Ch.13 Neonatal and Peds Flashcards
An APGAR score of 5 is determined 1 minute after delivery of a term infant. Which of the following should be done NEXT?
A. Stimulate and deliver low-to-moderate O2 concentrations.
B. Intubate and initiate mechanical ventilation.
C. Intubate and initiate CPAP and 80% O2.
D. Initiate nasal CPAP and 100% O2.
Stimulate and deliver low-to-moderate O2 concentrations.
The Apgar score assesses the neonate in five areas: heart rate, respiratory effort, color, reflex irritability, and muscle tone. Each area is scored 0, 1, or 2 points, and the higher the score, the better. A score of 7 to 10 is normal, and as the infant is observed, the upper airway is suctioned with a bulb syringe, and the infant is placed in a warmer. A score of 4 to 6, as seen in this question, indicates moderate asphyxia, which requires stimulation and O2 administration. A score of 0 to 3 indicates severe asphyxia, which requires immediate resuscitation with ventilator assistance.
The foramen ovale and ductus arteriosus remain patent in infants with persistent fetal circulation as a direct result of which of the following?
A. Hypocarbia
B. Pulmonary hypertension
C. Hyperoxia
D. Arterial hypotension
Pulmonary hypertension
High pulmonary artery pressures (pulmonary hypertension) are normal in utero. After birth, the infant breathes in air containing O2, which is a pulmonary vasodilator, which dilates the pulmonary vessels and results in a drop in pulmonary artery pressures. As the pressure drops, the foramen ovale and ductus arteriosus gradually close. If pulmonary pressures remain ele- vated, such as in persistent fetal circulation (PFC) or persistent hypertension of the neonate (PPHN), the high pressure keeps the foramen ovale and ductus arteriosus open, which results in blood shunting through these openings from the right side of the heart to the left, bypassing the lungs and resulting in hypoxemia.
Which of the following is not an indication for nasal CPAP in an infant?
A. To increase static lung compliance
B. To decrease functional residual capacity
C. To decrease pulmonary vascular resistance
D. To decrease intrapulmonary shunting
To decrease functional residual capacity
CPAP increases FRC by keeping alveoli from collapsing and maintaining more air in the lungs after exhala- tion occurs. CPAP is used to improve oxygenation. If atelectasis and intrapulmonary shunting are reduced and lung compliance is increased, PaO2 increases. Pulmonary vascular resistance begins to decrease as the PaO2 level increases by dilation of the pulmonary vasculature.
Which of the following are potential complications of an umbilical artery catheter (UAC)?
- Pneumothorax
- Thromboembolism
- Infection
A. 1only
B. 2 only
C. 1 and 3 only
D. 2 and 3 only
- Thromboembolism
- Infection
Potential complications of an umbilical artery catheter (UAC) include infection, thromboembolism, air embolism, and hemorrhage. UACs should be left in place no longer than 7 to 10 days so that these complications are avoided.
Which of the following may occur as a result of cold stress to an infant?
- Hypoxemia
- Metabolic acidosis
- Hypoglycemia
- Decreased O2 consumption
A. 1 and 3 only
B. 2 and 4 only
C. 1, 2, and 3 only
D. 1, 2, and 4 only
- Hypoxemia
- Metabolic acidosis
- Hypoglycemia
An infant that is cold stressed generates heat by breaking down brown fat. As brown fat is metabolized, O2 consumption increases, which often results in hypoxemia. This leads to lactic acidosis (metabolic acidosis). Cold stress may also result in hypoglycemia (decreased glucose) and apnea.
An elevation in the levels of chloride in sweat is diagnostic for which of the following lung conditions?
A. Bronchiolitis
B. Cystic fibrosis
C. Hyaline membrane disease
D. Epiglottitis
Cystic fibrosis
A diagnostic tool for cystic fibrosis is an elevated sweat chloride level. Ninety-eight percent of patients with CF have increased levels of chloride in their sweat (.60 mEq/L). The ability of the sweat glands to reabsorb sodium and chloride ions is defective, therefore increasing the levels in sweat.
A 28-week gestational age neonate is suspected of having a pneumothorax. Which of the following should the respiratory therapist recommend to help diagnose if this condition is present?
- Transillumination of the chest
- Transcutaneous PO2 monitoring
- Chest radiograph
- Arterial blood gases
A. 1 and 3 only
B. 1, 2, and 3 only
C. 2, 3, and 4 only
D. 1, 2, 3, and 4
- Transillumination of the chest
3.Chest radiograph
Chest radiographs are always observed to help diagnose a pneumothorax in all patients, but a transilluminator is used on neonates as well. The transilluminator utilizes a light source that is placed on the neonate’s chest wall. If air is present under the skin, an area of orange appears below the transilluminator as the air shines through the skin. This is an indication of an air leak or pneumothorax.
