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RTT 213 - Ch. 48
Ch. 48 - EGAN'S - Neonatal and Pediatric Respiratory Care
| Question | Answer |
|---|---|
| what is the first step toward acquiring the specialized knowledge needed to practice neonatal respiratory care? | thorough understanding of how the resp system develops in the fetus |
| what does the assessment of the newborn infant begin with? | the mother; condition/status of the fetus |
| what all affects the health of the fetus? | maternal health, physiology, behaviors; pregnancy complications |
| what conditions can result in an adverse outcome? | interference w/ placental blood flow or transfer of O2 |
| what are maternal conditions that can affect neonatal conditions? | previous complications, diabetes mellitus, age (<17,>35), smoking/drug/alcohol,placenta abruptio/previa, HTN |
| what is fetal assessment performed with? | ultrasonography, amniocentesis, fetal heart rate monitoring, fetal blood gas analysis |
| what does ultrasonography use? | high-frequency sound waves to obtain a picture of infant in-utero |
| what does ultrasonography allow the physician to view? | position of fetus/placenta, measure growth, identify anatomical anomalies, assess amniotic fluid |
| what does amniocentesis involve? | direct sampling/quantitative assessment of amniotic fluid |
| what is amniotic fluid inspected for? | meconium or blood; genetic normality of sloughed fetal cells; lung maturation |
| what is the lethicin-to-sphingomyelin ratio? | measurement of 2 phospholipids, synthesized by the fetus in utero |
| what does the L:S ratio rise with? | gestational age |
| at 34-35 weeks gestation, what does the ratio rise to? | >2:1 |
| what does a ratio >2.1 indicate? | stable surfactant production; mature lungs |
| _______________ is another lipid found in the amniotic fluid that is used to assess fetal lung maturity. when does this appear? | phosphatidylglycerol (PG); 35-36 wks gestation |
| if the PG is >1% of the total phospholipids, the is the risk of resp distress syndrome? | <1% |
| what is fetal heart monitoring? | measurement of fetal heart rate and uterine contractions during labor; monitor infant distress |
| what is a normal fetal heart rate? | 120-160 beats/min |
| what is fetal tachycardia a sign of? | fetal hypoxemia, prematurity, maternal fever |
| what are temporary drops in fetal heart rate called? and what are the 3 kinds? | decelerations; mild (<15 beats/min), moderate (15-45 beats/min), severe (>45 beats/min) |
| how are decelerations classified? | their occurance in the uterine contraction cycle |
| when do early decelerations occur? | fetal heart rate drops in beginning of contraction; benign, caused by vagal response |
| when does a late deceleration occur? | heart rate drops 10-30 secs after the onset of contractions |
| what does a late deceleration pattern indicate? | impaired maternal-placental blood flow or uteroplacental insufficiency |
| what happens with variable decelerations? | no clear relationship between contractions and HR |
| what is the most common pattern of decelerations? and what is it related to? | variable decelerations; umbilical cord compression |
| a completely monotonous HR tracing may be indicative of ______ ________. | fetal asphyxia |
| what is fetal heart reactivity? | ability of fetal HR to increase in response to movement or external stimuli |
| a healthy fetus will have ____ accelerations within a ___-minute period. | two; 20 |
| what is used to determine severity of problems? | fetal blood pH |
| where is fetal blood normally obtained from? | capillary sample taken from presenting body part, normally scalp |
| what is the normal fetal capillary pH range? | 7.35-7.25 (lower occuring late in labor) |
| what might a pH below 7.20 indicate? | fetus is experiencing asphyxia |
| when should scalp pH only be used? | assist in interpreting clinical signs of fetal distress |
| when does assessment of the neonate begin? | delivery |
| what is the initial standard steps at birth? | warming, positioning of head, drying, suctioning |
| assessment of the ______ ______ is performed 1 and 5 minutes postdelivery and should not be used to direct resuscitative efforts. | Apgar score |
| what is the Apgar score? | objective scoring system used to rapidly evaluate the newborn |
| what are the 5 components of the Apgar score? what is each parameter scored? | 1. HR 2. resp effort 3. muscle tone 4. reflex irritability 5. skin color; 0, 1, or 2 |
| what is a normal Apgar score? | 7 or higher at 1 minute |
| what might a score of 7 indicate? | supportive care (O2 or stimulation to breathe) |
| what might a score of 6 or less require? | more aggressive care |
