Disease Processes Flashcards
What is Respiratory Distress Syndrome or Hyaline Membrane Disease and what is its Pathophysiology?
Def: Surfactant deficiency of the lung causing decreased lung compliance and atelectasis
Patho:
-Collapse of the alveoli after each breath
-Plasma leaks out of the lung tissue
-Forms a hyaline membrane
Lack of surfactant-Alveolar Collapse
Increased Pressures needed-leads to vasoconstriction, acidosis, hypoxemia
Capillary endothelial damage with fluid leaking into alveolar space
Diffusion of O2 and CO2 difficult due to decreased pulmonary blood flow and atelectasis
Over inflation further damages Type II cells
Formation of hyaline membrane
Who are the infants at risk of RDS?
Premature infants
How can we detect RDS?
L/S ratio 2:1
PG+
Shake Test (Foam Stability Index>48) i
What are the clinical signs of RDS?
10 possible signs
Intercostal retractions Expiratory Grunting Nasal Flaring Tachypnea Apnea Decreased BS Cyanosis Metabolic and/or Respiratory Acidosis Poor Peripheral Perfusion Hypotension/shock
How can we treat RDS?
Oxygen Therapy Nasal CPAP Steroids Exogenous Surfactant Ventilatory Support--HFOV vs Conventional Vent Pulse Ox/TCM
How can we manage RDS?
Surfactant Replacement Therapy (Prophylactic or Rescue)
Prophylactic:
.30 FiO2 to maintain PaO2>50 or O2 sat>90%
-CXR consistent with RDS
What are the Management Strategies for RDS?
What is the Main objective for these management strategies?
*Lung Protective strategies Gentle suctioning prn Minimal handling--cluster care Fluid and electrolyte balance-keep on the dry side Maintain blood glucose 45-120 mg% Amp and Gent antibiotics
To do whatever I can do to avoid the use of Positive pressure ventilation.
What is PPHN?
Failure of shunts to close during transition from fetal circulation due to lack of O2
High PVR causing RightHe to Left shunt
Hypoxemia and acidemia causes further PVR and perpetuates the cycle
What are the clinical signs of PPHN?
6 signs
Severe Respiratory Distress
Cyanosis
Hypoxemia on 100% O2 with positive pressure
unexplained by degree of lung disease
CXR shows ¯Vascular Markings and enlarged heart
Breath sounds—rales
What 2 conditions need to Ruled out or diagnosed in the presence of PPHN?
Severe causing RDS
congenital Heart Defect
in general, just becuase you caught PPHN doesnt mean that that is the only thing wrong. could be PNA, diaphragmatic hernia, etc.
What is the true test for R-L shunt in PPHN?
What are some secondary tests? (3)
Contrast echocardiography used to confirm shunting
Ductal blood gas, 02 hyperoxia challenge (100% for 20 mins, hyper ventilation test)
What is the treatment for PPHN?
Prevent hypoxemia, acidosis and hypothermia
Correct hypoxemia by reversing R>L shunting
Drug Therapy [(INO, oxygen, Priscoline (tolazoline)] - drugs to reduce PVR
PPV with 100% Oxygen
What is the Vent strategy for PPHN?
High rate with short I-time. use just enough to move the chest
With a goal to Reduce PaCO2 to a level where PaO2 rises above 100mmHg.
Use enough FiO2 to keep PaO2 > 120mmHg if possible
What 3 drugs are used to treat PPHN?
What is the main objective of these drugs and its goal?
iNO, oxygen, Priscoline (tolazoline)
they are drugs to reduce PVR with the goal of closing the Patent ductus arteriosis
What is the most recognized site of infection in new borns within the first 24 hours of life?
Lungs
What are the sources of PNA?
intrapartum
- Aspiration in utero
- Aspiration during delivery
What are contributing factors to PNA?
premature rupture of the membrane (can introduce bacteria too soon) Prolonged labor Excessive obstrectric manipulation Maternal GI infection Infection (GBS, ecoli, herpes, listeria)
What are signs and symptoms of PNA?
5 signs and symptoms
MOM says Baby doesn’t “look” right/“Not acting right” Rapid Respiratory deterioration Apnea and/or bradycardia Especially Temp instability hypotension/poor perfusion
What does temperature instability appear like for term and preterm babies with PNA?
Term—hyperthermia
Preterm-– hypothermia
What are the treatment options for PNA?
Careful assessment and monitoring Antibiotic Therapy Fluid/Electrolyte support Blood Products/volume replacement Respiratory Support as needed
What do you watch out for in babies with PNA?
Watch out for septic shock!
