Question Answer
This normal part of the fetal circulatory system becomes a congenital defect if it doesn’t close at birth. Patent ductus arteriosus
With patent ductus arteriosus, these four physiological changes become problematic 1) volume overload 2) pressure overload 3) desaturation of blood 4) decreased net cardiac output
True or false, PDA may be present as an isolated defect, but never in combination with another congenital cardiac defect. False
PDA is more likely in a premature infant because of….. Decreased muscle development in the ductus arteriosus.
What pharmacological agent may be effective in closing the PDA in a premature infant? Indomethacin, a prostaglandin inhibitor
What pharmacological agent may be effective in closing the PDA in a term infant? none listed.
What hemodynamic results occur with PDA? Shunt increases the volume of blood causing 1)left ventricular overload 2)elecated left atrial pressure 3)pulmonary edema 4)CHF
If an infant in born in Colorado, what congenital disorder might they have? PDA
A continuous murmur is heard in infants with PDA false
CHF is a immediate result of PDA in the term infant. false, it does not present until weeks later
What methods are used to identify PDA? 1) echocardiography will show size 2) color doppler echocardiography will show the direction of flow across it and also disturbed pulmonary artery flow.
What treatment methods are available for PDA? Indomethacin for larger premature infants. Surgical closure via left thoracotomy.
What are contraindications for surgical PDA closure? If the clamped ductus increases pulmonary artery pressure and decreases systemic pressure, it is an indication of right to left shunt.
Describe a PDA. Patent ductus arteriosus is the failure of closure of this duct allowing oxygenated and deoxygenated blood to flow together through the pulmonary and cardic vasculature, and subsequently the systemic vasculature.
Describe VSD. VSD (ventricular septal defect) manifests in the septum that divides the right and left ventricles. There can be one or more, big or little, can be alone or in conjunction with other defects.
Ten percent of VSDs cause symptoms, true or false. true, they are the most common cause of CHF after the second week of life.
The infant with a small VSD will be asymptomatic. What happens with a larger defect? A L to R shunt will develop causing volume and pressure overload of the right ventricle. Sufficient decrease in PVR to become symptomatic by the second week of life, but others by 3 months of age.
Symptoms manifest sooner in premature or term babies? Premature
What is the logical result of increased pulmonary blood flow? 1)the size of the pulmonary arteries and left atrium increase 2) Increased size can cause mechanical obstruction of an airway and atlectasis. 3) low lung compliance results and leads to more resp infections and resp distress.
What is the logical result of decreased lung compliance? The right ventricle has increased pressure load and will fail.
A VSD can spontaneously close. True, small ones can close, large ones can become smaller. Either will lessen symptoms.
Clinical manifestations of VSD… 1)can be confirmed by echocardiography – showing location, number, size. 2)Shows associated defects like PDA, coarctation of the aorta, atrial septal defect, and R ventricular outflow obstruction
An infant who has VSD but is asymptomatic needs all but.. 1) immediate intervention 2) close monitoring 3) review for tetrology of fallot 4) review for septology of fallot 5) medication 6) a dacron patch
Describe ASD Atrial septal defect occurs when the foramen ovale remains open between the atria
When shunt occurs with ASD, is it L-to-R or R-to-L? L-to-R
An ostium secondum defect occurs in the same area as a VSD. True or false False, VSD occurs in the ventricular septum, and OSD occurs high in the atrium.
Which are the results of PFO? 1) increased L atrial pressure 2) volume overload on the right heart 3) regurge from the L ventricle to the R atrium 4) pulmonary congestion 5)blood from sup. vena cava causes arterial desat.
