Neonatal
Respiratory
Care
The respiratory therapist reviews the chart
of a newborn and notes a 1-minute Apgar
of 2 and a 5-minute Apgar of 3. For which
of the following is this newborn at
increased risk?
I. mental impairment
II. Atelectasis
III. Bronchiolitis
IV. first month mortality
A.I and III only
B.I and IV only
C.II and III only
D.II and IV only
APGAR Score
• 0 – 3 Resuscitate
• 4 – 6 Support
– Stimulate, warm, O2
• 7 – 10 Monitor
– Routine care
A 1000 g neonate who is 6 hours old is
receiving time-cycled, pressure-limited
ventilation. The neonate shows signs of
developing RDS on a chest radiograph and
severe hypoxemia is noted with an FIO2 of
0.80. Which of the following should the
respiratory therapist recommend be used?
A.extracorporeal membrane oxygenation
B.volume-controlled ventilation
C.exogenous surfactant
D.nitric oxide
Surfactant Administration
• Beneficial to premature neonates
with inadequate natural surfactant
(RDS)
– Preventive
– Rescue
• Watch for improved compliance
• Be prepared to reduce ventilator
settings shortly after administration
Respiratory Distress
Syndrome
• Immature lungs with inadequate
surfactant
– Leads to atelectasis and hypoxemia
– Leads to hyaline membrane disease
• Lecithin-Sphingomyelin Ratio < 2:1
• Infants bore before 35 weeks of
gestation
Respiratory Distress
Syndrome
• Clinical Manifestations
– Nasal flaring
– Grunting
– Retractions
– Tachypnea
– Cyanosis
• Chest X-ray
– “Ground glass” appearance
– Diffuse atelectasis
– Air bronchograms
Respiratory Distress
Syndrome
• Treatment
– O2 Therapy
– CPAP
– Mechanical Ventilation
– Surfactant replacement
– Thermoregulation
– Adequate fluids
– Packed RBCs
The major component of pulmonary
surfactant is
A. protein.
B. glucose.
C. phospholipid.
D. polysaccharide.
After instillation of exogenous surfactant, it is
expected that the patient’s lung compliance will
improve. As compliance improves, the RCP
should be prepared to make which of the
following ventilator changes?
I. Decrease pressure limit
II. Decrease PEEP
III.Decrease rate
IV.Decrease FiO2
A.
B.
C.
D.
I
I and II
I, II, and III
I, II, III, and IV
At 1 minute after birth a neonate has the
following:
acrocyanosis
slow, irregular respiratory effort
heart rate of 102/min
sneezes with the use of a nasal catheter
partial flexion of the extremities
The Apgar score for this neonate is
A. 3.
B. 5.
C. 7.
D. 9.
APGAR Score
The respiratory therapist is asked to review a
newborn's history. The following information is
available:
What would the respiratory therapist expect to see
for the 1 and 5 minute Apgar scores for this
neonate?
A.5,9
B.6,8
C.6,10
D.7,10
Tachypnea in the newborn is defined
as a respiratory rate greater than
what level?
A. 40/min
B. 50/min
C. 60/min
D. 70/min
Vital Signs
• Respiratory Rate: 30 – 60 bpm
• Heart Rate: 120 – 160 bpm
• Blood pressure: 60/40
– Preterm: 50/30
A 7-day-old neonate of 28-weeks
gestational age is having frequent
periods of apnea with desaturation.
Which of the following should the
respiratory therapist recommend?
A.racemic epinephrine (Vaponefrin)
B.naloxone (Narcan)
C.surfactant (Survanta)
D.theophylline (Aminophylline)
A 34-week gestational age infant is
receiving mechanical ventilation and
the chest is being transilluminated.
The transillumination device
produces a small halo appearance at
the point of contact with the skin.
Which of the following does this
indicate?
A. pneumothorax
B. pneumomediastinum
C. pneumopericardium
D. normal lung appearance
During which of the following should
apnea monitoring be implemented
for an infant?
