Module 3A: Sarah Flashcards
(112 cards)
1
Q
What are some common multi-system effects of prematurity (3)?
A
- intraventricular hemorrhage (IVH),
- patent ductus arteriosus (PDA),
- respiratory distress syndrome (RDS): most worrisome
- necrotizing enterocolitis (NEC),
- acute kidney injury (AKI),
- sepsis,
- hyperbilirubinemia,
- hypothermia,
- hypoglycemia, and
- apnea
2
Q
Of all the common multi-system effects on prematurity, which one is particularly worrisome?
A
- respiratory distress syndrome (RDS)
- RDS is the most common cause of respiratory distress for preterm infants
3
Q
What are 3 possible causes of respiratory distress?
A
- RDS
- TTN
- Sepsis
4
Q
What is respiratory distress syndrome (RDS)?
A
- a potentially life-threatening problem,
- common breathing disorder
- largely because of the pathophysiology that results from immature pulmonary structure and function
5
Q
What are some pathophysiology of respiratory distress syndrome (3)?
A
- Immature lungs and lack of surfactant are the major causes of RDS.
- Other contributing factors are poorly developed/few units of gas exchange and increased distance between alveolar-capillary units due to immature pulmonary vasculature.
- preterm infants have weak respiratory muscles, compliant rib cages, and non-compliant lungs.
- Alveoli collapse due to increased surface tension and hypercarbia, hypoxia, and respiratory acidosis result.
- Pulmonary vasoconstriction and worsening mixed acidosis occur.
- Intervention is aimed at improving oxygenation/ventilation through mechanical ventilation and artificial surfactant.
6
Q
How is RDS different from respiratory distress?
A
- The clinical picture of RDS will include respiratory distress, which is a response to a variety of causative factors.
- Respiratory distress is increased work of breathing, this can include tachypnea, retractions, tracheal tug, nasal flaring, and grunting.
- Respiratory distress is a symptom of RDS but can also be a symptom of many other common health challenges such as transient tachypnea of the newborn, sepsis, cold stress, among many others.
- respiratory distress is a common manifestation of many potential problems
7
Q
What other pulmonary disorders may present respiratory distress in preterm infants (3)?
A
- pneumonia,
- transient tachypnea of the newborn (TTN),
- pneumothorax,
- pulmonary edema,
- pulmonary hemorrhage,
- hypoplastic lung, and
- congenital diaphragmatic hernia (CDH).
8
Q
What are some non-pulmonary disorders that may present with respiratory distress in preterm infants (3)?
A
- necrotizing enterocolitis (NEC),
- sepsis,
- congenital heart disease,
- patent ductus arteriosus (PDA),
- hypothermia
9
Q
What is Trauma-informed care?
A
- a concept that is widely used in mental health to describe the understanding that traumatic events such as abuse and neglect can lead to long-term physical and psychological effects.
10
Q
What is “age-appropriate care”?
A
- introduced in order to assist caregivers in recognizing that patient needs over the different stages of life change, requiring care that adjusts with his or her developmental, biological, and socioemotional needs
11
Q
What is the concept of Trauma-informed, age-appropriate care?
A
- developmental concept that recognizes the physiological, neurobiological, and psychoemotional sequelae of trauma in early life and
- aims to mitigate the deleterious effects associated with the trauma experience through the provision of evidence-based, age-appropriate caring strategies
12
Q
What are some experiences infants are frequently exposed to in NICU environment that can be traumatic to contribute to psychological and emotional damage ?
A
- maternal separation,
- pain,
- stress,
- isolation,
- sleep deprivation,
- anxiety, and fear
13
Q
What are the 5 core measures for age-appropriate care in the NICU?
A
- The Healing Environment (Physical, Human, Systems)
- Family-Centred Care (Define, Assess, Empower, and Educate)
- Age-Appropriate Activities of Daily Living (Feeding, Positioning, Hygiene)
- Pain and Stress Assessment and Management (Assess, Manage, Mitigate)
- Protected Sleep (Assess, Protect, Support)
14
Q
What is the “healing environment” of the five core measures for age-appropriate care in the NICU?
A
- A soothing, spacious, and aesthetically pleasing environment conducive to rest, healing, and recovery.
