Dr Joepaul Joy, Dr Sajith Kesavan, Dr Greeshma, Dr C Jayakumar AIMS, Kochi
Seven months old Ex-preterm(29 wk + 5 days) old , male, 1st child of DCDA, was referred from outside hospital in view of frequent episodes of hypoxic arrest and prolonged ventilatory need for further evaluation and management. Antenatal history of mother having Dengue fever 2 weeks prior to delivery. Ba was delivered via LSCS, BW of 720gms, cried immediately after birth. Postnatally ba was shifted to NICU in view of LBW, Type2 RDS, Presumed sepsis, Neonatal hyperbilirubinemia for which phototherapy was given. Ba was requiring O2 nasal cannula till 4 weeks of age when his distress increased and was started on HFNC, but was unable to wean off O2. X-rays were suggestive of BPD. Started on Vitamin A and Diuretics. In view of persistant respiratory distress ECHO was done showed moderate PAH and started on sildenafil. NSG -normal,No ROP, Hearing B/L Refer. Ba was referred intubated with uncuffed ET tube from Hospital where ba was born. At admission child was in Type 1 and 2 Respiratory failure. Xray was showing a deeply fixed with Cuffed ET tube with collapse of the left lung which was repositioned and the ventilation was optimized. He was having severe wheeze which required nebulizations with Duolin. He was started on IV Piptaz after sending
relevant cultures. BAL culture on admission showed Pseudomonas which was sensitive. Rapid respiratory pathogen detection test was negative. Within 24 hours his blood gases were within normal limits and the Xray was showing good expansion. Once he passed the ERT bundle and SBT on D4 of ventilation was extubated to HFNC. As the child had feeble cry a flexible bronchoscopy was done which showed Left vocal cord palsy. His serial blood gases showed evidence of Chronic respiratory acidosis with persistantly raised CO2. Ba had recurrent wheezing episodes which were
managed with MgSO4 and bronchodilators which were gradually spaced out. There was difficulty in weaning off HFNC and hence DART regimen was initiated orally following which he showed significant improvement and was weaned off to Low flow oxygen via nasal cannula at 2 L/min.Child was already on Hydrochlorothiazide, Aldactone and Sildenafil in v/o PAH when he was transferred. NT propBNP was 8818 at admission. A bed side Echo showed ASD Left to right shunting, RV pressure – subsystemic septal position, Mild TR RVSP : 8+RAP (Incomplete jet) Normalbiventricular function Left arch, No coarctation. And the drug doses were optimized in consultation with the Pediatric Cardiologist. Ba had regurgitation of feeds and hence was continued on anti GER medications. As the ba had inadequate weight gain Stool examination was done which showed SOB positive which was noted the Pediatric Gastroenterologist and was adviced to repeat SOB after 2 weeks. Ba was continued on NG tubes as there is risk of aspiration in v/o the Left Vocal Cord palsy. Feeds were optimized and enriched with MCT oil, HMF and concentrated feeds (1.5 scoop in 35 ml as adviced the Pediatric Gastroenterologist. discharge weight is 2.74 Kg. Pediatric Surgery consultation obtained inview of the bilateral reducible inguinal hernia and was adviced to undergo Surgery once the child stabilizes.
Ba did not have any renal impairment during the hospital stay. Child required PRBC transfusions in v/o anaemia (12/2/24). No coagulation abnormalities noted. Child was started on Inj Piptaz and amikacin emperically. CRP was negative at admission but repeat values showed a mild transient increase. Blood cultures were sterile. BAL C/S grew Pseudomonas which was treated with Inj Piptaz and amikacin for 10 days. Child was given 2nd dose of Hexaxim, Rotavirus,OPV and PCV -13 on 26/2/24. In view the OAE bilateral Refer ,BERA was done which was normal. Child had multiple electrolyte abnormalities (Hypokalemia, Hypocalcaemia) which were managed as per protocol. As the child needs continued care in hospital stander wish to take the child to the hospital
of their choice for further management hence is being discharged with the following advice to the NICU, outside Hospital. At discharge child was on 2 L/min nasal prongs. Discharge weight was- 2.74Kg.
