Neonatal Physiology

Teka Siebenaler RRT

Cardiopulmonary Services
University of Minnesota Amplatz Childrens Hospital

Fetal Lung Stages of

Development
rd
th

Embryonic Stage 3 -8 week

Neural Tube closure
Diaphragm and lung bud
formation
Internal organs in primitive
formation
stomach, liver, pancreas, gall
bladder,
bladder and intestinal loop
Vascular systems appears

 Most congenital malformations

occur during the 4th-8th weeks
Anencephaly/Spina Bifida
Extremity deformities
Diaphragmatic hernia (85% on the
left side)

Fetal Lung Development

7-16 weeks the formation of the
bronchial tree
17-24 weeks primitive gas
exchange surface forms
24-40 weeks alveolar development
continues
35 weeks stable surfactant
production

Postnatal Lung
Development
Newborn
Airway branching complete
Alveolar formation is not complete
Age 1-10 years number of alveoli
increase
Age 10 to young adult lung grows
larger with little alveolar growth

Fun Facts
Surfactant is produced by alveolar
epithelial cells (type II)
Surfactant production increases 2
weeks prior to normal birth
We are born with on 1/6th the
number of alveoli we will need as
an adult.

Surfactant Replacement
Creates a layer between the
alveolar surface and the alveolar
gas and reduces alveolar collapse
by decreasing surface tension
within the alveoli.
Given to patients with immature
lungs, MAS, RDS, Pulmonary
Hypoplasia and CDH
Curosurf vs. Infasurf vs. Survanta

Cardiac Formation
By 22 days a endocardial tube has formed
At 28 days aortic roots, primitive left atrium,
pericardial cavity, left ventricle have formed
Blood begins to shunt from left to right during the
4th and 5th weeks of development
Abnormalities in heart formation, the most
common form of human birth defects, afflict nearly
1% of newborns, and their frequency in
spontaneously aborted pregnancies is estimated to
be tenfold higher
Hoffman, J.I. Incidence of congenital heart disease: II. Prenatal
incidence. Pediatr. Cardiol. 16, 155-165 (1995).

Fetal Circulation
Fetal Circulation
Oxygenated blood from placenta via
umbilical vein
66% shunted past liver by DUCTUS
VENOSUS to IVC
50% of this blood shunted from right
atrium to left atrium via FORAMEN OVALE
This blood continues to left ventricle,
ascending aorta, and arteries feeding head
and right arm

Fetal Circulation contd

Venous blood from head (SVC) is
directed via right atrium to right
ventricle into the pulmonary artery
90% of blood in PA is shunted away
from lungs and into descending aorta
via the DUCTUS ARTERIOUS and
returns to the placenta via the
umbilical arteries.

Changes in Circulation, Respiration After

Birth
Pulmonary vascular resistance decreases after
birth due to:
Increased alveolar and arterial oxygen tensions, which
increase nitric oxide
Lung expansion
Decrease in PaCO2
Increase in arterial pH

Pulmonary artery pressure decreases below systemic

pressure; pulmonary blood flow increases
Left and right ventricles pump in series rather than
in parallel
as in the fetal circulatory pattern

Normal Circulation
Closure of Umbilical arteries w/in
minutes after birth
Ligation of umbilical vein
(clamped cord)
Closure of PDA (minutes to days)
Closure of Foramen Ovale due to
increased pressure in Left Atrium
and Decreased pressures in Right
Atrium

Pulmonary Hypertension
(PPHN)
Occurs in 2 out of every 1,000 born
live infants
Complicates the course of 10% of
infants with respiratory distress
Typically seen in infants >34 weeks
More common in babies that were
hypoxic and acidemic around the
time of birth (Venous cord Ph <7.20
and BE -8)
More prevalent in infants whose
mothers took NSAIDS or SSRIs
during the 3rd trimester

 Due to a patent foramen ovale and

patent ductus arteriosus, which are
normally present early in life, elevated
pulmonary vascular resistance in the
newborn produces extrapulmonary
shunting of blood, leading to severe
and potentially unresponsive
hypoxemia. With inadequate pulmonary
perfusion, neonates are at risk for
developing refractory hypoxemia,
respiratory distress, and acidosis.
Robin Steinhorn, MD

Cardiac Complications
Persistent
pulmonary
hypertension

Normal Circulation

PPHN

3 types:
Result of abnormally constricted
pulmonary vasculature due to lung
parenchymal diseases leading to
hypoxia (mec aspiration,
pneumonia, RDS)
Idopathic (10-20% of all affected
infants)
Pulmonary hypoplasia or
structural defects (CDH, PROM)

How do you know it is

PPHN?

Cyanosis
Tachypnea
Grunting
Pre/post ductal split
Hypoxia/hypercapnea/acidosis
Response to oxygen and iNO
Cardiac Ultrasound

Treatment for PPHN

Oxygen therapy
Inhaled Nitric Oxide
Normal Lab Values
Blood Pressure support if needed
Mechanical Ventilation
ECMO
Time!

PPHN and ECMO

Can be V-A or V-V ECMO
Typically a short run (3-5 days)
Survival rates greater than 68% as
compared with 40% in infants treated
with conventional non-ECMO therapy

Patient needs time for the

pulmonary vasculature to relax
and for the patients heart is able
to pump blood to the lungs

Congenital Diaphragmatic
Hernia
Occurs in 1 of every 2000-3000
live births and accounts for 8% of
all major congenital anomalies.
Mortality rates are 25-60%....
The diaphragm initially develops
as a septum between the heart
and liver, progresses
posterolaterally, and closes at the
left Bochdalek foramen at
approximately 8-10 weeks'

 A severe CDH is believed to occur

during the pseudoglandular stage
of lung development. Weeks 7-17
and this is when pulmonary
circulation develops.
Lung compression results in
pulmonary hypoplasia (both lungs
may be abnormal). Pulmonary
hypoplasia is associated with
fewer bronchial generations,
alveoli, and arterial generations.

Left Sided Congenital

Diaphragmatic Hernia

Left CDH

CDH and ECMO

Typically VA ECMO
Can be a difficult cannulation due
to small vessels and cardiac
anatomy
Average run time 181-197 hours
and 50% of patients with a CDH
are treated with ECMO
Patients are often decannulated
and immediately repaired on the
NICU

ECMO and Respiratory

Failure
Meconium Aspiration Syndrome
Sepsis
Pneumonia
Alveolar Capillary Dysplasia
****All have a component of
PPHN******

Alveolar Capillary
Dysplasia
Very rare lethal congenital
anomaly
Failure of formation of the normal
air-blood diffusion barrier in the
newborn lung. Alveolar Capillary
Dysplasia is usually associated
with "misalignment" of the
pulmonary veins.

 Patient will not repond to

mechanical ventilation, iNO or
ECMO
75% of these patients will have
other organs affected
Longest reported survival is 2
months post ECMO run

 Questions??????