Persistent Pulmonary Hypertension of the Newborn: Pathophysiology by Andrea Moscatelli

Aug 24, 2023

Persistent Pulmonary Hypertension of the Newborn: Pathophysiology by Andrea Moscatelli

In this video, Dr. Andrea Moscatelli discusses the pathophysiology of persistent pulmonary hypertension of the newborn, PPHN.

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Content

8 -> [Music]

18.599 -> persistent pulmonary hypertension of the

21.189 -> newborn pathophysiology by dr. Andrea

24.16 -> Moscatelli hello my name is Umberto

28.029 -> Moscatelli and I'm director of the

30.189 -> neonatal and pediatric intensive care

31.839 -> unit at Casa de Children's Hospital in

35.5 -> this video we will address the

37.39 -> pathophysiology and the treatment of

39.46 -> persistent pulmonary hypertension of the

41.62 -> newborn or PPHN we will start with a

46.239 -> brief review of the pathophysiology of

49.29 -> transition circulation and PPHN because

53.32 -> it is extremely important to plan the

56.29 -> treatment of a baby with pulmonary

58.15 -> hypertension during fetal life pulmonary

61.689 -> vascular resistance is high and most of

64.839 -> the oxygenated blood coming from the

68.409 -> placenta to the right atrium is diverted

71.14 -> towards the foramen ovale and the ductus

74.5 -> arteriosus into the systemic circulation

78.03 -> the features as a low content of oxygen

82.84 -> in blood with a saturation which is

86.08 -> about 60 and the pao2 of 20 nevertheless

90.43 -> it is he's able to maintain a good

95.409 -> delivery of oxygen to tissues because

98.95 -> both the ventricle are working in

101.38 -> parallel towards the systemic

103.24 -> circulation during fetal life pulmonary

107.29 -> vascular resistance is I because the

110.26 -> lines are not ventilated but also

112.479 -> because there is a relative excess of

115.92 -> vasoconstricting agents like in the

118.869 -> tailing and Ron works in respect to the

121.93 -> vacillating agents the main was the

125.229 -> leading agents are nitric oxide and

128.399 -> prostacyclin nitric oxide increases the

132.67 -> levels of cGMP while the process icons

139 -> increase the levels of CA MP into the

143.26 -> smooth muscle cells GMP is metabolized

146.889 -> by the phosphodiesterases type v while

149.709 -> CA NP is

151.48 -> metabolized by phosphodiesterases type 3

154.3 -> and with increase in cgmp and CA NP

159.75 -> nitric oxide and prostitute a pulmonary

166.42 -> vasculature during the transition at

170.56 -> birth there is a rapid fall in pulmonary

174.069 -> vascular resistance with an increased

176.579 -> inflow of ten folds this is due to the

180.549 -> fact that her lungs become distended but

184.66 -> also because the written respiration the

187.45 -> increased oxidant

188.769 -> tension in blood and the increase of

191.349 -> flow to the lungs with the increasing

194.95 -> fuel stress would stimulate the

197.14 -> production of nitric oxide and

199.42 -> prostaglandins and they also activate

203.19 -> potassium channels would have a direct

207.69 -> vasodilatory effect on the pulmonary

210.22 -> vessels during a normal transition we

214.54 -> have an increase in flow to the lungs

217.239 -> and because the increase in systemic

221.65 -> pressures after the separation from the

224.56 -> placenta we have the closure of the

226.989 -> foramen ovale and the increase in oxygen

231.01 -> content in blood would lead to the

233.739 -> constriction of - to certain users so

237.4 -> now the delivery of oxygen to the

241.47 -> peripheral tissues in is mainly

244.09 -> dependent on the oxygen content of blood

248.41 -> respect to the cardiac output because

250.66 -> the right and the left ventricle are now

253.959 -> working in series and there is a slight

256.599 -> decrease in the cardiac output of the

260.38 -> newborn the last step in this adaptive

265.479 -> process is vascular remodeling which

269.05 -> takes place in the first week of life

271.26 -> with a reduction in the thickness of the

275.65 -> muscular layer of the pulmonary vessels

278.11 -> with a third decrease in pulmonary

281.05 -> vascular resistance in the PPHN

