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Respiratory Distress with Cardiomegaly in a Neonate
Respiratory Distress with Cardiomegaly iQ a Neonate * Dov B. Nudel, M.D., 00 and Michael A. Berman, M.D. t
T he patient was a 2,490 gm infant, the product of
a normal 37-week pregnancy and nonnal delivery. Apgar scores were 6 and 9. One hour after birth, she was noted to have labored breathing and a respiratory rate of 50 to 60 per minute. On the second day of life, cyanosis was observed. The respiratory rate increased to 120 per minute with substernal retractions and a weak cry was noted. Her pulse was 160 per minute. The heart sounds were °Department of Pediatries, Yale-New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut. oOUSPHS Fellow, Maternal and Child Health Service. tDirector, Pediatric Cardiac Catheterization Lahoratory, Yale-New Haven Hospital. Reprint requests: Dr. Nannan Talner, 333 Cedar Street, New Haven 06510
FIGURE
CHEST, 70: 2, AUGUST, 1976
1
normal and no heart munnurs were audible. Peripheral pulses and blood pressures were nonnal in all extremities. Laboratory results included nonnal hematocrit, blood sugar, serum calcium, and electrolytes. Umbilical arterial blood gases in room air revealed a pH of 7.26, a Po z of 34 mm Hg, and a Pcoz of 49 mm Hg. With the Floz increased to 70 percent these became: pH 7.20 Po z 118 mm Hg, and Pcoz 48 mm Hg. The electrocardiogram was nonnal and an echocardiogram ruled out structural abnonnalities of the heart. A chest roentgenogram was obtained (Fig 1). To improve respiration, an endotracheal tube was inserted with consideraWe difficulty and the infant promptly improved. A repeat chest film was made 24 hours following intubation (Fig 2).
FIGURE
2
RESPIRATORY DISTRESS WITH CARDIOMEGALY IN NEONATE 285
Diagnosis: Pulmonary Edema and Dyspnea Secondary to Congenital V oeal Cord Fusion
Figure 1 reveals pulmonary edema with air bronchograms and cardiomegaly secondary to the upper airway obstruction. Figure 2 shows a nonnal cardiac silhouette without pulmonary parenchymal abnormalities. The endotracheal tube is in place. At the time of intubation, the endotracheal tube was forcefully inserted through a partial fusion of the two vocal cords involving about three-fourths of their length. There was instantaneous improvement in respiratory status with the rate falling to 36 per minute. Umbilical arterial gases in room air 20 minutes later showed a pH of 7.51, a P02 of 87 mm Hg, and a PC02 of 26 mm Hg. The endotracheal tube was successfully and uneventfully removed six days later. No other cause for the airway obstruction could be identified at bronchoscopy. Cardiomegaly is an unusual problem in the first two days of life. Primary structural abnormalities of the heart that cause enlargement of the heart at this age include pulmonary valve atresia with intact ventricular septum and bicuspid insufficiency, Ebstein's anomaly, and congenital atrioventricular block. These, however, are not associated with pulmonary edema. Cor biatriatum and pulmonary vein stenosis will show pulmonary edema, but heart size is generally normal. Cardiac enlargement with pulmonary venous congestion may be due to prenatal narrowing or closure of the foramen ovale, myocarditis, peripheral arteriovenous fistula, or cardiac tumor. Cardiomegaly may also be seen in thyrotoxicosis,
adrenal insufficiency, severe anemia, infants of diabetic mothers, hypoglycemia, hypocalcemia, and neonatal asphyxia with acidosis. This infant did not have any of these underlying malformations. Pulmonary edema with cardiomegaly secondary to enlarged adenoids and tonsils with longstanding upper airway obstruction occurs almost exclusively in normal children. Abnormalities that may produce upper airway obstruction in the newborn include vascular malformations (ie, double aortic arch, pulmonary artery sling), choanal atresia, vocal cord fusion, tracheomalacia or tracheal Haps, subglottic stenosis, extrinsic tracheal compression by cervical or mediastinal tumor, cyst or tumor of the larynx, and micrognathia with pharyngeal obstruction by the tongue. The mechanism for pulmonary edema secondary to upper airway obstruction is presumed to be elevated transmural capillary pressure. This may be produced by the negative intrathoracic pressure from the striking inspiratory effort. The cardiomegaly most likely relates to the elevated pulmonary vascular resistance that results from the hypercapnea and hypoxemia. REFERENCES
1 Luke MJ, Mehrizi A, Folger GM Jr, et al: Chronic nasopharyngeal obstruction as a cause of cardiomegaly, cor pulmonale, and pulmonary edema. Pediatrics 37 :762-768, 1966 2 Schaffer AJ, Avery ME: Diseases of the Newborn. (3rd edition), Philadelphia, WB Saunders, 1971
Corrections Re article, ""Natural History Six Years after Acute Myocardial Infarction: Is There a Low-risk Group?" by Sylvan Lee Weinberg (Chest 69:23-28, 1976) following is complete, corrected reference 3: Weinberg SL, Col J: The changing coronary care unit. In Russek H, Lohman B (eds): Changing Concepts in Cardiovascular Disease (vol 19) . Baltimore, Williams and Wilkins, 1972, pp 204-214 Re article, '''Melioidosis Complicated by Pericarditis" by Martin J. RaH et al, (Chest 69:227-229, 1976) Dr. Raff is erroneously listed as Chief, Section of Infectious Diseases, University of Tennessee School of Medicine, Memphis. Dr. RaH is at the University of Louisville. Re article, "'Increased Serum Calcitonin Levels in Bronchogenic Cancer" by Omega L. Silva et al (Chest 69:495-499, 1976) on page 498, line 13, right column: < 400 p,p,g/ml should be > 400 p.p.g/ml.
