Anatomical differences of the upper airway in pedslarger tongue and more lymphoid tissue, epiglottis is larger & less flexible, larynx higher, narrowest point is cricoid ring, trach narrower and shorter
Physiological considerations of upper airwaylarger tongue and lymph tissue make infants obligate nose breathers, causing secretions or inflammation to increase resistance and WOB, increased risk of occlusion, susceptible to trauma
Larger tongue and more lymphoid tissue causesincreased risk of upper airway occlusion, is the reason infants are obligate nosebreathers
An infants epiglottis is susceptible to trauma becauseit is larger and less flexible than an adult, and lies more horizontal
An infant’s larynx is higher or lower in the neck in relation to the cervical spine?higher
The narrowest part of the infants larynx (airway) is thecricoids cartilage (ring), adult is glottis
Infants sternum and ribs are mostly made up ofcartilage, less stability to chest (movement of diaphragm or RR determines VT)
Infants VE comes fromincrease in RR, not VT
Low pulmonary reserve in infants is due to1 heart is large so lung volume is smaller, 2 instability of thoracic cage (VT not increased with chest expansion but RR), 3 proportionately large abdomen (pushing up diaphragm)
Infant Metabolism differencesinfants have higher BMR, infants have unpredictable response to medications do to BMR
Higher BMR in infants leads tohigher caloric requirements and increased O2 expenditure in proportion to body size compared to adults
Infant BMR and Med dose cautionunpredictable responses due to BMR means time and dose must be adjusted for each individual pt
Large surface area of skin compared to body weight in infants leads toprone to heat loss or difficult temperature control, and difficult maintenance of hydration
What percent of a newborns total body weight is H2O?80
How many grams in 1 lbs?454 grams per lbs
What weight of preemie is now considered viable?500 grams
Barriers to good communication arelanguage, culture and education level
Children presenting with what signs need to have a history taken?dyspnea and respiratory distress
Question to ask during history1 chronic, 2signs of infection, 3fever, 4Rx, 5family Hx, 6 Hx of resp probs 7 Hx of GI reflux 8 character of cough 9 breathing pattern 10 Hx wheezing 11cyanosis 12 chest pain 13 sputum 14 growth 15 environment 16 meds
Cyanosis presence with O2 delivery indicatesR-L shunting
Complaints of chest pains may be an indication ofpneumonia
3 primary goals in assessment of the pulmonary system in pediatric patient arelocalize the disease, observe the adequacy of gas exchange, determine nature of pt’s respirations
How do we localize the diseasegather Hx, additional testing ie CXR, auscultation, percussion, palpation, symmetric chest movement, trachea at sterna notch
How to we observe for adequacy of gas exchangeABG (not often, but sometimes heal stick), pulse ox, transcutaneous/end tidal CO2 monitors
How do we determine nature of pt’s respirationsrate and pattern, increased WOB, LOC, skin color wheezing accessory muscles etc
Pediatric Asthma isreversible airway obstruction, airway inflammation and airway hyperresponsiveness to a variety of stimuli
The majority of ped pt’s have extrinsic or intrinsic asthma?extrinsic associated with allergies
Asthma exacerbation characteristics aredry hacking cough with wheezing on auscultation, with cough becoming wetter and productive, increased RAW, audible wheeze, decreased PaO2 early due to V/Q mismatch, decreased PaCO2 due to hypoxia and accessory muscle use
The best way to gage if therapy is working in asthma attack is% change in Peak Flow
Change in peak flow calc is(post – pre/ pre)x100 acceptable change is 12 to 15% so anything greater than 12% is good
If pt stops wheezing what does this mean?impending respiratory failure
Most common asthma allergens arepollutants, dust mites, feathers, smoke, pet dander, house dust, cockroaches, food preservatives (sulfurs)
Decreased PaO2 early in an acute asthma attackV/Q mismatch
What does RT look for to measure severity of asthma attackPaCO2, 35 or less is mild, 40 or less is moderate, above 40 is severe and resp is imminent
First line treatment for asthma1. O2 (maintain SpO2 above 95%, 2. beta adrenergic (first two back to back then go to continuous neb) epi or terbutaline possible depends on doc 3 anti inflammatory (IV or inhaled) 4. Heli
Modality in ER to avoid intubationcontinuous neb with albuterol for enough for 8 treatments. Decreases need for intubation and perhaps decrease need for IV bronchodilators and terbutaline
Oxygen delivery or CAO2 equationCAO2 EQUALS (HGB*1.34*SAO2)+(PAO2*.003)
Why is the infant chest less stable?because the sternum and ribs are mostly cartilage
Adventitious BSwheezes, rhonchi, crackles/rales, stridor