The healing environment also includes: - the infant’s sensory environment: tactile (touch), vestibular (movement, proprioception, and balance), gustatory (taste), olfactory (smell), auditory (noise), and visual (light) systems
- a collaborative health care team that demonstrates collaboration, caring, and communication
15
Q
What is the “fammily-centred care” of the five core measures for age-appropriate care in the NICU?
A
- A trauma-informed approach to family-centred care in the NICU is a commitment to supporting families in crisis, protecting infant–parent attachment, and supporting parental-role development to foster short- and long-term family unity
16
Q
What is the “age-appropriate activities of daily living” of the five core measures for age-appropriate care in the NICU?
A
- Activities of daily living (ADLs) in the context of the NICU refer to everyday tasks, such as bathing, feeding, postural support, skin care, and diapering.
- These tasks are especially important in infants because it is also their initial contact with parents and caregivers; these activities teach the infant trust, caring, compassion, and social interaction. Many of the early experiences of preterm infants are associated with caregiving tasks such as feeding, positioning, and skin care.
- If these experiences are unpleasant, stressful, or painful, they set the stage to jeopardize future behaviour and development.
- Social and emotional behaviour are modified by experience; and stress and early life adversity have long-lasting consequences
17
Q
What is the “pain and stress assessment and management” of the five core measures for age-appropriate care in the NICU?
A
- Prevention and management of pain and stress are exceptionally important core measures for age-appropriate care in the NICU.
- Pain is usually associated with tissue damage, such as heel pokes, whereas stress is an experience that is perceived by the brain as a threat.
- Painful procedures are obviously stressful for preterm infants, but it is important to be aware of other stressors in the NICU environment, such as bright lights, sounds, parental separation, and procedures such as temperature taking and diaper changes.
- Unmanaged pain and stress can have a strong influence on the developing brain and lead to significant life-long consequences
18
Q
What is the “protected sleep” of the five core measures for age-appropriate care in the NICU?
A
- Protected sleep as a core measure incorporates assessing sleep–wake states, supporting sleep, and educating families about the importance of sleep.
- Well-organized sleep is associated with improved cognitive and psychomotor development, as well as stress reduction, increased immune function, improved growth, stable oxygenation, and autonomic stability
19
Q
What is family-centred care?
A
- Family-centred care is not about using a set of pre-established rules to provide care.
- It is about putting parents in the centre of the picture, working to establish a partnership with them, and providing care and making decisions that reflect their individual needs.
- I appreciated how Selina offered Brooke a few minutes of skin-to-skin contact with Sarah prior to transport to the NICU, and Terry offered some specific information about why Sarah required closer monitoring than could be provided in the delivery room.
20
Q
What is the difference of hypoxia and hypoxemia?
A
- Hypoxia: a deficiency in the amount of oxygen reaching the tissues
- Hypoxemia: a deficiency in the amount of oxygen in the blood
21
Q
What are 4 early signs/ responses to hypoxia?
A
- tachypnea: reflects efforts to increase oxygen intake
- tachycardia: reflects efforts to increase cardiac output, thereby increasing delivery of oxygen to cells
- pallor and mottling: reflects redistribution of blood away from non-vital organs such as skin, toward vital organs such as the heart and brain (often referred to as the “diving reflex”); other organs that receive less blood are skeletal muscles, liver, lungs, kidneys, and gut
- air hunger: reflects efforts to increase oxygen intake
22
Q
What are 4 late signs/responses to hypoxia?
A
- apnea: reflects central nervous system hypoxia and depression
- bradycardia: reflects cardiac hypoxia
- cyanosis: reflects increased amounts of deoxygenated hemoglobin reaching the cells
- lethargy: reflects generalized hypoxia, central nervous system depression, and tiring
23
Q
What is the “diving reflex”?
A
- redistributes blood away from the liver, lungs, skin, skeletal muscle, gut, and kidneys to the heart and brain, causing the non-vital organs to become hypoxic and ischemic
24
Q
What are some assessment of oxygenation include?
A
Monitoring for early and late signs of hypoxia:
- Respiratory rates,
- heart rates,
- skin colour,
- perfusion, and
-level of consciousness and
- activity all reflect how well an infant is oxygenated.
25
How can hypoxemia be assessed?
- assessed by looking at pO2 and SaO2 saturation
- SaO2 measured by pulse oximetry is denoted as SpO2
- p02 is a measurement of the amount of 02 dissolved in the blood
26
What are the 2 ways oxygen is carried in blood?