What are risk factors for Merconium aspiration?
Prolonged gestation >42 weeks
SGA
IUGR
Placental insufficiency (hypertension, Preeclampsia, Previa, Abruption)
Intrapartum asphyxia (Cord prolapse or Prolonged labor)
What causes Merconium Aspiration?
Fetal asphyxia to intestinal hypoxia then to hyperperiastalsis then anal sphincter relaxation causes merconium to enter the amniotic fluid.
this can happen before or after delivery
How can merconium aspiration happen after delivery?
baby can swallow the merconium during delivery cause a reflux and aspirate it into the lungs
What are some clinical signs of merconium aspiration?
Tachypnea with intercostal retractions
Cyanosis, grunting, flaring
Increased AP thoracic diameter
Coarse bronchial breath sounds
Airway obstruction/Air Trapping
Complete (atelectasis)
Incomplete (ball – valve action blocking airway from exhalation)
Alert, anxious LOOKWhat are treatment options for Merconium Aspiration?
Lung protection strategy
MOST IMPT, Do not stimulate to breathe.
When do you follow merconium protocols after the baby is born with suspected merconium aspiration?
If the baby is non-vigorous and flacid use merconium protocols
If the baby is vigorous and crying on their own, just treat the PNA
What do you do in merconium protocols?
3 things
intubate at first breath
Direct tracheal suction below cords with DeLee suction which connects directly and uses ET tube for suction.
PPV
HFOV is recommended
If conventional, high pressures with short i-times
Hyperoxygenate with hypocapnea, Alkalosis
What is the Vent strategy for RDS?
.30 FiO2
maintain PaO2>50 or O2 sat>90%
What does a CXR from RDS look like?
Uniform reticulogranular appearance
AKA ground glass
Low lung volumes
Air Bronchograms
Atelectasis
What does a CXR from PNA in infants look like?
2 things
Diffuse Bilateral infiltrates
patchy infiltrate in perihilar area
What is TTHN?
Failure of fetal lung fluid to clear causing respiratory distress
What are signs and symptoms of TTHN?
Minics clinical early RDS Tachypnea resulting in hyperventilation Mild respiratory alkalemia Cyanosis Barrel – shaped chest Retracitons/grunting Nasal Flaring
What does TTHN in CXR look like?
Wet LUNG
Perihilar congestion
There may be small collections of liquid at the costophrenic angles
Progressive clearing within 48-72 hours
What is the treatment for TTHN?
Supplemental Oxygen
100% by Head Hood
High flow nasal oxygen (vapotherm)
NCPAP
4 – 6 cwp
100% O2
What is PIE or air leaks?
Pulmonary Diseases Stiff non compliant lungs Aspriation syndromes Hypoplastic lungs Congenital lobar or pulmonary interstitial emphysema
Positive pressure ventilation
What are some prevention strategies for PIE?
HFV Permissive Hypercapnea Keep airways clear Pressure gauges Recognition of infants at risk
what are some signs and symptoms of PIE?
Restless Irritable Lethargy Tachypnea Increased respiratory effort profound general cyanosis Bradycardia Decreased of shifted breath sounds Chest asymmetry Severe hypotension and poor peripheral perfusion Cardiac arrest
What are conformations of PIE/Air leaks?
Transilumination of the Chest
CXR
What are treatment options for PIE?
Needle aspiration 2nd intercostal space midclavicular line
Oxygen therapy
HFV
What is BPD?
A Chronic lung condition that starts with severe RDS.
has 4 stages
Presents it self in Infants requiring high ventilator settings with high FiO2 after 10 days
What is the treatment for BPD?
Use lowest ventilatory support and FiO2 to permit lung to heal.
Titrate Fi02 keeping sats 88 – 92
HFOV recommended in early stages of RDS to prevent BPD.
Good nutrition to support lung growth
Treat infections
What is Chornal atresia and how do you check for it?
Formation of bone that blocks ventilation through the nasal passage.
Babies are obligate nose breathers. they can only breathe through crying.
conformation with size 6 french catheter’s inability to pass through nose.
What is esophageal atresia?
it is a birth defect wherein the esophagus is narrow or absence of connection to stomach.
What is the most common esophageal atresia?
Esophageal atresia with distal transesophegeal Fistula.
What are some clinical signs and symptoms of TEF and EA?
Inability of pass OG tube (This is Very impt Point)
Excessive drooling due to inability to swallow
Aspiration of gastric secretions
Choking/coughing with first feeding
Episodes of cyanosis
In RDS, what would show up on a CXR?
Air bronchograms
Ground glass