I. night time
II. breast feeding
III. naps
A. I only
B. I and II only
C. I and III only
D. II and III only
An 18-month-old infant is to receive 30%
oxygen by mist tent. While performing a
routine equipment check, the respiratory
therapist notices the oxygen analyzer
inside the tent reads 25%. After
calibrating the oxygen analyzer, it still
indicates 25%. The therapist should
A. change oxygen analyzers.
B. check the air inlet for an obstruction.
C. check the oxygen inlet for an obstruction.
D. add sterile water to the nebulizer
reservoir.
The respiratory therapist attended the birth
of a full-term neonate. Vital signs are:
Which of the following should be the initial
treatment?
A. manual ventilation with 100% O 2
B. endotracheal intubation
C. oxyhood with 100% O 2
D. chest compressions
Neonatal Flow Algorithm
Circulation 2005;112:IV-188-IV-195
Copyright ©2005 American Heart Association
During resuscitation of a newborn,
after 30 seconds of positive pressure
ventilation (PPV), what should the
clinician do?
A. Evaluate the heart rate.
B. Suction the mouth, then the nose.
C. Begin chest compressions.
D. Initiate medications.
Which of the following are indications to
start CPAP for a neonate?
I. Atelectasis
II.Respiratory distress syndrome
III.Pulmonary edema
IV.Ventilatory failure
A. I
B. I and II
C. I, II, and III
D. I, II, III, and IV
The decision is made to place the neonate
in CPAP. Which of the following settings
would you recommend to start CPAP?
I. CPAP 2 cmH2O
II.CPAP 5 cmH2O
III.FiO2 30%
IV.FiO2 60%
A. I and III
B. I and IV
C. II and III
D. II and IV
CPAP
•
Initial Settings
–
Usually 4 - 7 cmH2O
•
•
•
–
–
–
–
Adjusted based on clinical assessment
Increments of 1 – 2 cmH2O
Observe for changes in:SpO2, Respiratory rate,
WOB, Breath sounds, Blood pressure
Flow 5 – 10 L/min
FiO2 to maintain SpO2 > 90%
ABG in 30 – 60 minutes
CXR when stable to assess lung inflation
2 hours later the neonate has the following
clinical presentation: HR 130, RR 30,
SpO2 94%, expiratory grunting and nasal
flaring continues on CPAP of 5 cmH2O and
FiO2 30%. What adjustment would you
recommend at this time?
A.Increase CPAP by 2 cmH2O
B.Increase CPAP by 4 cmH2O
C.Increase FiO2 by 10%
D.Intubate and mechanically ventilate
4 hours later you notice a sudden drop
in the CPAP level, what could be the
cause of this?
A.The patient’s condition is improving
B.The patient’s condition in worsening
C.Disconnection
D.Occlusion
A patient on CPAP is demonstrating
frequent apnea episodes associated
with desaturation and bradycardia.
Which of the following actions would
you recommend?
A. Increase CPAP by 2 cm H2O
B. Obtain a chest x-ray and increase
FIO2
C. Institute high-frequency ventilation
D. Intubate and mechanically ventilate
CPAP Failure
•
•
•
•
Recurrent apnea or symptoms of
distress
Persistent acidosis (pH < 7.20)
Unsatisfactory PaO2 on > 50%
oxygen
Consider surfactant therapy if RDS
Weaning CPAP
•
•
Decrease FiO2 < .50
Decrease CPAP in increments of 1
– 2 cmH2O
Assess PaO2 with periodic ABGs
Remove patient interface when:
•
•
–
–
–
Adequate PaO2 at lower FiO2
No signs of respiratory distress
On 2 – 3 cmH2O and FiO2 < .50
Most neonatal mechanical ventilators
I. provide time-triggered, pressurelimited, time-cycled ventilation.
II.are pneumatically powered.
III.have electrical controls and alarms.
IV.feature a continuous flow of gas.
A. I
B. I and II
C. I, II, and III
D. I, II, III, and IV
Increasing the inspiratory flow on a neonatal
time-triggered, pressure-limited, timecycled mechanical ventilator will do which
of the following?