- Dissolved in plasma:
- attached to hemoglobin
27
How are oxygen in dissolved plasma measure?
Oxygen carried in blood by Dissolved in Plasma:
- accounts for only 2%–3% of the total oxygen content of blood
- measured by pO2
- pO2 values, arterial = 50–80, capillary = 40–60
- arterial pO2 values are more accurate than capillary pO2 values
28
How are oxygen being attached to hemoglobin measured?
- accounts for 97%–98% of the total oxygen content of blood
- is measured by SaO2 via pulse oximetry (SpO2)
- SaO2 is the oxygen saturation of arterial blood, while SpO2 is the oxygen saturation as detected by the pulse oximeter
29
What is pulse oximetry?
- a way of assessing oxygenation
- non-invasive, continuous, reliable, and easy to use
- a mainstay in the management of respiratory distress
- tells us about the oxygen attached to hemoglobin, which is the bulk of the oxygen available
- measures the extent to which hemoglobin is saturated with oxygen molecules
- oxygen bound to Hbg is measured as oxygen saturation and measured by pulse oximetry
- normal Sp02 range for infant receiving oxygen88-95%
30
Where can oxygen saturation probe be placed and where can it not be placed on infant?
- placed on foot, hand, wrist
- cant be placed on ear
- normal Sp02 range for infant receiving oxygen: 88-95%
31
What is pO2?
pO2 (Partial Pressure of Oxygen):
- a measurement of the amount of oxygen dissolved in the blood, done by a capillary or arterial blood sample
32
What is the difference between anemia and polycythemia?
- Anemia (decreased hemoglobin): Hgb = 90
- polycythemia (excess hemoglobin): Hgb = 200
Both affect oxygen saturation interpretation:
- whenever you are using pulse oximetry to assess oxygenation, you need to be aware of an infant’s hemoglobin. If it is normal, your oximeter readings are valid.
-If the hemoglobin is elevated, oximeter readings are falsely low.
- If the hemoglobin is low, oximeter readings are falsely high
33
What is low HCO3- a reflection of?
- low HCO3- is a reflection of excess lactic acid that has combined with HCO3-.
- This buildup of lactic acid is due to anaerobic metabolism, which is the result of hypoxia.
- This lactic acidosis is contributing to the metabolic component of Sarah’s mixed acidosis.
34
What can having poor blood gases have on infants body system? GI? Renal? Pulmonary?
- compromise her gastrointestinal functioning, putting her at risk for NEC.
- Hypoxia initially increases cerebral blood flow, which can lead to IVH in a preterm infant.
- Reduced renal blood flow will disrupt urine output, and therefore fluid and electrolyte imbalance.
- Reduced blood flow to the lungs interferes with surfactant production.
35
What are some nursing care to monitor S&S of sepsis and prevention of sepsis?
- monitor CBC, CRP, blood gas, vitals, work of breathing, colour, perfusion
- administer IV antibiotics
- maintain incubator isolation and clean and aseptic techniques
- limit handling and procedures
36
What are some risk factors that make infant vulnerable to infection (3)?
- preterm: immune system is both immature and inexperienced
- maternal infection (UTI)
- maternal fever/not feeling well: passing microorganisms to infant during delivery
- being handled since birth (by nurses, parents)
- Health care professionals’ hands, equipment, and invasive procedures all increase the risk of introducing microorganisms into infants environment
37
What are the main signs of infection in an infant (3)?
- Hypothermia, or temperature instability, is one of the main signs of sepsis.
- Apnea is a major sign of sepsis
- Lethargy is another main sign.
- Hyper- and hypoglycemia
- Poor feeding
- Abdominal distention
- Unexplained bradycardia
- rashes or petechiae.
- Laboured respirations and
- tachypnea
38
What is the most common metabolic disturbance occur in neonatal period?
- hypoglycemia
39
When should blood sugar be screened for at risk infants?
- screening at-risk infants and the management of low blood glucose levels in the first hours to days of life is a frequent issue in the care of the newborn infant
40
What is the the threshold blood glucose value for infant in first 72hours? after 72hours?
- If an infant is at-risk or unwell, a blood glucose of less than 2.6 mmol/L in the first 72 hours of life indicates the need for active management and ongoing surveillance.
