Neonates/peds Shellie final

Key developments of the Canalicular stage

• Capillary development

• Appearance of immature surfactant: remember that the development of both the capillaries and the presence of surfactant makes the very immature fetus viable for life around week 22 that can result in gas exchange. It may not be extremely effective, but it can result in viability with the assistance of technology.

• Development of acinar units, aka terminal bronchioles

• 22-24 weeks

What age will most alveoli be present?

After birth, the alveoli continue to develop increasing in numbers until 8 years of age

Oligohydramnios definition

Too little amniotic fluid

Polyhydramnios definition

Too much amniotic fluid

Association between oligohydramnios and lung hypoplasia:

• Failure of the lungs to develop in utero

• Lung compression

• Chest wall abnormalities

• Oligohydramnios

• Hormonal imbalances

What is the function of type 2 pneumocytes?

production, secretion, storage, and reuse of surfactant

What's the function of Wharton's jelly?

• prevents kinking of the cord

• protects the vessels within the umbilical cord

What organ develops completely first and what is the timeline for the development?

• The heart

• 3rd gestational week - fully functioning by week 8

Describe the flow of fetal circulation:

• Placenta -> umbilical vein -> ductus venosus -> inferior vena cava -> right atrium ->

◦ Deoxygenated blood from head and upper torso comes from superior vena cava -> some gets recycled into the right ventricle -> pulmonary artery -> ductus arteriosus -> aorta -> out to body

◦ part that doesn't (oxygenated) flows through foramen ovale -> left atrium -> left ventricle -> aorta -> out to body

• descending aorta -> umbilical arteries -> placenta

Where does gas exchange occur during fetal circulation?

It doesn't get oxygenated from the lungs in normal adult circulation, instead the oxygenated comes from the mother's placenta

What are the adverse effects of a mother who smokes while pregnant?

• carbon monoxide and nicotine decrease the availability of oxygen to the fetus and placenta (vasoconstriction on maternal side)

• lower birth weight, premature rupture of membranes (<37 weeks), placental abruption, placenta prevails and risk of SIDS

• lowers birth weight approx. 200 g less

What's are the adverse effects associated with premature rupture of the membrane?

• if the membrane ruptures before term (<37 weeks) or before the onset of normal labor at term (makes for non sterile environment which increases the risk of fetal infection)

• Volume of the fluid decreases may result in the compression of the umbilical cord which would compromise blood flow between placenta & fetus

What is the primary function of tocolytics and when are they used?

• medications used to suppress uterine contractions or inhibit labor (INMT)

• preterm labor <32 weeks

Omphalocele definition

membranous sac that encloses the abdominal contents into the umbilical cord

Define the actions necessary to ensure delivery room resuscitation for the term neonate

• Availability of skilled personnel

• Maintain warmth

◦ Provide/maintain airway

◦ Obtain vascular access

◦ Provide resuscitative drugs

• Rapid and skillful assessment of neonate condition

• Interventions appropriate to that condition

When should chest compressions be initiated and what is the compression to ventilation ratio?

- when HR <60 or 60-80 bpm and not rising

- 3:1 (90 compressions & 30 ventilations / minute)

When should PPV be initiated?

- HR <100

- shallow, slow, or absent respirations

What are the ethical scenarios that may deter the team from initiating resuscitation in the newborn?

• Extremely premature infants

• Congenital birth defects

• This does not preclude withdrawing life support later

◦ More time to gain better clinical information and counseling the family on outcomes

• Organ donation

• anencephaly

What is the scoring tool used to assess gestational age?

Ballard score

What is the scoring tool used to assess the severity of respiratory distress in the newborn?