To prevent the development of retinopathy of prematurity in a neonate, the partial pressure of oxygen in arterial blood (PaO2) should not exceed what level?
A. 40 mm Hg
B. 60 mm Hg
C. 80 mm Hg
D. 100mmHg
80 mm Hg
Studies indicate that if PaO2 levels are maintained below 80 mm Hg, the risk for ROP is reduced.
A pre- and postductal study is done on a neonate using two transcutaneous O2 monitors. The transcutaneous oxygen pressure (TcPO2) reads 60 mm Hg on the
right upper chest and 40 mm Hg on the thigh. This is indicative of which of the following?
A. Bronchopulmonary dysplasia (BPD)
B. Persistent pulmonary hypertension of the newborn (PPHN)
C. Tension pneumothorax
D. Retinopathy of prematurity (ROP)
Persistent pulmonary hypertension of the newborn (PPHN)
If persistent pulmonary hypertension of the neonate (PPHN) occurs, venous blood returning to the heart is shunted from the pulmonary artery through the ductus arteriosus to the descending aorta, delivering deoxygenated blood to the lower body. This can be diagnosed by placing a TcPO2 electrode on the right upper chest and one on the lower body. If the PaO2 reading on the right upper chest is more than 15 mm Hg higher than in the lower body, PPHN is likely. Ultrasonography should be done to verify this right-to-left shunt through the ductus arteriosus.
Which of the following is appropriate treatment for PPHN?
A. Permissive hypercapnia
B. Maintaining PaO2 levels at 40 to 50 mm Hg
C. Vasopressor administration
D. Inhaled nitric oxide
Inhaled nitric oxide
Therapy aimed at vasodilation is essential to dilate the pulmonary vascular beds, which helps close the ductus arteriosus. Nitric oxide is a vasodilator used for this purpose. Permissive hypocapnia and maintaining the PaO2 around 100 mm Hg for the first few days may also close the ductus by causing pulmonary vasodilation.
The APGAR assessment is done at 1 minute after delivery to determine whether immediate intervention is required and again at 5 minutes after birth.
know
APGAR score of ___________is normal; requires routine observation, suctioning the upper airway with bulb syringe, drying the infant, and placing under a warmer.
7 to 10
APGAR score of 4 to 6 indicates
moderate asphyxia; requires stimulation and O2 administration
indicates severe asphyxia; requires immediate resuscitation with ventilatory assistance.
0 to 3
APGAR stands for
A- appearance (color)
P- pulse ( heart rate)
G- grimace (reflex irritabilty)
A- activity (muscle tone)
R- respiration (respiratory effort)
Acrocyansosis or cyanosis in the hands and feet is
normal after birth
Cyanosis observed in the mucous membranes or lips indicates…
O2 must be given immdeiately
To assess gestational age which scoring system is the most accurate
Ballard
Indications for nasal CPAP
(1) To improve oxygenation
(2) To increase static lung compliance
(3) To increase functional residual capacity (FRC)
(4) To decrease the work of breathing
(5) To decrease intrapulmonary shunting
(6) To decrease pulmonary vascular resistance
(PVR)
What device is used to diagnosee pneumothorax in neonates?
Transilluminator
Respiratory Distress Syndrome affects
premature infants that is caused by inadequate amounts of pulmonary surfactant, which leads to massive atelectasis and hypoxemia. (Also known as hyaline membrane disease [HMD].)
Immature lungs with surfactant deficiency indicated by a lecithin-sphingomyelin (L:S) ratio of less than
2:1
Infants born before 35 weeks’ gestation are at risk of infant respiratory distress syndrome (IRDS).
KNOW
What are some clinical manifestation of RDS
a. Nasal flaring
b. Grunting
c. Retractions
d. Tachypnea
e. Cyanosis
f. ABG levels reveal hypercapnia and hypoxemia with a mixed respiratory and metabolic acidosis
Chest xray findings
a. Ground glass appearance
b. Diffuse atelectasis
c. Air bronchograms
Treatment for RDS
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease seen in infants with severe RDS after….
prolonged positive pressure ventilation and supplemental O2.
How many stages of BPD are there ?
4
occurs 2 to 4 days after birth and consists of:
(a) Hyaline membrane formation
(b) Atelectasis
(c) Necrosis of bronchiolar mucosa
(d) Bronchiolar metaplasia
Stage 1
occurs 4 to 10 days after birth and includes necrosis, repair of alveolar and bronchial epithelium, and emphysematous changes.
