CARDIOPULMONARY CHANGES AT BIRTH AND PRINCIPLES OF NEWBORN RESUSCITATION

Question 1

T/F: Before birth the lungs take no part in gas exchange

Answer 1

T
Before birth the future airways of the lungs are liquid-filled and the lungs take no part in gas exchange, which instead occurs across the placenta

Question 2

Pulmonary blood flow (PBF) is low because pulmonary vascular resistance (PVR) is high, redirecting the majority of right ventricular output (RVO) through the — and into the systemic circulation

Answer 2

ductus arteriosus (DA)

Question 3

Conversion of the fetal to adult circulation requires —, — and —

Answer 3

Elimination the umbilical – placental circulation

Increase of pulmonary blood flow to a level necessary for adequate gas exchange

Separation of the left sides of the heart by the closure of fetal channels

Question 4

T ventilation comprises two components —- and —

Answer 4

Physical expansion of the lungs with gas

Elimination of fluid in the alveoli and increase in alveolar concentration associated with breathing air

Question 5

T/F: Removal of placental circulation facilitates closure of the foramen ovale and causes a small decrease in right atrial pressure

Answer 5

T

Question 6

T/F: Removal of placental circulation enables functional closure of ductus arteriosus resulting in elimination of flow from the pulmonary trunk to the aorta

Answer 6

T

Question 7

T/F: In fetal life small pulmonary arteries have a thick MEDIAL layer composed predominantly of smooth muscle cells

Answer 7

T

Question 8

T/F: In fetal life the pulmonary vessels constrict markedly with hypoxia and dilate with an increase in PO2

Answer 8

T

Question 9

T/F: Following the immediate fall in pulmonary vascular resistance following birth, morphologic changes in the pulmonary vessels result in a PERMANENT fall in pulmonary vascular resistance

Answer 9

T

Question 10

T/F: The decrease in the thickness of the smooth muscle layer in the small arteries results in a gradual further decrease in pulmonary vascular resistance and pulmonary arterial pressure within 2-3 weeks after birth

Answer 10

T

Question 11

T/F: Within 2 -3wks after birth there a gradual further decrease in pulmonary vascular resistance and pulmonary arterial pressure

Answer 11

T

Question 12

4 conditions that can result from persistence of any fetal shunts/physiology

Answer 12

1. Persistent Ductus Arteriosus
2. Patent Foramen Ovale
3. Persistent Pulmonary
   hypertension of the Newborn
4. Transient Tachypnea of the newborn

Question 13

After birth functional closure of the ductus arteriosus occurs when

Answer 13

10 -15 hrs after birth by constriction of the medial smooth muscle

Question 14

T/F: Both functional and anatomic closure of the DA occur at the same time

Answer 14

F
Anatomic closure is completed by 2-3 weeks of age by permanent changes in the endothelium and the sub-intimal layers of the ductus

Question 15

Anatomic closure of the DA is completed at — wks after birth

Answer 15

2 -3 wks

Question 16

What causes the anatomic closure of the DA

Answer 16

permanent changes in the endothelium and the sub-intimal layers of the ductus

Question 17

Permanent changes in the – and – causes the anatomic closure of the DA

Answer 17

Endothelium and sub-intimal layers of the ductus

Question 18

% of PDA seen in all CHD

Answer 18

5 - 10%

Question 19

T/F: PDA can be asymptomatic

Answer 19

T
Usually asymptomatic when DA is small

Question 20

Persistent patency of the DA leaves a communication between the DA and —

Answer 20

Left pulmonary artery

Question 21

T/F: Large shunt PDA may cause CHF and recurrent pneumonia

Answer 21

T

Question 22

— disease may develop if large PDA with pulmonary hypertension is left untreated

Answer 22

Pulmonary vascular obstructive disease

Question 23

% of newborns with failure of functional closure of the foramen ovale

Answer 23

75%

Question 24

T/F: Patent foramen ovale causes a left-to-right shunt

Answer 24

T

Question 25

T/F: ASD is commoner in males

Answer 25

F. Has a female preponderance

Question 26

The 3 types of ASD

Answer 26

Primum defect Secundum defect Sinus venosus defect

Question 27

The most common of the ASDs

Answer 27

Secundum defect

Question 28

Location of the primum defect

Answer 28

Antero-inferior atrial septum

Question 29

Location of the secundum defect

Answer 29

Middle portion of atrial septum

Question 30

Location of the sinus venosus defect

Answer 30

Postero-superior atrial septum

Question 31

Defect in the middle portion of atrial septum

Answer 31

Secundum defect

Question 32

Defect in the antero-inferior atrial septum

Answer 32

Primum defect

Question 33

Defect in the postero-superior atrial septum

Answer 33

Sinus venosus defect

Question 34

% of children with PFO/ASD that will experience spontaneous closure in the first 4 years of life