| what are the 2 common systems used to determine gestational age? | 1. the dubowitz scale 2. ballard scales |
| what does the dubowitz score involve the assessment of? | 11 physical (skin texture/color, genetalia) and 10 neurologic (posture, arm/leg recoil) signs |
| what does the ballard scales involve the assessment of? | 6 physical, 6 neurologic |
| what are infants born between 38-42 wks considered? before 38 wks? after 42 wks? | term gestation; preterm; postterm |
| newborns weighing less than _____ grams are considered low birth weight. newborns less than _____ grams are considered very low birth weight. | 2500; 1500 |
| what weight percentile range is appropriate for gestational age? | 10th-90th |
| preterm babies do not have fully developed _____; their _________ ______ cannot absorb fat as well; _______ ________ are not yet capable of warding off infections; the ___________ is less well developed, increasing hte likelihood of hemorrhage. | lungs; digestive tracts; immune system; vasculature |
| preterm babies have a very ______ surface area-to-body weight ratio, what does this increase? | large; heat loss and impairs thermoregulation |
| what does infant physical assessment begin with measurement of? | vital signs |
| what is a normal newborn respiratory rate? the ______ the gestational age, the higher the normal RR will be. | 40-60 breaths/min; lower |
| what can tachypnea occur because of? | hypoxemia, acidosis, anxiety, pain |
| what are causes of bradypnea? | meds, hypothermia, neurologic impairment |
| what is the normal infant HR? where can heart rate be assessed? | 100-160 beats/min; auscultation at apical pulse, brachial, femoral |
| what does weak pulse indicate? bounding pulse? | hypotension, shock, vasoconstriction; major left-to-right shunt through pt ductus arteriosus (PDA) |
| what does a strong brachial pulse in the presence of a weak femoral pulse suggest? | PDA or coarctation of the aorta |
| what are the key physical signs that infants in resp distress typically exhibit? | nasal flaring, cyanosis, expiratory grunt, tachypnea, retractions, paradoxical breathing |
| what does nasal flaring coincide with? nasal flaring _________ the resistance to air flow. | increase in WOB; decreases |
| _______ may be absent in infants with anemia, even when PaO2 levels are low. | cyanosis |
| what masks cyanosis? | hyperbilirubinemia |
| when does grunting occur? | exhale against partially closed glottis |
| what does grunting help prevent? | airway closure and alveolar collapse |
| when is grunting most common? | respiratory distress syndrome |
| __________ represent the drawing in of chest wall skin between bony structures. | retractions |
| what is the difference in paradoxical breathing in infants and adults? | infants tends to draw in the chest wall during inspiration |
| retractions indicate...? paradoxical breathing indicates...? | increase WOB; increase ventilatory work |
| what are the noninvasive forms of blood gas analysis? | transcutaneous partial pressure of O2/CO2, pulse ox, capnography |
| blood gas is best for assessing infant's...? | oxygenation/ventilation status |
| what is capillary sampling provide information regarding? | ventilation and acid-base status |
| what is needed to produce maximum flow? | voluntary forced exhalation |
| _______ __________ _____ ________ technique was developed because infants cannot perform forced expiratory maneuver. | partial expiratory flow volume (PEFV) |
| how is the PEFV performed? | using compressive cuff placed around chest/abdomen of sedated infant; cuff rapidly inflated |
| what does the rapid external compressure do? | forces air out of lungs, flow measured by pneumotach attached to mask |
| what is the goal of O2 therapy? | provide adequate tissue oxygenation at the lowest inspired FiO2 |
| what is the primary indication for O2 therapy in infants/children? | documented hypoxemia |
| what indicates hypoxemia in a newborn older than 28 days? | PaO2 <60 mmHg or SpO2 <90% (same as adult) |
| research suggests that the growing lung is mroe sensitive to _______ ______ than the adult lung. | oxygen toxicity |
| _______ and its toxic effects may contribute to the development of bronchopulmonary dysplasia (infant COPD) and retinopathy in the premature infant. | hyperoxia |
| ____________ __ __________ is caused by an abnormal vascularization of the retina which in the severest cases leads to retinal detachment. | retinopathy of prematurity |
| what does hyperoxia promote? | PDA closure, could be fatal w/ PDA-dependent heart defect |
| what does hyperoxia increase and decrease? | increases aortic pressures/SVR; decreases CI and O2 transport in kids w/ acyanotic congenital heart disease |
| what is a potential complication in newborn O2 therapy? | flip-flop phenomenon |