Wheezeshigh pitched and musical sound, usually on expiration ( can be heard on inspiration with asthma), produced by air moving thru partially obstructed airways, seen in asthma, pulm edema, foreign body, airway tumor, external compression by vascular ring
Rhonchiproduced by air moving through airways with a large amount of secretion, low pitched and rumbling (straw in milk) heard in bronchiectisis, pneumonia, CF
Crackles (rales)sounds like popping of bubble wrap or sandpaper, only heard on inspiration, caused by air moving through fluid filled alveoli, or deflated alveoli re expanding, associated with atelectasis and pulm edema
Stridorproduced as air flow past the partial obstruction of the upper airway during inspiration, high pitched like wheezes, seen in croup, post exudation and foreign body aspiration
How do you tell the difference between stridor and wheezeslisten over larynx and chest, stridor heard over trachea and wheezes heard over chest
Normal VitalsHR nb-100-180 inf 100-160 tod 80-110 sch 65-110, adol 60-90, BP age*2+80over .57 * syst, perfusion state equals capillary refill greater than 3 seconds is low rate, urine 1-2 ml/kg/hr, RR NB 30-60 inf 24-40 tod 20-30 sch 20-25 5-12 16-20 adol 12-16
CXR consolidation and infection is what color?white
CXR of airtrapping is what color?dark distal to plugging
Dull percussion noteconsolidation
High pitched “tympanic” percussion notehyperaerated (airtrapping)
What is the best way to evaluate gas exchange?ABG
What are the physical signs of hypoxemiatachycardia, cyanosis, labored breathing, deterioration in mental state
Peak flow change equation ischange equals (post-pre)/pre* 100 (great than 12 % is acceptable change
Signs of hypercarbia arerapid, bounding pulse, confusion, muscular twitching
What are the steps in a pt scenario?History, examination (localization, accessing gas exchange, nature of respiration) diagnose and plan the treatment
Why does HGB saturation take so long to show signs of hypoxia?the lower the HGB count the longer it takes (5 grams)
When does a pt assessment start?as you enter the room
2 year old on peds floor is sleeping with RR of 70, what is the cause?Decreased PaCO2
(voice vibrations)that can be felt. increased by solids like consolidation and atelectasisfremitis
Heart Rate NormalsNB 100-180, INF 100-160, TOD 80-110, SCH 65-110, ADOL 60-90
Resp Rate NormalsNB 30-60, INF 24-40, TOD 20-30, SCH 20-25, age 5-12 16-20, ADOL 12-16
Adventitious Breath Sounds(abnormal Breath Sounds) Crackles/rales, Rhonchi, Wheeze, Pleural Friction Rub, Stridor, Diminished
Bronchial Breath Sounds(normal breath sounds) E
bronchophony(99 or 123 will be louder) increased intensity and clarity of vocal resonance, more tissue density than air (consolidation), easier to detect unilaterally, dull percussion, increased vocal fremitus bronchovesicular breath sounds
crackles/rales(adventitious BS) bubbling-crackling sounds, mainly on I, air flow through fluid, discontinuous-specific locations, does not clear with cough. caused by pulmonary edema, pneumonia, emphysema, atelectasis, pulmonary fibrosis
What conditions delay surfactant production?Acidosis, Hypoxia, shock, overinflation, mechanical ventilation, pulmonary edema, hypercapnia, maternal diabetes and small twin
What is considered a good L/S ratio?Lecithin/Sphingomylin Ratio of 2:1 *another test Surfactant/Albumin
Name the factors affecting prenatal and post-natal lung growthPneumonectomy, altered metabolic rate, high O2 concentrations, maternal cigarette usage, chest wall compression, oligohydramnious, decrease respiratory effort
What does surfactant do?Reduces surface tension in the alveoli
How does the radius of alveoli affect surface tension?↓Radius = ↑Surface tension Laplace’s Law
What is Pulmonary Hypoplasia?Failure of lung development in utero
What is Oligohydramnios?insufficient amniotic fluid
What is the only component of the lung to multiply post-natally?Alveoli
At what week is there a surge in surfactant production?32 weeks
At what week of development do “true alveoli” develop?32-34 weeks
What are the function of type I and type II cells?Type I – create A/C membrane Type II – produce surfactant
What is the age of viability and what stage is it in?23 weeks Canalicular
Name the 5 fetal developmental stages (in order)1. Embryonal 2. Pseudoglandular 3. Canalicular *Viable 4. Saccular 5. Alveolar
What are conditions that accelerate surfactant productions?Maternal diabetes, PROM-Premature Rupture of Membrane, Maternal Hypertension, Placental insufficiency, Maternal Admin of Betamethasone, Abruptio Placentae
At what gestational age is the heart fully developed?8 weeks
A fetal heart beat can be heard at what gestational age?4 weeks
What is a potential condition resulting from oligohydramnios?Renal disorder and/or cord collapse
What is a potential condition resulting from polyhydramnios?Downs Syndrome
What is polyhydramnios?Excessive Amniotic Fluid
What is the Amnion?The sac that surrounds the baby?