Answer 34

40%

Question 35

T/F: If a large PFO/ASD defect is untreated, CHF and pulmonary HTN may develop in the 1st decade of life

Answer 35

F 2nd or 3rd decade of life

Question 36

If a large PFO/ASD defect is untreated, --- and ---may develop in the 2nd or 3rd decade of life

Answer 36

CHF and pulmonary HTN

Question 37

Incidence of persistent pulmonary hypertension of the newborn

Answer 37

I in 1500 live births

Question 38

What type of shunt is seen in persistent pulmonary hypertension of the newborn

Answer 38

right to left shunt through PFO or PDA causing varying degrees of cyanosis

Question 39

3 causes of persistent pulmonary hypertension of the newborn

Answer 39

Pulmonary vasoconstriction in presence of normally developed pulmonary vascular bed Hypertrophy of pulmonary vascular smooth muscle Developmentally abnormal pulmonary arterioles with decreased cross sectional area of pulmonary vascular bed

Question 40

T/F: Symptoms of persistent pulmonary hypertension of the newborn manifest one week after birth

Answer 40

F. Symptoms begin 6-12 hours after birth

Question 41

5 signs and symptoms of persistent pulmonary hypertension of the newborn

Answer 41

1. Cyanosis 2. Retractions 3. Grunting 4. A gradient of 10% or more in sat between preductal/postductal ABG 5. Cardiomegaly on CXR

Question 42

T/F: A gradient of 10% or more in sat between preductal/postductal ABG is seen in persistent pulmonary hypertension of the newborn

Answer 42

T

Question 43

Transient tachypnea of the newborn is caused by ---

Answer 43

Retention of fetal lung fluid

Question 44

When do symptoms of tachypnea of the newborn appear in the newborn

Answer 44

2 hours after birth

Question 45

T/F: Transient tachypnea of the newborn is self-limiting

Answer 45

T

Question 46

T/F: Transient tachypnea of the newborn is a diagnosis of exclusion

Answer 46

T

Question 47

Treatment of transient tachypnea of the newborn involves -- and --

Answer 47

Oxygen therapy and non-invasive respiratory support

Question 48

T/F: Prenatal administration of steroids 48hrs before elective C- section @ 37- 39 weeks gestation reduces TTN but this has not become a common practice

Answer 48

T

Question 49

4 principles of neonatal resuscitation

Answer 49

1. Anticipation 2. Adequate Preparation 3. Accurate evaluation – Algorithm- Based 4. Post-resuscitative Care

Question 50

% of babies that will require some assistance at birth for normal transition

Answer 50

10%

Question 51

5 initial steps in resuscitation

Answer 51

Provide warmth Head position “ sniffing position” Clearing the airway, if necessary Drying the baby Tactile stimulation for breathing

Question 52

T/F: Stimulation of the posterior pharynx during the first minutes after birth can produce a vagal response leading to bradycardia or apnea

Answer 52

T

Question 53

T/F: Wet skin increases evaporative heat loss.

Answer 53

T

Question 54

T/F: All babies must be dried regardless of GA at birth

Answer 54

F Drying is not necessary for very preterm babies less than 32 weeks’ gestation because they should be covered immediately in polyethylene plastic.

Question 55

Contraindication to drying a baby immediately after birth

Answer 55

Very preterm babies less than 32 weeks’ gestation because they should be covered immediately in polyethylene plastic.

