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When we're talking about neonatal lung diseases,

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especially diffuse lung diseases, the most common

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abnormality that we're gonna see in the newborn nursery

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or neonatal intensive care unit is surfactant deficiency.

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So, uh, we're gonna spend a good deal

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of time talking about respiratory distress syndrome

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or lung disease of prematurity,

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which is also called surfactant deficiency.

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There are secondary etiologies

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of diffuse neonatal lung disease

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as well that we'll talk about.

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And then no matter the etiology, if you have an infant

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with respiratory distress, make sure you look

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for potential complications of, uh,

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the diffuse lung diseases

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and we'll go through these examples.

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So on the primary spectrum of diffuse lung diseases, by far

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and away the most common etiology is gonna be prematurity.

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So surfactant deficiency,

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which is also called respiratory distress syndrome, or RDS.

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The, uh, much less common primary etiology

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of a diffuse lung disease is surfactant dysfunction.

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And so those are the genetic abnormalities related to

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the patient has surfactant,

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but it is abnormally functioning, uh, surfactant

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because of a genetic, um, defect.

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So let's focus on the surfactant deficiency

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related to prematurity.

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So this has a pretty classic radiographic appearance.

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Um, usually patients are going to have an endotracheal tube

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because they're going to give exogenous surfactant

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to treat lung disease of prematurity.

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But the x-ray appearance is pretty classic.

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So my favorite description is

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somebody took the x-ray cassette,

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put sand from the beach all over the cassette,

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and then they took the image of the patient.

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So it's like these granular diffuse salt and pepper

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or sand like opacities diffusely throughout the lungs.

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My other favorite description is that, uh,

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surfactant deficiency gives you the best air bronchos you're

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ever gonna see in your whole life.

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And that's because these patients have diffuse

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micro atelectasis.

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So a reminder that surfactant is produced

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by the type two pneumocytes

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and the purpose of it is to decrease the surface tension

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of the alveoli.

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So if you don't have surfactant, you get collapse

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of the alveoli diffusely.

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And that's why we see these gorgeous central air bronchos

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'cause of that micro atelectasis.

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Um, surfactant deficiency.

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We will see radiographically within six hours of life.

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Typically these patients do not have a pleural effusion.

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They might have other complications like pulmonary

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interstitial emphysema or pneumothorax or pedia sign.

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I'll show you examples of that later.

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Just, um, to follow up on the support devices

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of this infant, this endotracheal tube is okay,

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as is the UVC, the UAC and what we see of this enteric tube.

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Obviously this patient is not gonna have ossified tumoral

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heads because it is a 28 week gestational

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age premature infant.

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Um, a companion case.

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This is a 33 week gestational age premature infant

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with these diffuse sand leg

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or granular opacities diffusely throughout the lungs,

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we see some, some central air bronchos.

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Um, in this case we see, uh, increased conspicuity

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of the minor fissure because of atelectasis, not necessarily

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because of fluid collecting, uh, in that fissure.

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One last case to illustrate surfactant deficiency.

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This is a two week old former 24 week gestational

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age premature infant.

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And this is the best air broncho grams of your life, right?

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We see these branching bronchi all the way out

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to the segmental level B laterally, and that's

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because of the diffuse micro atelectasis.

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A reminder, we call it surfactant deficiency

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or lung disease of prematurity

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or RDS up until 30 days of age of the infant.

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And then after that, we'll call it chronic lung

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disease of prematurity.

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In the age of our neonatologist able

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to give exogenous surfactant, we see much less severe cases

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of broncho pulmonary dysplasia.

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So that's the chronic lung disease of prematurity

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that we can see in infants that presents with kind of, um,

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linear and triangular, uh,

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subpleural opacities in these patients

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who have been in the NICU for a long time.

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Uh, so just a reminder, a surfactant is a service active

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lipoprotein complex that is created

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and excreted by type two pneumocytes.

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Um, again, it reduces surface tension to allow the, uh,

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alveola to remain expanded.

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Those type two pneumocytes are not functioning

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until 24 weeks gestational age,

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and then they're not, uh, fully operational

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until about 35 weeks gestational age.

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So if you have an infant

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who is younger than 35 weeks gestational age, um,

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and you see granular opacities on a chest x-ray,

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be concerned for lung disease at prematurity.

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Let's move on to the secondary causes

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of diffuse lung diseases.

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And, um, we're gonna go over some of these, uh, examples,

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uh, on this screen.

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And the first is meconium.

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So these are gonna be, uh, older patients,

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so they're not gonna be premature.

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They're gonna be term or post-term infants.

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And so most of these patients we will see a humeral head

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of epiphysis starting to ossify.