Question Answer
Etiology of Meconium Aspiration Hypoxia/Asphyxia, Gasping in Utero and Decreased rectal sphincter tone
What term babies can have meconium aspiration? Full term and post term
What is the composition of meconium? amniotic fluid and epithelial cells
In the Pathophysiology of Meconium Aspiration, the Ball-Valve obstruction results in what 4 things? air trapping, overinflation, alveolar collaps and pulmonary shunting
Chemical inflammation from Meconium aspiration causes what? Pneumonitis
When hypoxemia and acidosis from Meconium Aspiration are severe it leads to what? Persistent Pulmonary HTN
2 ways to prevent PPH from occuring d/t meconium aspiration are ob suctions nasopharynx during delivery, or intubate and suction infant at birth if not vigorous and crying per NRP guidelines
5 Clinical signs of Meconium Aspiration stained nails and cord, respiratory distress, Rhonchi, Metabolic Acidosis (ABG), Increased AP diameter and Hyperinflation on CXR (barrel chest)
Tx of Meconium Aspiration at birth includes CPT and Suctioning
Why do you want to keep PaO2 high after Meconium Aspiration? bc PaO2>100 helps prevent PPHN
Whay wouldn’t you use CPAP on infant with Meconium aspiration? CPAP causes overinflation and air leaks
Ventilation used in cases of meconium aspiration? mechanical ventilation or high frequency- NO PEEP
In severe cases after Mecnium aspiration, waht Tx is used? ECMO
Prognoses after meconium aspiration depends on what? degree of asphyxia and aspiration
What dx process is this describing: Severely incerased PVR with rt-lt shunting occurs in term or post term babies and can be related to a clinical condition or idiopathic Persistent Pulmonary Htn
Persistent Pulmonary HTN was formerly known as what Persistent Fetal Circulation
Primary PPHN is usually caused by what? anatomic malformations
Secondary PPHN is usually associated with what? a disease
If the baby is asphyxiated, the hypoxia and acidosis cause what to occur resulting in PPHN the pulmonary vasculature to constrict
4 disease processes that can lead to PPHN severe RDS, Meconium Aspiration, CDH, Sepsis
Clinical presentation of PPHN signs of respiratory distress, hypoxia with increased O2 requirements, swings in PaO2, Acidosis
3 ways to diagnose PPHN echo or cariac cath, hyperoxia test, and simultaneous preductal/postductal ABG’s
What is the hyperoxia test? place in 100% for 15 minutes and get ABG, if PaO2<50 infant has PPHN(or could be cardiac)
When simultaneously drawing ABGs from preductal/postductal sites, what result indicates PPHN present? shunting difference of 10-15
Tx for PPHN Keep PaO2 high(80-100+), wean O2 slowly, Hyperventilate , HFV, Nitric oxide, and ECMO
When hyperventilating a pt with PPHN, what do you want to keep you PaCO2 and pH between and why? PaCO2 20-30 and pH 7.45-7.55, mild pulmonary vasodilator
Why is HFV is used for Tx of PPHN? easy to creat alkalosis and decreases barotrauma
What does Nitric oxide cause? pulmonary vasodilation
Pharmacologic therapy for PPHN includes keep sedated, buffer the acidosis
What is Priscoline (Tolazoline hydrochloride), where must it be administered, and why? peripheral vasodilator given in the systemic side of the scalp so it can quickly reach the pulmonary system
What is Apnea of Prematurity and what is it associated with? no breathing for 20 seconds or greater, associated with bradycardia and desats
__% of all infants that present with Apnea of Prematurity are < __ grams 75%, 1250 grams
If a term infant presents with Apnea of Prematurity it is usually related to problems sucha as sepsis or respiratory distress
6 common causes of Apnea of Prematurity airway obstruction, CNS prematurity or disorder, Resp center depression, Temp instability, Sepsis, metabolic disorder
Tx of Apnea of Apnea of Prematurity involves what? treating the symptoms while looking for the cause
Ways to treat/find cause oo Apnea of Prematurity cardiac/apnea monitor, pulse ox, positioning, maintain temp, remove feeding tube, R/O sepsis, check ABG for acidosis or hypoxemia, bouncing bed, keep O2 los as possible, NCPAP, intubate/vent if necessary, Methylxanthines, and caffeine
Why is bouncing bed not a popular Tx for apnea of prematurity? danger of intraventricular hemorrhage
Name 3 congenital abnormalities of neonates Choanal Atresia, Treacheoesophageal Fistula, and Diaphragmatic Hernia (CDH)
What is Choanal Atresia? membrane or bony obstruction in nares, unilateral or bilateral, associated with other anomalies
3 Clinical signs for Choanal Atresia cyanosis, retractions, problems with feedings
Diagnosing Choanal atresia unable to pass a catheter down nare(s)
Tx for Choanal Atresia oral airway, hold feedings or use a special type of nipple, surgery for repair (a stent is placed during healing to hold open)