I. Increase MAP
II.Increase PaO2
III.Increase PaCO2
IV.Increase tidal volume
A. I and IV only
B. I and II only
C. II and III only
D. I, II, and IV only
Given the following choices, which would you
select to decrease the PaCO2 in a neonate
on a standard, pressure limited type
ventilator?
I. Increase FiO2
II.Decrease the pressure limit
III.Increase the rate
IV.Increase the flow
V. Increase the pressure limit
A. I only
B. II only
C. III, IV, and V
D. II and III
Given the following choices, which would you select
to increase the PaO2 in a neonate on a standard
pressure-limited type ventilator?
I. Increase inspiratory time
II. Increase the pressure limit
III.Decrease flow
IV.Increase PEEP
V. Decrease the IMV rate
A.
B.
C.
D.
I and V
II and III
III and IV
I, II, and IV
Meconium aspiration or other obstruction
causes uneven airflow and results in
which on the following?
I. Hypoxemia
II.Air trapping
III.auto-PEEP
IV.Increased risk of barotrauma
A. I
B. I and II
C. I, II, and III
D. I, II, III, and IV
Meconium Aspiration
Syndrome
• Aspiration of meconium
• Full or Post-term infants
• Hypoxemia in utero, may cause the
infant to pass meconium
• Stress in utero causes the infant to
breath deeper
• Plugs airways and leads to
atelectasis and increased Raw
Meconium Aspiration
• Plugs airways and leads to
atelectasis and increased Raw
• Air-trapping may lead to
hyperinflation and pneumothorax
• The infant may also have PDA due to
intrauterine hypoxemia
Meconium Aspiration
• Clinical Manifestations
– Hypoxemia
– Hypercarbia
– Tachypnea
– Retractions
– Nasal flaring
– Grunting
– Barrel chest
– Course crackles and rhonchi
Meconium Aspiration
• Chest X-ray
– Patchy infiltrates
– Atelectasis
– Consolidation
– Pneumothorax
– Hyperinflation
Management of Meconium
Meconium Aspiration
• Treatment
– Suction oral and nasal pharynx upon
delivery of the head before first cry
– Intubate and suction immediately after
delivery
– O2 Therapy
– May require mechanical ventilation
– CPT and Suctioning
Which of the following tests are done to
help confirm the diagnosis of PPHN?
I. Hyperoxia test
II.Preductal and postductal arterial
blood sampling
III.Hyperoxia-hyperventilation test
IV.Echocradiography
A. I
B. I and II
C. I, II, and III
D. I, II, III, and IV
PPHN Background
• High pulmonary vascular resistance
• Persistent Fetal Circulation (PFC)
– Associated with: term or post term
infants, asphyxia, meconium aspiration
syndrome, congenital diaphragmatic
hernia, pulmonary hypoplasia,
congenital heart disease, hyaline
membrane disease, pneumonia, &
myocardial dysfunction.
• Further right-to-left shunting
PPHN Pathophysiology
PPHN Clinical Manifestations
• Rapidly changing oxygen saturation
without changes in FiO2
• Hypoxemia out of proportion to the
lung disease detected on CXR
• Significant shunt through the PDA
– > 5% difference between pre- and postductal SpO2
PPHN Diagnosis
• Hyperioxa Test
– 100% O2 for 5 – 10 minutes
– PaO2 < 100 mmHg = RtL shunt
• Preductal vs. postductal ABG
– Preductal PaO2 15 mmHg > postductal
PaO2 = RtL shunt
– SpO2, TcPO2
PPHN Diagnosis cont.
• Hyperoxia-hyperventilation test*
– Hyperventilate
• CO2: 20 – 25 mmHg
• pH: > 7.50
– If PaO2 was < 50 mmHg before
hyperventilation and rises to > 100
mmHg after hyperventilation = PPHN
PPHN Diagnosis cont.