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Um, typically radiographically these patients present

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with either symmetrically

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or asymmetrically increased lung volumes.

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And the reason for that is meconium is this thick

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tar like gross substance that when the patient breathes in,

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it's like a ball valve mechanism.

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So air can get in past that tar like meconium,

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but it can't get out.

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And so they have high lung volumes.

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Importantly, patients

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with meconium aspiration syndrome present

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with pneumothorax almost half of the time.

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And so if you have a patient with these thick ropey,

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central opacities,

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hyper expanded lungs be pay close

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attention for pneumothorax.

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And don't be afraid to ask for two view imaging

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to exclude pneumothorax in these in these patients.

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A reminder that meconium looks like tar at the beach.

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I went to med school in Texas

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and we've, we saw tar like this all the time on the beach

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and imagine inhaling that like yes, that's going

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to cause some problems with, uh, pneumonitis

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and it's gonna be hard for air to, uh, be exhaled past that.

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So just a few examples from our institution.

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This is a patient who is intubated with these thick ropey

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patchy opacities bilaterally.

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The, there's some asymmetric hyperinflation at the right

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lung compared to the left.

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This is at our institution one

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of the more common indications for a patient

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to be supported by ecmo.

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So extra corporeal membrane oxygenation.

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Um, it is a temporary, uh, lifesaving device

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that will not only help oxygenate blood,

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it will help circulate blood as well,

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especially if it's venal arterial ecmo.

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So this is the venous cannula.

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Make sure that the radio pic marker is this,

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this case is a little bit on the low side.

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It's projecting over the in pack IVC.

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We want that to be ideally in the mid right atrium level.

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And then the arterial cannula is typically in either the,

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uh, low common carotid artery

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or right brachiocephalic artery.

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So this patient's support devices are pretty okay,

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just a little bit low lying, uh, pic marker of the tip

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of this ECMO cannula projecting over the int pad IVC.

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Again, these patients can be very sick.

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Um, and it is one of the more common indications for ecmo.

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An example of meconium aspiration syndrome

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where the patient did present with a pneumothorax.

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So, um, again, we have symmetrically hyperinflated lungs.

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This patient has an endotracheal tube

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that looks appropriately appropriate in position,

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but on this right side we have this, uh,

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pneumothorax at the inferior

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and superior aspect of that right hemithorax.

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If you look closely, there's a

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pneumothorax on the left as well.

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So there's increased lucency inferior at this right base.

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And then there's some subtle hyper lucency

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superiorly on the left as well on the cross table lateral.

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It's much easier to see this retrosternal, increased lucency

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of bilateral pneumothoraces.

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So don't forget to look

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for pneumothoraces if you have a patient with concern

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for meconium aspiration.

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And unfortunately a lot of these patients,

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once they're on ecmo, will have complete opacification

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of both hees, um,

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until they have clearance of that meconium.

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So complete wide out of both sides of the lungs

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and this infant who is on vino arterial ecmo, my only advice

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for knowing, uh,

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if the support devices are in the appropriate position when

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you have like no landmarks to be able

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to help you is good luck.

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So probably this endotracheal tube is a little on the,

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on the low side, but it's, it's challenging to see

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where is trachea, where is crya,

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where is right main stem bronchus.

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You just have to kind of do the best you can

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to guesstimate the levels.

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This is the umbilical arterial catheter.

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This patient had a right-sided chest tube

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and then a opal type enteric tube

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that looks okay in position.

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So key points to recap the diffuse lung diseases.

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If you can see the humeral heads know you have a term

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infant that you're looking at.

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And so look for the diseases that are associated with term

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or post-term infant such as meconium aspiration syndrome,

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pulmonary edema, with or without congenital heart disease.

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TTN stands for transient tachypnea of the newborn.

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Those patients will look like pulmonary edema,

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but they oftentimes they'll go away

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as in discharge home with mom. Uh, we won't

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Often even get radiographic follow-up

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'cause they do so well clinically Neonatal pneumonia can

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present at any gestational age,

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and so I've included that in your differential for a term

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or post-term infant.

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If you have low lung volumes,

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think about surfactant deficiency if you have a premature

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infant or potentially neonatal pneumonia.

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Neonatal pneumonia is more commonly going to present

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with pleural effusion as opposed to, uh,

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surfactant deficiency.

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If you have a pleural effusion, think transient tikia

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of the newborn edema.

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So look for car abnormal cardiac morphology.

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Neonatal pneumonia also presents with pleural effusion.

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And then if you have a pneumothorax,

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think surfactin deficiency in a premature infant

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or meconium aspiration in, uh, a term or post-term infant.

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So some kind of, uh, highlights

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to help you narrow your differential diagnosis

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of an abnormal diffusely abnormal chest x-ray.