Stage 2
occurs 10 to 20 days after birth and includes:
(a) Interstitial fibrosis
(b) Atelectasis
(c) Continuation of bronchiolar metaplasia
(d) Increased mucus production
(e) Bullae formation
Stage 3
occurs 30 days after birth and includes:
(a) Formation of emphysematous alveoli
(b) Atelectasis
(c) Continuation of interstitial fibrosis
Stage 4
Clinical manifestations of BPD
a. Increased airway resistance
b. Normal or increased static lung compliance
c. Ventilation/perfusion (V/Q) mismatching
d. Hypoxemia
e. Hypercapnia
f. Tachypnea
g. Barrel chest
h. Retractions
i. Inflammation
j. Bronchospasm
k. Pulmonary hypertension
l. Right ventricular hypertrophy
Chest xray of BPD
a. Ground glass appearance
b. Opacification
c. Atelectasis
d. Hyperlucency
e. Presence of bullae
f. Air bronchograms
Treatment for BPD
Meconium aspiration syndrome (MAS)
aspiration of meconium is most commonly associated with full-term or postterm infants. Meconium is discharged in the first fetal bowel movement and is composed of water, mucus, vernix, bile, epithelial cells, lanugo hair, digestive enzymes, and amniotic fluid, which are all toxic to the lungs.
Clinical manifestation for MAS
a. Long yellowed fingernails and peeling yellowed skin (signs of postmaturity)
b. Hypoxemia
c. Hypercarbia
d. Respiratory distress (tachypnea, retractions,
nasal flaring, grunting)
e. Barrel chest (from air trapping)
f. Cyanosis
g. Crackles and rhonchi on chest auscultation
Chest xray for MAS
a. Patchy infiltrates
b. Atelectasis
c. Consolidation
d. Pneumothorax (commonly observed)
e. Hyperinflation
Treatment for MAS
Persistent Pulmonary Hypertension of the Newborn (PPHN)
a condition in which fetal blood circulation through the heart persists after birth because of an elevated pulmonary vascular resistance resulting in pulmonary hypertension.
Causes of PPHN
The condition is most common in full-term or postterm infants because the pulmonary vessels are more reactive to hypoxia, leading to pulmonary vasoconstriction.
Conditions often accompained by PPHN
(1) Perinatal asphyxia
(2) MAS
(3) Pneumonia
(4) Sepsis
(5) Congenital heart defects
(6) Congenital diaphragmatic hernia (7) Hypoplastic lungs
(8) Hypoglycemia
Any condition that results in increased PVR can cause PPHN
KNOW
Maintaining low PaCO2 levels results in pulmonary vasodilation, which should allow less blood flow through the ductus arteriosus and foramen ovale. If shunting is occurring, PaO2 levels would increase during this test.
know
Chest xray for PPHN
a. Typically normal with an enlarged heart
b. Decreased pulmonary vasculature
Treatment for PPHN
a bacterial infection of the epiglottis,
most commonly affecting children 2 to 6 years old, resulting in inflammation and edema of the supraglottic area
Epiglottitis
What bacteria causes Epiglottitis
Haemophilus influenza type B
Clinical manifestations of epiglottitis
a. High fever (.38° C [100.4° F]).
b. Dysphagia with drooling.
c. Sore throat.
d. Dyspnea.
e. Tachycardia.
f. Inspiratory stridor
g. Intercostal and sternal retractions.
h. Use of accessory muscles during inspiration.
i. Hoarseness
Xray for epiglottitis
A lateral neck x-ray film will reveal a swollen epiglottis, known as the thumb sign because it resembles the distal end of a thumb.
Treatment for Epiglottitis
upper airway obstruction resulting from inflammation of the larynx and subglottic area to the bronchus; most commonly seen in children 6 months to 6 years old
Laryngotracheobronchitis (Croup)
Primary cause of croup
parainfluenza virus infection
Clinical manifestations of croup
a. Tachypnea
b. Tachycardia
c. Cyanosis
d. Inspiratory stridor (both inspiratory and expiratory as condition worsens)
e. Intercostal and sternal retractions
f. Use of accessory muscles for breathing
g. Barking cough
h. Several days’ history of respiratory-related
symptoms
i. Low-grade fever
j. SpO2 may indicate hypoxia
Xray for croup
a. A lateral neck x-ray film will reveal haziness in the subglottic region
b. The antero-posterior (A-P) chest radiograph shows the classic steeple sign caused by a sharply sloped, wedge-shaped narrowing of the trachea
Treat for croup
a. O2 therapy
b. Cool aerosol to reduce swelling
c. Aerosolized racemic epinephrine to reduce swelling
d. Oral dexamethasone to reduce inflammation
e. Adequate hydration
TTHN