Silverman scoring

Ballard score definition

Examination for estimating gestational age using scores based on 6 neuralgic and 7 physical signs (score 0 = 24 weeks) (score 40 = 40 weeks)

Silverman scoring definition

Assesses retractions, auscultation, chest and cardiovascular, and abdomen (5 areas scored form 0-2) - the higher the score, the more amount of respiratory distress (10 = significant respiratory distress)

Describe the appropriate sequence of action that should occur immediately following delivery of a healthy baby:

• place the infant on a a preheated radiant warmer

• position the infant with neck slightly flexed (sniffing position)

• place a small roll under the shoulders

• drying and warming

• suction (if necessary)

• stimulation

• quick visual inspection

• respiratory effort

• HR

• color

The Presence of both vascularization and surfactant are required for a fetus in the canalicular phase to be viable for life

True

Why are retractions more prominent in neonates rather than adults?

• Skin recesses around bones due to increased pressure gradient

• Musculature is thin and weak

• Thoracic cage is less rigid

What is the criteria that defines ventilatory failure in a neonate who requires intubation?

• Ph <7.20

• CO2 >60

ETT size & depth for a pediatric patient (> 1 yr old)

ETT= (age/4) + 4

Depth= ID x 3

ETT size, depth, and Fr for <1000 gm

2.5 ETT -> 7 cm depth -> 6 Fr

ETT size, depth, and Fr for 1000-2000gm

3.0 ETT -> 8 cm depth -> 6-8 Fr

ETT size, depth, and Fr for 2000-3000gm

3.5 ETT -> 9 cm depth -> 8 Fr

ETT size, depth, and Fr for 3000-4000gm

3.5-4.0 ETT -> 9-10 cm depth -> 8-10 Fr

ETT size, depth, and Fr for infant - 1 yr

4.0-4.5 ETT -> 10-12 cm depth -> 10 Fr

What's the purpose of providing a small roll or towel under the occipital of a child during intubation?

To keep the child in sniffing position w/ a slightly flexed neck

What's the proper ETT placement in the neonate in regard to CXR?

1-2 cm above carina

What is the most common cause of death for a trach dependent child?

• Tube obstruction

• Accidental Decannulation

What supplies should be available at bedside for a child with a tracheostomy?

• trach of correct size

• trach one size smaller

• obturator

• trach ties

• trach care supplies

• water soluble lube

Describe the appropriate process for utilizing a closed system suction catheter in a neonatal or pediatric patient with an ETT

• Pressures: -60 to -80 ELBW/ -80 to -100 neonatal/ -100 to -120 pediatric

• external diameter of suction catheter must be < ½ of the internal diameter of ETT

◦ 2.5 ETT - 6 Fr

◦ 3.0 - 6 to 8 Fr

• increase FiO2 10-20% above FiO2 for infants

• children: 100% FiO2 for at least 1-2min before suctioning

• suction no longer than 10 sec w/suction applied no longer than 5 sec

• length of suction catheter placement is lined with the markings of ETT

◦ Ex. 12 cm catheter marking aligned with 12 cm ETT marking

• if unable to obtain secretions advance ½ cm more

• suction catheter should be past end of ETT but doesn't touch carina

Pros of a self inflating bag

• don't need compressed gas source to inflate

• pressure-limited pop off valve makes barotrauma less likely

Cons of a self inflating bag

• must be placed onto an external oxygen source (or else will deliver RA)

• must have a reservoir attached to deliver high concentrations of oxygen

• minimizes control over breath size, pressure, and i time

• difficult in determining a good seal on a patient's face

• cannot deliver FiO2 free flow

• requires a PEEP valve

• cannot give CPAP (without PEEP valve)

Pros of a flow inflating bag

• Ability to deliver free-flow* i oxygen/CPAP through the mask

• if not a good seal bag will deflate

• ability to build compliance of the lungs when squeezing the bag

• reliable FiO2 delivery

Cons of a flow inflating bag

• Requires gas source to inflate

• requires a tight seal

• requires an adequate flow (8-10 lpm)

Clinical indicators for the initiation of CPAP

• Premature Infants

• Obstructive and restrictive lung disease

• To improve oxygenation

• Effective option for preventing extubation failure

• Pneumonia

• TTN (transient tachypnea of newborn)

• MAS (meconium aspiration syndrome)

• Paralysis of a hemidiaphragm

• Congestive heart failure, pulmonary edema, and pulmonary hemorrhage

What are the contraindications for nasal CPAP?