285.4 -> we have the persistence of I pulmonary

288.37 -> vascular resistance with a right left

292.24 -> front towards the foramen ovale and the

296.71 -> ductus arteriosus so the baby enters

301.06 -> this fascist cycle of hypoxia where I

304.12 -> parked the ITER cacnea acidosis and cold

306.76 -> are triggering pulmonary

308.44 -> vasoconstriction with increase in the

310.96 -> pulmonary vascular resistance and right

313.57 -> to left front auto maintaining hypoxia

318.03 -> PPHN is affecting two of 1,000 live born

322.9 -> to an infant's and it is complicating

325.69 -> ten percent of neonatal respiratory

328.33 -> failures of term with a five to ten

331.21 -> percent mortality despite adequate

333.88 -> therapy and 25% of newborns with

337.39 -> moderate to severe impaired neo logical

341.26 -> development the main cause of PPHN is

345.52 -> meconium aspiration syndrome followed by

349.03 -> primary PPHN RDS and pneumonia sepsis

353.68 -> and lung iPod leisure so we might have

357.64 -> an abnormal constriction of normally

360.25 -> developed vessels like in parenchymal

362.68 -> diseases but we can also have a normal

366.19 -> parenchyma with a normal muscular

368.68 -> ization of the pulmonary vessels which

370.81 -> happens to be the case of ideal Patek

374.83 -> PPHN which has been associated with the

379.39 -> closure in neutral of the Duke disorder

381.94 -> users or to the mother with the material

385.3 -> therapy with a serotonin reuptake

388.68 -> inhibitors the last cause of pulmonary

393.31 -> hypertension could be lung hyperplasia

396.43 -> and CDH where we have reduction in the

401.02 -> closer cross sectional area of the

403.33 -> pulmonary vessels all these conditions

406.6 -> share a certain amount of vascular

409.84 -> remodeling with an increase in thickness

412.72 -> of the middle layer of the pulmonary

415.15 -> vessels and Annis tension

418.18 -> of the muscular ization in to adalah at

422.199 -> the in Fastenal interest in our level

425.789 -> this is the case of idea Patek PPHN

431.009 -> where the substrate of pulmonary

433.99 -> hypertension is related to vascular

437.259 -> anomalies and it is also being it has

441.52 -> also been described in congenital

443.83 -> diaphragmatic hernia

445.24 -> while in parenchymal diseases the

447.94 -> substrate for pulmonary hypertension

450.19 -> is mainly functional and there is a less

453.46 -> extent of pathological remodeling and

458.11 -> muscular ization we can have an increase

462.13 -> in the pulmonary pressure just because

465.729 -> there is an increase of flow through the

468.46 -> lungs even if the resistance the

473.259 -> vascular resistance of the pulmonary

474.699 -> vessels is normal this can happen in

478 -> case of in cases of pulmonary overflow

481.72 -> which we might see in patients with VSD

486.34 -> large ventricular septal defects or in

489.58 -> babies with a large pattern ductus

492.43 -> arteriosus another cause of increase in

497.38 -> the pulmonary pressure is related to the

501.34 -> increase of the pressures in the left

503.56 -> atrium which is usually associated to an

507.789 -> obstruction to the inflow of the left

510.699 -> ventricle like in mitral stenosis or can

514.12 -> be associated with a dysfunction of the

517.75 -> left ventricle in this case the only way

520.779 -> to reduce the pulmonary pressure is to

524.56 -> fix the mitral stenosis or to sustain

528.6 -> the contractile function of the left

531.76 -> ventricle done does in improving its its

536.29 -> function a condition that should be

539.339 -> always excluded in a baby with PPHN is

544.12 -> an obstructed total anomalous pulmonary

547.27 -> venous return

549.41 -> point of clarification total anomalous

552.709 -> pulmonary venous return T a PVR refers

556.19 -> to heart defects in which none of the

558.199 -> pulmonary veins are connected to the

560.149 -> left atrium instead connecting to other

562.91 -> systemic veins or chambers of the heart

564.98 -> an obstructive T a PVR

567.56 -> pulmonary venous drainage is also

569.93 -> obstructed or narrowed making it

572.209 -> difficult for blood to return from the

