Egan’s Chapter 48 Practice Questions:


Question Answer
what is the first step toward acquiring the specialized knowledge needed to practice neonatal respiratory care? thorough understanding of how the respiratory 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