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Case 121

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A male newborn delivered by cesarean section at 33 weeks of gestation (due to insulin-dependent maternal diabetes and abnormalities of fetal vitality) presents with respiratory discomfort at birth (Silverman-Andersen score 4/10). He is treated with early nasal CPAP and transferred to the neonatal intensive care unit. At 3 hours of life, he is intubated and connected to mechanical ventilation due to deterioration of his respiratory status (S-A score 8/10) and a chest radiography is requested (image 1). Clinical improvement is noted after surfactant administration and another chest radiograph is taken (image 2). At 8 hours of life, he presents with central cyanosis, lack of pulses and bradycardia; cardiopulmonary resuscitation is performed, along with thoracocenthesis and chest radiography (image 3).

Based on the clinical history and images presented, the most likely diagnosis and the resulting complication are, respectively:

a) Respiratory distress syndrome and tension pneumothorax

25%

b) Early-onset neonatal sepsis and pneumothorax

25%

c) Meconium aspiration syndrome and pneumothorax

25%

d) Transient tachypnea of the newborn and tension pneumothorax

25%
   

Comments

- The respiratory distress syndrome (also called hyaline membrane syndrome) is a pulmonary disease which is common among preterm newborns and results from insufficient surfactant production.

- Risk factors include: prematurity, maternal diabetes, pregnancy-induced hypertension, intrauterine growth restriction, multiple birth and perinatal asphyxia.

- Diagnosis is based on the clinical history, risk factors, signs of early respiratory failure and presence of a reticulogranular infiltrate (ground glass) on chest radiography.

- Treatment includes CPAP, mechanical ventilation if necessary and exogenous surfactant.

- Positive-pressure ventilation (CPAP or mechanical ventilation) can result in barotrauma, leading to tension pneumothorax.

- Tension pneumothorax causes obstructive shock and is a medical emergency.

References

- Andrade Filho LO, Campos JRM, Haddad. Capítulo 8: Pneumotórax. J Bras Pneumol 32 - Supl 4: S212-S216; 2006.

- Colégio Americano de Cirurgiões, Comitê de Trauma. ATLS - Suporte Avançado de Vida no Trauma para Médicos, 8ª edição. Capítulo 4: Trauma Torácico; 2008.

- Hyzy RC. Pulmonary barotrauma during mechanical ventilation. UpToDate, 2013. Available at: http://www.uptodate.com/contents/pulmonary-barotrauma-during-mechanical-ventilation.

- Ministério da Saúde. Atenção à saúde do recém-nascido: guia para os profissionais de saúde. Brasília: Ministério da Saúde; 2011.

- Rego MAS, Anchieta LM. Assistência Hospitalar ao Neonato. 1a Edição. Secretaria de Estado de Saúde de Minas Gerais. Belo Horizonte; 2005.

- Saker F, Martin R. Pathophysiology and clinical manifestations of respiratory distress syndrome in the newborn. UpToDate, 2013. Available at: http://www.uptodate.com/contents/pathophysiology-and-clinical-manifestations-of-respiratory-distress-syndrome-in-the-newborn

Author

Fernanda de Souza Foureaux, 6th year medical student of UFMG School of Medicine

Email: fernandasfx[at]hotmail.com

Supervisor

Dra. Lêni Márcia Anchieta, member of the Department of Pediatrics (UFMG School of Medicine).

Email: lenima[at]terra.com.br

Reviewers

Glauber Coutinho, Luanna Monteiro and professor Viviane Parisotto

Translated by

Lucas Resende Lucinda, 6th year medical student of UFMG School of Medicine.
E-mail: lucasresendebh[at]hotmail.com

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