- Beyond 72 hours of age the threshhold for treatment increases to 3.3 mmol/L.
- In well term infants routine glucose monitoring is not recommended
41
Infants experiencing hypoxia, do they shift from aerobic metabolism to anaerobic metabolism?
yes
- Glycolysis is the major pathway of glucose metabolism
- during anaerobic metabolism, the rate of glucose formation (through glycolysis) is significantly reduced
- anaerobic glycolysis produces only two molecules of the energy molecule (ATP) per molecule of glucose, as compared to 36 molecules during aerobic oxidation
- both aerobic and anaerobic metabolism burn the same major intermediary substrate (pyruvic acid),
- anaerobic metabolism converts pyruvic acid to lactic acid.
- Aerobic metabolism further metabolizes pyruvic acid for extra energy
42
What are two ways that glycolysis occurs?
- aerobic metabolism
- anaerobic metabolism
43
What are the byproducts of aerobic metabolism? anaerobic metabolism?
- aerobic metabolism: CO2 and H2O
- anaerobic metabolism: lactic acid
44
What does product is converted from pyruvic acid from aerobic metabolism? anaerobic metabolism?
- aerobic metabolism: further metabolize pyruvic acid for extra enegy
- anaerobic metabolism converts pyruvic acid to lactic acid
45
How many moles of ATP is yielded from aerobic metabolism? anaerobic metabolism?
- aerobic metabolism: 36 moles of ATP per mole glucose
- anaerobic metabolism: 2 moles of ATP per mole of glucose
46
What is included in nursing care and monitoring for hypoglycemia (3)?
- Monitor serum glucose for all at-risk infants
- Feed or start IV glucose shortly after birth.
- Minimize glucose utilization by minimizing pain, stress, and handling
47
Which type of at risk infants should nurse monitor serum glucose (3)?
- are small for gestational age (SGA)
- have IUGR
- are LGA (wieght greater than 90th percentile)
- have experienced perinatal stress or hypoxemia
- are premature (including late preterm)
- are experiencing hypoxia or have been hypoxic
- have a diabetic mother (gestational or insulin-dependent)
48
Define PWOSAC and what does each one require?
- Pink: requires adequate ventilation and circulation.
- Warm: requires adequate heat.
- Sweet: requires sugar.
- Organized: requires developmentally supportive care.
- Attached: requires opportunities for positive human interaction.
- Clean: requires antibiotics and good aseptic technique.
49
Using PWSOAC framework to describe what stability looks like for infant?
- Pink: HR 110-160, RR 30-60, well perfused, pink colour. well oxygenated + breathing easily
- Warm: normal temperature 36.5-37.4
- Sweet: normal blood glucose level. not hypoglycemic + well hydrated (received IV fluid/dextrose)
- Organized: Support neurodevelopment by ensuring a quiet environment, eyes shaded from excess light, care is being paced, body supported by linen roll
- Attached: Supported by her family, who are well informed of her condition and participating in her care
- Clean: hand hygiene, clean surface before placing baby on it. not infected: receiving antibiotics
50
What are the potential adverse outcomes of hyperglycemia in infants (3)?
- increased mortality,
- sepsis,
- vision problems,
- reduced growth,
- white matter injury and
- intraventricular hemorrhages.
51
What value is considered hyperglycemia?
- Hyperglycemia is usually defined as a blood glucose >10 mmol/L
52
Why is hyperglycemia much more common in preterm than term infants (2)?
- Preterm infants have limited insulin secretion capacity,
- which limits glucose disposal and activates hepatic glucose production, both of which lead to hyperglycemia
- many preterm infants are growth restricted and have experienced, or do so after birth, intermittent to persistent hypoxia, which increases secretion of catecholamines (largely norepinephrine) that further suppress insulin secretion.
53
When care is aimed at lowering blood sugar, what should be included (3)?
- changing the fluids,
- treating sepsis,
- medications (eg: insulin infusion) and
- providing developmentally supportive care.
54
How does intermittent hypoxia and stress contribute to hypergylcemia?
- Intermittent hypoxia and other forms of stress also increase hepatic glucose production via increased secretion of cortisol, glucagon, and growth hormone.
- Administration of catecholamines (suppress insulin secretion) also contributes to hyperglycemia
55
What is the oxygen supply and demand?
