1. Neonatal Respiratory Care

2. IV. first month mortality A.I and III only B.I and IV only
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
EXPLANATIONS:   
I. True. A low 5-minute Apgar score is associated with an increased risk of mental impairment.  
II. False. There is no documented association between atelectasis and low Apgar scores. 
III. False. Newborns do not present with bronchiolitis and it is not related to low Apgar scores.
IV. True. A low 5-minute Apgar score is associated with increased mortality in the first month of life.
(u) A. Incomplete and incorrect response included. (c) B. Correct response. (u) C. Incorrect response. (u) D. Incomplete and incorrect response included.

3. APGAR Score 0 – 3 Resuscitate 4 – 6 Support 7 – 10 Monitor
Stimulate, warm, O2
7 – 10 Monitor
Routine care

4. A.extracorporeal membrane oxygenation B.volume-controlled ventilation
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 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
EXPLANATIONS:
(u) A. Performing extracorporeal membrane oxygenation (ECMO) in a neonate of this weight is not indicated as a first-line treatment and would increase the risk of complications (e.g., intraventricular hemorrhage).
(u) B. Pressure-controlled ventilation is preferred over volume-controlled ventilation in the neonate as a lung protection strategy (e.g., reduce the risk of barotrauma).
(c) C. Administering an exogenous surfactant is the preferred treatment for neonatal RDS because endogenous surfactant production in the immature lung is inadequate.
(u) D. Nitric oxide is not a first-line treatment for RDS.

5. 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

6. 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

7. Respiratory Distress Syndrome
Clinical Manifestations
Nasal flaring
Grunting
Retractions
Tachypnea
Cyanosis
Chest X-ray
“Ground glass” appearance
Diffuse atelectasis
Air bronchograms

8. Respiratory Distress Syndrome
Treatment
O2 Therapy
CPAP
Mechanical Ventilation
Surfactant replacement
Thermoregulation
Adequate fluids
Packed RBCs

9. The major component of pulmonary surfactant is A. protein. B. glucose.
C. phospholipid.
D. polysaccharide.
EXPLANATIONS:
(u) A. Protein is 7% of surfactant.
(u) B. No significant glucose content exists in surfactant.
(c) C. Phospholipid is 85% of surfactant.
(u) D. No significant independent polysaccharide exists in surfactant.

10. 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?
Decrease pressure limit
Decrease PEEP
Decrease rate
Decrease FiO2 I
I and II
I, II, and III
I, II, III, and IV

11. 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.
EXPLANATIONS:
(u) A. See explanation C.
(u) B. See explanation C.
(c) C. Correct answer. See chart below. (u) D. See explanation C.

12. APGAR Score

13. The respiratory therapist is asked to review a newborn's history
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
EXPLANATIONS:
(u) A. See C for calculation. (u) B. See C for calculation.
(c) C. The Apgar score uses the following information:
For this patient: (u) D. See C for calculation.

14. 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

15. Vital Signs Respiratory Rate: 30 – 60 bpm Heart Rate: 120 – 160 bpm
Blood pressure: 60/40
Preterm: 50/30

16. A.racemic epinephrine (Vaponefrin) B.naloxone (Narcan)
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)
EXPLANATIONS:
(u) A. Racemic epinephrine is most commonly used to treat laryngeal edema through vasoconstrictor properties. It has no ability to treat or prevent apnea.
(u) B. Naloxone is a narcotic antagonist used to reverse adverse effects caused by the administration of narcotics. This neonate most likely has apnea of prematurity, which would not respond to naloxone.
(u) C. Surfactant is administered to neonates who have a deficiency in endogenous surfactant. It is used to promote alveolar stability. This neonate most likely has apnea of prematurity and would not benefit from surfactant administration.
(c) D. Theophylline is used to treat apnea of prematurity because of its ability to stimulate the respiratory center in the brain of a newborn.

