RDS & Surfactant Flashcards
(110 cards)
1
Q
When was Surfactant deficiency determined to be the cause of RDS and when the first report of UAC for blood sampling?
A
1959
2
Q
In what decade was:
the first NICU in the world
phototherapy
& First PKU developed?
A
1960’s
3
Q
Who was the “mother of neonatology” who worked at Vanderbilt?
A
Mildred Stahlman-Initial research in Pediatric Cardiology–then moved in to premature lung dz, got grant for HMD research
4
Q
Who was the famous president’s baby born early (34.5 wks) and died from HMD?
A
JFK’s (Patrick Bouvier Kennedy)
5
Q
Baby Kennedy’s death sparked interest in research on?
Gave rise to what subspecialty? When?
A
Prematurity, specifically RDS
“Neonatology”–recognized in 1975
6
Q
When did NNP’s emerge as a role?
A
1970’s
7
Q
In 1970’s, what equipment became available?
A
Ventilators, ECMO (no sats, just ABG’s avail)
8
Q
When did certification for NNP’s develop?
A
1983
9
Q
What else happened in 1980’s besides NNP certification?
A
Jet vents
Pulse ox
Increased use perinatal steroids
Wide spread surfactant use
10
Q
When did FDA approve surfactant Therapy for RDS?
A
1990’s
11
Q
Bedsides Surfactant, what other treatments became available?
A
Partial liquid ventilation
HFOV
iNO-FDA approved for PPHN
12
Q
Along with the development of RDS, oxygen, ventilation, we created what?
A
BPD
13
Q
What is the most common diagnosis in NICU?
A
RDS
14
Q
RDS is characterized by?
A
Increased WOB, Grunting, Flaring
15
Q
What GA is affected by RDS?
A
All GA’s–but the causes differ
16
Q
If you are suspecting RDS, what are some differentials?
A
TTN
Pneumonia/Sepsis
Meconium Aspiration
Pulmonary
Hypoplasia/dysplasia
Symptomatic polycythemia
Pulmonary Hemorrhage
Perinatal Asphyxia
Pneumothorax
Congential cardiac
malformation
Chromosomal/Metabolic D/O
17
Q
What is another name for RDS?
A
HMD (hyaline membrane dz)
18
Q
Which group of infants has the highest rate RDS?
A
< 1500 gm
19
Q
More than ____ of ELBW’s have some type of respiratory distress
A
1/2
20
Q
RDS is characterized by development of?
A
Hyaline membranes (within the lung tissue)
-leakage of protein debris into airways–>can impair what surfactant is present
21
Q
How soon after a baby is born can Hyaline Membranes develop?
A
w/in 30 minutes
22
Q
RDS onset is with in _____ of birth
Gets worse/better over first 1-3 days
Improves/worsens gradually with duration usually 3-5 days
A
hours
worse
improves gradually
23
Q
True/False: TTN will show improvement w/in first 12 hours of birth.
A
True
24
Q
Name risk factors for RDS
A
Prematurity
Perinatal asphyxia
Maternal DM
C/S deliver
Absence of antenatal steroid
administration
Male
Caucasian
Multiple gestation
Surfactant dysfunction or
inactivation (MAS,
pulm. hemorrhage)
25
How is RDS prevented? (2 things)
Antenatal Steroids
| Prevent Asphyxia
26
When are Antenatal Steroids recommended?
24-34 wks (w/anticipated
| delivery situation
27
When are Antenatal steroids most effective?
>24 hours before delivery
28
What do Antenatal steroids reduce?
Neonatal death, development of RDS, IVH, & NEC
29
When does the benefit of Antenatal steroids begin to wane?
What could be done?
>1 wk before delivery
Repeat dosing--possibly
30
To prevent RDS, why would you want to prevent Asphyxia?
Asphyxia -->hypoxemia & acidosis-->reduce surfactant synthesis
31
What could you do to prevent asphyxia if in an outlying facility?
Transfer mom to experienced center if safe
32
What 8 things are noted in the clinical presentation of RDS?
1. Tachypnea (tries to increase CO2 & O2 exchange)
2. Grunting (attempt at PEEP)
3. Increased WOB
4. Cyanosis, Pallor, Lethargy
5. Poor Feeding
6. Apnea
33
What radiographic features are common to RDS? (5 things)
- Reticulogranular pattern (ground-glass)
- Air bronchograms
- Homogenously dense (wide-spread alveolar collapse)
- "white out" severe
- Low lung volumes
34
In absence of surfactant there is widespread?
Alveolar collapse with over-distension of open Alveoli
35
Reopening collapsed Alveoli requires what?
How is this clinically manifested in baby?
Increased pressure
Retractions during inspiration
36
Widespread alveolar collapse causes intrapulmonary shunting of?
How is this clinically manifested in baby?
blood past areas of atelectasis
Pulmonary HTN
37
Name the 4 steps in developing RDS.
1. Surfactant Deficiency
2. Alveoli Collapse
3. Atelectasis & V/Q mismatch
4. Hypoxemia and Respiratory Acidosis
38
Who's law explains why some alveoli collapse while others are over-expanded?