- if body cells are not supplied with oxygen: wont function properly
- balance between oxygen supply and demand influence end-organ perfusion
- all organs are interrelated, inadequate supply in one organ will impact functioning of others
56
What are 3 main factors that determine oxygen supply?
- AMOUNT of oxygen that is present in arterial blood when it leaves lungs (SaO2)
- CAPACITY of the blood to transport oxygen (Hgb)
- EFFECTIVENESS of the pump that circulate the blood throughout the body (cardiac output)
57
What is ventilation?
- the movement of air in and out of lungs
58
What are 2 factors that influence ventilation?
- respiratory rate (30-60bpm)
- tidal volume (size of breath)
- both are influenced by work of breathing (lung compliance, respiratory muscle function, airway resistance)
59
What is respiratory muscle function?
- the "pump" whose function is to move air in and out of lungs
- respiratory muscles, rib cage, anterior abdominal wall
60
Whats lung compliance (WOB) decrease compliance? increased compliance?
- a measure of distensibility of a tissue (ease of inflation)
- decreased compliance: requires more pressure within the lungs to inflate
- increased compliance: requires less pressure required within lungs to inflate
61
Whats airway resistance (WOB)?
- the resistance of respiratory tract to airflow
- airway resistance is increase due to reduced airway diameter (edema) NOT lung volume
62
What is work of breathing? What factors affect WOB?
- the amount of effort used to expand the lungs on inspiration
- doesn't refer to expiration
- factors: airway resistance, lung compliance, respiratory muscle function
63
Whats lung volume (4)?
- tidal volume (TV): amount of air breathed in or out during normal respiration
- inspiratory reserve volume (IRV): additional air that can be inhaled after a normal tidal breathe
- expiratory reserve volume ERV): additional air that can be pushed out after normal expiration
- residual volume (RV): amount of air that is always in the lungs and can never be expired (after maximal expiration)
64
Whats lung capacities (4)?
- inspiratory capacity (IC): maximum volume which can be inspired after a normal expiration
- vital capacity (VC): amount of air that can be forced out of the lungs after maximal inspiration
- functional residual capacity (FRC): volume of air left in the lungs after a normal breath
- total lung capacity (TLC): total volume of lungs when fully inflated
65
What are 2 regulators of ventilation (control breathing)?
- central (brainstem) and peripheral (aortic arch + carotid arteries) chemoreceptors control breathing
- operate in a feedback loop
66
Where is central chemoreceptors vs peripheral chemoreceptors?
central chemoreceptors
- located in brainstem
- sensitive to PaCO2 levels
- control respiratory drive and rates
peripheral chemoreceptors
- located in aortic arch and carotid arteries (neck)
- sensitive to PaO2 levels
- regulate respiratory drive
67
What are the bad signs and symptoms of "work of breathing" by infant (4)?
- grunting
- nasal flaring
- tracheal tug
- indrawing (substernal, intercoastal)
68
What is a key determinate of arterial oxygen saturation and subsequently oxygen supply?
- exchange of gases across the alveolar-capillary membrane
- the two gas are exchanged: O2 and CO2
69
What 3 factors that affect alveolar gas exchange?
- ventilation
- perfusion
- diffusion
70
What are 4 factors affecting diffusion?
- thickness of alveolar capillary membrane: increase thickness will decrease rate of diffusion
- surface area of membrane: decrease in surface area will decrease rate of diffusion
- diffusion coefficient
- driving pressure
- solubility of gases: CO2 diffuses 20x more rapidly than O2
**CO2 level are primarily influenced by ventilation NOT diffusion
71
What is V/Q?
- V: ventilation: air that reaches the alveoli
- Q: perfusion: the blood that reaches the alveoli
- if V/Q are not matched: gas exchange cannot occur in this area of the lung
- V/Q matching: the amount of air that reaches the lungs equals the amount of blood flow in the capillaries in your lungs
**optimal gas exchange occurs when ventilated alveoli are also perfused (V/Q matching)
72
What are 3 gas exchange dependent on?
- Adequate ventilation
- Adequate respiration
- Adequate cardiac pump
73
What is dead space?
- ventilation with no perfusion (no blood flow)
74
What is intrapulmonary shunting?
- perfusion with no ventilation (fluids in alveoli)
75
What is hemoglobin affinity for oxygen mean?
