranial pathology, pain Fighting the ventila
16、tor Actions: Exclude other pathology with physical examination Consider patient-triggered ventilation mode like synchronized IMV or Assist-control. Sedation only if no plan to extubate and above measures are ineffective.The infant is placed on SIMV mode with pressure support of 12 cm H20, with otherwise similar settin