• Consistent PaCO2 > 60 mm Hg

• pH < 7.25

• Upper airway abnormalities (Choanal atresia, cleft palate, tracheoesophageal fistula, or preoperative diaphragmatic hernia)

• Neuromuscular disorders

• Infants receiving CNS depressant medications

• Central or frequent apnea resulting in desaturation or bradycardia

• Severe cardiorespiratory instability

• Poor respiratory drive

Describe how positive pressure is initiated in a bubble CPAP system and how to ensure the proper pressure level is established during administration of Bubble CPAP

• A water column is filled to 10 cm w/ sterile water or 25% acetic acid solution

• Small pressure fluctuations are created by the back pressure of bubbles in the underwater seal are transmitted to the airway

• A pressure manometer reading the pressure being delivered as well as the amount of bubbling present

What is the proper flow required for a Bubble CPAP system?

8-10 lpm

What can occur when the flow is too low on bubble CPAP?

• Inadequate ventilation

• Rebreathing of carbon dioxide

• Severe respiratory failure

What can occur when the flow is too high on bubble CPAP?

• Increased resistance to breathing (leads to increased WOB)

• Comprises gas exchange

Advantages of CPAP over mechanical ventilation

• Decreases the risk of barotrauma

• Decreases WOB

• Improves:

◦ PaO2

◦ Lung mechanics

◦ V/Q ratio

◦ Distribution of ventilation

• Reduces thoracoabdominal asynchrony

• Stabilizes chest wall

• Maintains FRC

• Keeps alveoli open

• Results in better gas exchange

• Allows for spontaneous breathing

What signifies the need to wean CPAP?

• The patient is stable

• No incidents of apnea

• Exhibits acceptable vital signs, blood gas values, and chest radiographic findings

Amplitude definition

the peak-to-peak oscillatory pressure measured at the airway opening (Vt-ventilation)

When to increase amplitude?

more ventilation (removes CO2)

When to decrease amplitude?

less ventilation (increases CO2)

Mean airway pressure definiton

Constant distending pressure (PEEP-oxygenation)

When to increase MAP?

more oxygenation (will expand lungs more if they're hypoexpanded)

When to decrease MAP?

less oxygenation (will decrease expansion for the lungs if they're hyperexpanded)

Hertz definiton

the number of breaths per minute or how fast the high frequency waves are delivered (rate-ventilation)

When to increase hertz?

less ventilation (lowers Vt = more CO2)

When to decrease hertz?

more ventilation (increases Vt = less CO2)

How would you determine if a patient has an airway obstruction in a patient receiving HFJ?

Decreased Servo

Define surfactant replacement therapy and how it is beneficial

• Creates an air-liquid interface that reduces surface tension

• Increases lung compliance

• Promotes homogeneous gas distribution during inhalation

• Allows residual volume gas to be evenly distributed throughout the lung during exhalation

• Maintains FRC

Indications for surfactant replacement therapy

• Prematurity/RDS

• Pulmonary Hemorrhage

◦ Blood is a strong inactivator of surfactant

• MAS

• PNA/Sepsis

◦ Combination of edema and leak of plasma proteins into the alveolus leads to surfactant dysfunction.

◦ CDH

◦ ECMO

What's the purpose of prophylactic surfactant administration?

Given within the first 15 minutes of life

• improves oxygenation

• decreases ventilatory requirements

• fewer pneumothoraces

What's the purpose of rescue surfactant administration?

Provide early rescue (therapeutic) surfactant for those infants with evidence of moderate to severe RDS on chest radiograph and FiO2 above 30% to 50%

LISA definition

Less invasive surfactant administration

MIST definition

Minimally invasive surfactant therapies

What method of surfactant administration is preferred in the United States?