- The strength at which the oxygen binds to hemoglobin has important clinical implications
- If it binds too loosely the hgb may give up its oxygen before it reaches the tissues
- If it binds too tightly it may not transfer to the tissues at all
76
Whats dissociation of oxygen?
- To release (“dissociates”) oxygen on demand, the hemoglobin affinity for oxygen needs to shift with the metabolic demand of the tissues
- for this reason, SpO2 are not a good indicator for PaO2 levels**
- The efficiency of the oxygen transport system depends on the ability of the hemoglobin molecule to bind oxygen in the lung and to release it at the tissue level on demand
77
What is the oxygen dissociation curve?
- at tissue: O2 leaves the blood + Hgb and enters into cells "O2 dissociates" (low SaO2, low PaO2)
- at lungs: oxygenated blood leave the alveoli and jump on Hgb "O2 binds" (high SaO2, high PaO2)
78
What happens when oxygen dissociation curve shifts to the right? to the left?
curve shifts to the right (decreased affinity):
- when you shift curve to right: you decrease y-axis (SaO2)
- which means there is less O2 on the Hgb so therefore O2 must be in the tissue
- shift to the Right --> increase release of O2 from Hgb to tissue
- causes: acidosis, fever, elevated PCO2
curve shifts to the left (increased affinity)
- when you shift the curve to the left: you increase the y-axis (SaO2)
- which means there is MORE O2 on the Hgb therefore O2 must be away from tissue
- shift to the Left --> decrease release of O2 from hgb to tissue (with left shift, tissue if left behind)
- causes: alkalosis, hypothermia, low PCO2
79
What is oxygenation best assessed by?
- arterial PaO2
80
What system controls the cardiovascular (heart) function?
- autonomic nervous system
- alters heart rate
- alters stroke volume
81
What is cardiac output (CO)?
- the volume of blood pumped by the heart per minutes (mL blood /min)
- ie. CO in mL/min = HR (beats/min) x SV (mL/beat)
- increasing either heart rate (HR) or Stroke volume (SV) increases cardiac output
***neonatal CO depends more on HR than SV
82
What 3 factors effect stroke volume?
- preloads: The stretch on the heart before it contracts (volume in ventricle)
- afterload: The pressure that the heart must overcome before ejection of blood from the ventricles (resistance)
- contractility: the forcefulness of contraction of individual ventricular muscle fibers (strength of contraction)
83
How is Mean arterial pressure (MAP) calculated?
MAP = [2 (diastolic BP) + (systolic BP)] / 3
- represents the average blood pressure in the systemic circulation
- good indication of organ perfusion
- ie. if infant is 24 weeks then MAP should be above 24
84
What affects BP in neonates (4)?
- gestational age
- chronological age
- corrected age
- birth weight
85
What is oxygen demand?
- oxygen consumption will increase or decrease as result of metabolic demands
- increased metabolic demands: hyperthermia, increased activity, stress
- decrease in metabolic demands: activity is diminished, hypothermia
86
How do you know if oxygen supply is not meeting oxygen demand of body (each organ)?
Assess adequacy of end-organ perfusion:
- brain: bleed from HUS
- heart: increase HR
- lungs: apnea, low sat
- gut: NEC, increase girth, feeding intolerance
- liver: see lab values (bilirubin)
- kidneys: low urine output, decrease creatinine
- tissue perfusion: cyanosis, pale, cold to touch
87
What are the sequence/steps of cell injury (7)?
supply not meeting demand --> decrease oxygen to cells --> body switch to anaerobic metabolism --> lactic acid production --> toxic chemicals to bloodstream, vessel wall damage --> failure in Na/K+ pump --> cell death (if enough cells die then organ failure)
88
Does a decrease in arterial oxygen saturations can result in an increase in the respiratory rate?
- yes, true
89
Does a bolus of NS increase preload?
- yes, true
90
What are the 5 phases of normal lung growth in neonate?
- embryonic: week 3 - 6
- pseudoglandular: week 6-16
- canalicular: weeks 16-24 (appearance of surfactant)
- saccular: weeks 24-40 (development of gas-exchange sites)
- alveolar: birth to 2 years (expansion of surface area)
91
What does surfactant do (3)?
