Prenatal and pediactric
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Why does cyanosis occur in babies?
Why does nasal flaring occure in babies?
Decrease aiway resistance
Why do retractions occur in babies?
- Soft ribs
- Large change in intraplueral pressures
Why does grunting occure in babies?
The biggest problem in RDS!
Lack of surfactant
Decribe the snowball pattern of RDS!
- Decreased surfactant production
- Decreased alveolar size
- Decreased surface area
- Decreased gas exchange
- Decreased O2 and increased CO2
- Damages alveoil
Explain how RDS causes increased WOB and altered ABG's!
- Decreased alveolar Size
- Decreased compliance
- Increased WOB
- Decreased tidal volume
What does early CPAP do for the RDS patient and how might this be better than SRT in more mature infants?
Minimal surfactant with CPAP will increase alveolar size and will maintain better oxygenation and better oxygenation continues surfactant production
What are the primarily and secondary pathophysiologic changes?
- Primarily is compliance
- Secondary is diffusion
What can be done to prevent RDS!
- Premature deliery should be delayed
- Glucocorticoids given for at least 2 days before delivery.
Which types of patients are more likely to develop tachypnea of the newborn?
Boys and infants with perinatal asphyxia
What are the treatments for tachypnea of the newborn?
What symptoms are unique to GBS?
- Poor peripheral perfusion
- Decreased blood pressure
- Metabolic acidosis
How is GBS similar to RDS?
- Because the endotoxin produced by the organism breaks down surfactant
- Same snowball effects as RDS
What are the treatments?
- MV with respiratory acidosis
- Surfactant replacement
What type of acidosis is seen with pneumonia?
- Metabolic and respiratory
How is RDS treated?
- O2- Hypoxic
- Mechanical vent- Resp acidosis
Why are antibiotics given to RDS babies?
Because it is similar to pneumonia
What are the complications associated with RDS?
- Chronic lung disease
- Retinopathy of prematurity
- Intraventricular hemorrhage
- Necrotizing Entrocolitis
- Air leaks
What changes are seen in CBC with GBS pneumonia?
Abnormal low white blood cell count
What is meconium?
- The first stool of a baby
- Green tinged
What causes it to be passed in utero?
Something stresses the baby
What is the delivery room management of meconium aspiration?
- Do not want them to aspirate
What are the two major consequenses of MAS?
- Airway problem chemical nuemonitits
Explain airway obstruction associated with MAS?
- Can be peripheral or central (proximal)
- Peripheral comes in 2 forms, total airway obstruction or partial airway obstruction
What is the result of total airway obstruction associated with MAS?
What is the result of partial airway obstruction associated with MAS?
What is the ball valve effect with MAS?
- On inspiration they get air in and on expiration they don't
- Air tarpping
What is the treatment of MAS?
- Ventilate (HFOV) only if necessary
- Keep well oxygenated
What are the complication of MAS?
What complications occur during SRT adminatration?
- Plugging of endotracheal tube (ETT) by
- Hemoglobin desaturation and increased need for supplemental O2
- Bradycardia due to hypoxia
- Tachycardia due to agitation, with reflux of
- surfactant into the ETT
- Pharyngeal deposition of surfactant
- Administration of surfactant to only one lung
- Administration of suboptimal dose
What diseases can SRT be used for?
RDS and MAS
How are ven setting altered if the SRT is effective?
- Reduction in FIO2
- Reduction in ventilatory support
What are the positive effect of SRT?
- Reduction in WOB
- Improvement of aeration
- Improvement in lung compliance
- Improvement in ratio of arterial to alveolar PO2 and oxygen index
When do you give SRT?
- Delivery room- prevent
- NICU- treat
What are the three categories associated with the changes in pulmonary vascular resistance? Major causes of PPHN
- Hypoplasic development
Maladaptation associated with PPHN!
- MAS and GBS babies
Muscularization associated with PPHN!
- Increased muscle mass
- Inappropriate muscle location
Hypoplasic development associated with PPHN!
- Diaphragmatic hernia
- Pulmonary hypoplasia
Explain the PPHN snowball!
- Decreases pulmonanary perfusion
- Increase PVR
- Increased R to L shunt threw DA
Hyperoxygenate the patient and if he not respond then there is a right to left shunt
Pre and Post-ductal PaO2!
- If there is a difference then the patient has a right to left shunt threw the ductus arteriosus
- If the difference is 20 then ductal shunting
- Respiratory alkalosis causes pulmonary vasodilation (CO2 of 30)
- which decreases PVR, Increases PBF and decreases PAP
- PaO2 should rise because change in PBF
- Increase in PaO2 is secondary to increase in PBF that came from the decrease in PVR
- (O2<25) + (>100) = PPHN
- Causes pulmonary vasodilation
- Which increases PBF
- And increases PaO2
What is the treatment for PPHN?
- Mechanical vent to increase pulmonary vasodilation, increase PBF, and increase O2
What is the treatment for maladaption associated with PPHN?
What is the treatment for muscularization associated with PPHN?
What is the treatment for hypoplasic developement associated with PPHN?
What are the complications of PPHN?
- Neurologic problems
- Cerebral infraction
What medications can be used for PPHN?
Why does iNO work best for excessive muscularization and least for CDH?
- Because the pulmonary blood vessels that CDH have are normal, there already open
- The problem is they dont have enough of them
How is nitric oxide administered?