| what does flip-flop refer too? | larger than expected drop in PaO2 when FiO2 is lowered |
| what is this probably due too? | reactive pulmonary vasoconstriction and increased right-to-left shunting |
| what avoids flip-flop? | decreasing FiO2 in small increments of 1-2% |
| what are the safe levels of FiO2, SpO2, and PaO2? | FiO2: <50%, SpO2: 88%-94%, PaO2: 60-80 |
| what does the effectiveness of O2 devices depend on? | performance of device; tolerance of pt for using device |
| what does selection of an O2 device need to be based on? | degree of hypoxemia; emotional/physical needs of child and family |
| how can O2 be delivered to infants and children? | mask, cannula, incubator, oxyhood |
| what are the secretion techniques that can be applied to infants/children? | CPT, PEP therapy, autogenic drainage, flutter therapy, mechanical in-exsufflation |
| what conditions is secretion retention common in? | pneumonia, bronchopulmonary dysplasia, CF, bronchiectasis |
| when is secretion clearance considered? | secretion accumulation impairs function, new infiltrates see on CXR |
| ________ _______ _______ can also be valuable in the initial management of aspirated foreign bodies. | bronchial hygiene therapy |
| what should you be careful about during percussion? | abdominal damage |
| ________ is used when secretions are mobilized with postural drainage and percussion. | suctioning |
| what might help with pulmonary clearance in larger children with excessive secretions? | combining directed coughing with postural drainage and percussion |
| what has been useful for CF pts? | PEP, flutter, intermittent percussive ventilation |
| what are the complications associated with bronchial hygiene therapy in infants/children? what can this be avoided by? | regurgitation and possible aspiration; nasogastric tube |
| what are other complications of percussion and postural drainage? | rib fractures, subperiosteal hemorrhages, increased risk of intraventricular hemorrhage |
| what may precipitate intraventricular hemorrhage? | increased ICP |
| what position is contraindicated in these kinds of children? | head-down |
| what is monitoring crucial with? what should be monitored? | instability; vital signs, colors, ICPs, breath sounds (before, during, after tx) |
| ________ FiO2 during tx often required. | increased |
| what are the key differences in humidity and aerosol therapy in infants/children? | assessent of pt response to therapy, age-related physiologic changes, equipment application |
| what decreases evaporative heat and water loss in premature infants, minimizing temperature stress and fluid imbalances? | high ambient humidity and temp levels provided by environmental O2 devices |
| because of newborn thermoregulation, adjustment and monitoring of _________ ____ are essential. | inspired gas |
| what will excessive gas temp result in? inadequate gas temp? | hyperpyrexia and tachycardia; hypothermia, apnea, acidosis, stress |
| what must be provided when the upper airway is bypassed by intubation? | supplemental humidification w/ heated humidifier or nebulizer |
| what is usually avoided in infants/children? | continuous nebulization |
| what is humidification of inspired gases for infants and children receiving MV commonly provided by? | servo-controlled humidifier |
| what are common problems with humidifier systems? | condensation in tubing (prevented by heated wire circuits); inadequate humidification |
| what is an alternative to heated humidification systems? | hygroscopic condensor humidifiers |
| what is a good alternative to systemic routes, especially for pulmonary disorders? | topical administration |
| the ________ ______ is also safer and more comfortable than oral and parenteral approaches. | aerosol route |
| what can be used to deliver aerosolized drugs to infants/children? | SVNs, MDIs, DPIs |
| what is used for pts unresponsive to intermittent SVN treatments and prior to intubation? | continuous aerosol drug therapy |
| how should equipment and tecnique be tailored to each child? | according to size, weight, postpartum age |
| what is used to estimate proper ET tube size and depth of insertion? | infant's age or weight |
| what happens if the tube is too small? | a leak may result, decreasing delivered VE |
| what do small ETT have? | high inspiratory resistance, increasing spontaneous WOB |
| what happens when an inappropriately large tube is used? | cause mucosal and laryngeal damage, resulting in UAO |
| most neonatal and pediatric ETT are ______ to eliminate cuff-related problems. | uncuffed (aspiration more prevalent) |
| what are important in reducing complications? | proper head positioning and avoidance of cumbersome connecting apparatus |