- reduces surface tension at the air-liquid interface of the alveolus
- prevent alveolar collapse (atelectasis) at end expiration and loss of lung volume
- Maintain functional residual capacity
- Decrease the pressure required to inflate the lungs
- decrease surface tension and increase compliance
- Production is decreased in the presence of hypoxia
- Production is increased with the administration of prenatal corticosteroids
92
What are consequences of lack of surfactant (3)?
- atelectasis: leads to intrapulmonary shunting owing to perfusion of unventilated lung = hypoxia
- pool alveolar (pulmonary) compliance
- decreased gas exchange
- severe hypoxia, and acidosis
93
What does surfactant dysfunction/inactivation increase risk for (3)?
- Acidemia (hypercapnia)
- Hypoxia
- Acute respiratory distress syndrome due to GBS sepsis
- meconium aspiration syndrome (MAS)
- pneumonia
- pulmonary hemorrhage
94
What is respiratory distress? signs and symtoms?
- difficulty breathing
- physically laboured ventilation or respiratory efforts
signs and symptoms:
- tachypnea
- increased work of breathing
- retractions
- nasal flaring
- grunting
***all of the above result in increased oxygen demand + increased energy output
95
What are the 5 most common causes of respiratory distress?
- Meconium aspiration syndrome (MAS)
- Pneumonia/infection
- Pneumothorax
- Respiratory distress syndrome (RDS)
- Transient tachypnea of the newborn (TTN/wet lung)
96
What is RDS? What does it leads to? Preventions?
- RDS is the result of anatomic pulmonary immaturity and deficiency of surfactant
- restrictive lung disease
- common in preterm <32 weeks
- Characterized by poor gas exchange, respiratory acidosis and ventilatory failure
- RDS remains the most common single cause of death in the first month of life in the developed world
- Also known as hyaline membrane disease
- RDS leads to: atelectasis, increased WOB, respiratory acidosis, hypoxemia
Preventions:
- antenatal steroids to promote lung maturation
- Supplemental oxygen
- Exogenous surfactant administration
- CPAP – continuous positive airway pressure
- Mechanical ventilation (invasive and noninvasive)
- Supportive care
97
What does exogenous surfactant do (2)? complications (3)?
- Reduction in surface tension
- Dramatic and rapid improvement in gas exchange
- Decrease oxygen requirement and ventilatory support, hence less barotrauma
- Improves lung compliance and volume
- administered via ETT, by RT/ITT/MD, within first 2 hours of life is
complications:
- Pulmonary hemorrhage
- ETT blockage
- Apnea, Desaturation – hypoxia or vagal response
- Hypotension
- Delivery to only right lung (if ETT in wrong spot)
98
What are acute and chronic complications of RDS (3 each)?
Acute Complications
- Patent ductus arteriosus (PDA)
- Pulmonary hemorrhage
- Apnea/bradycardia
- Necrotizing enterocolitis (NEC)
- Hypertension
Chronic complications:
- Bronchopulmonary dysplasia (BPD)
- Retinopathy of prematurity (ROP)
- Failure to thrive
- Intraventricular hemorrhage (IVH)
- Periventricular leukomalacia (PVL)
99
What is needed when supplementing oxygen to infants? how can it be given?
- ensure infant is on saturation monitor
- maintain saturations within safe level
- attach to blender to titrate oxygen concentration
***oxygen is a drug with serious side effects
can be given by:
- incubator
- low flow nasal prongs
- flow inflating bag and mask
- via the circuit of invasive and non-invasive ventilatory support
100
What is CPAP? benefits (3)?
- Provides a continuous low pressure to maintain alveoli open
**** Used in Infant with respiratory drive
CPAP benefits
- Establish FRC
- Recruit collapsed alveoli (over a period)
- Prevents atelectasis
- Minimizes lung injury
- Preserves the functional properties of surfactant
- Allows for a reduction of oxygen concentrations
- May reduce the need for mechanical ventilation
101
What is mechanical ventilation used for (3)?
used to correct abnormalities:
- Oxygenation (low PaO2)
- Alveolar ventilation (high PaCO2)
- Respiratory effort (apnea, WOB)
102
What is Transient tachypnea of the newborn TTN? signs (3)?management (3)?