How much lung fluid is removed during a vaginal birth?1/3
What is the composition & quantity of fetal lung fluid?Term 20-30 ml/kg mainly electrolytes
Fetal lung fluid is a metabolically active organ. true or false?True
What is an indication for chest compressions i a neonate?HR<60
What are indications for PPV in a neonate?1. shallow or slow respirations 2. Gasping or apnea 3. HR<100 *after stimulation
What are the causes for fetal asphyxia?Maternal Hypoxia, Insufficient placental blood flow, Blockage of placental blood flow, Fetal disorders
What is the term for the umbilical cord being wrapped around the neck?Nuchal Chord
What are possible causes for Rales/Crackles in a neonate?Pulmonary Edema, RDS, Pneumonia
What are the possible causes for diminished or absent breath sounds in a neonate?Pneumothorax, atelectasis, loss of lung volume
What are the signs of respiratory distress in a neonate?1. Tachypnea 2. Central Cyanosis 3. Nasal Flaring 4. Expiratory Grunting 5. Retractions (clavical the worst)
How do you calculate mean B/P in a neonate?Gestational age (weeks) +5
What is the normal HR for a neonate?Norm 120-170 Bradycardia HR<100 Tachycardia HR>170 *apical pulse
What is a normal RR for a neonate?40-60 -Not always regular -Period breathing not apnea <10 seconds
A blue hue to the lips, head or trunk indicate what?Central Cyanosis (possible hypoxemia)
A newborns’ yellowish coloring indicates what?Possible jaundice
What is Acrocyanosis?Peripheral bluing (hands/feet)
What will the ears and feet look like on a preemie?Ears-floppy, Feet-slick soles
What is lanugo?Body hair that appears at 26 weeks and starts to disappear at 36 weeks and is gone at 40 weeks
What is Vernix and how does it help with estimating age?Vernix cheese-like covering that appears at 20-24 weeks and begins to disappear at 36 weeks.
