儿科学-培训课件PPT
儿科学-培训课件PPT,儿科学,培训,课件,PPT
Neonatal Respiratory Distress Syndrome新生儿呼吸窘迫综合征新生儿呼吸窘迫综合征Dr.SUN YI 孙轶孙轶E-mail:Department of NeonatologyThe 2nd Affiliated Hospital of Guangzhou Medical UCompany LogovAlso known as hyaline membrane diseaseOverviewHMD肺透明膜病肺透明膜病Company LogoOverviewvMost common disorder in preterm infantsvSurvival90%vSequelae:chronic lung disease 慢性肺疾病慢性肺疾病 vProgressively respiratory distress after Company LogoOverviewIncidencevTerm 2%v36 weeks 5%v32 weeks 25%v28 weeks 70%v26 weeks 90%Incidence and severity increase with decreasing gestation Company LogoRDSProphylaxisEtiologyPathophysiologyClinical PresentationsManagementDCompany LogoEtiologyvStructually immature lungDecreased number and size of alveoli 肺泡Weak chest wall musclesvPulmonary surfactant(PS)deficiency 肺表面活性物质缺乏肺表面活性物质缺乏vConfirmed by Avery&Mead in 1959 Company LogoEtiologyMature lungImmature Company Logo What is PS?vA complex mixture of phospholipids磷脂磷脂 and proteins vSynthesized and secreted by alveolar type cells 肺泡肺泡型细胞型细胞vBegin to produce from 20-24 weeks gestation and increase rapidly till 35 Company LogoRoles of PSvDecreases surface tension 表面张力表面张力at air-liquid interfacevKeeps lung alveoli open vStablize functional residual capacity(FRC,功能残气量,功能残气量)vMaintain normal oxygenation 氧合氧合 and ventilation 通气通气Company LogoRoles of PSvSurface tension 表面张力表面张力Company LogoRoles of PSSurfactant spreads out over surface of alveolus with weaker bondingINFLATION吸气吸气InhalationSurfactant compressed over surface of alveolus with stronger bonding and reduces increasingsurface tensionEXPIRATIONExhalation呼气呼气(Laplaces law)Company LPathophysiologyDiminishedsurfactantSupressed surfactant synthesis/activityImpaired cellular metabolismDeteriorated blood gas Defected gas diffusion气体弥散障碍气体弥散障碍 pCO2,pO2,pH Ventilation-perfusion mismatching 通气血流比例失调通气血流比例失调 Generalized atelectasis 广泛性肺不张广泛性肺不张Proteinaceous debris leakageHyaline membrane formation肺透明膜形成肺透明膜形成Prematurity Surfactant deficiencyVicious Company LogoRisk FactorsvPrematurity 早产早产vInfants of diabetic mothers 糖尿病母亲婴儿糖尿病母亲婴儿 vCesarean delivery without labor 无宫缩剖腹产无宫缩剖腹产 vPerinatal asphyxia 围产期窒息围产期窒息 vMultiple birth 多胎妊娠多胎妊娠vMale男性男性Company LogoClinical PresentationsvTachypnea气促气促vGrunting呻吟呻吟vNasal flaring鼻搧鼻搧vChest retraction 三凹征三凹征vCyanosis紫绀紫绀vDecreased breath sounds bilaterally 双肺呼吸音减低双肺呼吸音减低Progressively respiratory distress over the first few hours after birth生后数小时(生后数小时(6h)内出现呼吸困难,并进行性加重)内出现呼吸困难,并进行性加重Company LogoClinical PresentationsChest X-rayvDiffuse reticular granular pattern in both lung fields 弥漫性网状颗粒影弥漫性网状颗粒影vGround glass 毛玻璃样改变毛玻璃样改变Company LogoClinical PresentationsChest X-rayvAir bronchograms 支气管充气征支气管充气征vSmall lung Volumes肺容量减少肺容量减少vUnclear cardiac border心界模糊心界模糊vWhite lung白肺白肺Company LogoComplicationsvPatent ductus arteriosus,PDA 动脉导管未闭动脉导管未闭vPulmonary air leak 肺气漏肺气漏 Pneumothorax 气胸气胸vBronchopulmonary Dysplasia 支气管肺发育不良支气管肺发育不良 Chronic lung disease 慢性肺疾病慢性肺疾病vRetinopathy of prematurity,ROP 早产儿视网膜病早产儿视网膜病vVentilator associated pneumonia 呼吸机相关性肺炎呼吸机相关性肺炎 Company LogoComplicationsvPDA 动脉导管未闭动脉导管未闭Left to right shunt 左向右分流Increased FiO2,apnea 呼吸暂停,metabolic acidosis,feeding difficultyPulse pressure 脉压差增大Bounding pulse 水冲脉Murmur 心脏杂音Heart rateCardiomegaly 心脏扩大Company LogoDifferential DiagnosisvGroup B streptococcal pneumonia B