17. D. normal lung appearance
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
EXPLANATIONS:
(u) A. When there is excessive air or fluid present, light transmission will be increased. Transillumination of the air-filled chest in the neonate with a pneumothorax results in lighting up the affected side of the chest.
(u) B. Transillumination will light up the chest in patients with pneumomediastinum. See explanation A.
(u) C. Transillumination is not used to determine pneumopericardium.
(c) D. The halo appearance is produced by a normal, inflated lung absorbing the light.

18. 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
EXPLANATIONS:   
I. True. The infant should be monitored during any sleep or when not being directly observed.  
II. False. The infant should be monitored during any sleep. Infants are usually awake and being directly observed during feeding.
III. True. The infant should be monitored during any sleep or when not being directly observed. (u) A. Incomplete response. (u) B. Incomplete and incorrect response included. (c) C. Correct response. (u) D. Incomplete and incorrect response included.

19. A. change oxygen analyzers. B. check the air inlet for an obstruction.
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.
EXPLANATIONS:
(u) A. Proper calibration indicates correct functioning of the analyzer. Replacement not indicated.
(u) B. Obstruction of the air inlet can only increase the F I O 2 .
(c) C. Obstruction of the oxygen inlet can decrease the F I O 2 .
(u) D. Adding water to the reservoir will not affect F I O 2 inside the tent.

20. Which of the following should be the initial treatment?
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
EXPLANATIONS:
(c) A. According to NRP guidelines, manual positive pressure ventilation is indicated in this situation.
(h) B. According to NRP guidelines, endotracheal intubation is not indicated at this time and could cause delay in proper therapy.
(h) C. Spontaneously inhaled oxygen is not sufficient. See explanation A.
(h) D. According to NRP guidelines, chest compressions are not indicated for a heart rate greater than 60/min while providing positive pressure ventilation with 100% oxygen.

21. Neonatal Flow Algorithm
Circulation 2005;112:IV-188-IV-195
Copyright ©2005 American Heart Association

22. 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.

23. Which of the following are indications to start CPAP for a neonate?
Atelectasis
Respiratory distress syndrome
Pulmonary edema
Ventilatory failure I
I and II
I, II, and III
I, II, III, and IV
Hypoxemia due to mild to moderate intrapulmonary shunting.
Usually accompanied by signs of respiratory distress:
Tachycardia, Severe retractions, Grunting, Periodic breathing, Recurrent apnea, Chest radiograph, Nasal flaring, Pale or cyanotic, Tachypnea, Low SpO2, Low lung volume
PaO2 < 50 mmHg on an FiO2 > .50, with a PaCO2 < 50 mmHg and a pH > 7.25
Reduces V/Q mismatch by improving FRC.

24. The decision is made to place the neonate in CPAP
The decision is made to place the neonate in CPAP. Which of the following settings would you recommend to start CPAP?
CPAP 2 cmH2O
CPAP 5 cmH2O
FiO2 30%
FiO2 60%
I and III
I and IV
II and III
II and IV

25. CPAP Initial Settings Usually 4 - 7 cmH2O Flow 5 – 10 L/min
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

26. 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?
Increase CPAP by 2 cmH2O
Increase CPAP by 4 cmH2O
Increase FiO2 by 10%
Intubate and mechanically ventilate

27. 4 hours later you notice a sudden drop in the CPAP level, what could be the cause of this?
The patient’s condition is improving
The patient’s condition in worsening
Disconnection
Occlusion

28. 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

29. CPAP Failure Recurrent apnea or symptoms of distress
Persistent acidosis (pH < 7.20)
Unsatisfactory PaO2 on > 50% oxygen
Consider surfactant therapy if RDS

30. 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

31. Most neonatal mechanical ventilators
provide time-triggered, pressure-limited, time-cycled ventilation.
are pneumatically powered.
have electrical controls and alarms.
feature a continuous flow of gas. I
I and II
I, II, and III
I, II, III, and IV