Name 4 important items of OB history1. Number of pregnancies 2. Number of premature deliveries 3. Number of abortion/miscarriages 4. Number of living children
Trace blood flow from the RA to the aorta1. RA 2. RV 3. Pulmonary Artery 4. Lungs (10%) 5. Pulmonary Vein 6. LA 7. LV 8. Aorta (body)
Where is the most oxygen-rich blood found int he fetal circulatory system?Inferior vena cava
Trace blood flow from the superior vena cava to the descending aorta1. SVC 2. RA 3. RV 4. Pulmonary Artery 5. Ductus arteriosus 6. Descending aorta (lower body)
Trace fetal blood flow from the RA to the aorta1. RA 2. Foramen ovale 3. LA 4. LV 5. Aorta (body/brains)
What are the first four steps of fetal blood flow?1. Placenta 2. Umbilical vein 3. Ductus venosus 4. Inferior vena cava
The placenta contains as much as 50% of fetal blood volume true or false?True
The ductus arteriosus shunt blood away from which fetal organThe lungs
The ductus venosus shunts approximately 50% of blood around the fetal liver. true or false?True
The ductus arteriosus is usually fully closed 2-4 weeks after birth. true or false?True It becomes ligamentum arteriosum
What are reasons for decreased PVR in normal transitions?1. Fluid is removed from alveoli 2. As alveoli expand they pull pulmonary vessels 3. O2 increases reverse vasoconstriction
What establishes FRC?Baby’s first breath
What must occur for fetal shunts to close?PVR must decrease below SVR
Name the 4 things that must occur for successful fetal-neonatal transition1. Activation of CNS and ANS 2. Replace lung fluid with air 3. Establish pulmonary circulation 4. Change blood flow in heart & great vessels
The umbilical cord has one artery and two veins. True or False?False Two arteries carrying mixed blood back to the placenta and one vein carrying oxygenated blood to the fetus
What is the gelatinous covering on the umbilical cord?Wharton’s Jelly
Name the three fetal shunts1. Ductus venosus 2. Foramen ovale 3. Ductus Arteriosis
Why is fetal PVR higher than SVR?Fluid in the alveolus (increased pressure) Vasculature is poor (increased resistance)
Pulmonary vascular resistance is lower in fetal circulation True or False?False
What is the name of the shunt between the RA and LA in fetal circulation?Foramen Ovale
What is Placenta Previa?Placental implantation at the cervix preventing vaginal delivery
What is prolapse cord?When the umbilical cord precedes delivery of the body
What is the name for a placenta that has prematurely separated?Abruptio Placentae
How is IVH/PVL confirmed?Cranial ultrasound
What is the key clinical presentation of IVH/PVL?Abrupt drop in hemocrit with no response to transfusion
What is periventricular leukomalacia (PVL)?Leaky vessels in the brain
What is intraventricular hemorrhage (IVH)?Vessel rupture in the brain as a result of weak vessels or anoxic brain injury
What is retinopathy of prematurity (ROP)Eye damage caused by retinal constriction in response to excessive O2
What is pulmonary interstitial emphysema (PIE)?Air dissects throughout the interstitial tissue of the lungs
What defines chronic lung disease (CLD) in infants?1. Requires O2 or mechanical ventilation and 2. Continues to require O2 at 36 weeks
What is the name of the CLD that exhibits over and under distention?Broncho pulmonary dysplasia (BPD)
What is the lung disease that appears to resolve and returns 1-5 weeks later?Wilson-Mikity Syndrome
Lung damage in infants younger than 30 weeks is preventable. True or False?False
What defines Apnea of Prematurity?1. Absence of breathing >20 seconds or 2. shorter episodes with bradycardia or cyanosis
What is the gold standard for confirming PPHN?Echo-cardiograms
What is another name for persistent pulmonary hypertension?Persistent fetal circulation
All infants get w/MAS get suctioned completely. True or false?False-vigorous infants are not suctioned below vocal chords
Cerebral palsy can be caused by hyperoxia at birth. True or false?False-caused by hypoxemia
Meconium Aspiration Syndrome can lead to hyper inflated alveoli. True or False?True-Ball Valve Effect
Name the five causes for transplacental pneumonia (TORCH)?Toxoplasm Other- Rubella CMV-Cytomeglia Herpes
What ate the three categories of neonatal pneumonia?Transplacental Perinatal Post Natal
What is the primary Tx for TTN?1. Oxygen Therapy 2. CPAP or Mechanical Ventilation
What is another name for “Wet Lung Syndrome”?Transient Tachypnea of the newborn (TTN)
What is the cause of transient tachypnea of the newborn?Delayed re-absorption of fetal lung fluid
What does the X-ray look like for RDS?Clouded, opaque and ground glass
What are the respiratory clinical presentations of RDS?Grunting, tachypnea, retractions, nasal flaring, cyanosis
The net effect of RDS is Hypoxia and Mixed Acidosis. True or false?True
Severe RDS patients tend to die from other problems. True or False?True
Term infants with RDS typically have what maternal influence?Diabetes
RDS is a syndrome associated with prematurity or stressed high risk infants. True or false?True
Surfactant surges when?34 weeks
What is another name for RDS?Hyaline Membrane Disease
When does RDS peak?72 hours
What happen to the umbilical cord after 40 weeks?It becomes stiff
What may be indicated by wheezes?Any CLD