Re article, ""Application of Systolic Time Intervals to Acute
286 NUDn, BERMAN
Cardiomyopathy with Echovirus 2" by Leopold A. Schleissner et al (Chest 69:563-565, 1976) the term, echovirus type 2 is used incorrectly in the title and in the article. The echovirus reported is type 11. Re article, ""Continuous Positive Airway Pressure without Tracheal Intubation in Spontaneously Breathing Patients" by Dennis M. Greenbaum et al (Chest 69:615-620), on page 615, the Pa02 at which patients were admitted to the study was 70 rather than 65 mm Hg, and in Table 3, page 618, the heading on the last column should read Pa02 rather than PaC02. He article by Hussain et aI, ""Ozone-induced Increase of Lung Proline Hydroxylase Activity and Hydroxy-proline Content" (Chest 69:273-275, 1976 Supplement) the correct title is ""Ozone-induced Increases in Lung Collagen Synthesis: Comments Concerning Possible Involvement of Superoxide Anion." The correct authors are M. Z. Hussain, J. McManus, C. E. Cross, M. G. Mustafa and H. S. Bhatnagar.
CHEST, 70: 2, AUGUST, 1976
T he patient was a 2,490 gm infant, the product of
a normal 37-week pregnancy and nonnal delivery. Apgar scores were 6 and 9. One hour after birth, she was noted to have labored breathing and a respiratory rate of 50 to 60 per minute. On the second day of life, cyanosis was observed. The respiratory rate increased to 120 per minute with substernal retractions and a weak cry was noted. Her pulse was 160 per minute. The heart sounds were °Department of Pediatries, Yale-New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut. oOUSPHS Fellow, Maternal and Child Health Service. tDirector, Pediatric Cardiac Catheterization Lahoratory, Yale-New Haven Hospital. Reprint requests: Dr. Nannan Talner, 333 Cedar Street, New Haven 06510
FIGURE
CHEST, 70: 2, AUGUST, 1976
1
normal and no heart munnurs were audible. Peripheral pulses and blood pressures were nonnal in all extremities. Laboratory results included nonnal hematocrit, blood sugar, serum calcium, and electrolytes. Umbilical arterial blood gases in room air revealed a pH of 7.26, a Po z of 34 mm Hg, and a Pcoz of 49 mm Hg. With the Floz increased to 70 percent these became: pH 7.20 Po z 118 mm Hg, and Pcoz 48 mm Hg. The electrocardiogram was nonnal and an echocardiogram ruled out structural abnonnalities of the heart. A chest roentgenogram was obtained (Fig 1). To improve respiration, an endotracheal tube was inserted with consideraWe difficulty and the infant promptly improved. A repeat chest film was made 24 hours following intubation (Fig 2).