- NO is bled into the brething circuit before the humidifier
- Usually start out at 20 ppm
How does it maximize V/Q matching?
Increasing perfusion where ventilation is good
When can you discontinue nitric oxide?
- Decrease the iNO by 5 ppm untill you are down to just 5 ppm
- Stay at 5 ppm for a couple of days
- If FiO2 is less that 40-60% you can D/C or wean by 1 ppm
What are the complications of nitric oxide?
- Nitrogen dioxide
Nitric oxide is an...
- Highly reactive
- Diatomic free radical
What chemical is most associated with smooth muscle contractility?
Inhaled nitric oxide reduces shunt by...
Vasodilating only pulmonary capillaries adjacent to functional lung units
How does ECMO work?
- The technique of supporting the function of the heart or lungs, or both, with external artificial organs.
- Enables the pracitiner to minimize the ventilator's support, thereby avoiding iatrogenic damage to the lungs and the problems associated with high mean airway pressure while allowing the disease process to run its natural course
- Allows us to rest the lung and let it heal from whatever is going on and allows for gas exchange outside the body
What patients and diseases can be treated with ECMO?
- Aspiration syndromes
What are the risks and complications of ECMO?
- Hemorrhage- Cardiac dysrhythmia
- CNS damage- Renal Failure
- Seizures- Hyperbilirubinemia
- Fluid retention and severe edema- Sepsis
What is the oxygen index to indicate ECMO?
>40 on 2 or more arterial blood gas measurements
How do you calculate oxygen index?
(MAP x FIO2 x 100)/ PaO2
Explain the many causes of chronic lung disease!
- Mechanical vent
- O2 toxicity
- Infection (VAP, sepsis)
- Surfactant deficiency
- Decrease alveoli
- Decrease pulmonary vessels
How is chronic lung disease like COPD in terms of alveoli and airway changes?
- Fewer and larger alveoli
- Damaged airway and bronchoconstriction problems
- Abnormal blood vessels changes leading to cor pulmonal
- Blood gas
How can chronic lung disease be prevented?
- Minimize ventilation
- Keep sats low
- Minimize barotrauma
- Early treatment
What is the treatment for chronic lung disease!
- Settle for less than normal blood gas
- RSV immunization
What are the complications of chronic lung disease?
- Cor pulmonale
- Increased risk of respiratory infections
- Asthma like symptons
- Altered respiratory function for years
Are the complications of GBS the same for premies and for term babies?
No they are not
Complications for premies with GBS!
Complications for term babies with BPD!
The five sign of respiratory in neonates occurs to...
Try to normalize the blood gas
What happens last in the five signs of respiratory distress in neonates?
- Slow desaturation
Why does PDA occur just as the patient is geting better from RDS?
- Small lungs
- Increased PVR
- Give surfactant open lungs decrease PVR
- Normal SVR
- Low PVR
- Left to right shunt
Why does SRT not cure RDS in all paitents?
- More probles than just surfacant deficiency
- Thickened alveolar capillary membrane
- Poor surface area for gas exchange
- Weakened diaphram
- Inmature respiratory drive
What are the complications of TTN?
A 25 week gestation newborn appears cyanotic and with ABG analysis indicating hypoxia and hypercarbia. The infant has severe chest wall retractions with inspiratory effort. The amniotic fluid appeared normal at birth. What is most likely the cause of respiratory distress?
A full term infant is delivered via cesarean section and demonstrates mild symptoms of RDS including cyanosis, tachypnea, and nasal flaring. APGAR scores are good and chest radiograph shows hyperexpansion and perihilar streaking. What situation most likely fits this case?
The infant has TTN and will likely recover completely by 72 hours
A newborn infant begins to develope symptoms of respiratory distress at 5 days of life. A cerebrospinal fluid culture tests positive for B strep infection. Which modes of transmission is most likely the cause of the infection?
Perinatal or postnatal
Which condition would be most critical in leading the caregiver to anticipate MAS?
Yellowish green colored amniotic fluid
fetuses may be assessed as “at risk” for MAS, including those with
- Abnormal fetal heart rate tracings
PPHN can be associated with which underlying pulmonary disorder?
A full term newborn diagnosed with PPHN is refractory to oxygen therapy and mechanical ventilation. Which would be the next logical therapy to try?
A newborn at 34 weeks gestation is experiencing breif periods of apnea, which results in bradycardia and cyanosis. Blood and cerebrospinal fluid cultures test negative for infection. Which interventions can help reduce the incidence of apneic episodes?
- Upright positioning
- Temperature stability
- Low FiO2 of 0.23 to 0.25
What are the complications of surfactant production?
- Airway obstruction
- Pulmonary hemorrhage
What surfactant associated protein deficiency is fetal in infancy without lung transplantation?
The high placement of the umbilical artery catheter should be visually confirmed at which anatomic landmark, using an X-Ray?
How is CLD defined in an infant?
Requring oxygen or mechanical ventilation, and continuing to requrie oxygen at 36 weeks GA
What is an important component to preventing oxidative stress in the treatment of CLD in the newborn?
- Resuscitating with a minimum FiO2 at birth
- Administration of vitamin E
What is the most important cause of intraventricular hemorrhage?
Lack of autoregulation and resulting fluctuations in cerebral blood flow
What percedure is performed to diagnose intraventricular hemorrhage?
A head ultrasound
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