574.1 -> lungs to the heart such babies

577.22 -> they present at birth in fraught with

580.899 -> pulmonary edema with a right-to-left

586.1 -> front towards the ductus arteriosus and

590.42 -> a severe pulmonary hypertension and an

594.62 -> abstract T a PVR can be excluded if we

598.31 -> can demonstrate with cardiac echo the

601.579 -> presence of the of at least three of the

604.67 -> venous returns to the left atrium so if

609.949 -> we put everything into practice we can

614.18 -> go through the K through a real case we

617.839 -> have a 41 weeks gestational age baby who

621.769 -> was delivered by caesarian section

624.019 -> because of acute fetal distress during

626.779 -> labor the amniotic fluid was stained

629.959 -> with meconium and the baby has been

632.029 -> resuscitated at birth on ICU admission

636.47 -> she was extremely disoriented with

642.189 -> hypertension a capillary refill of more

646.759 -> than seven seconds and a severe

649.279 -> respiratory and metabolic acidosis

655.809 -> thinking into account of the history and

661.24 -> looking at the chest x-ray the admission

665.72 -> the admission impression is that of a

669.17 -> meconium aspiration syndrome complicated

672.139 -> by PPHN which was demonstrated by a

677.389 -> differential saturation between the pre

680.54 -> ductal and postdoc

683.31 -> oximeter probe of more than 20% point of

688.05 -> clarification a diagnosis of PPHN is

691.92 -> usually suggested by a sustained

693.99 -> difference in pre and post ductal oxygen

696.72 -> saturation of greater than 10% and there

701.37 -> is also writing pneumothorax which is a

704.009 -> condition often associated with meconium

707.579 -> aspiration syndrome when dealing with a

712.74 -> baby with pulmonary hypertension it is

716.1 -> extremely important to have a careful

719.939 -> cardiac echo assessment usually we look

724.79 -> to the front towards ductus arteriosus

732.82 -> the foramen ovale

738.57 -> which which could be bi-directional but

742.29 -> with a prominent writer last component

744.779 -> or exclusively write the left and if we

749.04 -> have a short axis cut of the left

753.45 -> ventricle we would see a dish shape left

757.35 -> ventricle because of the increase in the

759.63 -> pressures in the right ventricle which

762.63 -> are displacing the interventricular

764.67 -> septum to the last with the use of

769.709 -> cardiac echo we can also calculate the

774.029 -> pulmonary system pressure this is we can

779.01 -> calculate the difference between the

782.04 -> right ventricular pressure and the right

784.74 -> atrial pressure with the application of

787.44 -> the modified Bernoulli equation so this

791.22 -> difference would be given by 4 times the

795.6 -> square of the peak velocity of the

797.94 -> tricuspid regurgitation jet which we

801.12 -> usually see in severe cases of PPHN if

805.56 -> we head to this value the right atrial

809.67 -> pressure which can be estimated by the

812.459 -> central venous pressure we have the

815.1 -> pulmonary systolic pressure which is

818.339 -> usually either or Supra systemic so the

825.959 -> findings and admission at eco are a

829.92 -> normal Anatomy with normal pulmonary

832.339 -> venous return so there isn't an

835.38 -> obstructed total anomalous pulmonary

837.87 -> venous return the PDA is big with the

841.589 -> right left front the right atrium is

845.029 -> distended with a right left front

849.3 -> towards the foramen ovale

853.52 -> the RV is dilated with a moderate rapid

857.04 -> regurgitation

858.029 -> we have a d-shaped left ventricle and

860.49 -> either systemic pulmonary systolic

863.82 -> pressures so everything is saying to us

867.69 -> that this baby has a severe pulmonary

870.98 -> hypertension the plan on a mission is to

876.5 -> place a chest rain to start mechanical

879.98 -> ventilation to start therapy with a

883.16 -> pulmonary vasodilator agent and to

886.339 -> tailor the mo dynamic support to the

889.67 -> needs of the baby please help us improve

894.5 -> the content by providing us with some

896.6 -> feedback

904.79 -> you

Source: https://www.youtube.com/watch?v=WkBsat8Qh1w