La Place law
39
What does surfactant do?
Decreases surface tension
40
The amount of pressure required to KEEP alveoli open during expiration is ________compared to complete loss of gas.
Minimal
41
During inflation, surface tension increases faster/slower?
If Alveoli are inter-connected, air will flow into smaller/larger Alveoli?
Faster
Smaller (keeping them the same size)
42
What does a lack of Surfactant cause? (5 things)
1. Increased pressure requirements
2. Decreased compliance
3. Decreased FRC
4. Decreased V/Q mismatch
5. R-->L shunting
43
If supportive therapy of RDS is successful, the repair phase begins on what day?
2nd day after birth
44
During repair, what happens to the debris?
What happens to the damage tissue?
What happens to edema?
It is phagocytosed
It is regenerated
It is mobilized into the lymphatic system-->diuretic phase of RDS (high UOP)
45
How is RDS Diagnosed? (6 things)
```
1. Arterial or cap blood gas:
PaCO2 near normal (d/t tachypnea) usually elevated
PaO2 low d/t hypoxia
2. Blood glucose: <40
3. CBC Hct : >65
4. Blood culture & CRP
5. AP and lateral CXR
6. Echo (if indicated)
```
46
Almost all NB's have elevated CRP's, how long do most nurseries wait to collect one?
12-24 hours
47
Name some complications of RDS (3)
1. Airleak (PIE, Pneumo)
2. Pulmonary Hemorrhage (hemorrhagic pulm. edema)
-L.V. failure & excessive
L-->R flow through PDA = over-circulation to lungs
3. BPD or CLD
-Abnormal lung repair following RDS
48
What is the tx of RDS? (5 things)
1. Nutritional support
- 60-80 mL/kg/day
- parenteral nutrition
2. Abx
3. Oxygen
4. CPAP or vent
4. Exogenous surfactant
- Surfactant deficiency
- Surfactant Deactivation (pulm. hemorrhage and MAS)
49
What 3 types of resp support can you provide to babies with RDS?
1. Intubation
2. CPAP
3. HFNC
50
When would you think about intubation for RDS (2 times)?
To support respiratory effort
| Give surfactant
51
What does CPAP provide?
1. Prevents end-expiratory alveoli collapse
2. Reduces WOB
3. Improves ventilation to perfusion V/Q
4. improve & maintain FRC
5. Recruitment
52
What are some draw backs to using humidified HFNC?
1. Pressure variable
2. Unpredictable
3. Unregulated
4. Not FDA approved
53
Name some treatment complications of RDS
1. Equipment issues
-keeping in place
-pressure necrosis of nasal
septum
-clefts in palates
2. Hyperoxic injuries
-ROP
3. Added lung injury
-Infection from prolonged
intubation
-BPD
54
Surfactant Provides: (6 things)
1. Thin layer at air liquid interface
2. lowers surface tension
3. Prevents Alveolar collapse w/expiration
4. Reduces pressure needed for next alveolar inflation
5. Maintains FRC
6. Improves compliance & thus WOB
55
What is surfactant made up of?
90% lipids
| 10% protein
56
What is the main phospholipid of surfactant?
DPPC (dipalmitoylphosphatidylcholine) or lecithin
57
Surfactant has a ________ head and a _______ tail
hydrophilic head
| hydrophobic tail
58
What cells make surfactant?
Type II pneumocytes
59
What is phosphatidylglycerol (PG) used for?
A marker for lung maturity
60
What are the names of the 4 surfactant proteins that make up surfactant?
1. SP-A
2. SP-B
3. SP-C
4. SP-D
61
What does SP-A do?
Which other protein has this characteristic?
Plays role in immune defense
Also SP-D too
62
What is characteristic of SP-B & SP-C? (4 things)
1. Hydrophobic
2. Essential for transiiton to a monolayer at the air-liquid surface
3. Facilitate absorption and spreading of DPPC-->lower surface tension
4. Commercially available
63
Name the three component types of surfactants
1. Nonprotein Synthetic Surfactants
2. Protein-Containing Animal Surfactants
3. Peptide-Containing Synthetic Surfactants
64
What do nonprotein synthetic surfactants contain?
What do they lack?
Contained DPPC
Lack SP-B
65
Name 2 nonprotein synthetic surfactants.
1. Adsurf
| 2. Exosurf
66
Name the 3 protein-containing animal surfactants and what they are made from
1. Curosurf (poractant)-Porcine (pig)
2. Infrasurf (Calactant)-Bovine/calf
3. Survanta (Beractant)-Bovine-cow
67
Name the type of Peptide-containing Synthetic Surfactant
Surfaxin (Lucinactant)
68
Do natural or artificial surfactants act faster?
This type also has lower incidence of what?
Natural
Pneumothorax and Mortality
69
Clinical trials comparing natural surfactants are ______________.
True/False: there are no differences in long-term outcomes between types of natural surfactants
Inconclusive
True
70
There is a new generation of synthetic surfactants (peptide-containing) produced due to what concerns?