| what laryngoscope blade is more appropriate for intubation? | Miller (straight) blade (large tongue/high epiglottis) |
| what can small changes in position result in? | bronchial/esophageal placement of ETT |
| __________ are most useful to determine proper placement in trachea or esophagus. | capnographs |
| what is the tube internal diameter equation? | (age + 16)/4 |
| what does nasopharyngeal and tracheal suctioning help with? | minimizing aspiration, prevents ETT occlusion, lowers RAW |
| what can oral and pharyngeal suctioning be done with? | bulb syringe |
| what can be used for nasopharyngeal and nasotracheal suctioning? | DeLee trap or a mechanical vacuum source w/ catheter |
| what is the recommended suction pressure for neonates? what range is safe for large infants and children? | -60 to -80 mmHg; -80 to -100 mmHg |
| what is done before suctioning? | 1-min preoxygenation; raise FiO2 by 10%-15% for 1-min before suctioning |
| preoxygenation with ___% O2 should be avoided in infants younger than 1 month. | 100 |
| what is the time limit on suctioning to minimize hypoxemia? | 5 secs or less |
| what does CPAP do? | maintains I/E pressures above ambient, improves FRC and static CL |
| when is CPAP indicated? | when arterial oxygenation is inadequate despite a high FiO2 |
| when is CPAP commonly used? | PaO2 <50 mmHg while infant breathes FiO2 of 0.60 or greater, PaCO2 < or equal to 50 mmHg and pH is >7.25 |
| the application of CPAP is most commonly accomplished _____________. | noninvasively |
| what is used with CPAP on preterm/term infants? children? | nasal prongs or nasal pharyngeal tubes; nasal or full-face mask |
| what are initial CPAP levels and what increments are they adjusted by? | 5-6 cmH2O; 1-2 cmH2O |
| when do you know that the appropriate CPAP level is achieved? | RR decreases to near-normal, resp distress lessened, SpO2 rises while O2 requirements reduced |
| when is weaning and eventually discontinuing CPAP considered? | FiO2 <0.30-0.40, sustained reduction in WOB, CXR/clinical assessment indicate resolution |
| when is short-term CPAP used? long-term? | apnea in prematurity; obstructive airway problems, chronic lung disease, neuromuscular disorders |
| what is the most comfortable and simplest mean of supplemental O2 administration in infants/children? | nasal cannula |
| __-__ L/min for NC is as effective and is easier to apply than a nasal CPAP system. | 2-8 |
| what is the one limiting factor for nasal cannula? | utilize simple bubble humidifiers (doesn't provide sufficient levels of humidification to preserve mucosal integrity) |
| what might high-flow NC provide for pt? | stabilizes acute resp failure caused by hypoxemia, reducing need for non/invasive ventilation |
| ___________ _________ __________ is the delivery of a bulk flow of humidified gas into and out of the lungs. | conventional mechanical ventilation |
| what is the removal of CO2 directly related to? | alveolar ventilation |
| what is the magnitude of pressure required to move a particular amount of volume derived from? | the CL of the pulmonary system, resistance of airways |
| what are the basic goals of MV? | improve O2 delivery to meet metabolic demand/eliminate CO2, while reducing WOB |
| what breath types do infants primarily use? | pressure-controlled |
| what are the most common modes for infant/children? | PCV-SIMV with PSV |
| when is VCV-SIMV more commonly used? | when CL is essentially normal (neuromuscular disorders) |
| what mode is not commonly used for infants? | AC |
| during PCV, the ____ is preselected and is the ________ pressure that is reached and sustained throughout the inspiratory phase. | PIP; inflation |
| the difference between PIP and PEEP determines the delivered ______ ______. | tidal volume |
| what level of PIP increases the likelihood of barotrauma? | >25 cmH2O |
| what is the target VT values for neonates? children? | 5-7 ml/kg; 6-8 ml/kg |
| what is the first step when applying VCV? | selecting a VT |
| ______ rates have been used to try and mimic neonatal ventilation. | faster |
| __________ __________ is a commonly used strategy that allows the use of less mechanical support with the aim minimizing barotrauma. hwat is the target PCO2? | permissive hypercapnia; 45-55 mmHg |
| I time is set as low as ___ second for neonates and as long as ___ second for older children. | 0.3; 1.0 |
| what determines the I:E ratio? | I time and ventilator rate |
| ____ is kept low as possible to avoid O2 toxicity. what is the SpO2 range for preterm infant FiO2? | FiO2; 88%-94% |
| _____ is used to increase FRC and treat refractory hypoxemia. what is the normal range? | PEEP; 5-8 cmH2O |