B族族溶血性链球菌感染溶血性链球菌感染Similar chest X-ray/Maternal infection/preterm rupture of the membrane胎膜早破vWet lung 湿肺湿肺Term/transient tachypnea/CXR/improve in 1-2d vDiaphragmatic hernia 膈疝膈疝 Company LogoLaboratory testsvFoam testNo foam-RDSvAssessment of fetal lung maturity 胎肺成熟度判定胎肺成熟度判定Lecithin-sphingomyelin(L/S)ratio 卵磷脂卵磷脂/鞘磷脂比值鞘磷脂比值 L/S2 mature L/S 1.5-2 questionable L/S1.5 immaturevBlood Gas 血气分析血气分析Acidosis/hypoxia/Company LogoComplicationsvCXR of Diaphragmatic hernia 左侧胸腔内可见充气的胃泡和肠管影,纵隔向左侧胸腔内可见充气的胃泡和肠管影,纵隔向对侧移位对侧移位Company LogoDiagnosisvCase studyBaby C,boy,G2P2,GA 32W,C-section delivery due to antenatal bleedingBW 1.8Kg,Bloody amniotic fluid血性羊水,Apgar score 81,85Grunting and retracting at 10 minutes after Company LogoDiagnosisvCase studyCyanosis was noticed,oxygen was given,transfer to NICUBlood gas at 30 minutes after birth:PH 7.20 PCO2 65mmHg PO2 48mmHg BE-6mmol/L HCO3-18mmol/LMixed respiratory&metablic Company LogoDiagnosisvChest X-rayImpression?Dont forget to rule out infection!Company LogoDiagnosisvHistoryPrematurityInfant of diabetic mathervProgressive respiratory distress over the first few hours after birthvChest X-ray Diffuse reticular granular patternGround glassAir bronchogramsWhite lung Company LogoManagementvGeneral treatment:Keep warmFluid&nutritionCardiac supportAntibioticsvRespiratory Company LogoManagementvRespiratory supportOxygenNasal CPAP(Continuous Positive Airway Pressure 持续气道正压通气)Mechanical ventilation 机械通气Surfactant replacement therapy 替代治疗Natural SCompany LogoNasal CPAPPressure:4-6cmH2OCompany LogoNasal CPAPCompany LogoMechanical VentilationIndications:PaO260mmHg PHCompany LogoSurfactant Replacement TCompany LogoSurfactant Replacement Therapyv100-200mg/kg given through endotracheal tube 气管导管气管导管vMay repeat 1-2 doses every 6-12 hours according to the patient statusvGive as early as Company Logo5 s10 s15 s25 s20 s30 s40 s50 sSurfactant instillation:1 Company Logo2 min4 min6 min8 min12 min16 min20 min24 min8 minSurfactant instillation:2-24 Company Logo35Before PSBefore PS After PSAfter PS Chest X-Company Logo Meta-analysis:Surfactant Tx Death or severe disability at 1-2 years of age Surfactant Control OR 95%CI 1100/3521 1260/3513 0.8 0.7-0.9 Sinn JKH,et al.J Paediatr Child Health 2002;38:Company LogoTreatment for PDAvClose the ductIndomethacin消炎痛 0.2mg/kg iv q12h3Ibuprofen布洛芬 10mg/kg,then 5mg/kg at 24&48hvFluid limitationvDiureticsvSurgery ligation 外科结扎外科结扎Company LogoProphylaxisvAntenatal steroids 34wBetamethasone 12mg im q24h2Dexmethasone 6mg im q12h4vRegular prenatal carevPrevent preterm laborvPostnatal surfactant Company LogoSummaryvRDS is common in preterm infantsvDue to surfactant deficiency and lung immaturityvProgressively respiratory distress after birthvCharacteristically chest X-ray appearancesvSurfactant replacement therapy has specific Company LogoQuestionsvWhat is the roles for surfactant?vWhat are the clinical characteristics for neonatal RDS?vHow do you treat a baby with RDS?Company LogoReferencesvTextbook of Pediatrics,Chen Shubao,2006,Science Press.v儿科学儿科学,沈晓明,沈晓明 王卫平主编,第王卫平主编,第7版,人版,人民卫生出版社民卫生出版社.vAverys Diseases the Newborn,Edited by CA.Gleason&SU.Devaskar,2012.vThe Newborn LungNeonatology Questions and Controversies,Edited by Eduardo Bencalari,2009.E-mail:Company Logo
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