Concerns from current synthetics and immunlogic/infectious complications from animal-derived
71
The new generation synthetic surfactant (peptide-containing) mimics what?
Actions of Natural surfactant proteins SP-B and SP-C
72
What is the name of the peptide containing synthetic surfactant?
Lucinactant
73
Lucinactant is superior to what?
Is their superiority proven from animal-derived?
The old synthetic surfactants
No
74
In what patients is prophylactic surfactant given?
The highest-risk patients
75
When is prophylactic surfactant given?
To whom?
Within 15 minutes of birth
< 26 wks or
26-30 wks without antenatal steroids or need intubation
76
When is Early Rescue Surfactant given?
To whom?
1-2 hours of age
< 30 wks at risk w/first signs of RDS
77
What is the latest time surfactant is given?
Why?
within 12 hours of age
To treat established RDS
Ventilated & at least 30-40% FiO2
78
True/False: Prophylactic or early surfactant is more beneficial than late in highest-risk populations
True
79
True/False: Surfactant dosing provides improved CPAP administration
True
| ~advocate for early tx & CPAP
80
When multiple doses are used, what do Meta-analysis suggest?
Reduction in pneumothorax and mortality
81
What is the greatest number of doses of Surfactant that can be given?
4
82
When should Surfactant be discontinued?
After 48 hours or w/minimal ventilator/O2 requirement
83
Name an advantage of Curosurf (versus Survanta and others)
It has a higher concentration, so less volume to lung, infant may handle it better
84
Is the dosing frequency the same among types of survanta?
No, some are 8 hrs, some are 12 hrs, etc.
85
What are some complications of surfactant? (7)
1. Quickly improved lung compliance and FRC
2. Air leak syndrome
3. Lung injury
4. Pulmonary Hemorrhage
5. Plugging of ETT
6. Administration to one lung
7. Lack of response
86
In pulmonary hypoplasia are both lungs or just one lung affected?
either both or one :-)
87
what 2 common conditions mentioned in lecture might lead to pulmonary hypoplasia?
1. CDH
| 2. Renal Anomalies
88
True/false: it is often difficult to diagnose the severity of pulmonary hypoplasia?
true
89
Is pulmonary hypoplasia fatal in preemies?
Yes, usually
90
What 5 types of anomalies can cause pulmonary hypoplasia?
1. Space occupying lesions (CDH, CCAM, Effusion)
2. Oligohydramnios (Renal anomalies, PPROM)
3. Skeletal anomalies (OI)
4. Neuromuscular (anencephaly)
5. Cardiac (HLHS, HRHS, pulmonary stenosis, ebstein's)
91
What is the risk of pulm. hypoplasia if PPROM occurs:
15 wks, ____%
19 wks, ____%
After 26 wks, ____%
80%
50%
near 0%
92
What is the treatments of PPROM? (2)
1. Amnioinfusion
| 2. Tracheal Occlusion
93
What are the risks of Amnioinfusion? (2)
1. Chorioamnionitis
| 2. Abruption
94
What is the benefit of amnioinfusion?
Increasing latency period & stimulating fetal lung growth
95
What should happen if Tracheal Occlusion is performed?
Delivery within 1 week
96
What happens with tracheal occlusion?
Increased lung blood flow and increased fetal lung volume (it's controversial)
97
True/False: Impairment of lung development directly corresponds to time in gestation when these structures are developing
True
98
What are 7 signs of Pulmonary Hypoplasia?
1. Immediate signs of RDS & cyanosis
2. Small or bell-shaped thorax
3. Flattening of faces or deformation ie. contractures
4. Resp Failure (w/in minutes)
5. Hypercarbia
6. Pulmonary Hypertension
7. Pneumothorax
99
What is the treatment for pulmonary hypoplasia? (7)
1. Supportive, similar to RDS
2. Assisted ventilation (HFO-is gentler, less expansion)
3. Exogenous Surfactant replacement
4. Decompression of pneumo
5. iNO
6. ECMO (if reversible-if not, it is a contraindication to ECMO)
100
What is the incidence of Pneumonia in infants w/resp distress (mostly term)?
5%
101
Pneumonia is the ____ most likely cause of resp distress?
3rd
102
What are the previously common pathogens to cause pneumonia?
GBS, E-Coli, H. influenza
103
What are the most recent pathogens to cause pneumonia?
E-Coli, GBS, CONS
104
Clinical signs of Pneumonia are indistinguishable from what?
RDS
| -there's surfactant deficiency
105
Bacterial pneumonia is usually accompanied by what?
Sepsis
106
True/False: the clinical signs of pneumonia include those of RDS, sepsis, shock
True
107
What are 2 signs of shock/sepsis?
Poor perfusion
| hypotension
108
With pneumonia, what would you see on CBC?
CRP?
Blood culture?
```
Leukopenia
Increased
Could have low yield
(w/maternal abx)
Tracheal culture
```
109
What would an x-ray taken later in Pneumonia course look like?
Infiltrates
110
What is the tx of pneumonia?
```
Abx
-Amp/Gent (broad range and synergistic effect)
-Narrow if org. ID'd
Exogenous Surfactant
Respiratory Support
```