| _____ _______ ________ is the avg of all pressure applied to the pt airway throughout one full inspiratory and expiratory cycle, influenced by PIP, I and E time, and PEEP. | mean airway pressure |
| what does the most appropriate PAW improve? | oxygenation; minimizes side effects (barotrauma, decreased CO) |
| what level of PAW is considered dangerous and what is needed if it gets to this point? | >15 cmH2O; high-frequency ventilation |
| _____ may be used in the short term to manage acute resp failure that is likely to reverse such as pulmonary edema. | NPPV |
| what does NPPV treat? | neuromuscular disorders and postextubation resp failure |
| what are the components of a ventilator assessment? | 1. evaluation of artifical airway 2. physical exam 3. pt-vent interaction 4. analysis of lab/radiographic data 5. assess humidification 6. check alarms |
| what does the artifical airway assessment include? | airway is secure, at established landmark, in correct position by auscultation/CXR, if leak |
| what might the absence of a leak prior to extubation indicate? | postextubation stridor from airway edema |
| what are routined airway graphics displayed? | scalar waveforms of flow, airway pressure, and volume |
| what are ideal humidification systems for pediatrics? | low compressible-volume chambers, a closed continuous water feed, heated-wire circuits |
| what is the goal of MV during the weaning phase? | facilitate effective spontaneous breathing as the WOB is gradually returned to the pt |
| what is an essential component of weaning? | pt-vent synchrony |
| what does testing for extubation readiness include? | switching to PSV that overcomes resistance of ETT, reducing PEEP to 5 cmH2O |
| ____-_________ __________ is a method of assisted ventilation that delivers small VTs (__-__ ml/kg) at rapid rates (>___/min). | high-frequency ventilation; 1-3; 150 |
| what are the 2 forms of HFV? | 1. jet 2. oscillation |
| what does HFJV provide? | pulse of high-velocity gas, PEEP/sigh breaths from vent, rates: 100-600, I time: 20-40 msecs, E passive |
| what are the frequencies for HFOV? what are I and E? | 3-15 Hz (180-900 beats/min); active oscillating around PAW |
| what is oxygenation determined by? | FiO2 and PEEP |
| what is the CO2 elimination determined by? | amplitude and rate (lower rate results in better CO2 elimination) |
| what are the principle benefits of HFV? | improved gas exchange w/ potentially less barotrauma |
| where is HFV commonly used? and in what? | newborn ICUs; severe hypoxic resp failure, severe resp distress, air leaks, severe ARDS |
| CO2 elimination during HFV is determined by delivered ________ ___________. | alveolar ventilation |
| what should ventilator frequency be set to achieve? what determines this? | resonant frequency of the lung; underlying lung structure and age |
| what determines lung expansion during HFV? | delivered Paw |
| what are the 2 HFV strategies? | 1. high vol strategy (recruitment) 2. low vol strategy (air leak) |
| when the FiO2 is equal to or <___, the Paw is weaned slowly. when the Paw is <___-___ cmH2O, the pt may be trialed off or transitioned to conventional ventilation. | 0.6; 15-18 |
| _______ ______ ______ is a selective pulmonary vasodilator used to treat newborns who require MV for hypoxic resp failure. | inhaled nitric oxide |
| what does it improve and reduce the need of? | oxygenation; extracorporeal membrane oxygenation |
| what is the recommended INO dose? what happens once a response has been achieved and sustained? | 20 parts per million; INO dose gradually reduced, 50% each step, final dose is 1 ppm |
| why is monitoring so crucial? | NO and O2 turn into NO2 which is potentially toxic |
| a metabolite of INO is the formation _____________ as the NO molecule is bound to the RBC. | methemoglobin |
| what is INO used for? | congenital heart diseases; ARDS |
| ____________ _________ __________ is a modified form of cardiopulmonary bypass used to provide relatively long-term pulmonary or cardiopulmonary life support when maximum medical interventions have failed. | extracorporeal membrane oxygenation |
| what are the 2 types if ECMO support? | 1. venoarterial (VA) (heart/lung function supported) 2. venovenous (VV) (lungs supported) |
| what is included in VA? | blood taken from RA; CO2 removed, O2 added; heated returned right common carotid artery |
| what is included in VV? | same process but returned to right heart |
| what conditions has ECMO shown to improve in infants? | pulmonary HTN, meconium aspiration, sepsis, resp distress syndrome, congenital diaphragmatic hernia; ARDS |
| what is the most prevalent complication with ECMO? | bleeding |
| where is treatment of a critically ill infant or child usually provided at? | tertiary care facility |
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