Question 56

T/F: Very preterm babies less than 32 weeks gestation should be covered in polyethylene plastic immediately after birth

Answer 56

T

Question 57

T/F: Babies require vigorous stimulation during resuscitation

Answer 57

F Gently rub the newborn’s back, trunk, or extremities. Overly vigorous stimulation is not helpful and can cause injury

Question 58

T/F: If a newborn remains apneic despite rubbing the back or extremities for several seconds, begin PPV

Answer 58

T

Question 59

T/F: Initiate PPV when there is poor respiratory effort

Answer 59

F Needed when there is no improvement in HR

Question 60

Rate of PPV delivery

Answer 60

40-60 breaths /min to achiece and maintain HR>100 /min

Question 61

Devices for PPV

Answer 61

BMV ET (endotracheal tube), LMA(laryngeal mask airway) Pulse oximetry

Question 62

Technique for positioning of facemask in neonatal resuscitation

Answer 62

E-C clamp technique

Question 63

Describe the E-C technique of mask positioning

Answer 63

The hand is positioned so that the little, ring and middle fingers are spread over the mandible from the angle of the jaw forward towards the chin in the configuration of the letter 'E'. The jaw is then lifted, pulling the face into the mask. The thumb and forefinger are placed are placed over the mask in the shape of the letter "C". The mask is squeezed onto the face and a seal is formed between the mask and the face.

Question 64

Targeted SPO2 1 minute after birth

Answer 64

60 - 65%

Question 65

Targeted SPO2 10 minutes after birth

Answer 65

85 - 90%

Question 66

Targeted SPO2 5 minutes after birth

Answer 66

80 - 85%

Question 67

Targeted SPO2 in the 2nd, 3rd and 4th minutes of life

Answer 67

65 - 70% 70 - 75% 75 - 80%

Question 68

T/F: If heart rate is less than 100beats per minute, but greater than 60 beats per minute consider alternate airway

Answer 68

T

Question 69

Size of laryngoscope for preterm infants

Answer 69

No. 0

Question 70

Size of laryngoscope for term infants

Answer 70

No. 1

Question 71

Endotracheal tube size 3.5 to 4 is used for which babies

Answer 71

> 38wks > 3000g

Question 72

Size 3.5 endotracheal tube is used for which babies

Answer 72

34 to 38wks 2000 to 3000g

Question 73

Size 3 endotracheal tube is used for which babies

Answer 73

28 to 34 wks 1000 to 2000g

Question 74

Size 2.5 endotracheal tube is used for which babies

Answer 74

< 28 wks < 1000g

Question 75

What are the various sizes of endotracheal tubes

Answer 75

2.5, 3 3.5 4

Question 76

When do you start chest compressions in neonatal resuscitation

Answer 76

Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec

Question 77

Site and depth of neonatal chest compressions

Answer 77

lower third of sternum depth 1/3 of AP diameter of chest

Question 78

2 techniques for chest compression

Answer 78

2 thumb-encircling hands technique Compression with 2 fingers and second hand supporting the back

Question 79

compression/ventilation ratio

Answer 79

3:1 90 comp : 30 ventilations

Question 80

T/F: In neonatal chest compressions, the area of the xiphoid process should be avoided

Answer 80

T To prevent injury to the liver, spleen and stomach

Question 81

T/F: With the 2 finger method, the fingers should be perpendicular to the chest and straight

Answer 81

T

Question 82

The most sensitive indicator of a successful resuscitation is ---

Answer 82

Increase in heart rate

Question 83

T/F: Most important step to treat bradycardia is establishing adequate ventilation

Answer 83

T

Question 84

Route, dose and concentration of epinephrine used in neonatal resuscitation

Answer 84

IV 0.01 - 0.03mg/kg/dose 1:10,000 (0.1 mg/ml)

Question 85

Fluid dose for volume expansion

Answer 85

10ml/kg

Question 86

T/F: Post resuscitation care is required for those who needed PPV

Answer 86

T

Question 87

Oxygen flow rate in neonatal resuscitation

Answer 87

up to 10L/min

Question 88

T/F: Laryngeal mask and stylet are optional intubation equipments

Answer 88

T

Question 89

Sizes for oropharyngeal airways

Answer 89

0, 00, 000 and 30, 40 and 50mm lengths

Question 90

T/F: For very preterm babies, use compressed air source in neonatal resuscitation

Answer 90

T Use O2 blender to mix oxygen and compressed air