• Echocardiogram
– Increased pulmonary artery pressures
– Right-to-left shunting
– Tricuspid regurgitation
– Right ventricular dilation
PPHN Treatment
• Remove the underlying cause
– Oxygen for hypoxemia
– Surfactant for RDS
– Glucose for hypoglycemia
– Inotropes for  cardiac output
PPHN Treatment
• Hyperventilation
– MV
– HFV
• Tolazoline
– IV vasodilator
• Nitric Oxide
– Inhaled vasodilator
• ECMO
Which of the following arterial blood
sampling sites are considered preductal?
I. Right radial
II.Left radial
III.Right brachial
IV.Left brachial
A. I and II
B. I and III
C. II and IV
D. III and IV
What is inhaled nitric oxide?
A.A surface tension reducing agent
B.A pulmonary vasodilator
C.A systemic vasodilator
D.A bronchodilator
A newborn infant is on pressure-limited,
time-cycled ventilation with the following
settings: PIP 20 cmH2O; rate 30/min;
FiO2 0.70; PEEP 7 cmH2O; I time 0.4
sec. Umbilical artery blood gas results
are: pH 7.34; PaCO2 42 mmHg; PaO2 86
mmHg. Which of the following ventilator
changes would you recommend?
A. Decrease rate
B. Decrease PEEP
C. Decrease FiO2
D. Maintain current settings
Common Settings
Normal Lungs
Stiff Lungs
Vt
6-8 ml/kg
6-8 ml/kg
PIP
10-20 cmH2O
20-25 cmH2O
Rate
10-20/min
20-40/min
I:E
1:2 to 1:10
1:2
I time
< .4 sec
0.4 – 0.7 sec
PEEP
0-4 cmH2O
2-5 to 8-10 cmH2O
Flow
5-8 L/min
5-8 L/min
ABGs
• PaO2
– Neonatal safe range: 50-70 mmHg
• PaCO2
– Neonatal safe range: 35-45 mmHg
– Chronic disease: <60 mmHg
• pH
– Neonatal safe range: 7.35-7.45
– Acceptable range: 7.30-7.50
A newborn infant has been intubated and
placed on pressure-limited, time-cycled
ventilation with the following settings:
PIP 25 cmH2O; I time 0.4 sec; PEEP 5
cmH2O; rate 20/min; FiO2 0.60.
Umbilical artery blood gas reveals: pH
7.24; PaCO2 60 mmHg; PaO2 56 mmHg;
HCO3- 21 mEq/L. Which ventilator
adjustment would you recommend?
A. Increase PIP
B. Increase rate
C. Increase FiO2
D. Increase PEEP
Ventilatory support parameters for an infant
being weaned include: an FiO2 of 0.35; a
PIP of 30 cmH2O; a PEEP of 4 cmH2O; a
rate of 30/min; and an inspiratory time
of 0.5 sec. Which of these parameters
would you recommend trying to reduce
at this time?
A. FiO2
B. PIP
C. PEEP
D. Rate
Weaning from MV
• Normal ABG, adequate spontaneous
respirations, increased muscle tone and
activity
– FiO2: wean to <0.4 in 0.2-0.5 increments
– PEEP: wean to 3-4 cmH2O in 1-2 cmH2O
increments
– PIP: wean to 15-18 cmH2O in increments of 12 cmH2O
• Failure to Wean: tachycardia, bradycardia,
retractions, hypercapnia, cyanosis.
Restore previous settings.
Ventilatory support parameters for an infant
being weaned include the following: FIO2
of 0.35; peak pressure of 18 cm H2O;
positive end expiratory pressure (PEEP)
level of 4 cm H2O; breathing rate of
10/min; and inspiratory time of 0.4
seconds. Assuming that blood gases are
acceptable on these settings, which of the
following actions would you now
recommend?
A.
Decrease the PEEP level to 2 cm H2O.
B.
Decrease the breathing rate to 5/min.
C.
Switch the infant to 5 cm H2O CPAP.
D. Increase the peak pressure to 25 cm
H2O.
In high-frequency oscillatory
ventilation, CO2 elimination depends
mainly on which of the following?
A. Pressure amplitude
B. Mean airway pressure
C. High frequency rate
D. Sinusoidal waveform
The End!