FIGURE
2
RESPIRATORY DISTRESS WITH CARDIOMEGALY IN NEONATE 285
Diagnosis: Pulmonary Edema and Dyspnea Secondary to Congenital V oeal Cord Fusion
Figure 1 reveals pulmonary edema with air bronchograms and cardiomegaly secondary to the upper airway obstruction. Figure 2 shows a nonnal cardiac silhouette without pulmonary parenchymal abnormalities. The endotracheal tube is in place. At the time of intubation, the endotracheal tube was forcefully inserted through a partial fusion of the two vocal cords involving about three-fourths of their length. There was instantaneous improvement in respiratory status with the rate falling to 36 per minute. Umbilical arterial gases in room air 20 minutes later showed a pH of 7.51, a P02 of 87 mm Hg, and a PC02 of 26 mm Hg. The endotracheal tube was successfully and uneventfully removed six days later. No other cause for the airway obstruction could be identified at bronchoscopy. Cardiomegaly is an unusual problem in the first two days of life. Primary structural abnormalities of the heart that cause enlargement of the heart at this age include pulmonary valve atresia with intact ventricular septum and bicuspid insufficiency, Ebstein's anomaly, and congenital atrioventricular block. These, however, are not associated with pulmonary edema. Cor biatriatum and pulmonary vein stenosis will show pulmonary edema, but heart size is generally normal. Cardiac enlargement with pulmonary venous congestion may be due to prenatal narrowing or closure of the foramen ovale, myocarditis, peripheral arteriovenous fistula, or cardiac tumor. Cardiomegaly may also be seen in thyrotoxicosis,
adrenal insufficiency, severe anemia, infants of diabetic mothers, hypoglycemia, hypocalcemia, and neonatal asphyxia with acidosis. This infant did not have any of these underlying malformations. Pulmonary edema with cardiomegaly secondary to enlarged adenoids and tonsils with longstanding upper airway obstruction occurs almost exclusively in normal children. Abnormalities that may produce upper airway obstruction in the newborn include vascular malformations (ie, double aortic arch, pulmonary artery sling), choanal atresia, vocal cord fusion, tracheomalacia or tracheal Haps, subglottic stenosis, extrinsic tracheal compression by cervical or mediastinal tumor, cyst or tumor of the larynx, and micrognathia with pharyngeal obstruction by the tongue. The mechanism for pulmonary edema secondary to upper airway obstruction is presumed to be elevated transmural capillary pressure. This may be produced by the negative intrathoracic pressure from the striking inspiratory effort. The cardiomegaly most likely relates to the elevated pulmonary vascular resistance that results from the hypercapnea and hypoxemia. REFERENCES
1 Luke MJ, Mehrizi A, Folger GM Jr, et al: Chronic nasopharyngeal obstruction as a cause of cardiomegaly, cor pulmonale, and pulmonary edema. Pediatrics 37 :762-768, 1966 2 Schaffer AJ, Avery ME: Diseases of the Newborn. (3rd edition), Philadelphia, WB Saunders, 1971
Corrections Re article, ""Natural History Six Years after Acute Myocardial Infarction: Is There a Low-risk Group?" by Sylvan Lee Weinberg (Chest 69:23-28, 1976) following is complete, corrected reference 3: Weinberg SL, Col J: The changing coronary care unit. In Russek H, Lohman B (eds): Changing Concepts in Cardiovascular Disease (vol 19) . Baltimore, Williams and Wilkins, 1972, pp 204-214 Re article, '''Melioidosis Complicated by Pericarditis" by Martin J. RaH et al, (Chest 69:227-229, 1976) Dr. Raff is erroneously listed as Chief, Section of Infectious Diseases, University of Tennessee School of Medicine, Memphis. Dr. RaH is at the University of Louisville. Re article, "'Increased Serum Calcitonin Levels in Bronchogenic Cancer" by Omega L. Silva et al (Chest 69:495-499, 1976) on page 498, line 13, right column: < 400 p,p,g/ml should be > 400 p.p.g/ml.
Re article, ""Application of Systolic Time Intervals to Acute
286 NUDn, BERMAN
Cardiomyopathy with Echovirus 2" by Leopold A. Schleissner et al (Chest 69:563-565, 1976) the term, echovirus type 2 is used incorrectly in the title and in the article. The echovirus reported is type 11. Re article, ""Continuous Positive Airway Pressure without Tracheal Intubation in Spontaneously Breathing Patients" by Dennis M. Greenbaum et al (Chest 69:615-620), on page 615, the Pa02 at which patients were admitted to the study was 70 rather than 65 mm Hg, and in Table 3, page 618, the heading on the last column should read Pa02 rather than PaC02. He article by Hussain et aI, ""Ozone-induced Increase of Lung Proline Hydroxylase Activity and Hydroxy-proline Content" (Chest 69:273-275, 1976 Supplement) the correct title is ""Ozone-induced Increases in Lung Collagen Synthesis: Comments Concerning Possible Involvement of Superoxide Anion." The correct authors are M. Z. Hussain, J. McManus, C. E. Cross, M. G. Mustafa and H. S. Bhatnagar.
CHEST, 70: 2, AUGUST, 1976