In the outside hospital:
Child had mild RD WITH spo2:90-94% on 2L O2, continued on HFNC. Chest xray suggestive of establised BPD. In view of worsening respiratory distress, child was changed to Nasal CPAP after 1 week. Child was managed with IV antibiotics, DART regimen, and other medications for management of PAH. Over 80 days of hospital stay child had recurrent episodes of desaturation with worsening RD requiring MV thrice which was later weaned off to NIV. CT Chest showed symmetrical perihilar
consolidation in both lungs predominantly involving posterior segments of both upper lobes and superior segments of lower lobes(Atypical infection). ECHO done showed moderate PAH, large ASD(6mm). Repeat ECHO showed increased size of ASD(9.3mm).NSG was normal. USG Abdomen
showed inguinal hernia defect measuring 9.2mm on right side and 10mm on left side with protrusion of bowel. Contents seen reaching upto neck of scrotum on both sides.Minimal reactive fluid in both hemiscrotum. Bilateral pelvicaliectasia(R>L). Milk scan showed no GER.
Course in AIMS:
At admission child was alert, conscious with SPO2 maintaining on NP at 2L O2.Chest xray showed BPD changes with cardiomegaly .Blood gas showed PH-7.4 PCO2-86.8 PO2-88.8 HCO3-62.3 LAC-0.7. Child was started on IV Piptaz., nebulisations and other supportive medications. Child had
respiratory distress and was given a trial on BIpAP on D3 of admission, but as child had desaturation with high O2 demand, child was intubated with 3mm microcuffed tube and put on AC PC mode with rate-35,PEEP-8, PS-30, Fio2-80%. ECHO don showed severe PAH, End systolic septal
flattening+ and multifenestrated atrial septum, largest defect ~ 3mm predominantly left to right shunt, Intact IAS, hence was started on Ambisentan and continue on Sildenafil. In view of hypoxia and severe PAH, with an underlying BPD changes in lung , child was also started on nitric oxide. As the child had low hemoglobin , blood transfusion given.Child had hypotension for which was started on low dose inotropes. IV Methyl prednisolone was also given .As child had fever spikes and cultures
were sent and was treated empirically with antibiotics. Blood culture sent was CONS . Considering the child’s condition with history of recurrent intubations and oxygen dependency , child was planned for tracheostomy along with gastrostomy. Pediatric surgery consultation was sought for the same. Pediatric neurology consult availed in view of sudden episodes of desaturation? seizures and advised conservative management. Child was nasally intubated on D7 of admission with 3.5mm microcuffed tube.Tracheostomy and gastrostomy under GA done on D14. Feed were slowly introduced via gastrostomy and reached full feeds after 10 days. Child was given a trial on PS CPAP on mechanical ventilator and slowly transitioned to home ventilator on PSV mode: PEEP:8, Pinsp:20, PS-12, FiO2:10L. Bystanders were counselled regarding the condition and also taught regarding tracheostomy care and Home ventilator .
Bronchopulmonary dysplasia (BΡD) is a chronic lung disease characterized disruption of pulmonary development and/or lung injury in the context of preterm birth. It remains a major complication of prematurity, resulting in significant mortality and morbidity. Risk factors that contribute to the development of BPD include premature birth, fetal growth restriction, maternal smoking, mechanical ventilation, οxygen toxicity, infections, and patent ductus arteriosus. Physical findings of BPD vary. Most affected infants are tachypneic. Other findings include retractions, rаles, and wheezes.
The chest rаdiоgraрh in infants with BΡD changes with evolution of the disease from clear lung fields to findings that include diffuse haziness and a coarse interstitial pattern, which reflect atelectasis, inflammation, and/or pulmonary edema.
A clinical diagnosis of ΒРD is made based upon meeting the following criteria:
•The infants is preterm (<32 weeks GA), and
•There is rаԁiοgraphiϲ evidence of parenchymal lung disease, and
•The infant requires supplemental οxygeո and/or respiratory support at either 28 days postnatal age or 36 weeks postmenstrual age (PMA)
If there is uncertainty, the diagnosis can be confirmed physiologic testing (οхygen reduction test), which involves placing the infant in room air to document the need for supplemental охуgen.
•Mild BΡD (grade I) – Requiring low-flow nasal cannula (<2 L/min) at 36 weeks PMA
•Moderate BPD (grade II) – Requiring high-flow nasal cannula flow (≥2 L/min), continuous positive airway pressure, or noninvasive intermittent positive pressure ventilation (NIPPV) at 36 weeks PMA
•Severe BPD (grade III) – Requiring invasive mechanical ventilation at 36 weeks PMA
Most infants with ΒPD improve gradually during the first two to four months. Those with severe disease (grade III BРD) may require prolonged mechanical ventilation and are at risk for developing pulmonary hуреrtеոѕiοո and other complications.