32. Increasing the inspiratory flow on a neonatal time-triggered, pressure-limited, time-cycled mechanical ventilator will do which of the following?
Increase MAP
Increase PaO2
Increase PaCO2
Increase tidal volume
I and IV only
I and II only
II and III only
I, II, and IV only

33. Given the following choices, which would you select to decrease the PaCO2 in a neonate on a standard, pressure limited type ventilator?
Increase FiO2
Decrease the pressure limit
Increase the rate
Increase the flow
Increase the pressure limit
I only
II only
III, IV, and V
II and III

34. Given the following choices, which would you select to increase the PaO2 in a neonate on a standard pressure-limited type ventilator?
Increase inspiratory time
Increase the pressure limit
Decrease flow
Increase PEEP
Decrease the IMV rate
I and V
II and III
III and IV
I, II, and IV

35. Meconium aspiration or other obstruction causes uneven airflow and results in which on the following?
Hypoxemia
Air trapping
auto-PEEP
Increased risk of barotrauma I
I and II
I, II, and III
I, II, III, and IV

36. 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

37. 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

38. Meconium Aspiration Clinical Manifestations Hypoxemia Hypercarbia
Tachypnea
Retractions
Nasal flaring
Grunting
Barrel chest
Course crackles and rhonchi

39. Meconium Aspiration Chest X-ray Patchy infiltrates Atelectasis
Consolidation
Pneumothorax
Hyperinflation

40. Management of Meconium
After delivery, the appropriate method for clearing the airway further will depend on
The presence of meconium
The baby’s level of activity
Studies have shown that direct suctioning of the trachea should be performed only if a meconium-stained newborn has depressed respirations, depressed muscle tone, and/or a heart rate less than 100 beats per minute.
Instructor Tip: No clinical studies warrant basing tracheal suctioning guidelines on meconium consistency.

41. 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

42. Which of the following tests are done to help confirm the diagnosis of PPHN?
Hyperoxia test
Preductal and postductal arterial blood sampling
Hyperoxia-hyperventilation test
Echocradiography I
I and II
I, II, and III
I, II, III, and IV

43. 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

44. PPHN Pathophysiology

45. 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 post-ductal SpO2

46. PPHN Diagnosis Hyperioxa Test Preductal vs. postductal ABG
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

47. 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

48. PPHN Diagnosis cont. Echocardiogram
Increased pulmonary artery pressures
Right-to-left shunting
Tricuspid regurgitation
Right ventricular dilation

49. PPHN Treatment Remove the underlying cause Oxygen for hypoxemia
Surfactant for RDS
Glucose for hypoglycemia
Inotropes for  cardiac output

50. PPHN Treatment Hyperventilation Tolazoline Nitric Oxide ECMO MV HFV
IV vasodilator
Nitric Oxide
Inhaled vasodilator
ECMO

51. Which of the following arterial blood sampling sites are considered preductal?
Right radial
Left radial
Right brachial
Left brachial
I and II
I and III
II and IV
III and IV

52. What is inhaled nitric oxide?
A surface tension reducing agent
A pulmonary vasodilator
A systemic vasodilator
A bronchodilator

53. 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

54. Common Settings Normal Lungs Stiff Lungs Vt 6-8 ml/kg PIP 10-20 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

55. ABGs PaO2 PaCO2 pH Neonatal safe range: 50-70 mmHg
Chronic disease: <60 mmHg pH
Neonatal safe range:
Acceptable range:

56. 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; FiO 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

57. 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

58. Weaning from MV
Normal ABG, adequate spontaneous respirations, increased muscle tone and activity
FiO2: wean to <0.4 in increments
PEEP: wean to 3-4 cmH2O in 1-2 cmH2O increments
PIP: wean to cmH2O in increments of 1-2 cmH2O
Failure to Wean: tachycardia, bradycardia, retractions, hypercapnia, cyanosis. Restore previous settings.

59. 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.

60. 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

61. The End!