- obstructive lung disease: airway obstruction
- An excessive amount or a delay in removing lung fluid after birth
- Late preterm born via s-section without labour
- Other predisposing factors include low birth weight, maternal diabetes, macrosomia, male sex
Clinical signs and symptoms include:
- tachypnea, grunting, retractions, mild cyanosis
- milder symptoms (usually) than other forms of respiratory distress
Management:
- Clinical monitoring of respiratory status and infant stability
- Monitoring for evidence of PPHN or shunting
- Fluids and glucose support as indicated
- Delay oral feeding but offer OIT
- Developmental supportive care
103
What is pneumonia?
- Lung infection acquired from the maternal genital tract or the NICU
- Onset may be within hours after birth or after 7 days
- Early-onset is usually involved with generalized sepsis
- Late-onset is most common with prolonged endotracheal intubation (VAP)
- Respiratory distress: ventilation support
- treatment: Course of antibiotics (typical 7 days)
104
What is meconium aspiration syndrome? Leads to (3)?
- MAS describes a spectrum of disorders of infants born through meconium-stained amniotic fluid (MSAF), without any congenital respiratory disorders or other underlying pathology.
Can lead to:
- Airway obstruction
- Fetal hypoxia
- Infection
- Pulmonary inflammation
- Surfactant inactivation
- PPHN
105
What is pulmonary air leaks (pneumothorax)? signs? diagnosis? treatment?
- Common complications of mechanical ventilation
- Involve dissection of air out of the normal pulmonary airspaces
signs and symptoms:
- sudden deterioration (hypotension, desaturation)
- bradycardia, muffled heart sounds, PMI shift
- decreased breath sound on the affected side
diagnosis:
- transilluminating the chest
- Chest x-ray
treatment:
- oxygenation
- Removal of air via needle aspiration/chest tube placement
106
Why is pulmonary air leaks common and severe among neonates with lung disease (3)?
- poor lung compliance and the need for high airway pressures
- prematurity, RDS, pneumonia
- air trapping which leads to alveolar overdistention
107
What are the 4 types of air leaks?
- air escapes into spaces inside one or both lungs (PIE)
- air escapes into spaces between the lungs (Pneumomediastinum)
- air escapes into spaces around the heart (Pneumopericardium)
- air escapes into spaces around the lungs
108
What is bronchopulmonary dysplasia (BPD)?
- BPD is a form of chronic lung disease
- defined as: “Oxygen requirement at 28 days with consistent radiologic changes and/or
- continuing need for oxygen therapy at 36 weeks corrected gestational age”.
infants with BPD may have:
- abnormal respiratory function
- asthma-life symptoms
- airway problems
** babies with BPD have fewer, larger alveoli with thicker walls (which makes it harder for baby to breath)
seeing less BPD due to (have altered clinical picture):
- antenatal steroids
- surfactant
- use of CPAP
- decreased use of oxygen
109
What are the 4 distinct clinical and pathological stages of BPD?
- progressing from typical RDS
- alveolar interstitial edema and atelectasis
- massive fibrosis and consolidation of lung
- areas of cystic emphysema and overinflation
110
What complication does pulmonary hypertension PPHN leads to (3)?
- pulmonary edema and congestive heart failure
- complications including BPD spells
- inability to wean from oxygen
- recurrent infections
- developmental delays
- sudden death
- gastroesophageal reflux
111
What is BPD management (3)?
- Slow and regimental wean on ventilatory support
- Strict saturation targets
- Permissive hypercapnia
- Nutritional and feeding support
- Cardiac support for PDA, PPHN
- Routine monitoring of ROP
-Support neurodevelopment
- targeted use of steroids: DART, stop "BPD"
- caffeine
- diuretics
- DSC
- family involvement
- RSV prophylaxis on discharge
112
What is the difference between DART protocol and SToP- BPD?
DART:
- Dexamethasone: A Randomized Trial (DART Protocol)
- Late (> 7 days) corticosteroid therapy
- Typically 10-day course systemic steroids
- Reduce lung inflammations
- Provides a window to “wean” ventilatory settings/support, oxygen requirement
- Aim to extubate
- Affects neurodevelopment outcome
STopP-BPD:
- Systemic Hydrocortisone to Prevent Bronchopulmonary Dysplasia in Preterm Infants
- Use of early low-dose prophylactic hydrocortisone for prevention of BPD (infants <28 weeks) especially for infants born to mothers with suspected/confirmed chorioamnionitis, and who did not receive antenatal steroids
- Lower dose, longer course
- Increase risk of late onset sepsis