ETT (InSURE)

What's the leading cause of death in premature infants?

RDS

Hazards associated with surfactant replacement therapy

• Obstruction/Plugging

• Desaturations

• Bradycardia

• Unequal administration

• Administration of suboptimal dose

• Apnea

• Pulmonary Hemorrhage

• Volutrauma

• Expedited need to treat a PDA

Proper dosage of Curosurf

• 1st dose- 200mg/kg/dose (2.5mL/kg)

• repeat dosing- 1.25 mL/kg Q12 (up to 2 total doses)

What is the composition of surfactant?

• 90% lipids (80-85% phospholipids)

• 10% proteins (SP-A {most abundant}, B,C,D)

What are the risk factors associated with Bronchopulmonary dysplasia (BPD)?

• Lung immaturity

• Respiratory failure

• Oxygen supplementation

• Positive pressure mechanical ventilation

How can hyperoxia lead to oxidative lung injury?

During the acute phase:

• Hyperoxia worsens oxidative lung injury

• Intermittent hypoxia has been shown to also cause lung injury

What's the clinical presentation of a Congenital Diaphragmatic Hernia (CDH) patient?

• Lung tissue is hypoplastic including the pulmonary vasculature

• Hypoxia, hypercapnia, and acidosis develop causing constriction of the arterioles

◦ Exacerbates pulmonary hypertension and persistent fetal circulation

What is the proper treatment that should occur immediately in the delivery room for a CDH patient?

• Large 10 Fr NG tube is inserted to remove swallowed air

• ETT is inserted and Pt is ventilated very gently

• MASK VENTILATION IS CONTRAINDICATED

• avoid high pressure ventilation

What ventilator strategy is appropriate for a meconium aspiration (MAS) patient?

Mechanical ventilation:

- high peak pressures (30-35)

- long Ti (0.4-0.5)

- slow rates (20-25)

HFV:

- low pressures

- high frequencies

(decrease risk of barotrauma and increase mobilization of secretions)

What can trigger PPHN in the CDH patient?

• Hypoxia

• hypercapnia

• acidosis

• hypothermia

What ventilator strategy is most effective for the CDH baby?

• Keep PaO2 >/= 150 mm HG

• Relative alkalosis : pH >/= 7.44

• Usually maintained with PaCO2 levels : 25-30 mmHg

• low pressures

• low Vt

• short Ti

• cuffed ET tube

Effective strategies for management of the BPD patient

• Use gentle ventilation (low tidal volumes, permissive hypercapnia)

• Prefer non-invasive support (CPAP, NIPPV) when possible

• Avoid oxygen toxicity — target SpO₂ around 90-95%

• Early surfactant using LISA/INSURE techniques

• Give caffeine to reduce apnea and support breathing

• Use diuretics to reduce pulmonary edema

• Consider steroids (like dexamethasone) if prolonged ventilation

• Trial bronchodilators if airway reactivity suspected

• Provide adequate calories and fluid management

• Treat significant PDA to reduce lung stress

• Prevent infections (strict hygiene, RSV prophylaxis)

• Ensure multidisciplinary follow-up (pulm, nutrition, therapy)

What is the preferred Xanthine for the management of BPD?

Caffeine

What is the most common cause of TTN?

C-section delivery w/out labor

What is the clinical presentation of a TTN baby?

• Tachypnea possible cyanosis within the first few hours after birth (“comfortably tachypneic”)

-crackles or diminished breath sounds

-Nasal flaring,

- grunting,

- retractions

- cyanotic

-CXR: pulmonary vascular congestion, prominent perihilar streaking, fluid in interlobular fissures, hyper-expansion, flat diaphragm

-ABG: mild to moderate hypoxemia, hypercapnia and respiratory acidosis

What is the proper treatment for TTN?

• supplemental O2

• CPAP

• IV fluids

• fluid restrictions

What are the proper techniques associated with determining the presence of a pneumothorax?