What is the definition of a T-E Fistula? a congenital interuption and or fistulous connection of the trachea and esophagus
4 Clinical signs of T-E Fistula excessive salive, drooling, choking, cyanotic episodes
Diagnosing T-E Fistula inability to pass NG tube into stomach, CXR(observe coiling of tube in esophagus), Esophageal pouch often filled with air
Tx for T-E Fistula place on abdomen and eleveate head 45 degrees, suction pouch, start IV or place Gtube, avoid agitation, trach if surgery to be delayed, surgical repair
What is a diaphragmatic hernia(CDH)? migration of abdominal viscera into the thoracic cavity
CDH occurs in how many births? 1in 3000
70% of Diaphragmatic hernias are on which side of the body? left side
Symptoms of CDH vary with what? degree of hernia and pulmonary hypoplasia
Clinical signs of CDH include scaphoid abdomen, respiratory distress, decreased BS on affected side, and mediastinal shift
A CXR of a pt with CDH would show what? air filled bowl in the thoracic cavity
What should you not do to Tx a pt with CDH do not bag/mask ventilate
Tx for CDH includes stabilize, place affected side down, keep vent pressures low to avoid barotrauma and pneumos, treat as PPHN (keep PO2>100, keep alkalotic, using HFV works well), ECMO, surgery to repair, outcome is improving
When is ECMO used to Tx CDH? used to stabilize and may also be needed after surgery
Question Answer
RDS is AKA Hyaline membrane disease
What is the etiology of RDS? Prematurity of pulmonary system leading to a deficiency of surfactant production
7 risk factors for RDS premature, birth wt < 1200g, males, multiple gestations, prenatal maternal complications, maternal diabetes, placental and cord problems
5 anatomical structures that are immature in an RDS neonate terminal air sacs, pulmonary vasculature, cehst wall, respiratory muscles, and CNS
lack of stable surfactant in RDS neonate leads to what 6 things atelectasis, hypoxia, hypercapnia, acidosis, damage to capillaries and alveolar wall
5 Clinical signs for RDS RR>60, grunting, retracting, flaring, cyanosis
Diagnosing RDS maternal hx, shake test, ABG’s, CXR, hypothermic, flaccid
RDS ABG’s would show what 3 things hypoxia, hypercapnia, mixed acidosis
How would a CXR appear in an infant with RDS underaerated, opaque, “ground glass”, air bronchograms
If an infant diagnosed with RDS dies after 72 hours what is it related to? complications
RDS has shown to be prevented maternally if given what? glucocorticoids for at least 24 hours before birth
What affect does glucocorticoids have? produces more type II cells, more lamellar bodies in type II cells and stable surfactant
Tx of RDS support pt/tx symptoms, O2, PPV, thermoregulation, surfactant administration
Complications from RDS include BPD from long term vent use, IVH(interventricular hemorrhage) which occurs in 40% of those under 1500g, infections, and PDA (d/t hypoxemia)
3 names of marketed surfactant and what they are made from Curasurf-pigs, Survanta- cows, Infasurf-minced cow lung
What disease is AKA RDS type II? ransient tachnypnea of the newborn (TTN, TTNB)
Etiology of TTNB retention of fetal lung fluid, term or near term infants, cesarean or precipitous deliveries
Risk factors for TTNB maternal sedation and asphyxia of the baby during labor/birth
Clinical signs of TTNB RR>60-usually very high, signs of respiratory distress, cyanotic
Babies with TTNB abg’s usually show what hypoxia with normal CO2
What would appear on the CXR of a baby with TTNB? streaky infiltrates
Tx for TTNB stabilize, tx symptoms, O2, NCPAP/ventilate, Positioning with CPT, Antibiotics
Why is there very few complications from TTNB bc the fluid causing it usually clears in 2-48hrs and the infant makes a complete recovery
3 ways a newborn can acquire Pneumonia transplacental, perinatal, and postnatally
This type of bacteria cross the transplacental route group B streptococci
4 diseases that can cross transplacentally(ToRCH) toxoplasmosis, rubella, cytolomegalovirus, Herpes
4 maternal factors that could cause newborn to have pneumonia PROM-ruptures membrane, infection, fever, stained amniotic fluid
Clinical signs of Pneumonia vary with organism but name a few generic signs apnea, poor peripheral perfusion, tachycardia, lethargy, temp instability, hypotensive
Pneumonia ABG shows hypoxia and hypercarbia (metabolic acidosis)
Pneumonia CXR would appear with what things present diffuse granular pattern, patchy infiltrates, atelectasis
Tx for Pneumonia would include aggresive mgmt, ABT or antivirals, support pt, O2/ventilation, ECMO
What signs would a neonate with pneumonia present with to determine if ECMO should be used mottles, apneic, swinging BP’s
This strain of streptococcus is most unresponsive to treatment Group B