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On day of life 23, the infant transitioned to 1/8 Lpm of 100%<br />

oxygen via nasal cannula. All nebulizers were discontinued. At 31<br />

days of age, the infant transitioned to room air. Capillary blood<br />

gas showed: 7.344/pCO2 51 mmHg/27 mmol/L. Echocardiogram<br />

was normal, with resolution of PPHN and normal contractility.<br />

Discussion<br />

A 40 4/7 week infant was admitted for meconium aspiration<br />

syndrome with severe pulmonary hypertension, which has at<br />

discharge. The infant’s hospital course was complicated by eight<br />

days on endotracheal tube ventilation, 15 days of NIPPV, 5 days<br />

of NCPAP, and 8 days of straight flow nasal cannula. The hild<br />

had 11 days of iNO, and one week of systemic steroids. He had<br />

a course of IV antibiotics for MAS and required IV sedation. Off<br />

of the sedation the infant experienced fussiness and went home<br />

on acetamiophen. Prior to discharge, the infant was able to be<br />

weaned to room air, tolerated all feeding orally, and had good<br />

weight gain.<br />

The parents elected not to have brain MRI because the vEEG<br />

was normal. Head ultrasound did reveal bilateral grade 1 IVH.<br />

In review of this case, the child tolerated iNO delivered by RAM<br />

cannula. However, following extubation the oxygen requirement<br />

increased from 0.30 to 0.40. Although the chest X-ray revealed<br />

areas of hyperinflation, the SIMV had to be increased. It may<br />

have been beneficial to increase the iNO dose at the time of<br />

extubation.<br />

Furthermore, did increasing positive pressure via a RAM cannula<br />

could cause more irritation, and increased effort for exhalation.<br />

Meconium will inactivate a newborn’s endogenous surfactant<br />

and decrease levels of surfactant proteins A and B. 1 Causing a<br />

severe inflammatory response. MAS impacts alveolar circulation.<br />

This was a severe case of both inflammation and circulation<br />

impairment. 3<br />

Nair, 4 et al reported a case PPHN with mild respiratory distress<br />

responding to nasasl cannula iNO. Our case represents severe<br />

MAS with severe PPHN, with on going iNO requirement after<br />

extubation. The child tolerated iNO by RAM cannula.<br />

References<br />

1. Donn, Steven M. Manual of Neonatal Respiratory Care. Third<br />

Edition. 2012.<br />

2. Fanaroff, Avroty A. and Fanaroff, Jonathon M. Care of the<br />

High-Risk Neonate. 6th Edition. 2013.<br />

3. Lindenskov PH, Castellheim A, Saugstad OD, Mollnes TE.<br />

Meconium aspiration syndrome: possible pathophysiological<br />

mechanisms and future potential therapies. Neonatology<br />

2015;107(3):225-30.<br />

4. Nair et al, Successful Treatment of a Neonate with Idiopathic<br />

Persistent Pulmonary Hypertension. AJP Rep. 2012<br />

neonatal <strong>INTENSIVE</strong> <strong>CARE</strong> Vol. 29 No. 4 • Fall 2016 31

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