• Transillumination (fiberoptic light placed against chest wall)

◦ Affected hemithorax will light up in presence of pneumothorax

• CXR is gold standard for diagnosis except in rapid situations

What's the clinical presentation of a choanal atresia baby?

• Complete nasal obstruction can cause immediate respiratory distress that requires intubation or an oral airway

• 1st breath: tongue comes in contact with the hard and soft palates creating a vacuum

• Bilateral atresia: intermittent cyanosis cycling with momentary relief from obstruction

• Unilateral Atresia: may not cause acute respiratory distress and may present as unilateral mucoid discharge

What is the proper care for a post op choanal atresia baby?

• Ensuring proper breathing, feeding, and overall recovery

• Avoid re-stenosis of choanae

What occur physiologically when meconium is aspirated?

• Causes cytokine release, serious airway obstruction, air trapping, enhanced growth of bacteria

• Enzymes in meconium can break down certain surfactant components

What are the clinical indications of a pneumothorax?

Rapid clinical deterioration resulting in:

• Cyanosis

• Hypotension

• Hypoxemia (often rapid decline in SpO2)

• Hypercapnia

• Respiratory acidosis

Unilateral pneumothorax:

• Breath sounds decreased on ipsilateral side (affected side)

• Cardiac apex shift towards contralateral side (unaffected side)

Tension pneumothorax: signs of shock

Tracheoesophageal fistula (TEF) definition and how it develops

• Potential aspiration of saliva or gastric secretions through a fistula between the esophagus and trachea

• Condition starts when the separation of the foregut and the trachea fails to occur

What syndrome is often associated with TEF?

VACTERL syndrome:

• Vertebrate

• Anus

• Cardiac (heart)

• Trachea

• Esophagus

• Renal (kidneys & urinary tract)

• Limb and radius

What are the clinical indicators of CDH?

• Scaphoid abdomen (sunken)(key indicator)

• diminished breath sounds

• Respiratory distress

• Heart sounds shifted to unaffected side

Define the events that occur during the change from fetal to extrauterine life

Separation from the placenta results in increased SVR while initiation of ventilation in the lungs lowers PVR

Patent ductus arteriosus definiton

• During intrauterine life the Ductus Arteriosus acts as a shunt that allows the blood to flow from the pulmonary artery to the descending aortic arch which carries blood to the body.

• During extrauterine life it should close within 96 hours after birth, if it fails to close this is when a PDA is present.

What is a big factor that plays role in Patent ductus arteriosus closure?

Decrease in PgE2 + increase in Pao2 = closure

How does a PDA affect blood flow?

Left-to-right shunt;
blood from the aorta flows into the pulmonary artery which leads to increased pulmonary blood flow,
increased strain on the heart,
and possible damage to the lungs.

Atrial septal defect definiton

failure of the atrial septum to develop correctly or the foramen ovale to close

What are the clinical manifestations of atrial septal defect?

• Initially healthy w/ failure to thrive

• Difficulty feeding

• Turns blue occasionally especially after crying, feeding, burping, playing, sleeping on side

What are the anatomic alterations of atrial septal defect?

• LV is thicker walled and has a higher systolic pressure

• It's compliance during ventricular diastole is slightly lower than that of the RV

What happens to the flow in the heart with a atrial septal defect?

Blood flows from the left atrium to the right atrium via the ASD

Complete Atrioventricular Canal definition

• characterized by absence of a portion of the atrial septum and the ventricular septum, and the presence of a single, common atrioventricular (AV) valve
  

• Most common congenital heart lesion in infants with Down syndrome (trisomy 21)

What are the clinical manifestations of a Complete Atrioventricular Canal?

• Usually develop signs of heart failure in early life

◦ Respiratory Distress

◦ Pulmonary Edema

◦ Failure to Thrive

• Chest radiography usually reveals cardiomegaly and increased pulmonary vascular markings